@Article{info:doi/10.2196/58167, author="Wood, E. Helen and Karampatakis, Dimitrios Georgios and Coulson, S. Neil and Sastry, Nishanth and Li, Xiancheng and Taylor, C. Stephanie J. and Griffiths, J. Chris and De Simoni, Anna", title="Moderators' Experiences of the Safety and Effectiveness of Patient Engagement in an Asthma Online Health Community: Exploratory Qualitative Interview Study", journal="J Med Internet Res", year="2025", month="Apr", day="25", volume="27", pages="e58167", keywords="asthma", keywords="online health communities", keywords="moderators", keywords="peer support", keywords="digital health", keywords="qualitative research", keywords="patient safety", abstract="Background: Among 5.4 million people receiving treatment for asthma in the United Kingdom, more than 2 million experience suboptimal control, leading to the use of health care services and resulting costs as well as poorer quality of life. Online health communities (OHCs) are increasingly used as a source of lay health advice, providing opportunities for learning and mutual support and complementing information from ``official'' health sources. While engagement with OHCs has the potential to improve self-management, concerns remain about the reliability and usefulness of the information posted. Professional moderation of such communities is essential for supporting sensitive patients, ensuring adherence to forum guidelines, and maintaining clinical safety. Objective: This study aims to examine the experiences of moderators in an asthma OHC, identifying challenges and possible areas to optimize the safety and effectiveness of patient engagement. Methods: All 6 current moderators of a nationwide charity-hosted OHC participated in in-depth, semistructured, audio-recorded, remote interviews. Audio recordings were transcribed verbatim and qualitatively analyzed using reflexive inductive thematic analysis. Results: The 6 moderators interviewed comprised 4 (67\%) specialist respiratory nurses, 1 (17\%) volunteer patient ambassador, and 1 (17\%) customer support manager (all female, with average age 45, SD 10.5 y). In total, 5 (83\%) moderators had at least a year's experience of OHC moderation. Three main themes were generated from data analysis: moderation processes, challenges to effective moderation, and OHC effectiveness. The first theme focused on the different moderator roles and tasks undertaken, including the application of OHC guidelines in dealing with inappropriate content. The second theme covered difficult issues, such as mental health, and practical challenges, including lack of time and concerns about missing problematic posts. The third theme focused on the factors that made the OHC effective and increased its effectiveness, including keeping users safe, generating more OHC activity, encouraging discussion, and raising awareness of the OHC. We found a contradiction in how the moderators perceived the OHC's effectiveness and their role in moderating it. While they expressed concerns about having insufficient time to moderate the OHC, they also felt that it was underused and would be more effective if it were busier or more active. Conclusions: Building on the challenges experienced by the moderators, several recommendations were put forward to optimize the safety and effectiveness of the asthma OHC. Moderators often work in isolation without external training or interaction with others. More research into OHC moderation is needed. A continuous professional development framework could improve moderation quality and user support, aligning with the evolving needs of these communities. These results can be relevant to national and international policy, attempting to enhance the safety of patients' engagement with OHCs. ", doi="10.2196/58167", url="https://www.jmir.org/2025/1/e58167" } @Article{info:doi/10.2196/64212, author="He, Xing and Bian, Jiang and Berlinski, Ariel and Guo, Yi and Simmons, Larry A. and Marshall, Alexandra S. and Greene, J. Carolyn and Brown, Hudson Rita and Turner, Jessica and Perry, T. Tamara", title="Mobile Health App for Adolescent Asthma Self-Management: Development and Usability Study of the Pulmonary Education and Knowledge Mobile Asthma Action Plan", journal="JMIR Form Res", year="2025", month="Apr", day="24", volume="9", pages="e64212", keywords="asthma self-management", keywords="mobile health", keywords="user-centered design", keywords="usability", keywords="adolescents", keywords="mobile phone", abstract="Background: Adolescents with asthma are vulnerable to poor asthma outcomes due to inadequate self-management skills and nonadherence to medications. Mobile health (mHealth) apps have shown promise in improving asthma control, medication adherence, and self-efficacy. However, existing mHealth asthma apps lack personalization and real-time feedback and are not tailored for at-risk adolescents. Objective: This study aimed to design, develop, and test a smartphone-based mHealth Asthma Action Plan for adolescents, called Pulmonary Education and Knowledge Mobile Asthma Action Plan (PEAK-mAAP), in preparation for a large-scale randomized controlled trial. Methods: We employed user-centered design principles to develop our app, leveraging our previous work and following guidelines from the National Heart, Lung, and Blood Institute. The app consists of a patient-facing mobile app and a provider-facing portal. A convenience sample of 13 adolescents (aged 12?20 years) was recruited from the Arkansas Children's Research Institute database or direct health care provider referrals. Participants underwent a task-based usability assessment followed by the System Usability Scale assessment to measure user satisfaction, interface effectiveness, and overall system usability. Results: PEAK-mAAP integrates 7 core modules supporting personalized asthma self-management, symptom monitoring, medication tracking, and real-time feedback. The mean System Usability Scale score was 83/100 (SD 5.54), indicating high user satisfaction and system usability. Notably, older adolescents (>17 years) reported higher usability scores (87.5) than younger users (77.5), suggesting potential age-related differences in app navigation and engagement. Conclusions: The results demonstrate that PEAK-mAAP is a feasible and user-friendly mHealth intervention for adolescent asthma self-management. While the high usability score reflects a positive user experience, some participants encountered initial usability challenges, highlighting the need for minor refinements and user training materials. The integration of personalized self-management tools and real-time feedback distinguishes PEAK-mAAP from existing asthma apps, addressing key barriers to adherence and engagement. Moving forward, an ongoing randomized controlled trial will assess its clinical effectiveness, long-term engagement, and impact on asthma outcomes, providing further insights into its potential as a scalable solution for adolescent asthma care. ", doi="10.2196/64212", url="https://formative.jmir.org/2025/1/e64212" } @Article{info:doi/10.2196/65794, author="Fedele, A. David and Ray, M. Jessica and Mallela, L. Jaya and Bian, Jiang and Chen, Aokun and Qin, Xiao and Salloum, G. Ramzi and Kelly, Maria and Gurka, J. Matthew and Hollenbach, Jessica", title="Development of a Clinical Decision Support Tool to Implement Asthma Management Guidelines in Pediatric Primary Care: Qualitative Study", journal="JMIR Form Res", year="2025", month="Mar", day="18", volume="9", pages="e65794", keywords="clinical decision support", keywords="asthma", keywords="primary care", keywords="guidelines", keywords="pediatric", keywords="asthma care", keywords="morbidity", keywords="health information technology", keywords="electronic health record", keywords="EHR", keywords="user-centered design", keywords="inductive approach", keywords="digital health", keywords="health technology", abstract="Background: There is a longstanding gap between national asthma guidelines and their implementation in primary care. Primary care providers (PCPs) endorse numerous provider and practice or clinic-related barriers to providing guidelines-based asthma care. To reduce asthma morbidity in primary care, PCPs need access to tools that facilitate adherence to national guidelines, which can be delivered at the point of care, are minimally burdensome, and fit within the clinic workflow. Clinical decision support (CDS) tools are health IT systems that can be housed in the electronic health record (EHR) system. Objective: This study aimed to follow user-centered design principles and describe the formative qualitative work with target stakeholders (ie, PCPs and IT professionals) to inform our design of an EHR-embedded CDS tool that adheres to recent, significant changes in asthma management guidelines. Methods: Purposive sampling was used to recruit three separate subgroups of professionals (n=15) between (1) PCPs with previous experience using a paper-based CDS tool for asthma management, (2) PCPs without previous experience using CDS tools for asthma management, and (3) health care IT professionals. The PCP interview guide focused on their practice, familiarity with national asthma guidelines, and how a CDS tool embedded in the EHR might help them provide guideline-based care. The health care IT professional guide included questions on the design and implementation processes of CDS tools into the EHR. Qualitative data were audio-recorded, transcribed, and then analyzed using an inductive approach to develop themes. Results: Themes were organized into 2 domains, current practice and CDS tool development. The themes that emerged from PCPs included descriptions of assessments conducted to make an asthma diagnosis, previous attempts or opportunities to implement updated national asthma guidelines, and how a CDS tool could be implemented using the EHR and fit into the current asthma management workflow. The themes that emerged from health care IT professionals included processes used to design CDS tools and strategies to collect evidence that indicated a tool's value to a practice and the broader health system. Conclusions: In this study, user-centered design principles were used to guide a qualitative study on perceived barriers and facilitators to a primary care--based, EHR-integrated asthma CDS tool. PCPs expressed their interest in adopting an asthma CDS tool that was low burden and efficient but could help them adhere to national asthma guidelines and improve clinic workflow. Similarly, health care IT professionals perceived an asthma CDS tool to be useful, if it adhered to EHR design standards. Implementation of a CDS tool to improve adherence of PCPs to recently updated national asthma guidelines could be beneficial in reducing pediatric asthma morbidity. ", doi="10.2196/65794", url="https://formative.jmir.org/2025/1/e65794" } @Article{info:doi/10.2196/59811, author="Jayamini, Darsha Widana Kankanamge and Mirza, Farhaan and Bidois-Putt, Marie-Claire and Naeem, Asif M. and Chan, Yan Amy Hai", title="Perceptions Toward Using Artificial Intelligence and Technology for Asthma Attack Risk Prediction: Qualitative Exploration of M?ori Views", journal="JMIR Form Res", year="2024", month="Oct", day="30", volume="8", pages="e59811", keywords="asthma risk prediction", keywords="artificial intelligence", keywords="machine learning", keywords="m?ori perceptions", keywords="health system development", keywords="mobile phone", abstract="Background: Asthma is a significant global health issue, impacting over 500,000 individuals in New Zealand and disproportionately affecting M?ori communities in New Zealand, who experience worse asthma symptoms and attacks. Digital technologies, including artificial intelligence (AI) and machine learning (ML) models, are increasingly popular for asthma risk prediction. However, these AI models may underrepresent minority ethnic groups and introduce bias, potentially exacerbating disparities. Objective: This study aimed to explore the views and perceptions that M?ori have toward using AI and ML technologies for asthma self-management, identify key considerations for developing asthma attack risk prediction models, and ensure M?ori are represented in ML models without worsening existing health inequities. Methods: Semistructured interviews were conducted with 20 M?ori participants with asthma, 3 male and 17 female, aged 18-76 years. All the interviews were conducted one-on-one, except for 1 interview, which was conducted with 2 participants. Altogether, 10 web-based interviews were conducted, while the rest were kanohi ki te kanohi (face-to-face). A thematic analysis was conducted to identify the themes. Further, sentiment analysis was carried out to identify the sentiments using a pretrained Bidirectional Encoder Representations from Transformers model. Results: We identified four key themes: (1) concerns about AI use, (2) interest in using technology to support asthma, (3) desired characteristics of AI-based systems, and (4) experience with asthma management and opportunities for technology to improve care. AI was relatively unfamiliar to many participants, and some of them expressed concerns about whether AI technology could be trusted, kanohi ki te kanohi interaction, and inadequate knowledge of AI and technology. These concerns are exacerbated by the M?ori experience of colonization. Most of the participants were interested in using technology to support their asthma management, and we gained insights into user preferences regarding computer-based health care applications. Participants discussed their experiences, highlighting problems with health care quality and limited access to resources. They also mentioned the factors that trigger their asthma control level. Conclusions: The exploration revealed that there is a need for greater information about AI and technology for M?ori communities and a need to address trust issues relating to the use of technology. Expectations in relation to computer-based applications for health purposes were expressed. The research outcomes will inform future investigations on AI and technology to enhance the health of people with asthma, in particular those designed for Indigenous populations in New Zealand. ", doi="10.2196/59811", url="https://formative.jmir.org/2024/1/e59811" } @Article{info:doi/10.2196/53662, author="Ruchonnet-M{\'e}trailler, Isabelle and Siebert, N. Johan and Hartley, Mary-Anne and Lacroix, Laurence", title="Automated Interpretation of Lung Sounds by Deep Learning in Children With Asthma: Scoping Review and Strengths, Weaknesses, Opportunities, and Threats Analysis", journal="J Med Internet Res", year="2024", month="Aug", day="23", volume="26", pages="e53662", keywords="asthma", keywords="wheezing disorders", keywords="artificial intelligence", keywords="deep learning", keywords="machine learning", keywords="respiratory sounds", keywords="auscultation", keywords="stethoscope", keywords="pediatric", keywords="mobile phone", abstract="Background: The interpretation of lung sounds plays a crucial role in the appropriate diagnosis and management of pediatric asthma. Applying artificial intelligence (AI) to this task has the potential to better standardize assessment and may even improve its predictive potential. Objective: This study aims to objectively review the literature on AI-assisted lung auscultation for pediatric asthma and provide a balanced assessment of its strengths, weaknesses, opportunities, and threats. Methods: A scoping review on AI-assisted lung sound analysis in children with asthma was conducted across 4 major scientific databases (PubMed, MEDLINE Ovid, Embase, and Web of Science), supplemented by a gray literature search on Google Scholar, to identify relevant studies published from January 1, 2000, until May 23, 2023. The search strategy incorporated a combination of keywords related to AI, pulmonary auscultation, children, and asthma. The quality of eligible studies was assessed using the ChAMAI (Checklist for the Assessment of Medical Artificial Intelligence). Results: The search identified 7 relevant studies out of 82 (9\%) to be included through an academic literature search, while 11 of 250 (4.4\%) studies from the gray literature search were considered but not included in the subsequent review and quality assessment. All had poor to medium ChAMAI scores, mostly due to the absence of external validation. Identified strengths were improved predictive accuracy of AI to allow for prompt and early diagnosis, personalized management strategies, and remote monitoring capabilities. Weaknesses were the heterogeneity between studies and the lack of standardization in data collection and interpretation. Opportunities were the potential of coordinated surveillance, growing data sets, and new ways of collaboratively learning from distributed data. Threats were both generic for the field of medical AI (loss of interpretability) but also specific to the use case, as clinicians might lose the skill of auscultation. Conclusions: To achieve the opportunities of automated lung auscultation, there is a need to address weaknesses and threats with large-scale coordinated data collection in globally representative populations and leveraging new approaches to collaborative learning. ", doi="10.2196/53662", url="https://www.jmir.org/2024/1/e53662", url="http://www.ncbi.nlm.nih.gov/pubmed/39178033" } @Article{info:doi/10.2196/57981, author="Xu, Jie and Talankar, Sankalp and Pan, Jinqian and Harmon, Ira and Wu, Yonghui and Fedele, A. David and Brailsford, Jennifer and Fishe, Noel Jennifer", title="Combining Federated Machine Learning and Qualitative Methods to Investigate Novel Pediatric Asthma Subtypes: Protocol for a Mixed Methods Study", journal="JMIR Res Protoc", year="2024", month="Jul", day="8", volume="13", pages="e57981", keywords="pediatric asthma", keywords="machine learning", keywords="federated learning", keywords="qualitative research", abstract="Background: Pediatric asthma is a heterogeneous disease; however, current characterizations of its subtypes are limited. Machine learning (ML) methods are well-suited for identifying subtypes. In particular, deep neural networks can learn patient representations by leveraging longitudinal information captured in electronic health records (EHRs) while considering future outcomes. However, the traditional approach for subtype analysis requires large amounts of EHR data, which may contain protected health information causing potential concerns regarding patient privacy. Federated learning is the key technology to address privacy concerns while preserving the accuracy and performance of ML algorithms. Federated learning could enable multisite development and implementation of ML algorithms to facilitate the translation of artificial intelligence into clinical practice. Objective: The aim of this study is to develop a research protocol for implementation of federated ML across a large clinical research network to identify and discover pediatric asthma subtypes and their progression over time. Methods: This mixed methods study uses data and clinicians from the OneFlorida+ clinical research network, which is a large regional network covering linked and longitudinal patient-level real-world data (RWD) of over 20 million patients from Florida, Georgia, and Alabama in the United States. To characterize the subtypes, we will use OneFlorida+ data from 2011 to 2023 and develop a research-grade pediatric asthma computable phenotype and clinical natural language processing pipeline to identify pediatric patients with asthma aged 2-18 years. We will then apply federated learning to characterize pediatric asthma subtypes and their temporal progression. Using the Promoting Action on Research Implementation in Health Services framework, we will conduct focus groups with practicing pediatric asthma clinicians within the OneFlorida+ network to investigate the clinical utility of the subtypes. With a user-centered design, we will create prototypes to visualize the subtypes in the EHR to best assist with the clinical management of children with asthma. Results: OneFlorida+ data from 2011 to 2023 have been collected for 411,628 patients aged 2-18 years along with 11,156,148 clinical notes. We expect to complete the computable phenotyping within the first year of the project, followed by subtyping during the second and third years, and then will perform the focus groups and establish the user-centered design in the fourth and fifth years of the project. Conclusions: Pediatric asthma subtypes incorporating RWD from diverse populations could improve patient outcomes by moving the field closer to precision pediatric asthma care. Our privacy-preserving federated learning methodology and qualitative implementation work will address several challenges of applying ML to large, multicenter RWD data. International Registered Report Identifier (IRRID): DERR1-10.2196/57981 ", doi="10.2196/57981", url="https://www.researchprotocols.org/2024/1/e57981", url="http://www.ncbi.nlm.nih.gov/pubmed/38976313" } @Article{info:doi/10.2196/52456, author="Tian, Fenglin and Zhong, Xinqi and Ye, Yufeng and Liu, Xiaohan and He, Guanhao and Wu, Cuiling and Chen, Zhiqing and Zhu, Qijiong and Yu, Siwen and Fan, Jingjie and Yao, Huan and Ma, Wenjun and Dong, Xiaomei and Liu, Tao", title="Mutual Associations of Exposure to Ambient Air Pollutants in the First 1000 Days of Life With Asthma/Wheezing in Children: Prospective Cohort Study in Guangzhou, China", journal="JMIR Public Health Surveill", year="2024", month="Apr", day="17", volume="10", pages="e52456", keywords="pregnancy", keywords="air pollution", keywords="asthma", keywords="wheezing", keywords="birth cohort", keywords="children", abstract="Background: The first 1000 days of life, encompassing pregnancy and the first 2 years after birth, represent a critical period for human health development. Despite this significance, there has been limited research into the associations between mixed exposure to air pollutants during this period and the development of asthma/wheezing in children. Furthermore, the finer sensitivity window of exposure during this crucial developmental phase remains unclear. Objective: This study aims to assess the relationships between prenatal and postnatal exposures to various ambient air pollutants (particulate matter 2.5 [PM2.5], carbon monoxide [CO], sulfur dioxide [SO2], nitrogen dioxide [NO2], and ozone [O3]) and the incidence of childhood asthma/wheezing. In addition, we aimed to pinpoint the potential sensitivity window during which air pollution exerts its effects. Methods: We conducted a prospective birth cohort study wherein pregnant women were recruited during early pregnancy and followed up along with their children. Information regarding maternal and child characteristics was collected through questionnaires during each round of investigation. Diagnosis of asthma/wheezing was obtained from children's medical records. In addition, maternal and child exposures to air pollutants (PM2.5 CO, SO2, NO2, and O3) were evaluated using a spatiotemporal land use regression model. To estimate the mutual associations of exposure to mixed air pollutants with the risk of asthma/wheezing in children, we used the quantile g-computation model. Results: In our study cohort of 3725 children, 392 (10.52\%) were diagnosed with asthma/wheezing. After the follow-up period, the mean age of the children was 3.2 (SD 0.8) years, and a total of 14,982 person-years were successfully followed up for all study participants. We found that each quartile increase in exposure to mixed air pollutants (PM2.5, CO, SO2, NO2, and O3) during the second trimester of pregnancy was associated with an adjusted hazard ratio (HR) of 1.24 (95\% CI 1.04-1.47). Notably, CO made the largest positive contribution (64.28\%) to the mutual effect. After categorizing the exposure according to the embryonic respiratory development stages, we observed that each additional quartile of mixed exposure to air pollutants during the pseudoglandular and canalicular stages was associated with HRs of 1.24 (95\% CI 1.03-1.51) and 1.23 (95\% CI 1.01-1.51), respectively. Moreover, for the first year and first 2 years after birth, each quartile increment of exposure to mixed air pollutants was associated with HRs of 1.65 (95\% CI 1.30-2.10) and 2.53 (95\% CI 2.16-2.97), respectively. Notably, SO2 made the largest positive contribution in both phases, accounting for 50.30\% and 74.70\% of the association, respectively. Conclusions: Exposure to elevated levels of mixed air pollutants during the first 1000 days of life appears to elevate the risk of childhood asthma/wheezing. Specifically, the second trimester, especially during the pseudoglandular and canalicular stages, and the initial 2 years after birth emerge as crucial susceptibility windows. Trial Registration: Chinese Clinical Trial Registry ChiCTR-ROC-17013496; https://tinyurl.com/2ctufw8n ", doi="10.2196/52456", url="https://publichealth.jmir.org/2024/1/e52456", url="http://www.ncbi.nlm.nih.gov/pubmed/38631029" } @Article{info:doi/10.2196/54081, author="Rojas-Anaya, Hector and Kapur, Akshat and Roberts, Graham and Roland, Damian and Gupta, Atul and Lazner, Michaela and Bayreuther, Jane and Pappachan, John and Jones, Christina and Bremner, Stephen and Cantle, Fleur and Seddon, Paul", title="High-Flow Humidified Oxygen as an Early Intervention in Children With Acute Severe Asthma: Protocol for a Feasibility Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Mar", day="28", volume="13", pages="e54081", keywords="asthma", keywords="child", keywords="wheezing", keywords="oxygen therapy", keywords="high-flow humidified oxygen therapy", abstract="Background: Acute severe asthma (ASA) is a leading cause of hospital attendance in children. Standard first-line therapy consists of high-dose inhaled bronchodilators plus oral corticosteroids. Treatment for children who fail to respond to first-line therapy is problematic: the use of intravenous agents is inconsistent, and side effects are frequent. High-flow humidified oxygen (HiFlo) is widely used in respiratory conditions and is increasingly being used in ASA, but with little evidence for its effectiveness. A well-designed, adequately powered randomized controlled trial (RCT) of HiFlo therapy in ASA is urgently needed, and feasibility data are required to plan such an RCT. In this study, we describe the protocol for a feasibility study designed to fill this knowledge gap. Objective: This study aims to establish whether a full RCT of early HiFlo therapy in children with ASA can be conducted successfully and safely, to establish whether recruitment using deferred consent is practicable, and to define appropriate outcome measures and sample sizes for a definitive RCT. The underlying hypothesis is that early HiFlo therapy in ASA will reduce the need for more invasive treatments, allow faster recovery and discharge from hospital, and in both these ways reduce distress to children and their families. Methods: We conducted a feasibility RCT with deferred consent to assess the use of early HiFlo therapy in children aged 2 to 11 years with acute severe wheeze not responding to burst therapy (ie, high-dose inhaled salbutamol with or without ipratropium). Children with a Preschool Respiratory Assessment Measure score ?5 after burst therapy were randomized to commence HiFlo therapy or follow standard care. The candidate primary outcomes assessed were treatment failure requiring escalation and time to meet hospital discharge criteria. Patient and parent experiences were also assessed using questionnaires and telephone interviews. Results: The trial was opened to recruitment in February 2020 but was paused for 15 months owing to the COVID-19 pandemic. The trial was reopened at the lead site in July 2021 and opened at the other 3 sites from August to December 2022. Recruitment was completed in June 2023. Conclusions: This feasibility RCT of early HiFlo therapy in children with ASA recruited to the target despite major disturbances owing to the COVID-19 pandemic. The data are currently being analyzed and will be published separately. Trial Registration: International Standard Randomised Controlled Trial Number Registry ISRCTN78297040; https://www.isrctn.com/ISRCTN78297040 International Registered Report Identifier (IRRID): DERR1-10.2196/54081 ", doi="10.2196/54081", url="https://www.researchprotocols.org/2024/1/e54081", url="http://www.ncbi.nlm.nih.gov/pubmed/38546733" } @Article{info:doi/10.2196/55327, author="Yang, Cheng-hao and Li, Xin-yu and Lv, Jia-jie and Hou, Meng-jie and Zhang, Ru-hong and Guo, Hong and Feng, Chu", title="Temporal Trends of Asthma Among Children in the Western Pacific Region From 1990 to 2045: Longitudinal Observational Study", journal="JMIR Public Health Surveill", year="2024", month="Mar", day="14", volume="10", pages="e55327", keywords="allergic disorders", keywords="global burden of disease", keywords="disability-adjusted life years", keywords="DALYs", keywords="incidence", keywords="prevalence", abstract="Background: Asthma has become one of the most common chronic conditions worldwide, especially among children. Recent findings show that the prevalence of childhood asthma has increased by 12.6\% over the past 30 years, with >262 million people currently affected globally. The reasons for the growing asthma epidemic remain complex and multifactorial. Objective: This study aims to provide an up-to-date analysis of the changing global and regional asthma prevalence, mortality, disability, and risk factors among children aged <20 years by leveraging the latest data from the Global Burden of Disease Study 2019. Findings from this study can help inform priority areas for intervention to alleviate the rising burden of childhood asthma globally. Methods: The study used data from the Global Burden of Disease Study 2019, concentrating on children aged 0 to 14 years with asthma. We conducted an in-depth analysis of asthma, including its age-standardized prevalence, incidence, mortality, and disability-adjusted life years (DALYs), across diverse demographics, such as region, age, sex, and sociodemographic index, spanning 1990 to 2019. We also projected the future burden of the disease. Results: Overall, in the Western Pacific Region, the age-standardized prevalence rate of asthma among children increased slightly, from 3898.4 cases per 100,000 people in 1990 to 3924 per 100,000 in 2019. The age-standardized incidence rate of asthma also increased slightly, from 979.2 to 994.9 per 100,000. In contrast, the age-standardized death rate of asthma decreased from 0.9 to 0.4 per 100,000 and the age-standardized DALY rate decreased from 234.9 to 189.7 per 100,000. At the country level, Japan experienced a considerable decrease in the age-standardized prevalence rate of asthma among children, from 6669.1 per 100,000 in 1990 to 5071.5 per 100,000 in 2019. Regarding DALYs, Japan exhibited a notable reduction, from 300.6 to 207.6 per 100,000. Malaysia also experienced a DALY rate reduction, from 188.4 to 163.3 per 100,000 between 1990 and 2019. We project that the burden of disease in countries other than Japan and the Philippines will remain relatively stable up to 2045. Conclusions: The study indicates an increase in the prevalence and incidence of pediatric asthma, coupled with a decrease in mortality and DALYs in the Western Pacific Region between 1990 and 2019. These intricate phenomena appear to result from a combination of lifestyle shifts, environmental influences, and barriers to health care access. The findings highlight that nations such as Japan have achieved notable success in managing asthma. Overall, the study identified areas of improvement in view of persistent disease burden, underscoring the need for comprehensive collaborative efforts to mitigate the impact of pediatric asthma throughout the region. ", doi="10.2196/55327", url="https://publichealth.jmir.org/2024/1/e55327", url="http://www.ncbi.nlm.nih.gov/pubmed/38483459" } @Article{info:doi/10.2196/49521, author="Meng, Glen and Jan Ali, Maliha and Tse, Man Sze", title="Caregivers' Perceptions, Needs, and Data Sharing Concerns in mHealth Research on Pediatric Asthma: Cross-Sectional Survey Study", journal="JMIR Pediatr Parent", year="2023", month="Dec", day="19", volume="6", pages="e49521", keywords="asthma", keywords="mHealth", keywords="mobile health", keywords="app", keywords="application", keywords="apps", keywords="applications", keywords="pediatrics", keywords="caregivers", keywords="knowledge translation", keywords="cross-sectional", keywords="survey", keywords="surveys", keywords="respiratory", keywords="pulmonary", keywords="lung", keywords="pediatric", keywords="data sharing", keywords="information sharing", keywords="privacy", keywords="usability", keywords="confidentiality", keywords="child", keywords="children", keywords="caregiver", keywords="caregiving", keywords="patient knowledge", abstract="Background: Pediatric asthma is the most common chronic respiratory disease of childhood. Caregivers often report lacking knowledge in several aspects of asthma management at home. Although the use of mobile health (mHealth) tools, such as mobile apps, could facilitate asthma self-management and, simultaneously, the collection of data for research, few studies have explored the features that caregivers would like to see in such a tool and their perceptions on data sharing. Objective: This study evaluates caregivers' perceived knowledge gaps in asthma management; their perceptions of certain features and resources that should be included in a potential mobile app; and any concerns that they may have regarding data sharing for research, including privacy and security concerns. Methods: In this cross-sectional study, we surveyed 200 caregivers of children (aged 1-13 y) with asthma who were followed at a pediatric tertiary care center in Montreal, Canada. Anonymous data were collected through the institutional web-based survey platform. We collected the participants' answers by using a 5-category Likert scale (``completely agree,'' ``agree,'' ``neither agree nor disagree,'' ``disagree,'' and ``completely disagree''), multiple-choice questions, and free-text questions on the abovementioned topics. Descriptive statistics were performed, and answers were compared between caregivers of preschool-aged children and caregivers of school-aged children. Results: Participating children`s mean age was 5.9 (SD 3.4) years, with 54\% (108/200) aged ?5 years and 46\% (92/200) aged >6 years. Overall, caregivers reported having adequate knowledge about asthma and asthma self-management. Nonetheless, they identified several desirable features for a mobile app focused on asthma self-management. The most frequently identified features included receiving alerts about environmental triggers of asthma (153/199, 76.9\%), having videos that demonstrate symptoms of asthma (133/199, 66.8\%), and being able to log children's asthma action plans in the app (133/199, 66.8\%). Interestingly, more caregivers of preschool-aged children preferred textual information when compared to caregivers of school-aged children (textual information for explaining asthma: P=.008; textual information for the symptoms of asthma: P=.005). Caregivers were generally highly in favor of sharing data collected through a mobile app for research. Conclusions: Caregivers of children with asthma in our study identified several desirable educational and interactive features that they wanted to have in a mobile app for asthma self-management. These findings provide a foundation for designing and developing mHealth tools that are relevant to caregivers of children with asthma. ", doi="10.2196/49521", url="https://pediatrics.jmir.org/2023/1/e49521" } @Article{info:doi/10.2196/48822, author="Kan, Kristin and Morales, Lu and Shah, Avani and Simmons, Emily and Barrera, Leonardo and Massey, Liana and List, Greta and Gupta, S. Ruchi", title="Digital Technology Characteristics and Literacy Among Families With Children With Asthma: Cross-Sectional Study", journal="JMIR Pediatr Parent", year="2023", month="Nov", day="29", volume="6", pages="e48822", keywords="pediatric asthma", keywords="digital literacy", keywords="health equity", keywords="equity", keywords="asthma", keywords="respiration", keywords="respiratory", keywords="pulmonary", keywords="child", keywords="children", keywords="youth", keywords="survey", keywords="surveys", keywords="disparity", keywords="disparities", keywords="socio-demographic", keywords="sociodemographic", keywords="use", keywords="technology use", keywords="self-management", keywords="family", abstract="Background: The use of digital technology in pediatric asthma management has emerged as a potential tool for improving asthma management. However, the use of digital tools has the potential to contribute to the inequitable delivery of asthma care because of existing social factors associated with asthma disparities. Our study focused on parents' chosen language and sociodemographic factors that might shape the use of digital technology in asthma self-management. Objective: This study aims to estimate and compare patient, family, and technology-related characteristics by parents' chosen language (English or Spanish) and compare a digital literacy measure by sociodemographic factors. Methods: Survey data were collected from July to December 2021 from parents of children with asthma who were seen by a Chicago pediatric health system pulmonary provider. Questions assessed patient and family characteristics, digital technology use, and digital literacy, measured using the validated eHealth Literacy Scale (eHEALS). Chi-square tests and multivariable logistic regression were used for comparisons, and Kruskal-Wallis tests were used for comparing median eHEALS scores by social characteristics. Results: Of the 197 parents surveyed, 24.4\% (n=49) of parents identified as a race categorized as other, 37.1\% (n=67) as White, and 38.6\% (n=75) as Black; 47.2\% (n=93) identified as Hispanic/Latino/Latina. Additionally, 79.7\% (n=157) of parents preferred English, and 20.3\% (n=40) preferred Spanish. English-speaking parents were more likely to report having a data plan for their smartphone (117/157, 74.5\%) or high-speed internet (138/157, 87.9\%) compared to Spanish-speaking parents (smartphone: 23/40, 58\%; P=.03; internet: 27/40, 68\%; P=.002). Compared with Spanish-speaking parents, English-speaking parents were less likely to report having a lot or some concern about paying for internet (28/40, 70\% vs 83/157, 52.9\%; P=.046) or about data privacy (35/40, 88\% vs 105/157, 67.5\%; P=.01). Digital literacy scores differed significantly by race, income, education level, and language. In a multivariable model, language was not a significant factor for having high-speed internet service (P=.12) or concern about paying for internet at home (P=.60), but it was a significant factor for concerns about data privacy (P=.04). Conclusions: The significant differences in technology-related characteristics suggest that digital connectivity, affordability, and data privacy may also be important factors in considering digital technology use in asthma care. ", doi="10.2196/48822", url="https://pediatrics.jmir.org/2023/1/e48822" } @Article{info:doi/10.2196/50085, author="Belhassen, Manon and Nolin, Maeva and Jacoud, Flore and Marant Micallef, Claire and Van Ganse, Eric", title="Trajectories of Controller Therapy Use Before and After Asthma-Related Hospitalization in Children and Adults: Population-Based Retrospective Cohort Study", journal="JMIR Public Health Surveill", year="2023", month="Sep", day="26", volume="9", pages="e50085", keywords="asthma", keywords="hospitalization", keywords="inhaled corticosteroids", keywords="trajectories", keywords="quality of care", keywords="clustering", abstract="Background: Inappropriate use of inhaled corticosteroids (ICSs) for asthma impairs control and may cause exacerbation, including asthma-related hospitalization (ARH). In prospective studies, ICS use peaked around ARH, but information on routine care use is limited. Since ARH is a major outcome, controller therapy use in routine care before and after ARH should be documented. Objective: This study aimed to distinguish ICS use typologies (trajectories) before and after ARH, and assess their relationships with sociodemographic, disease, and health care characteristics. Methods: A retrospective cohort study was performed using a 1\% random sample of the French claims database. All patients hospitalized for asthma between January 01, 2013, and December 31, 2015, were classified as either children (aged 1-10 years) or teens/adults (aged ?11 years). Health care resource use was assessed between 24 and 12 months before ARH. ICS use was computed with the Continuous Measures of Medication Acquisition-7 (CMA7) for the 4 quarters before and after ARH. Initially, the overall impact of hospitalization on the CMA7 value was studied using a segmented regression analysis in both children and teens/adults. Then, group-based trajectory modeling differentiated the groups with similar ICS use. We tested different models having 2 to 5 distinct trajectory groups before selecting the most appropriate trajectory form. We finally selected the model with the lowest Bayesian Information Criterion, the highest proportion of patients in each group, and the maximum estimated probability of assignment to a specific group. Results: Overall, 863 patients were included in the final study cohort, of which 447 (51.8\%) were children and 416 (48.2\%) were teens/adults. In children, the average CMA7 value was 12.6\% at the start of the observation period, and there was no significant quarter-to-quarter change in the value (P=.14) before hospitalization. Immediately after hospitalization, the average CMA7 value rose by 34.9\% (P=.001), before a significant decrease (P=.01) of 7.0\% per quarter. In teens/adults, the average CMA7 value was 31.0\% at the start, and there was no significant quarter-to-quarter change in the value (P=.08) before hospitalization. Immediately after hospitalization, the average CMA7 value rose by 26.9\% (P=.002), before a significant decrease (P=.01) of 7.0\% per quarter. We identified 3 and 5 trajectories before ARH in children and adults, respectively, and 5 after ARH for both groups. Trajectories were related to sociodemographic characteristics (particularly, markers of social deprivation) and to potentially inappropriate health care, such as medical management and choice of therapy. Conclusions: Although ARH had an overall positive impact on ICS use trajectories, the effect was often transient, and patient behaviors were heterogeneous. Along with overall trends, distinct trajectories were identified, which were related to specific patients and health care characteristics. Our data reinforce the evidence that inappropriate use of ICS paves the way for ARH. ", doi="10.2196/50085", url="https://publichealth.jmir.org/2023/1/e50085", url="http://www.ncbi.nlm.nih.gov/pubmed/37751244" } @Article{info:doi/10.2196/44453, author="Byrne, Catrin and Pfeffer, E. Paul and De Simoni, Anna", title="Experiences of Diagnosis, Symptoms, and Use of Reliever Inhalers in Patients With Asthma and Concurrent Inducible Laryngeal Obstruction or Breathing Pattern Disorder: Qualitative Analysis of a UK Asthma Online Community", journal="J Med Internet Res", year="2023", month="Aug", day="14", volume="25", pages="e44453", keywords="asthma", keywords="breathing pattern disorder", keywords="inducible laryngeal obstruction", keywords="BPD", keywords="ILO", keywords="short-acting beta-agonist", keywords="salbutamol", keywords="breathing disorder", keywords="breathing", keywords="chest tightness", keywords="community", keywords="symptoms", keywords="diagnosis", abstract="Background: Breathing pattern disorders (BPDs) and inducible laryngeal obstruction (ILO) cause similar symptoms to asthma, including dyspnea and chest tightness, with an estimated prevalence of up to one-fifth of patients with asthma. Both conditions can be comorbid with asthma, and there is evidence that they are misdiagnosed and mistreated as asthma. Objective: This study aims to explore whether the symptoms of ILO and BPD were topics of discussion in a UK asthma online health community and patient experiences of diagnosis and treatment, in particular their use of reliever inhalers. Methods: A qualitative thematic analysis was performed with posts from an asthma community between 2018 and 2022. A list of key ILO or BPD symptoms was created from the literature. Posts were identified using the search terms ``blue inhaler'' and ``breath'' and included if describing key symptoms. Discussion threads of included posts were also analyzed. Results: The search retrieved a total of 1127 relevant posts: 1069 written by 302 users and 58 posted anonymously. All participants were adults, except 2 who were parents writing about their children. Sex and age were only available for 1.66\% (5/302; 3 females and 2 males) and 9.93\% (30/302) of participants (27 to 73 years old), respectively. The average number of posts written by each participant was 3.54 (range 1-63). Seven participants wrote >20 posts each. Participants experiencing undiagnosed ILO or BPD symptoms, whether or not comorbid with asthma, expressed frustration with the ``one-size-fits-all'' approach to diagnosis, as many felt that their asthma diagnosis did not fully explain symptoms. Some suspected or were formally diagnosed with BPD or ILO, the latter reporting relief on receiving a diagnosis and appropriate management. Participants showed awareness of their inappropriate salbutamol use or overuse due to lack of effect on symptoms. BPD and ILO symptoms were frequently comorbid with asthma. The asthma online community was a valuable resource: engagement with peers not only brought comfort but also prompted action with some going back to their clinicians and reaching a diagnosis and appropriate management. Conclusions: Undiagnosed ILO and BPD symptoms and lack of effects of asthma treatment were topics of discussion in an asthma online community, caused distress and frustration in participants, and affected their relationship with health care professionals, showing that patients experiencing BPD and ILO have unmet needs. Clinicians' education on BPD and ILO diagnosis and management, as well as increased access to appropriate management options, such as respiratory physiotherapy and speech and language therapy, are warranted particularly in primary care. Qualitative evidence that engagement with the online community resulted in patients taking action going back to their clinicians and reaching a diagnosis of ILO and BPD prompts future research on online peer support from an established online health community as a self-management resource for patients. ", doi="10.2196/44453", url="https://www.jmir.org/2023/1/e44453", url="http://www.ncbi.nlm.nih.gov/pubmed/37578820" } @Article{info:doi/10.2196/46341, author="Pogge, Gabrielle and Fedele, A. David and Waters, A. Erika and Maki, Julia and Hunleth, M. Jean and Prabhakaran, Sreekala and Bowen, J. Deborah and Shepperd, A. James", title="Exploring Caregiver Interest in and Preferences for Interventions for Children With Risk of Asthma Exacerbation: Web-Based Survey", journal="JMIR Form Res", year="2023", month="Aug", day="2", volume="7", pages="e46341", keywords="asthma", keywords="children", keywords="caregivers", keywords="decision-making", keywords="intervention", keywords="asthma exacerbations", abstract="Background: Maintaining control of asthma symptoms is the cornerstone of asthma treatment guidelines in the United States. However, suboptimal asthma control and asthma exacerbations among young people are common and are associated with many negative outcomes. Interventions to improve asthma control are needed. For such interventions to be successful, it is necessary to understand the types of interventions that are appealing to caregivers of children with different levels of risk of exacerbation. Objective: This study aimed to evaluate whether caregivers of children with high (vs low) risk of asthma exacerbation show different levels of interest in and preferences for potential intervention programs and delivery methods. Methods: We contracted with Ipsos to administer a web-based survey to caregivers of children with asthma who were residing in the United States. Caregivers (N=394) reported their interest (1=not at all; 3=a lot) in 9 possible intervention programs and 8 possible intervention delivery methods. Caregivers also indicated their preferences by selecting the 3 intervention programs and 3 delivery methods that ``most'' interested them. Finally, caregivers completed 2 open-ended questions asking what other resources might be useful for managing their children's asthma. We classified children as having a high risk of exacerbation if they had an exacerbation in the past 3 months (n=116) and a low risk of exacerbation if otherwise (n=278). Results: Caregivers reported higher levels of interest in all intervention programs and delivery methods if they cared for a child with a high risk rather than a low risk of exacerbation. However, regardless of the child's risk status, caregivers expressed the highest levels of interest in programs to increase their child's self-management skills, to help pay for asthma care, and to work with the school to manage asthma. Caregivers expressed the highest levels of interest in delivery methods that maintained personal control over accessing information (websites, videos, printed materials, and smartphone apps). Caregivers' preferences were consistent with their interests; programs and delivery methods that were rated as high in interest were also selected as one of the 3 that ``most'' interested them. Although most caregivers did not provide additional suggestions for the open-ended questions, a few caregivers suggested intervention programs and delivery methods that we had not included (eg, education about avoiding triggers and medication reminders). Conclusions: Similar interests and preferences among caregivers of children with high and low risk of exacerbation suggest a broad need for support in managing childhood asthma. Providers could help caregivers by directing them toward resources that make asthma care more affordable and by helping their children with asthma self-management. Interventions that accommodate caregivers' concerns about having personal control over access to asthma information are likely to be more successful than interventions that do not. ", doi="10.2196/46341", url="https://formative.jmir.org/2023/1/e46341", url="http://www.ncbi.nlm.nih.gov/pubmed/37531188" } @Article{info:doi/10.2196/34629, author="Sharrad, Kelsey and Martini, Caitlin and Tai, Andrew and Spurrier, Nicola and Smith, Ross and Esterman, Adrian and Gwilt, Ian and Sandford, Debra and Carson-Chahhoud, Kristin", title="Mixed Reality Technology to Deliver Psychological Interventions to Adolescents With Asthma: Qualitative Study Using the Theoretical Framework of Acceptability", journal="JMIR Hum Factors", year="2023", month="Jul", day="26", volume="10", pages="e34629", keywords="asthma", keywords="augmented reality", keywords="virtual reality", keywords="mixed reality", keywords="psychological distress", keywords="adolescent", keywords="cognitive behavioral therapies", keywords="mental health", abstract="Background: Interactive, mixed reality technologies such as augmented reality, virtual reality, and holographic technology may provide a novel solution to fast-track the translation of evidence into practice. They may also help overcome barriers to both mental health and asthma management service uptake, such as cost, availability of appointments, fear of judgment, and quality of care. Objective: This study aimed to investigate if mixed reality technology is an acceptable mechanism for the delivery of a component of cognitive and behavioral therapies for the management of elevated psychological distress among young people with asthma. Methods: To explore the perceived acceptability of these technologies, mixed reality tools were evaluated via qualitative, 1-on-1 interviews with young people with asthma and symptoms of psychological distress, parents/caregivers of young people with asthma and symptoms of psychological distress, and relevant health professionals. The Theoretical Framework of Acceptability was used for the deductive coding of the recorded interview transcripts. Results: This study enrolled the following participants: (1) 3 adolescents with asthma and symptoms of psychological distress with a mean age of 14 (SD 1.7) years; (2) 4 parents/caregivers of adolescents with asthma with a mean age of 55 (SD 14.6) years; and (3) 6 health professionals with a mean age of 40.8 (SD 4.3) years. A total of 4 constructs---experienced affective attitude, experienced effectiveness, self-efficacy, and intervention coherence---were coded in all participant transcripts. The most frequently coded constructs were experienced affective attitude and intervention coherence, which were reported a total of 96 times. The least frequently coded construct was anticipated opportunity cost, which was reported a total of 5 times. Participants were mostly positive about the mixed reality resources. However, some concerns were raised regarding ethicality, particularly regarding privacy, accessibility, and messaging. Participants noted the need for technology to be used in conjunction with face-to-face engagement with health professionals and that some patients would respond to this type of delivery mechanism better than others. Conclusions: These results suggest that mixed reality technology to deliver psychological interventions may be an acceptable addition to current health care practices for young people with asthma and symptoms of psychological distress. Trial Registration: Australia and New Zealand Clinical Trials Registry ACTRN12620001109998; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380427 ", doi="10.2196/34629", url="https://humanfactors.jmir.org/2023/1/e34629", url="http://www.ncbi.nlm.nih.gov/pubmed/37494096" } @Article{info:doi/10.2196/40219, author="O'Connor, Antonia and Tai, Andrew and Brinn, Malcolm and Hoang, Hien Amy Nguyen Thuc and Cataldi, Daniele and Carson-Chahhoud, Kristin", title="Co-design of an Augmented Reality Asthma Inhaler Educational Intervention for Children: Development and Usability Study", journal="JMIR Pediatr Parent", year="2023", month="Jul", day="25", volume="6", pages="e40219", keywords="asthma", keywords="asthma education", keywords="pediatric", keywords="pediatric asthma", keywords="co-design", keywords="usability", keywords="development", keywords="smartphone", keywords="tablet", keywords="augmented reality", keywords="health education", keywords="mobile app", keywords="mobile phone", abstract="Background: Smartphone and tablet apps that deliver health care education have been identified as effective in improving patient knowledge and treatment adherence in asthma populations. Despite asthma being the most common chronic disease in pediatrics, there are few apps that are targeted specifically for children. Only half of children with asthma have acceptable control of their symptoms, and 40\%-98\% do not use their inhalers correctly. With children being increasingly connected to technology, there is an opportunity to improve asthma inhaler technique education by delivery via smartphone or tablet apps. Augmented reality (AR) technology was used in this study to capitalize on growing technological innovations. Digital health interventions that use a co-design process for development have the highest likelihood of successful uptake and effectiveness on their intended outcomes. Perceived usability also has been shown to improve the effectiveness of education as well as the acceptance of the intervention. Objective: The aims of this study were to describe the co-design process, development, and design outcomes of a smartphone or tablet app that incorporates AR technology to deliver asthma inhaler technique education to children with asthma. This study also aimed to provide a usability evaluation, using the System Usability Scale to inform our work and future research, and recommendations for others performing similar work. Methods: The development of the AR asthma inhaler technique education app was based on an iterative co-design process with likely end users (children with asthma, their caregivers, and health care professionals). This involved multiple stages: recruitment of end users for qualitative interviews and usability testing with a previously designed educational intervention, which used an AR-embedded smartphone or tablet app; ideation of content for a specific asthma inhaler technique education intervention with end users; development of the specific asthma inhaler intervention; and 2 further rounds of interviews and usability testing with the redesign of the initial prototype. Results: We included 16 participants aged 9-45 years. Using the co-design process, the AR asthma inhaler technique education app was designed, incorporating the preferences of end users. After iteration 1, animation was included based on the feedback provided. Iteration 2 feedback resulted in increased AR experiences and the removal of the requirement of a paper-based resource to trigger AR in the third iteration. Throughout all rounds, the ease of use of the app and the novel nature of the intervention were frequently described. The usability of the intervention overall was perceived to be excellent, and the mean System Usability Scale score of the intervention was found to be highest in the final round of evaluation (90.14). Conclusions: The results from this co-design process and usability evaluation will be used to develop a final AR asthma inhaler technique educational intervention, which will be evaluated in the clinical setting. International Registered Report Identifier (IRRID): RR2-10.1177/16094069211042229 ", doi="10.2196/40219", url="https://pediatrics.jmir.org/2023/1/e40219", url="http://www.ncbi.nlm.nih.gov/pubmed/37490325" } @Article{info:doi/10.2196/45896, author="van der Kamp, R. Matti{\`e}nne and Hengeveld, S. Vera and Brusse-Keizer, J. Marjolein G. and Thio, J. Boony and Tabak, Monique", title="eHealth Technologies for Monitoring Pediatric Asthma at Home: Scoping Review", journal="J Med Internet Res", year="2023", month="Jul", day="21", volume="25", pages="e45896", keywords="telemedicine", keywords="wearable electronic devices", keywords="asthma", keywords="child", keywords="pediatrics", keywords="internet-based interventions", keywords="monitoring", keywords="computers", keywords="hand-held device", keywords="medication", keywords="spirometry", abstract="Background: eHealth monitoring technologies offer opportunities to more objectively assess symptoms when they appear in daily life. Asthma is the most common chronic disease in childhood with an episodic course, requiring close follow-up of pediatric asthma control to identify disease deterioration, prevent exacerbations, and enhance quality of life. eHealth technologies in pediatric asthma care show promising results regarding feasibility, acceptability, and asthma-related health outcomes. However, broad systematic evaluations of eHealth technologies in pediatric asthma are lacking. Objective: The objective of this scoping review was to identify the types and applications of eHealth technologies for monitoring and treatment in pediatric asthma and explore which monitoring domains show the most relevance or potential for future research. Methods: A scoping review was conducted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. A systematic and comprehensive search was performed on English papers that investigated the development, validation, or application of eHealth technologies for home monitoring or treatment of pediatric asthma in the following databases: PubMed, Cochrane Library, IEEE, Scopus, CINAHL, PsycINFO, and ACM Digital Library. Two authors independently assessed eligibility and extracted data. Data were presented by a descriptive analysis of characteristics and a narrative report for each eHealth domain. Results: The review included 370 manuscripts. The following 10 monitoring domains were identified: air quality, airway inflammation markers, lung function, physical activity, sleep, audiovisual, other physiological measurements, questionnaires, medication monitoring, and digital environment (ie, digital platforms, applications, websites, and software tools to monitor or support monitoring). Rising numbers of studies were seen, and the numbers accelerated in the last few years throughout most domains, especially medication monitoring and digital environment. Limited studies (35/370, 9.5\%) of multiparameter monitoring strategies, using three or more domains, were found. The number of monitoring validation studies remained stable, while development and intervention studies increased. Intervention outcomes seemed to indicate the noninferiority and potential superiority of eHealth monitoring in pediatric asthma. Conclusions: This systematic scoping review provides a unique overview of eHealth pediatric asthma monitoring studies, and it revealed that eHealth research takes place throughout different monitoring domains using different approaches. The outcomes of the review showed the potency for efficacy of most monitoring domains (especially the domains of medication monitoring, lung function, and digital environment). Future studies could focus on modifying potentially relevant hospital-based diagnostics for the home setting to investigate potential beneficial effects and focus on combining home-monitoring domains to facilitate multiparameter decision-making and personalized clinical decision support. ", doi="10.2196/45896", url="https://www.jmir.org/2023/1/e45896", url="http://www.ncbi.nlm.nih.gov/pubmed/37477966" } @Article{info:doi/10.2196/37318, author="Drouin, Olivier and Perez, Tamara and Barnett, A. Tracie and Ducharme, M. Francine and Fleegler, Eric and Garg, Arvin and Lavoie, Kim and Li, Patricia and M{\'e}tras, Marie-{\'E}laine and Sultan, Serge and Tse, Man Sze and Zhao, Jiaying", title="Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study", journal="JMIR Res Protoc", year="2023", month="Mar", day="7", volume="12", pages="e37318", keywords="asthma", keywords="adherence", keywords="unmet social needs", keywords="behavioral sciences", keywords="future discounting", keywords="scarcity", keywords="pediatrics", abstract="Background: Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions. Objective: In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma. Methods: This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression. Results: The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024. Conclusions: This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma. Trial Registration: ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000 International Registered Report Identifier (IRRID): PRR1-10.2196/37318 ", doi="10.2196/37318", url="https://www.researchprotocols.org/2023/1/e37318", url="http://www.ncbi.nlm.nih.gov/pubmed/36881458" } @Article{info:doi/10.2196/40231, author="O'Connor, Antonia and Tai, Andrew and Brinn, Malcolm and Hoang, Hien Amy Nguyen Thuc and Cataldi, Daniele and Carson-Chahhoud, Kristin", title="The Acceptability of Using Augmented Reality as a Mechanism to Engage Children in Asthma Inhaler Technique Training: Qualitative Interview Study With Deductive Thematic Analysis", journal="JMIR Pediatr Parent", year="2023", month="Jan", day="13", volume="6", pages="e40231", keywords="asthma", keywords="asthma education", keywords="pediatric asthma", keywords="augmented reality", keywords="mobile phone", abstract="Background: Inhaled medications or inhalers provide first-line pharmacotherapeutic treatment for patients with asthma for both acute symptomatic relief and long-term management to keep symptoms under control. A good technique requires only basic instruction and training; however, a recent study identified that 92\% of children do not follow all correct steps when using inhalers. There is a growing interest in technology-enhanced asthma education, with evidence demonstrating improvements in knowledge and treatment adherence. Subsequently, there are calls to explore the role of technology-based solutions in improving asthma management and disease outcomes from public health experts, health professionals, and patients with asthma. Augmented reality (AR) technology is an information delivery mechanism with proven efficacy in educational settings. AR displays digital content in a real-world environment using the camera on a smartphone or tablet device to create an immersive learning experience. Objective: The study aimed to evaluate the acceptability of AR as a mechanism for delivering asthma inhaler technique education from the perspective of children with asthma and their parents and health professionals, examined through the theoretical framework of acceptability (TFA). Methods: An asthma education resource enhanced with AR technology was created to provide inhaler technique education to children. An iterative co-design process was undertaken with target end users for a qualitative evaluation. The participants were 8 to 12 years old with asthma, their caregivers, and health professionals who had experience in managing asthma. Qualitative data were obtained through semistructured one-on-one interviews. Deductive thematic analysis using TFA was undertaken using NVivo software 2020 to assess the acceptability of AR as a delivery modality for asthma inhaler technique education. Results: Overall, 6 health care professionals, 5 asthmatic children, and 5 caregivers of children with asthma totaled a sample of 16. The use of AR in the asthma inhaler resource was found to be acceptable when responses were examined in accordance with TFA. Each of the 7 component constructs of TFA was coded throughout the 16 interviews, with perceived effectiveness (157 times) and affective attitude (63 times) coded most frequently. Positive responses included the intervention being accessible, easy to use, interesting, and fitting within the users' value systems. Negative responses included the need to maintain an interest in children and concerns about the loss of face-to-face interaction with health professionals. Conclusions: AR appears to be an acceptable modality for delivering asthma education to children when explored using TFA constructs. Although some challenges were identified with the use of AR, the results were predominantly positive. Future designs of asthma education interventions involving AR should consider the results of this study, and further research should focus on the feasibility, usability, and barriers and facilitators of behavior change to ensure the successful implementation and uptake of AR into clinical settings. International Registered Report Identifier (IRRID): RR2-10.1177/16094069211042229 ", doi="10.2196/40231", url="https://pediatrics.jmir.org/2023/1/e40231", url="http://www.ncbi.nlm.nih.gov/pubmed/36637889" } @Article{info:doi/10.2196/34121, author="Brons, Annette and Braam, Katja and Broekema, Aline and Timmerman, Annieck and Millenaar, Karel and Engelbert, Raoul and Kr{\"o}se, Ben and Visser, Bart", title="Translating Promoting Factors and Behavior Change Principles Into a Blended and Technology-Supported Intervention to Stimulate Physical Activity in Children With Asthma (Foxfit): Design Study", journal="JMIR Form Res", year="2022", month="Jul", day="25", volume="6", number="7", pages="e34121", keywords="intervention mapping", keywords="technology-supported intervention", keywords="mobile health", keywords="mHealth", keywords="tailoring", keywords="exercise", keywords="cocreation", keywords="social participation", keywords="gamification", keywords="mobile app", keywords="web-based dashboard", keywords="chronic disease", keywords="mobile phone", abstract="Background: Children with asthma can decrease the impact of their disease by improving their physical activity (PA). However, health care providers lack interventions for children with asthma that effectively increase their PA levels and achieve behavior change. A technology-supported approach can positively influence PA and physical functioning in children. Objective: The aims of this study were to develop a technology-supported intervention that facilitates health care providers in promoting PA for children (aged 8 to 12 years) with asthma and to systematically describe this developmental process. Methods: Intervention mapping (IM) was applied to develop a blended and technology-supported intervention in cocreation with children with asthma, their parents, and health care providers. In accordance with the IM framework, the following steps were performed: conduct a needs assessment; define the intervention outcome, performance objectives, and change objectives; select theory-based intervention methods and strategies; create components of the intervention and conduct pilot tests; create an implementation plan; and create an evaluation plan. Results: We developed the blended intervention Foxfit that consists of an app with a PA monitor for children (aged 8 to 12 years) with asthma and a web-based dashboard for their health care provider. The intervention focuses on PA in everyday life to improve social participation. Foxfit contains components based on behavior change principles and gamification, including goal setting, rewards, action planning, monitoring, shaping knowledge, a gamified story, personal coaching and feedback, and a tailored approach. An evaluation plan was created to assess the intervention's usability and feasibility for both children and health care providers. Conclusions: The IM framework was very useful for systematically developing a technology-supported intervention and for describing the translational process from scientific evidence, the needs and wishes of future users, and behavior change principles into this intervention. This has led to the technology-supported intervention Foxfit that facilitates health care providers in promoting PA in children with asthma. The structured description of the development process and functional components shows the way behavior change techniques are incorporated in the intervention. Trial Registration: International Clinical Trial Registry Platform NTR6658; https://tinyurl.com/3rxejksf ", doi="10.2196/34121", url="https://formative.jmir.org/2022/7/e34121", url="http://www.ncbi.nlm.nih.gov/pubmed/35877162" } @Article{info:doi/10.2196/37118, author="Kim, Sunyoung and Stanton, Kaitlyn and Park, Yunoh and Thomas, Stephen", title="A Mobile App for Children With Asthma to Monitor Indoor Air Quality (AirBuddy): Development and Usability Study", journal="JMIR Form Res", year="2022", month="May", day="23", volume="6", number="5", pages="e37118", keywords="asthma", keywords="children", keywords="indoor air quality", keywords="mobile app", keywords="smartphone", keywords="mHealth", abstract="Background: Indoor air quality is an important environmental factor that triggers and exacerbates asthma, the most common chronic disease in children. A mobile app to monitor indoor air quality could help occupants keep their indoor air quality clean. However, no app is available that allows children to monitor and improve their indoor air quality. Objective: Previously, we conducted a series of user-centered design studies to identify user needs and design requirements toward creating a mobile app that helps children with asthma to engage in monitoring and improving indoor air quality as part of their asthma management. Based on the findings from these studies, we created AirBuddy, a child-friendly app that visualizes air quality indoors and outdoors. Methods: This paper reports on the findings from a field deployment with 7 pediatric asthma patients, where we evaluated AirBuddy's usability and usefulness in real-world settings by conducting weekly semistructured interviews for 8 weeks. Results: All participants positively responded to the usefulness and usability of AirBuddy, which we believe is thanks to the iterative, user-centered design approach that allowed us to identify and address potential usability issues early on and throughout the design process. Conclusions: This project contributes to the field of mHealth app design for children by demonstrating how a user-centered design process can lead to the development of digital devices that are more acceptable and relevant to target users' needs. ", doi="10.2196/37118", url="https://formative.jmir.org/2022/5/e37118", url="http://www.ncbi.nlm.nih.gov/pubmed/35604753" } @Article{info:doi/10.2196/34509, author="Iio, Misa and Sato, Miori and Narita, Masami and Yamamoto-Hanada, Kiwako and Oishi, Taku and Kishino, Ai and Kawaguchi, Takahiro and Nishi, Rin and Nagata, Mayumi and Ohya, Yukihiro", title="Development and Feasibility of a Mobile Asthma App for Children and Their Caregivers: Mixed Methods Study", journal="JMIR Form Res", year="2022", month="May", day="20", volume="6", number="5", pages="e34509", keywords="children", keywords="caregivers", keywords="asthma", keywords="mobile app", keywords="feasibility", keywords="health app", keywords="mHealth", keywords="pediatric", keywords="usability", keywords="mobile phone", abstract="Background: Mobile health apps can support the self-management of pediatric asthma. Previous studies on mobile apps for children aged >7 years with asthma are limited, and most reports on asthma apps do not consider interactions between the children and their caregivers. Therefore, we developed an asthma app for children aged 0-12 years and their caregivers based on the results of our previous study regarding user needs. Objective: The aim of this study was to evaluate the feasibility of a developed mobile app for children with asthma and their caregivers and to modify and complete the app according to the feasibility results. Methods: We recruited children diagnosed with persistent asthma by an allergy specialist at 2 children's hospitals, 1 university hospital, 2 general hospitals, and 1 pediatric clinic. Thereafter, the app usage was assessed, and questionnaires were administered. This study used convergent mixed methods, including providing user feedback about the pediatric asthma app, completing questionnaire surveys regarding preferences, and obtaining quantitative data about app usage. Quantitative data were analyzed based on the ratings provided for the app features used by the participants, and the usage of the app features was analyzed using descriptive statistics. Qualitative data were analyzed via a descriptive qualitative research analysis and were used to identify codes from the content-characteristic words. Results: In total, 30 pairs of children aged 2-12 years and their caregivers responded to the 3-month survey, and 20 pairs of children aged 4-12 years and their caregivers responded to the 6-month survey. In the 3- and 6-month surveys, ``record'' was the most commonly used feature by both caregivers and children. The average access logs per month among the 20 pairs ranged from 50 to 79 in the 6-month survey. The number of access logs decreased over time. In the qualitative results, app utilization difficulties were identified for 6 categories: record, preparing, alert settings, change settings, mobile phone owner, and display and motivation. Regarding app feasibility, 60\% (12/20) of the caregivers strongly agreed or agreed for all evaluation items, while 63\% (7/11) of the children strongly agreed or agreed for 6 items, excluding satisfaction. In the qualitative results, feasibility evaluation of the app was classified into 3 categories: high feasibility of the app, improvement points for the app, and personal factors preventing app utilization. Based on the results of the feasibility analysis, the final version of the app was modified and completed. Conclusions: The app feasibility among children with asthma and their caregivers was generally good. Children aged 7-12 years used elements such as record, quiz, and manga. This app can support the continuous self-management of pediatric asthma. However, efforts must be taken to maintain and improve the app quality. Trial Registration: UMIN Clinical Trials Registry UMIN000039058; https://tinyurl.com/3na9zyf8 ", doi="10.2196/34509", url="https://formative.jmir.org/2022/5/e34509", url="http://www.ncbi.nlm.nih.gov/pubmed/35594073" } @Article{info:doi/10.2196/33389, author="Silva-Lavigne, Nicole and Valderrama, Alena and Pelaez, Sandra and Bransi, Myriam and Balli, Fabio and Gervais, Yannick and Gaudy, Thomas and Tse, Man Sze", title="Acceptability of Serious Games in Pediatric Asthma Education and Self-management: Pilot Study", journal="JMIR Pediatr Parent", year="2022", month="Apr", day="7", volume="5", number="2", pages="e33389", keywords="asthma", keywords="pediatrics", keywords="video games", keywords="eHealth", keywords="self-management", abstract="Background: Asthma is the most common chronic pediatric disease. Despite existing tools to manage asthma, 40\%-55\% of children with asthma experience uncontrolled asthma. Serious games (SGs) represent a novel approach in promoting asthma education and self-management for children. Objective: In this qualitative pilot study with an embedded quantitative design, we aim to use focus groups and questionnaires to describe the perceived role of SGs in different aspects of asthma self-management by children and their parents. These aspects include asthma perception and knowledge, the impact of asthma and barriers to asthma self-management, and the support system for asthma self-management. Methods: A total of 5 children with asthma and their parents were invited to participate in an organized gaming session. Children and their parents completed a pregaming questionnaire on their medical history and asthma knowledge. Then, they were invited to test 4 original SG prototypes, after which the children answered a postgaming questionnaire on their asthma knowledge and perception of the SGs. Children and their parents subsequently participated in parallel focus groups, which were video-recorded or audio-recorded, transcribed verbatim, and analyzed by reaching consensus among members of the research team. Results: The mean age of the children was 10.3 (SD 1.5) years, with 20\% (1/5) of the children being male. Qualitative data from the transcripts were coded into three separate domains: asthma self-management perception and knowledge, impact of asthma and barriers to asthma self-management, and support system for asthma self-management. We specifically explored the perceived roles of SGs within each domain. A key takeaway message was identified for each of these three domains: heterogeneity of asthma knowledge and the ability of SGs to encourage knowledge transfer through games, consequences and limitations of asthma and the ability of SGs to allow for identification and management of real-life situations through games, and insufficient support system and the ability of SGs to encourage playing with others for support and shared knowledge. Conclusions: Our pilot study explored the role of SGs in the self-management of asthma, as perceived by children and their parents. Our findings support the acceptability of SGs in asthma education and self-management in pediatrics and the necessity for future development in this field. ", doi="10.2196/33389", url="https://pediatrics.jmir.org/2022/2/e33389", url="http://www.ncbi.nlm.nih.gov/pubmed/35389354" } @Article{info:doi/10.2196/34117, author="Sonney, Jennifer and Cho, E. Emily and Zheng, Qiming and Kientz, A. Julie", title="Refinement of a Parent--Child Shared Asthma Management Mobile Health App: Human-Centered Design Study", journal="JMIR Pediatr