Evaluation of a pilot national online asthma e-learning program for secondary school students

Digital Health Technology in Asthma: A Comprehensive Scoping Review

BACKGROUND

A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements.

OBJECTIVE

To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma.

METHODS

We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient.

RESULTS

Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use.

CONCLUSIONS

Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.

How Do Publicly Available Allergy-Specific Web-Based Training Programs Conform to the Established Criteria for the Reporting, Methods, and Content of Evidence-Based (Digital) Health Information and Education: Thematic Content Evaluation

Background

Allergic diseases, such as allergic asthma, rhinitis, and atopic eczema, are widespread, and they are a considerable burden on the health care system. For patients and health care professionals, Web-based training programs may be helpful to foster self-management and provide allergy-specific information, given, for instance, their good accessibility.

Objective

This study aimed to assess an exploratory sample of publicly available allergy-specific Web-based training programs—that is, interactive, feedback-oriented Web-based training platforms promoting health behavior change and improvement of personal skills—with regard to (1) general characteristics, aims, and target groups and (2) the extent to which these tools meet established criteria for the reporting, methods, and content of evidence-based (digital) health information and education.

Methods

Web-based training programs were identified via an initial Google search and a search of English and German language websites of medical and public health services, such as the European Centre for Allergy Research Foundation (German), Asthma UK, and Anaphylaxis Canada. We developed a checklist from (1) established guidelines for Web-based health information (eg, the Journal of the American Medical Association benchmarks, DISCERN criteria, and Health On the Net code) and (2) a database search of related studies. The checklist contained 44 items covering 11 domains in 3 areas: (1) content (completeness, transparency, and evidence), (2) structure (data safety and qualification of trainers and authors), and (3) impact (effectiveness, user perspective, and integration into health care). We rated the Web-based training programs as completely, partly, or not satisfying each checklist item and calculated overall and domain-specific scores for each Web-based training program using SPSS 23.0 (SPSS Inc).

Results

The 15 identified Web-based training programs covered an average of 37% of the items (score 33 out of 88). A total of 7 Web-based training programs covered more than 40% (35/88; maximum: 49%; 43/88). A total of 5 covered 30% (26/88) to 40% (35/88) of all rated items and the rest covered fewer (n=3; lowest score 24%; 21/88). Items relating to intervention (58%; 10/18), content (49%; 9/18), and data safety (60%; 1/2) were more often considered, as opposed to user safety (10%; 0.4/4), qualification of staff (10%; 0.8/8), effectiveness (16%; 0.4/2), and user perspective (45%; 5/12). In addition, in 13 of 15 Web-based training programs, a minimum of 3 domains were not covered at all. Regarding evidence-based content, 46% of all Web-based training programs (7/15) scored on use of scientific research, 53% on regular information update (8/15), and 33% on provision of references (5/15). None of 15 provided details on the quality of references or the strength of evidence.

Conclusions

English and German language allergy-specific Web-based training programs, addressing lay audiences and health care professionals, conform only partly to established criteria for the reporting, methods, and content of evidence-based (digital) health information and education. Particularly, well-conducted studies on their effectiveness are missing.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

A review of the use and effectiveness of digital health technologies in patients with asthma

OBJECTIVE

A new generation of digital health technologies (DHT) offers the opportunity to improve adherence and asthma control. Recent literature was reviewed to summarize the use of technological aids and evaluate their impact on health outcomes in patients with asthma.

DATA SOURCES

PubMed and Embase were searched to identify articles published over the past 5 years (2013 to 2017).

STUDY SELECTIONS

All records were judged for eligibility by 2 independent reviewers; 28 articles met the inclusion criteria.

RESULTS

Interactive websites were the most frequently evaluated type of DHT (50% of all studies), followed by mobile apps in adult patient cohorts. Relatively few studies assessed electronic monitoring devices, phone calls, or text messaging. Among the 16 studies that focused on children, most interventions that used interactive websites (n = 8) showed at least some benefit, although results varied based on the specific outcome. Twelve studies focused on adults, with interventions using interactive websites (n = 6) reporting results that were generally less consistent compared with the pediatric studies. The 6 studies that assessed mobile apps with adult patients reported consistent benefits across a range of outcomes, including medication adherence and asthma control.

CONCLUSION

Most interventions reported at least some benefit, although results varied based on the specific outcome. Overall, technology that included more interactive features, such as website-based daily diary entries and apps that provided real-time feedback, was associated with increased asthma control, as was the case for multidimensional interventions that combined the use of several complementary types of DHT.

The Seven Stages of Man: The Role of Developmental Stage on Medication Adherence in Respiratory Diseases

The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested.