Developing, refining and feasibility study of mobile app to support asthma self-management (A4A - APP for Asthma).

Background: Self-management with an action plan, as opposed to passive self-monitoring, improves health outcomes. However, engaging patients is challenging. Mobile technology, incorporating education, personalised asthma action plans and facilitating professional support, is an option for supporting asthma self-management. Clinical research has focussed on health-related outcomes rather than informing the features that patients want and will use in a self-management app. Technology developers focus on user engagement as opposed to developing telehealth based on clinical evidence, leaving patients struggling to choose safe telehealth to support their asthma self-management. Risk aversion results in legislation that can be a barrier to the development of asthma apps. Aims and objectives: Using phases of the MRC Framework for developing complex interventions, and the Oxford app roadmap to develop a prototype app, I aimed, from clinical, patient, technology and legislative perspectives to: •(Phase 1) Identify the evidence base •(Phase 2) Model key aspects of app development •(Phase 3) Explore the feasibility of a mobile app to support self-management Methods: •(Phase 1) Systematic review, online social forum analysis, asthma apps review, and legislation regulation review were used to identify evidence. Results were analysed with reference to the PRISMS taxonomy of self-management support. •(Phase 2) Using results from phase 1, and with the advice of lay and professional advisory groups, I made decisions about the design of the prototype app and the feasibility study in phase 3. I also reviewed the legislative issues regarding self-management app development. •(Phase 3) I undertook a feasibility study of using asthma mobile apps. Within the three-month feasibility study, five practices in Lothian/Oxford and Asthma UK’s social media invited adults with active asthma to try out our prototype app. I observed patient’s download rate and app usage. Of the patients recruited from practices, I purposively sampled patients (based on age/sex, experience of asthma, current self-management and technology use) and interviewed them before and after using the app for one month about their preferred features. Interviews were transcribed, and thematically analysed with reference to the PRISMS taxonomy of self-management support. Results: •(Phase 1) Telehealth was at least as effective as traditional approaches to supported self-management. Most asthma patients using online social forums commented on self-monitoring features, such as logging peak flow and symptoms, as opposed to self-management features. No one explicitly discussed asthma action plans though some patients were positive to the apps which had incorporated an action plan. Similarly the most downloaded asthma apps offered self-monitoring features rather than action plans. Current medical device legislation is ambiguous: it is unclear if apps with an action plan are ‘medical devices’. •(Phase 2) The final prototype app included the Asthma UK asthma action plan and monitoring features such as the morbidity questions of the Royal College of Physicians three questions, peak flow, use of reliever inhaler, other medication use and lifestyle status. A mixed method approach was chosen for the feasibility study. •(Phase 3) 111 asthma patients used the prototype app. The ownership of action plans increased 43% to 63% after the study. Most patients preferred digital to paper action plans though the digital format did not improve usage. Action plans and monitoring features were the most ‘wanted’ features by patients, GPs, asthma nurses and the administration staff in the practices. Some patients also ‘wanted’ more advanced features such as predictive exacerbation warnings, identifying precise triggers, learning about what caused/affected their asthma. Conclusions: Mobile apps are a feasible option to support asthma self-management. Ease of access to download is the key to adoption as well as sufficient motivation (e.g. personal invitation from their GP or asthma nurse). Motivation (specifically GP and asthma nurse’s encouragement and perception of benefit) is the key to adherence, but it will be more effective if the app is easy to use. Action plans and self-management features were the most ‘wanted’ features by patients and professionals. Other features that patients ‘wanted’ varied; one size does not fit all. Advanced features might encourage on-going use of asthma apps to support self-management. Choice of features, service promotion and service deployment should be considered carefully when implementing mobile app in ‘real world’ setting. The key technological barriers were to provide seamless Wi-Fi and to connect the app with the practice’s software platforms. ‘Medical device’ legislation is currently a barrier for self-management app development, further discussions with all stakeholders is needed to reach consensus on risks involved in incorporating action plans in an app