Parent", year="2022", month="Feb", day="17", volume="5", number="1", pages="e34117", keywords="parent--child shared management", keywords="school-age children", keywords="asthma", keywords="participatory design", keywords="mHealth", keywords="prototype", keywords="usability", keywords="family health informatics", abstract="Background: The school-age years, approximately ages 7 through 11, represent a natural transition when children begin assuming some responsibility for their asthma management. Previously, we designed a theoretically derived, tailored parent--child shared asthma management mobile health app prototype, Improving Asthma Care Together (IMPACT). Objective: The purpose of this study was to use human-centered design (HCD) to iteratively refine IMPACT to optimize user experience and incorporate evidence-based longitudinal engagement strategies. Methods: This study used a mixed methods design from December 2019 to April 2021. Our app refinement used the HCD process of research, ideation, design, evaluation, and implementation, including 6 cycles of design and evaluation. The design and evaluation cycles focused on core app functionality, child engagement, and overall refinement. Evaluation with parent--child dyads entailed in-person and remote concept testing and usability testing sessions, after which rapid cycle thematic analyses identified key insights that informed future design refinement. Results: Twelve parent--child dyads enrolled in at least one round of this study. Eight of the 12 child participants were male with a mean age of 9.9 (SD 1.6) years and all parent participants were female. Throughout evaluation cycles, dyads selected preferred app layouts, gamification concepts, and overall features with a final design prototype emerging for full-scale development and implementation. Conclusions: A theoretically derived, evidence-based shared asthma management app was co-designed with end users to address real-world pain points and priorities. An 8-week pilot study testing app feasibility, acceptability, and preliminary efficacy is forthcoming. ", doi="10.2196/34117", url="https://pediatrics.jmir.org/2022/1/e34117", url="http://www.ncbi.nlm.nih.gov/pubmed/35175214" } @Article{info:doi/10.2196/33103, author="Robinson, Billy and Gong, Enying and Oldenburg, Brian and See, Katharine", title="Functionality and Quality of Asthma mHealth Apps and Their Consistency With International Guidelines: Protocol for a Systematic Search and Evaluation of Mobile Apps", journal="JMIR Res Protoc", year="2022", month="Feb", day="9", volume="11", number="2", pages="e33103", keywords="asthma", keywords="mHealth", keywords="mobile phone", keywords="applications", keywords="self-management", keywords="chronic disease", keywords="respiratory", keywords="smartphone", keywords="asthma app", abstract="Background: Asthma is a chronic respiratory disorder that requires long-term pharmacotherapy and patient empowerment to manage the condition and recognize and respond to asthma exacerbations. Mobile health (mHealth) apps represent a potential medium through which patients can improve their ability to self-manage their asthma. Few studies have conducted a systematic evaluation of asthma mobile apps for quality and functionality using a validated tool. None of these reviews have systematically assessed these apps for their content and evaluated them against the available international best practice guidelines. Objective: The objective of this study is to conduct a systematic search and evaluation of adult-targeted asthma mHealth apps. As part of this review, the potential of an mHealth app to improve asthma self-management and the overall quality of the app will be evaluated using the Mobile App Rating Scale framework, and the quality of the information within an app will be evaluated using the current Global Initiative for Asthma guidelines as a reference. Methods: A stepwise methodological approach was taken in creating this review. First, the most recent Global Initiative for Asthma guidelines were independently reviewed by 2 authors to identify key recommendations that could be feasibly incorporated into an mHealth app. A previously developed asthma assessment framework was identified and was modified to suit our research and ensure that all of these identified recommendations were included. In total, 2 popular app stores were reviewed to identify potential mHealth apps. These apps were screened based on predefined inclusion and exclusion criteria. Suitable apps were then evaluated. Technical information was obtained from publicly available information. The next step was to perform an app quality assessment using the validated Mobile App Rating Scale framework to objectively determine the quality of an app. App functionality was assessed using the Intercontinental Medical Statistics Institute for Health Informatics Functionality Scoring System. Finally, the mHealth apps were assessed using our developed checklist. Results: Funding has been received for the project from the Respiratory Department at Northern Health, Victoria. Three reviewers have been recruited to systematically evaluate the apps. The results of this study are expected in 2022. Conclusions: To our knowledge, this review represents the first study to examine all mHealth apps available in Australia that are targeted to adults with asthma for their functionality, quality, and consistency with international best practice guidelines. Although this review will only be conducted on mHealth apps available in Australia, many apps are available worldwide; thus, this study should be largely generalizable to other English-speaking regions and users. The results of this review will help to fill gaps in the literature and assist clinicians in providing evidence-based advice to patients wishing to use mHealth apps as part of their asthma self-management. Trial Registration: PROSPERO 269894; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=269894 International Registered Report Identifier (IRRID): PRR1-10.2196/33103 ", doi="10.2196/33103", url="https://www.researchprotocols.org/2022/2/e33103", url="http://www.ncbi.nlm.nih.gov/pubmed/35138257" } @Article{info:doi/10.2196/17959, author="Beerthuizen, Thijs and Rikkers-Mutsaerts, M. E. R. V. and Snoeck-Stroband, B. Jiska and Sont, K. Jacob", title="The Role of Education, Monitoring, and Symptom Perception in Internet-Based Self-management Among Adolescents With Asthma: Secondary Analysis of a Randomized Controlled Trial", journal="JMIR Pediatr Parent", year="2021", month="Dec", day="7", volume="4", number="4", pages="e17959", keywords="web-based monitoring", keywords="internet self-management", keywords="adolescents", keywords="asthma", keywords="education", keywords="perception", abstract="Background: 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. Objective: 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. Methods: 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. Results: Adolescents who attended education sessions had significant and clinically relevant improvements in asthma control (ACQ score difference: ?0.6; P=.03) and exhibited a nonsignificant trend of improvement in asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire score difference: ?0.45; P=.15) when compared to those who did not adhere to education. Frequent monitoring alone did not improve asthma control (P=.07) and quality of life (P=.44) significantly, but its combination with education did result in improved ACQ scores (difference: ?0.88; P=.02). There were no significant differences in outcomes between normoperceivers and hypoperceivers. Conclusions: 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. ", doi="10.2196/17959", url="https://pediatrics.jmir.org/2021/4/e17959", url="http://www.ncbi.nlm.nih.gov/pubmed/34879001" } @Article{info:doi/10.2196/29218, author="Oppelaar, C. Martinus and van den Wijngaart, S. Lara and Merkus, M. Peter J. F. and Croonen, A. Ellen and Hugen, C. Cindy A. and Brouwer, L. Marianne and Boehmer, M. Annemie L. and Roukema, Jolt", title="It Is Not Just the FEV1 That Matters, but the Personal Goals We Reach Along the Way: Qualitative, Multicenter, Prospective, Observational Study", journal="J Med Internet Res", year="2021", month="Oct", day="20", volume="23", number="10", pages="e29218", keywords="eHealth", keywords="asthma", keywords="pediatrics", keywords="telemonitoring", keywords="lung function tests", keywords="lung function", keywords="spirometry", keywords="home monitoring", keywords="mHealth", keywords="app", keywords="smartphone", keywords="asthma control", keywords="child", keywords="outpatients", keywords="remote consultations", keywords="quality improvement", keywords="patient care management", keywords="telemetry", keywords="application", keywords="FEV1", keywords="pulmonary care", abstract="Background: The COVID-19 pandemic has boosted the use of forced expiratory volume in 1 second (FEV1) telemonitoring in pediatric asthma, but a consensus on its most efficient and effective implementation is still lacking. To find answers, it is important to study how such an intervention is perceived, experienced, and used by both patients and health care professionals (HCPs). Objective: The aim of this study was to provide perspectives on how FEV1 home monitoring should be used in pediatric asthma. Methods: This is a qualitative, multicenter, prospective, observational study which included patients with asthma aged 6-16 and HCPs. Primary outcomes were results of 2 surveys that were sent to all participants at study start and after 3-4 months. Secondary outcomes consisted of FEV1 device usage during 4 months after receiving the FEV1 device. Results: A total of 39 participants (26 patients and 13 HCPs) were included in this study. Survey response rates were 97\% (38/39) at the start and 87\% (34/39) at the end of the study. Both patients and HCPs were receptive toward online FEV1 home monitoring and found it contributive to asthma control, self-management, and disease perception. The main concerns were about reliability of the FEV1 device and validity of home-performed lung function maneuvers. FEV1 devices were used with a median frequency of 7.5 (IQR 3.3-25.5) during the 4-month study period. Conclusions: Patients and HCPs are receptive toward online FEV1 home monitoring. Frequency of measurements varied largely among individuals, yet perceived benefits remained similar. This emphasizes that online FEV1 home monitoring strategies should be used as a means to reach individual goals, rather than being a goal on their own. ", doi="10.2196/29218", url="https://www.jmir.org/2021/10/e29218", url="http://www.ncbi.nlm.nih.gov/pubmed/34668868" } @Article{info:doi/10.2196/25472, author="Neves, Lu{\'i}sa Ana and J{\'a}come, Cristina and Taveira-Gomes, Tiago and Pereira, Margarida Ana and Almeida, Rute and Amaral, Rita and Alves-Correia, Magna and Mendes, Sandra and Chaves-Loureiro, Cl{\'a}udia and Val{\'e}rio, Margarida and Lopes, Cristina and Carvalho, Joana and Mendes, Ana and Ribeiro, Carmelita and Prates, Sara and Ferreira, Alberto Jos{\'e} and Teixeira, Fernanda Maria and Branco, Joana and Santalha, Marta and Vasconcelos, Jo{\~a}o Maria and Lozoya, Carlos and Santos, Natacha and Cardia, Francisca and Moreira, Sofia Ana and Taborda-Barata, Lu{\'i}s and Pinto, Sofia Cl{\'a}udia and Ferreira, Ros{\'a}rio and Morais Silva, Pedro and Monteiro Ferreira, Tania and C{\^a}mara, Raquel and Lobo, Rui and Bordalo, Diana and Guimar{\~a}es, Cristina and Esp{\'i}rito Santo, Maria and Ferraz de Oliveira, Jos{\'e} and C{\'a}lix Augusto, Jos{\'e} Maria and Gomes, Ricardo and Vieira, In{\^e}s and da Silva, Sofia and Marques, Maria and Cardoso, Jo{\~a}o and Morete, Ana and Aroso, Margarida and Cruz, Margarida Ana and Nunes, Carlos and C{\^a}mara, Rita and Rodrigues, Natalina and Abreu, Carmo and Albuquerque, Lu{\'i}sa Ana and Vieira, Cla{\'u}dia and Santos, Carlos and P{\'a}scoa, Ros{\'a}lia and Chaves-Loureiro, Carla and Alves, Adelaide and Neves, {\^A}ngela and Varanda Marques, Jos{\'e} and Reis, Bruno and Ferreira-Magalh{\~a}es, Manuel and Almeida Fonseca, Jo{\~a}o", title="Determinants of the Use of Health and Fitness Mobile Apps by Patients With Asthma: Secondary Analysis of Observational Studies", journal="J Med Internet Res", year="2021", month="Sep", day="22", volume="23", number="9", pages="e25472", keywords="mobile apps", keywords="smartphone", keywords="patient participation", keywords="self-management", keywords="asthma", abstract="Background: Health and fitness apps have potential benefits to improve self-management and disease control among patients with asthma. However, inconsistent use rates have been reported across studies, regions, and health systems. A better understanding of the characteristics of users and nonusers is critical to design solutions that are effectively integrated in patients' daily lives, and to ensure that these equitably reach out to different groups of patients, thus improving rather than entrenching health inequities. Objective: This study aimed to evaluate the use of general health and fitness apps by patients with asthma and to identify determinants of usage. Methods: A secondary analysis of the INSPIRERS observational studies was conducted using data from face-to-face visits. Patients with a diagnosis of asthma were included between November 2017 and August 2020. Individual-level data were collected, including age, gender, marital status, educational level, health status, presence of anxiety and depression, postcode, socioeconomic level, digital literacy, use of health services, and use of health and fitness apps. Multivariate logistic regression was used to model the probability of being a health and fitness app user. Statistical analysis was performed in R. Results: A total of 526 patients attended a face-to-face visit in the 49 recruiting centers and 514 had complete data. Most participants were ?40 years old (66.4\%), had at least 10 years of education (57.4\%), and were in the 3 higher quintiles of the socioeconomic deprivation index (70.1\%). The majority reported an overall good health status (visual analogue scale [VAS] score>70 in 93.1\%) and the prevalence of anxiety and depression was 34.3\% and 11.9\%, respectively. The proportion of participants who reported using health and fitness mobile apps was 41.1\% (n=211). Multivariate models revealed that single individuals and those with more than 10 years of education are more likely to use health and fitness mobile apps (adjusted odds ratio [aOR] 2.22, 95\%CI 1.05-4.75 and aOR 1.95, 95\%CI 1.12-3.45, respectively). Higher digital literacy scores were also associated with higher odds of being a user of health and fitness apps, with participants in the second, third, and fourth quartiles reporting aORs of 6.74 (95\%CI 2.90-17.40), 10.30 (95\%CI 4.28-27.56), and 11.52 (95\%CI 4.78-30.87), respectively. Participants with depression symptoms had lower odds of using health and fitness apps (aOR 0.32, 95\%CI 0.12-0.83). Conclusions: A better understanding of the barriers and enhancers of app use among patients with lower education, lower digital literacy, or depressive symptoms is key to design tailored interventions to ensure a sustained and equitable use of these technologies. Future studies should also assess users' general health-seeking behavior and their interest and concerns specifically about digital tools. These factors may impact both initial engagement and sustained use. ", doi="10.2196/25472", url="https://www.jmir.org/2021/9/e25472", url="http://www.ncbi.nlm.nih.gov/pubmed/34550077" } @Article{info:doi/10.2196/27447, author="Kim, Sunyoung and Park, Yunoh and Ackerman, K. Matthew", title="Designing an Indoor Air Quality Monitoring App for Asthma Management in Children: User-Centered Design Approach", journal="JMIR Form Res", year="2021", month="Sep", day="22", volume="5", number="9", pages="e27447", keywords="asthma", keywords="children", keywords="indoor air quality", keywords="mobile