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Internet-based self-management programs improve asthma control and the asthma-related quality of life in adults and adolescents. The components of self-management programs include education and the web-based self-monitoring of symptoms; the latter requires adequate perception in order to timely adjust lifestyle or medication or to contact a care provider.
We aimed to test the hypothesis that adherence to education and web-based monitoring and adequate symptom perception are important determinants for the improvement of asthma control in self-management programs.
We conducted a subgroup analysis of the intervention group of a randomized controlled trial, which included adolescents who participated in the internet-based self-management arm. We assessed the impacts that attendance in education sessions, the frequency of web-based monitoring, and the level of perception had on changes in asthma control (Asthma Control Questionnaire [ACQ]) and asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire) from baseline to 12 months after intervention.
Adolescents who attended education sessions had significant and clinically relevant improvements in asthma control (ACQ score difference: −0.6;
Education, especially in combination with frequent web-based monitoring, is an important determinant for the 1-year outcomes of asthma control in internet-based self-management programs for adolescents with partly controlled and uncontrolled asthma; however, we could not establish the effect of symptom perception. This study provides important knowledge on the effects of asthma education and monitoring in daily life.
Asthma control is the goal in long-term asthma management, but despite the availability of effective therapies, this goal is not reached in three-quarters of patients with persistent asthma [
Asthma control and asthma-related quality of life can be improved in adults and adolescents, and the number of outpatient visits can be reduced by participating in an internet-based self-management (IBSM) support program [
A detailed description of the methodology and patient recruitment process has been published before [
To assess possible predictors of favorable outcomes in an IBSM support program, this study conducted an analysis of adolescents who participated in the intervention group of a randomized parallel trial (the SMASHING trial), which had a 1-year follow-up with 2-week evaluation periods at baseline and at 12 months [
Patients were defined as being adherent to education if they attended at least 1 of the 2 education sessions and as being nonadherent if they did not follow any education session.
Adherence to monitoring was based on the frequency of monitoring ACQ entries during the follow-up period. Adolescents were asked to monitor ACQ entries weekly. We presumed that at the start of the trial, all participants would be motivated to perform monitoring, whereas during the follow-up of the program, only dedicated participants would continue to perform monitoring. We assumed that a monitoring frequency of at least 30 records in 12 months (full compliance in the first month and 50% compliance in the remaining period) would reflect adequate adherence to the intervention. Therefore, participants were divided into subgroups based on whether they adhered to ACQ monitoring (adherent subgroup: ≥30 ACQ entries; nonadherent subgroup: <30 ACQ entries).
Perceptions of dyspnea were assessed in 2 ways, and patients were categorized as normoperceivers or hypoperceivers of dyspnea. First, perceptions of dyspnea were assessed during the methacholine inhalation challenge test. Methacholine was administered in doubling concentrations (range 0.15-640 μmol/mL). The challenge test was discontinued if the FEV1 decreased by more than 20% of the baseline value. All subjects were asked to assess the severity of their breathlessness before the first measurement of lung function, after the inhalation of a placebo (saline), and after receiving each incremental dose of methacholine. Patients rated the severity of the breathlessness that they experienced during the challenge test on a revised Borg scale [
The outcome parameters consisted of the difference between the baseline and 1-year outcomes of the PAQLQ and the individual averages of ACQ scores and FEV1 measurements from the 2-week diary cards. The minimal important change for both PAQLQ scores and ACQ scores was a difference of 0.5 points on their respective scales [
To assess the effect that education has on outcomes, we compared improvements in asthma-related quality of life and asthma control among adherent participants who had followed at least 1 of the 2 education sessions to those improvements in participants who did not follow any education session (the nonadherent participants), by using the Student 2-tailed
We assessed whether adolescents who performed frequent monitoring (≥30 entries) clinically improved at 12 months after intervention in terms of asthma control (∆ACQ score≤−0.5) or quality of life (∆PAQLQ score≥0.5) by using the Student
We also assessed whether normoperceivers clinically improved (ie, in terms of asthma control [∆ACQ score≤−0.5] or quality of life [∆PAQLQ score≥0.5]) more than hypoperceivers at 12 months after intervention by using the Student
All analyses were performed with the Stata 11.0 (StataCorp LLC) statistical software package.
In the SMASHING study, 46 patients were randomized to the intervention arm. Of these participants, 11 dropped out during follow-up. Of the remaining 35 participants, 9 did not submit the final 12-month questionnaire. In an attempt to obtain at least the primary outcomes of the original study, we asked participants to fill out the PAQLQ. Hence, only 9 participants submitted this PAQLQ at the 12-month follow-up (
Study flow diagram. ACQ: Asthma Control Questionnaire; PAQLQ: Pediatric Asthma Quality of Life Questionnaire; SMASHING: Self-Management in Asthma Supported by Hospitals, Internet, Nurses and General Practitioners.
Patient characteristics.
Characteristics | Internet-based self-management group (SMASHINGa study; n=35) | Nonadherence to education (n=13) | Adherence to educationb (n=22) | |
Males, n (%) | 14 (40) | 6 (46) | 9 (36) | |
Age (years), mean (range) | 14.1 (12-17) | 13.7 (12-16) | 14.1 (12-17) | |
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General practitioner | 12 (34) | 2 (15) | 10 (45) |
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Pediatrician | 23 (66) | 11 (85) | 12 (55) |
FEV1c (L), mean (range) | 2.86 (1.74-4.31) | 3.08 (1.99-4.30) | 2.74 (1.74-4.26) | |
FEV1 (prebronchodilator; %), mean (range) | 93 (65-125) | 93.6 (73.2-117.7) | 91.8 (64.5-125.9) | |
Daily inhaled corticosteroid dose (μg), mean (range) | 353 (0-1000) | 335 (100-1000) | 402 (0-1000) | |
Pediatric Asthma Quality of Life Questionnaire score, mean (range) | 5.78 (3.51-6.97) | 5.84 (4.47-6.63) | 5.75 (3.51-6.97) | |
Asthma Control Questionnaire score, mean (range) | 1.22 (0.22-2.91) | 1.03 (0.22-2.30) | 1.33 (0.29-2.91) |
aSMASHING: Self-Management in Asthma Supported by Hospitals, Internet, Nurses and General Practitioners.
bAdherence is defined as having attended at least 1 of the 2 education sessions.
cFEV1: forced expiratory volume in 1 second.
Of the 35 participants, 22 (63%) followed at least 1 education session (
Asthma control improvement dichotomized by education, monitoring, and perception. A lower (negative) score represents a more favorable outcome.
Categories | ACQ6a score (n=26), mean (95% CI) | |||
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Nonadherence (n=7) | −0.015 (−0.68 to 0.65) | N/Ab | |
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Adherence (n=19) | −0.62 (−0.86 to −0.37) | N/A | |
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Difference | −0.60 (−1.12 to −0.08) | .03 | |
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<30 entries (n=16) | −0.28 (−0.56 to 0) | N/A | |
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≥30 entries (n=10) | −0.73 (−1.23 to −0.24) | N/A | |
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Difference | −0.45 (0.94 to 0.05) | .07 | |
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Education nonadherence and <30 monitoring entries (n=5) | −0.05 (−0.92 to 0.82) | N/A |
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Education adherence and ≥30 monitoring entries (n=8) | −0.93 (−1.32 to −0.53) | N/A |
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Difference | −0.88 (−1.59 to −0.17) | .02 |
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Education adherence and <30 monitoring entries (n=11) | −0.39 (−0.67 to −0.11) | N/A |
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Education adherence and ≥30 monitoring entries (n=8) | −0.93 (−1.33 to −0.53) | N/A |
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Difference | −0.54 (−0.98 to −0.11) | .02 |
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Hypoperceiver (n=8) | −0.18 (−0.72 to 0.36) | N/A | |
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Normoperceiver (n=6) | −0.66 (−1.25 to −0.07) | N/A | |
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Difference | −0.48 (−1.20 to 0.24) | .17 | |
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Hypoperceiver (n=15) | −0.49 (−0.91 to −0.07) | N/A | |
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Normoperceiver (n=7) | −0.49 (−0.86 to −0.13) | N/A | |
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Difference | 0 (−0.26 to 0.26) | .99 |
aACQ6: 6-item Asthma Control Questionnaire.
bN/A: not applicable.
Asthma-related quality of life improvement dichotomized by education, monitoring, and perception. A higher (positive) score represents a more favorable outcome.
Categories | PAQLQa score (n=35), mean (95% CI) | |||
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Nonadherence (n=13) | −0.094 (−0.65 to 0.47) | N/Ab | |
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Adherence (n=22) | 0.36 (−0.01 to 0.73) | N/A | |
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Difference | 0.45 (−0.17 to 1.07) | .15 | |
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<30 entries (n=24) | 0.11 (−0.20 to 0.42) | N/A | |
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≥30 entries (n=11) | 0.36 (−0.42 to 1.15) | N/A | |
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Difference | 0.25 (0.41 to 0.91) | .44 | |
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Education nonadherence and <30 monitoring entries (n=11) | 0.07 (−0.42 to 0.55) | N/A |
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Education adherence and ≥30 monitoring entries (n=9) | 0.66 (0.01 to 1.32) | N/A |
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Difference | 0.60 (−0.15 to 1.34) | .11 |
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Education adherence and <30 monitoring entries (n=13) | 0.14 (−0.32 to 0.61) | N/A |
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Education adherence and ≥30 monitoring entries (n=9) | 0.66 (0.01 to 1.32) | N/A |
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Difference | 0.52 (−0.21 to 1.25) | .15 |
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Hypoperceiver (n=8) | −0.02 (−0.60 to 0.57) | N/A | |
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Normoperceiver (n=10) | 0.09 (−0.46 to 0.63) | N/A | |
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Difference | 0.10 (−0.64 to 0.84) | .77 | |
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Hypoperceiver (n=16) | 0.25 (−0.33 to 0.83) | N/A | |
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Normoperceiver (n=7) | 0.17 (−0.39 to 0.74) | N/A | |
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Difference | 0.079 (−0.84 to 1.00) | .86 |
aPAQLQ: Pediatric Asthma Quality of Life Questionnaire.
bN/A: not applicable.
We found no statistically significant difference in improvements in ACQ scores between adolescents who had more than 30 monitoring entries compared to those who conducted monitoring less frequently (∆ACQ score: mean −0.45; 95% CI −0.94 to 0.045;
Lung function improvement dichotomized by education, monitoring, and perception. A higher (positive) value represents a more favorable outcome.
Categories | FEV1a value (n=29), mean (95% CI) | |||
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Nonadherence (n=9) | 0.12 (−0.10 to 0.33) | N/Ab | |
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Adherence (n=20) | 0.31 (0.061 to 0.56) | N/A | |
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Difference | 0.19 (−0.41 to 0.58) | .32 | |
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<30 entries (n=18) | 0.24 (−0.04 to 0.52) | N/A | |
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≥30 entries (n=11) | 0.27 (0.01 to 0.44) | N/A | |
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Difference | 0.03 (−0.40 to 0.35) | .89 | |
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Education nonadherence and <30 monitoring entries (n=7) | 0.16 (−0.08 to 0.39) | N/A |
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Education adherence and ≥30 monitoring entries (n=9) | 0.33 (0.19 to 0.46) | N/A |
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Difference | 0.17 (−0.06 to 0.40) | .13 |
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Education adherence and <30 monitoring entries (n=11) | 0.29 (−0.18 to 0.77) | N/A |
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Education adherence and ≥30 monitoring entries (n=9) | 0.33 (0.19 to 0.46) | N/A |
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Difference | 0.04 (−0.47 to 0.55) | .88 |
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Hypoperceiver (n=8) | 0.44 (−0.13 to 1.00) | N/A | |
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Normoperceiver (n=8) | 0.12 (−0.20 to 0.43) | N/A | |
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Difference | 0.32 (−0.26 to 0.91) | .26 | |
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Hypoperceiver (n=16) | 0.19 (0.01 to 0.38) | N/A | |
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Normoperceiver (n=7) | 0.10 (−0.18 to 0.39) | N/A | |
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Difference | 0.09 (−0.23 to 0.41) | .57 |
aFEV1: forced expiratory volume in 1 second.
bN/A: not applicable.
A total of 21 participants in the IBSM group performed the methacholine test and had Borg scores (
Outcomes in normoperceivers and hypoperceivers based on Borg and symptom slopes.
Slopes and outcomes | Value (number of normoperceivers) | Value (number of hypoperceivers) | Difference (95% CI) | ||
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∆mACQ0-12a | −0.66 (6) | −0.18 (8) | 0.48 (−0.24 to 1.2) | .17 |
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∆PAQLQ0-12b | 0.09 (10) | 0.02 (8) | −0.10 (−0.84 to 0.63) | .77 |
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∆mFEV1,0-12c | 0.12 (8) | 0.44 (8) | 0.32 (−0.26 to 0.90) | .26 |
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∆mACQ0-12 | −0.49 (15) | −0.49 (7) | 0 (0.65 to 0.78) | >.99 |
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∆PAQLQ0-12 | 0.25 (16) | 0.17 (7) | 0.08 (−0.84 to 0.10) | .86 |
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∆mFEV1,0-12 | 0.19 (16) | 0.10 (7) | 0.09 (−0.23 to 0.41) | .57 |
a∆mACQ0-12: change in mean Asthma Control Questionnaire scores from 0 months to 12 months after intervention.
b∆PAQLQ0-12: change in mean Pediatric Asthma Quality of Life Questionnaire scores from 0 months to 12 months after intervention.
c∆mFEV1,0-12: change in mean forced expiratory volume in 1 second values from 0 to 12 months after intervention.
This study showed that participation in education sessions, especially in combination with frequent monitoring, is an important determinant for the 1-year outcomes of asthma control in IBSM programs for adolescents with partly controlled and uncontrolled asthma.
Attending at least 1 education session was a predictor of significant improvement in asthma control during the follow-up when compared to not attending any education session. Frequent monitoring alone was not a predictor of significant improvement in asthma control. However, for the group of education-adhering adolescents, frequent monitoring was a predictor of even further improved asthma control when compared to frequent monitoring in the nonadherent group. We did not observe important improvements in asthma-related quality of life in these groups. Differences in quality of life and asthma control were found between the subgroup that was nonadherent to both education and monitoring and the subgroup that was adherent to both education and monitoring. However, these subgroups were too small for establishing a solid conclusion. Our linear effects model showed the favorable effect that education and monitoring have on asthma control. No significant differences in asthma control or quality of life were observed between the small groups of normoperceivers and hypoperceivers, as determined by the Borg score (asthma control:
Although no causal relationship could be established due to the design of this study, the findings contribute to previous literature reporting that education and monitoring are generally associated with improved asthma control; however, results have been mixed for improvements in quality of life [
Several limitations need to be addressed. High dropout rates are a common challenge in studies with adolescent populations. Consequently, our small sample size could have contributed to a loss of statistical power and an increase in uncertainty for several outcomes. Nonetheless, several significant and clinically relevant predictors of improved asthma control were established in this study. Enrolling a higher percentage of the eligible population of 688 patients would have been desirable for increasing statistical power. We note that in the randomized controlled trial, monitoring was performed by using short text messages, and this was a more laborious process compared to other easy-to-use methods, such as using mobile phone apps, that can be implemented by using modern mobile communication technology. We believe that a simple web application and the absence of long questionnaires (eg, the questionnaires to which adolescents had to commit themselves in order to be enrolled in the trial) would help with increasing adolescent participation in self-management interventions in clinical practice.
With respect to possible selection bias, one could argue that the improvement in asthma control in patients who adhered to education and monitoring might not have been due to adherence to the intervention itself but, instead, might have been due to the selection of a cooperative and adherent patient population that can be expected to exhibit better health statuses. However, even within a potentially adherent patient group, we observed further improvements in asthma control among patients who attended education sessions.
Unfortunately, not all participants completed the methacholine inhalation challenge test. Therefore, we constructed a “real-life” measure for perceptions of symptom severity (ie, the symptom slope). Although we found good interobserver agreement for this novel measure, there were no important differences among comparison groups. Therefore, the absence of differences in symptom perceptions did not seem to depend on our chosen methodology or a lack of statistical power.
With regard to external validity, one could argue that only highly motivated adolescents participate in extensive studies such as ours. Therefore, our results might not apply to the entire population of adolescents with asthma. We however argue that the problems of adolescent chronic health care do not lend themselves well to a one-size-fits-all approach. Although we might not reach all adolescents, promoting health in motivated groups is desirable in itself, and effective self-management in motivated adolescents might increase motivation among youth. Therefore, we believe that our results provide useful insights for supporting self-management in adolescents with asthma.
Our results imply that following at least 1 educational group session results in a significant and clinically relevant improvement in asthma control when compared to following no education at all. This emphasizes and supports the importance of educating adolescents with asthma, which is in line with several other studies [
In our study, we could not find a significant difference in the results of adolescents who were normoperceivers and those who were hypoperceivers. It can be argued that the assessment of the perception of airway obstruction during a methacholine challenge does not reflect real-life symptom perception. However, this perception, which was assessed based on the relationship between symptoms and lung function, was not related to improvements in asthma control and quality of life. This suggests that the role of symptom perception in self-management is complex, and this illustrates that the concept of perception is difficult to capture with indices based on the relationship between symptom scores and lung function.
We conclude that the results of our study emphasize the importance of education adherence and frequent monitoring in improving asthma control among adolescents with partly controlled and uncontrolled asthma. No significant association between improvements in asthma control and perceptions of asthma control was found.
Asthma Control Questionnaire
forced expiratory volume in 1 second
internet-based self-management
Pediatric Asthma Quality of Life Questionnaire
Self-Management in Asthma Supported by Hospitals, Internet, Nurses and General Practitioners
None declared.