app", keywords="smartphone", keywords="user-centered design", abstract="Background: Indoor air pollution is a well-known risk factor that triggers and exacerbates asthma, the most common pediatric chronic disease. Using a mobile app to monitor indoor air quality could be promising in engaging children in keeping their indoor air quality clean and healthy as secondary environmental prevention for asthma management. However, no app is available to allow children to monitor, assess, and improve their indoor air quality. Objective: This study aims to design a mobile app that encourages children to monitor indoor air quality and track their asthma conditions through a user-centered, iterative design approach. Methods: We reviewed existing apps for indoor air quality monitoring or asthma management for children and conducted two sets of semistructured interviews with 12 children with asthma. We then iteratively created prototypes and evaluated and revised them. Results: Participants raised a series of outstanding questions on the prototype features and content that described their needs and perspectives, which informed the final designs. Following the identified requirements and recommendations, we developed two versions of the app: AirBuddy for presenting concrete information for indoor air quality and AirPet for gamifying the practice of monitoring indoor air quality. Conclusions: By following an iterative, user-centered design process, we developed two versions of an app to encourage children with asthma to monitor indoor air quality and track their asthma condition. The user-centered design approach revealed two crucial aspects that require deeper consideration when creating a child-friendly app, including balancing brevity and expressivity and considering the longitudinal effects of gamification. As a next step, we plan to conduct a longitudinal deployment study to evaluate the real-world effects of our apps. ", doi="10.2196/27447", url="https://formative.jmir.org/2021/9/e27447", url="http://www.ncbi.nlm.nih.gov/pubmed/34550080" } @Article{info:doi/10.2196/27999, author="Milne-Ives, Madison and Lam, Ching and Meinert, Edward", title="Digital Technologies for Monitoring and Improving Treatment Adherence in Children and Adolescents With Asthma: Scoping Review of Randomized Controlled Trials", journal="JMIR Pediatr Parent", year="2021", month="Sep", day="17", volume="4", number="3", pages="e27999", keywords="asthma", keywords="disease management", keywords="child", keywords="adolescent", keywords="telemedicine", abstract="Background: Inadequate pediatric asthma care has resulted in potentially avoidable unplanned hospital admissions and morbidity. A wide variety of digital technologies have been developed to monitor and support treatment adherence in children and adolescents with asthma. However, existing reviews need to be updated and expanded to provide an overview of the current state of research on these technologies and how they are being integrated into existing health care services and care pathways. Objective: This study aims to provide an overview of the current research landscape and knowledge gaps regarding the use of digital technologies to support the care of children and adolescents with asthma. Methods: This study was structured according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) and Population, Intervention, Comparator, Outcome, and Study frameworks. Five databases (PubMed, the Cochrane Central Register of Controlled Trials, Web of Science, Embase, and PsycINFO) were systematically searched for studies published in English from 2014 onward. Two reviewers independently screened the references and selected studies for inclusion based on the eligibility criteria. Data were systematically extracted per research question, which were synthesized in a descriptive analysis. Results: A wide variety of study characteristics, including the number and age of participants, study duration, and type of digital intervention, were identified. There was mixed evidence for the effectiveness of the interventions. Of the 10 studies that evaluated treatment adherence, 7 (70\%) found improvements, but the evidence was inconsistent for asthma control (6/9, 67\% of studies reported improvement or maintenance, but only 1 was significantly different between groups) and health outcome variables (5/9, 56\% of studies found no evidence of effectiveness). The 6 studies that examined patient perceptions and assessments of acceptability and usability generally had positive findings. Conclusions: A wide range of digital interventions are being developed and evaluated to support the monitoring and treatment adherence of children and adolescents with asthma. Meta-analyses are inhibited by the use of samples with a variety of overlapping age ranges; a theoretical framework for evaluating specific age groups would aid comparison between studies. Most studies found significant evidence for improved adherence to treatment or medications, but there was mixed evidence of the impact of the digital interventions on asthma control and other health outcomes. There are gaps in the literature relating to cost-effectiveness and integration with existing clinical care pathways. This study will be necessary to determine which digital interventions for children and young people with asthma are worth supporting and adopting in the clinical care pathways. ", doi="10.2196/27999", url="https://pediatrics.jmir.org/2021/3/e27999", url="http://www.ncbi.nlm.nih.gov/pubmed/34533463" } @Article{info:doi/10.2196/28796, author="Sarasmita, Ary Made and Larasanty, Febryana Luh Putu and Kuo, Li-Na and Cheng, Kuei-Ju and Chen, Hsiang-Yin", title="A Computer-Based Interactive Narrative and a Serious Game for Children With Asthma: Development and Content Validity Analysis", journal="J Med Internet Res", year="2021", month="Sep", day="13", volume="23", number="9", pages="e28796", keywords="asthma", keywords="computer", keywords="children", keywords="interactive narrative", keywords="serious game", keywords="digital education", keywords="mobile phone", abstract="Background: Nonadherence to medications, failure to prevent exposure to asthma triggers, lack of knowledge about using medications, and fixed mindsets contribute to poor asthma control in children. Digital learning could provide a new strategy for improving health-related outcomes in children with asthma. Objective: The aim of this study is to develop and design a digital educational program, titled Module of Inhaler and Asthma Triggers for Children (MIRACLE), for Indonesian children with asthma. The program comprises an interactive narrative and a serious game. It was proposed to increase the understanding of asthma self-management, instruct on proper inhaler techniques, improve asthma control, and promote a growth mindset for children with asthma. Methods: Two phases of research were conducted to develop the program. In the first phase, a literature search and two rounds of the Delphi technique were conducted to obtain agreement from an expert panel regarding elements of asthma self-management and the design of interactive narratives and a serious game. The expert panel item statements were evaluated using the content validity index (CVI). In the second phase, the SERES framework, Norma Engaging Multimedia Design, and Psychological Theory of Growth Mindset were applied to create a storyline, learn objectives, and game challenges. Results: In the first phase, 40 experts were invited to participate in Delphi round 1. Forty responses were collected to generate 38 item statements that consisted of part 1, elements of asthma self-management (25 items), and part 2, design of an interactive narrative and a serious game (13 items); 38 experts were involved in Delphi round 2. In total, 24 statements in part 1 and 13 items in part 2 had item-CVI values >0.80. The average CVI was 0.9, which was considered acceptable. Four narrative plots and five game sessions were developed during the second phase. Challenges with the scenario, scoring, and feedback on asthma difficulties were designed to promote a growth mindset for learners. Conclusions: We developed a culture-specific, computer-based asthma program containing an interactive narrative and a serious game to deliver asthma self-management and promote a growth mindset among Indonesian children. ", doi="10.2196/28796", url="https://www.jmir.org/2021/9/e28796", url="http://www.ncbi.nlm.nih.gov/pubmed/34515641" } @Article{info:doi/10.2196/28784, author="Murphy, Jane and McSharry, Jenny and Hynes, Lisa and Molloy, J. Gerard", title="A Smartphone App to Support Adherence to Inhaled Corticosteroids in Young Adults With Asthma: Multi-Methods Feasibility Study", journal="JMIR Form Res", year="2021", month="Sep", day="1", volume="5", number="9", pages="e28784", keywords="asthma", keywords="young adult", keywords="medication adherence", keywords="self-management", keywords="mobile applications", keywords="mHealth", keywords="intervention", keywords="usability", keywords="acceptability", keywords="feasibility", keywords="multi-methods", keywords="mobile phone", abstract="Background: Young adults with asthma often report low adherence to inhaled corticosteroids (ICS), leading to uncontrolled symptoms and poor disease outcomes. Technology-enabled digital supports such as mobile health (mHealth) asthma smartphone apps have the potential to support adherence to ICS and asthma self-management. There is a need for feasibility studies to determine the usability, acceptability, and feasibility of these interventions. In addition, it is essential to determine the feasibility of recruiting and retaining young adults to plan future efficacy and effectiveness trials and therefore, establish evidence-based asthma apps. Objective: This study aimed to determine (1) the feasibility of recruiting and retaining young adults to a trial and (2) the usability, acceptability, and feasibility of using the AsthmaMD app to support adherence to ICS in a population of young adults living with asthma. Methods: A multi-methods feasibility study was conducted. Young adults aged 18-30 years with asthma and current prescription for ICS were eligible and invited to take part through a university circular email, social media, and general practice sites. Participation involved completing a baseline self-report questionnaire, downloading and using the AsthmaMD app for 2 weeks, and completing the follow-up assessment, including self-report and open-ended questions about participants' experience of using the app. Primary outcomes included participant recruitment and retention and the usability, acceptability, and feasibility of using AsthmaMD. Quantitative self-report data were analyzed using descriptive statistics, and qualitative open-ended data were analyzed using inductive reflexive thematic analysis. Results: A total of 122 young adults (females, n=101, 82.8\%) with a mean age of 24.4 (SD 3.8) years were recruited and they completed baseline measures. Of the 122 young adults, 59 (48.4\%) completed the study. The AsthmaMD app received a mean score of 63.1/100 (SD 20.1) on the System Usability Scale (ie, a standardized measure of usability for technology-based apps), and an overall user satisfaction score of 5.8/10 (SD 2.2). Of the 59 participants who completed the study, 49 (83\%) participants used the app ?1 day per week. Two main themes were identified in the qualitative analysis of user experiences: (1) learning how to use the app to suit the individual and (2) benefits and relevance of using the app. Conclusions: The findings from this study indicate that it is feasible to recruit and retain young adults to examine efficacy and effectiveness in a future trial and that young adults living with asthma may find AsthmaMD to be usable, acceptable, and feasible to support adherence to ICS. Our findings also identified opportunities to further optimize the usability of AsthmaMD and similar apps. Based on our findings, we recommend providing more accessible information on how to use the app and replacing medical terminology with simplified language within the app to improve usability. Trial Registration: ISRCTN Registry ISRCTN11295269; https://www.isrctn.com/ISRCTN11295269 ", doi="10.2196/28784", url="https://formative.jmir.org/2021/9/e28784", url="http://www.ncbi.nlm.nih.gov/pubmed/34468325" } @Article{info:doi/10.2196/24634, author="van der Kamp, Mattienne and Reimering Hartgerink, Pamela and Driessen, Jean and Thio, Bernard and Hermens, Hermie and Tabak, Monique", title="Feasibility, Efficacy, and Efficiency of eHealth-Supported Pediatric Asthma Care: Six-Month Quasi-Experimental Single-Arm Pretest-Posttest Study", journal="JMIR Form Res", year="2021", month="Jul", day="26", volume="5", number="7", pages="e24634", keywords="telemedicine", keywords="feasibility studies", keywords="child", keywords="self-management", keywords="asthma", keywords="patient acceptance of health care", keywords="ambulatory care", keywords="remote sensing technology", keywords="cost-benefit analysis", keywords="health care costs", abstract="Background: Early detection of loss of asthma control can effectively reduce the burden of the disease. However, broad implementation in clinical practice has not been accomplished so far. We are in need of research investigating the operationalization of eHealth pediatric asthma care in practice, which can provide the most potential benefits in terms of adoption, efficiency, and effectiveness. Objective: The aim of this study was to investigate the technical and clinical feasibility, including an exploration of the efficacy and cost-efficiency, of an eHealth program implemented in daily clinical pediatric asthma practice. Methods: We designed an eHealth-supported pediatric asthma program facilitating early detection of loss of asthma control while increasing symptom awareness and self-management. In the 6-month program, asthma control was monitored by 4 health care professionals (HCPs) by using objective home measurements and the web-based Puffer app to allow timely medical anticipation and prevent treatment delay. Technical feasibility was assessed by technology use, system usability, and technology acceptance. Clinical feasibility was assessed by participation and patient-reported health and care outcomes and via a focus group with HCPs regarding their experiences of implementing eHealth in daily practice. The efficacy and cost-efficiency were explored by comparing pretest-posttest program differences in asthma outcomes (asthma control, lung function, and therapy adherence) and medical consumption. Results: Of 41 children, 35 children with moderate-to-severe asthma volunteered for participation. With regard to technical feasibility, the Puffer app scored a good usability score of 78 on the System Usability Scale and a score of 70 for technology acceptance on a scale of 1 to 100. Approximately 75\% (18/24) of the children indicated that eHealth helped them to control their asthma during the program. HCPs indicated that home measurements and real time communication enabled them to make safe and substantiated medical decisions during symptom manifestations. With an average time commitment of 15 minutes by patients, eHealth care led to a 80\% gross reduction (from {\texteuro}71,784 to {\texteuro}14,018, US \$1={\texteuro}0.85) in health care utilization, 8.6\% increase (from 18.6 to 20.2, P=.40) in asthma control, 25.0\% increase (from 2.8 to 3.5, P=.04) in the self-management level, and 20.4\% improved (from 71.2 to 76.8, P=.02) therapy adherence. Conclusions: eHealth asthma care seems to be technically and clinically feasible, enables safe remote care, and seems to be beneficial for pediatric asthma care in terms of health outcomes and health care utilization. Follow-up research should focus on targeted effectiveness studies with the lessons learned, while also enabling individualization of eHealth for personalized health care. ", doi="10.2196/24634", url="https://formative.jmir.org/2021/7/e24634", url="http://www.ncbi.nlm.nih.gov/pubmed/34309568" } @Article{info:doi/10.2196/28865, author="Habukawa, Chizu and Ohgami, Naoto and Arai, Takahiko and Makata, Haruyuki and Tomikawa, Morimitsu and Fujino, Tokihiko and Manabe, Tetsuharu and Ogihara, Yoshihito and Ohtani, Kiyotaka and Shirao, Kenichiro and Sugai, Kazuko and Asai, Kei and Sato, Tetsuya and Murakami, Katsumi", title="Wheeze Recognition Algorithm for Remote Medical Care Device in Children: Validation Study", journal="JMIR Pediatr Parent", year="2021", month="Jun", day="17", volume="4", number="2", pages="e28865", keywords="asthma", keywords="children", keywords="infant", keywords="wheezing", keywords="wheeze recognition algorithm", keywords="pediatrics", keywords="remote", keywords="medical devices", keywords="validation", keywords="home management", keywords="algorithm", keywords="detection", keywords="chronic illness", abstract="Background: Since 2020, peoples' lifestyles have been largely changed due to the COVID-19 pandemic worldwide. In the medical field, although many patients prefer remote medical care, this prevents the physician from examining the patient directly; thus, it is important for patients to accurately convey their condition to the physician. Accordingly, remote medical care should be implemented and adaptable home medical devices are required. However, only a few highly accurate home medical devices are available for automatic wheeze detection as an exacerbation sign. Objective: We developed a new handy home medical device with an automatic wheeze recognition algorithm, which is available for clinical use in noisy environments such as a pediatric consultation room or at home. Moreover, the examination time is only 30 seconds, since young children cannot endure a long examination time without crying or moving. The aim of this study was to validate the developed automatic wheeze recognition algorithm as a clinical medical device in children at different institutions. Methods: A total of 374 children aged 4-107 months in pediatric consultation rooms of 10 institutions were enrolled in this study. All participants aged ?6 years were diagnosed with bronchial asthma and patients ?5 years had reported at least three episodes of wheezes. Wheezes were detected by auscultation with a stethoscope and recorded for 30 seconds using the wheeze recognition algorithm device (HWZ-1000T) developed based on wheeze characteristics following the Computerized Respiratory Sound Analysis guideline, where the dominant frequency and duration of a wheeze were >100 Hz and >100 ms, respectively. Files containing recorded lung sounds were assessed by each specialist physician and divided into two groups: 177 designated as ``wheeze'' files and 197 as ``no-wheeze'' files. Wheeze recognitions were compared between specialist physicians who recorded lung sounds and those recorded using the wheeze recognition algorithm. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value for all recorded sound files, and evaluated the influence of age and sex on the wheeze detection sensitivity. Results: Detection of wheezes was not influenced by age and sex. In all files, wheezes were differentiated from noise using the wheeze recognition algorithm. The sensitivity, specificity, positive predictive value, and negative predictive value of the wheeze recognition algorithm were 96.6\%, 98.5\%, 98.3\%, and 97.0\%, respectively. Wheezes were automatically detected, and heartbeat sounds, voices, and crying were automatically identified as no-wheeze sounds by the wheeze recognition algorithm. Conclusions: The wheeze recognition algorithm was verified to identify wheezing with high accuracy; therefore, it might be useful in the practical implementation of asthma management at home. Only a few home medical devices are available for automatic wheeze detection. The wheeze recognition algorithm was verified to identify wheezing with high accuracy and will be useful for wheezing management at home and in remote medical care. ", doi="10.2196/28865", url="https://pediatrics.jmir.org/2021/2/e28865", url="http://www.ncbi.nlm.nih.gov/pubmed/33875413" } @Article{info:doi/10.2196/26442, author="J{\'a}come, Cristina and Almeida, Rute and Pereira, Margarida Ana and Amaral, Rita and Mendes, Sandra and Alves-Correia, Magna and Vidal, Carmen and L{\'o}pez Freire, Sara and M{\'e}ndez Brea, Paula and Ara{\'u}jo, Lu{\'i}s and Couto, Mariana and Antol{\'i}n-Am{\'e}rigo, Dar{\'i}o and de la Hoz Caballer, Bel{\'e}n and Barra Castro, Alicia and Gonzalez-De-Olano, David and Todo Bom, Ana and Azevedo, Jo{\~a}o and Leiria Pinto, Paula and Pinto, Nicole and Castro Neves, Ana and Palhinha, Ana and Todo Bom, Filipa and Costa, Alberto and Chaves Loureiro, Cl{\'a}udia and Maia Santos, Lilia and Arrobas, Ana and Val{\'e}rio, Margarida and Cardoso, Jo{\~a}o and Emiliano, Madalena and Gerardo, Rita and Cidrais Rodrigues, Carlos Jos{\'e} and Oliveira, Georgeta and Carvalho, Joana and Mendes, Ana and Lozoya, Carlos and Santos, Natacha and Menezes, Fernando and Gomes, Ricardo and C{\^a}mara, Rita and Rodrigues Alves, Rodrigo and Moreira, Sofia Ana and Bordalo, Diana and Alves, Carlos and Ferreira, Alberto Jos{\'e} and Lopes, Cristina and Silva, Diana and Vasconcelos, Jo{\~a}o Maria and Teixeira, Fernanda Maria and Ferreira-Magalh{\~a}es, Manuel and Taborda-Barata, Lu{\'i}s and C{\'a}lix, Jos{\'e} Maria and Alves, Adelaide and Almeida Fonseca, Jo{\~a}o", title="Feasibility and Acceptability of an Asthma App to Monitor Medication Adherence: Mixed Methods Study", journal="JMIR Mhealth Uhealth", year="2021", month="May", day="25", volume="9", number="5", pages="e26442", keywords="mHealth", keywords="smartphone", keywords="technology assessment", keywords="medication adherence", keywords="self-management", keywords="gamification", keywords="patient participation", abstract="Background: Poor medication adherence is a major challenge in asthma, and objective assessment of inhaler adherence is needed. The InspirerMundi app aims to monitor adherence while providing a positive experience through gamification and social support. Objective: This study aimed to evaluate the feasibility and acceptability of the InspirerMundi app to monitor medication adherence in adolescents and adults with persistent asthma (treated with daily inhaled medication). Methods: A 1-month mixed method multicenter observational study was conducted in 26 secondary care centers from Portugal and Spain. During an initial face-to-face visit, physicians reported patients' asthma therapeutic plan in a structured questionnaire. During the visits, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients registered the intake (inhaler, blister, or other drug formulation) by using the image-based medication detection tool. At 1 month, patients were interviewed by phone, and app satisfaction was assessed on a 1 (low) to 5 (high) scale. Patients were also asked to point out the most and least preferred app features and make suggestions for future app improvements. Results: A total of 107 patients (median 27 [P25-P75 14-40] years) were invited, 92.5\% (99/107) installed the app, and 73.8\% (79/107) completed the 1-month interview. Patients interacted with the app a median of 9 (P25-P75 1-24) days. At least one medication was registered in the app by 78\% (77/99) of patients. A total of 53\% (52/99) of participants registered all prescribed inhalers, and 34\% (34/99) registered the complete asthma therapeutic plan. Median medication adherence was 75\% (P25-P75 25\%-90\%) for inhalers and 82\% (P25-P75 50\%-94\%) for other drug formulations. Patients were globally satisfied with the app, with 75\% (59/79) scoring ?4,; adherence monitoring, symptom monitoring, and gamification features being the most highly scored components; and the medication detection tool among the lowest scored. A total of 53\% (42/79) of the patients stated that the app had motivated them to improve adherence to inhaled medication and 77\% (61/79) would recommend the app to other patients. Patient feedback was reflected in 4 major themes: medication-related features (67/79, 85\%), gamification and social network (33/79, 42\%), symptom monitoring and physician communication (21/79, 27\%), and other aspects (16/79, 20\%). Conclusions: The InspirerMundi app was feasible and acceptable to monitor medication adherence in patients with asthma. Based on patient feedback and to increase the registering of medications, the therapeutic plan registration and medication detection tool were redesigned. Our results highlight the importance of patient participation to produce a patient-centered and engaging mHealth asthma app. ", doi="10.2196/26442", url="https://mhealth.jmir.org/2021/5/e26442", url="http://www.ncbi.nlm.nih.gov/pubmed/34032576" } @Article{info:doi/10.2196/24907, author="Franzmair, Julian and Diesner-Treiber, C. Susanne and Voitl, M. Julian J. and Voitl, Peter", title="Effective German and English Language mHealth Apps for Self-management of Bronchial Asthma in Children and Adolescents: Comparison Study", journal="JMIR Mhealth Uhealth", year="2021", month="May", day="19", volume="9", number="5", pages="e24907", keywords="asthma", keywords="apps", keywords="mobile health", keywords="self-management", keywords="recommended apps", keywords="German", keywords="English", keywords="mobile phone", abstract="Background: Mobile health (mHealth) apps hold great potential for asthma self-management. Data on the suitability of asthma apps intended for children are insufficient, and the availability of German language apps is still inadequate compared with English language apps. Objective: This study aims to identify functional asthma apps for children in German and to compare them with English language apps. In line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the Google Play Store and Apple App Store are systematically searched to preselect the most efficient apps, which are then compared according to a self-compiled criteria catalog. Methods: Both app stores were screened for the term asthma. Following a PRISMA preselection process, the apps that met the inclusion criteria (ie, available free of charge, German or English language, and suitable for children) were rated by 3 independent persons following a criteria catalog consisting of 9 categories, some conceived for this purpose (availability, child-friendly, learning factor, and range of functions) and some adopted from existing validated catalogs (functionality and design, ease of use, potential for improving asthma self-management, fun factor and incentives, and information management and medical accuracy). The highest rated apps in German and English were compared. Results: A total of 403 apps were identified on the Google Play Store and the Apple App Store. Finally, 24 apps that met the inclusion criteria were analyzed. In the first step of the quality assessment, only 4 available German language asthma apps were compared with 20 English language asthma apps. The 4 German language apps were then compared with the 4 highest rated English language apps. All selected apps, independent of the language, were comparable in the following categories: availability, functionality and design, ease of use, and information management and medical accuracy. The English language apps scored significantly higher in the following categories: potential for improving self-management, child-friendly, fun factor, learning factor, and range of function. English language apps (mean total points 34.164, SD 1.09) performed significantly better than German language asthma apps (mean total points 22.91, SD 2.898; P=.003). The best rated English language app was Kiss my asthma (36/42 points), whereas the best rated German language app Kata achieved only 27.33 points. Conclusions: The recommended English language apps are Kiss my asthma, AsthmaXcel, AsthmaAustralia, and Ask Me, AsthMe!, whereas the only recommended German language app is Kata. The use of apps plays an increasingly important role in patients' lives and in the medical field, making mHealth a staple in the future of asthma treatment plans. Although validated recommendations on rating mHealth apps have been published, it remains a challenging task for physicians and patients to choose a suitable app for each case, especially in non--English-speaking countries. ", doi="10.2196/24907", url="https://mhealth.jmir.org/2021/5/e24907", url="http://www.ncbi.nlm.nih.gov/pubmed/34009134" } @Article{info:doi/10.2196/25811, author="Kan, Kristin and Shaunfield, Sara and Kanaley, Madeleine and Chadha, Avneet and Boon, Kathy and Foster, C. Carolyn and Morales, Luis and Labellarte, Patricia and Vojta, Deneen and Gupta, S. Ruchi", title="Parent Experiences With Electronic Medication Monitoring in Pediatric Asthma Management: Qualitative Study", journal="JMIR Pediatr Parent", year="2021", month="Apr", day="23", volume="4", number="2", pages="e25811", keywords="pediatric asthma", keywords="digital health", keywords="outpatient care", keywords="asthma management", keywords="pediatric", keywords="asthma", keywords="parents", keywords="caregivers", keywords="Bluetooth sensors", keywords="inhaler", abstract="Background: Electronic medication monitoring (EMM) is a digital tool that can be used for tracking daily medication use. Previous studies of EMM in asthma management have been conducted in adults or have examined pediatric interventions that use EMM for less than 1 year. To understand how to improve EMM-enhanced interventions, it is necessary to explore the experiences of parents of children with asthma, recruited from outpatient practices, who completed a 12-month intervention trial. Objective: The objective of our study was to use qualitative inquiry to answer the following questions: (1) how did using an EMM-enhanced intervention change parents'/caregivers' experiences of managing their child's asthma, and (2) what do parents recommend for improving the intervention in the future? Methods: Parents were recruited from the intervention arm of a multicomponent health intervention enhanced by Bluetooth-enabled sensors placed on inhaler medications. Semistructured interviews were conducted with 20 parents of children aged 4-12 years with asthma. Interviews were audio-recorded, transcribed, and inductively analyzed using a constant comparative approach. Results: Interview participants reflected an even mix of publicly and privately insured children and a diverse racial-ethnic demographic. Parents discussed 6 key themes related to their experience with the EMM-enhanced intervention for the management of their child's asthma: (1) compatibility with the family's lifestyle, (2) impact on asthma management, (3) impact on the child's health, (4) emotional impact of the intervention, (5) child's engagement in asthma management with the intervention, and (6) recommendations for future intervention design. Overall, parents reported that the 12-month EMM intervention was compatible with their daily lives, positively influenced their preventive and acute asthma management, and promoted their child's engagement in their own asthma management. While parents found the intervention acceptable and generally favorable, some parents identified compatibility issues for families with multiple caregivers and frustration when the technology malfunctioned. Conclusions: Parents generally viewed the intervention as a positive influence on the management of their child's asthma. However, our study also highlighted technology challenges related to having multiple caregivers, which will need to be addressed in future iterations for families. Attention must be paid to the needs of parents from low socioeconomic households, who may have more limited access to reliable internet or depend on other relatives for childcare. Understanding these family factors will help refine how a digital tool can be adopted into daily disease management of pediatric asthma. ", doi="10.2196/25811", url="https://pediatrics.jmir.org/2021/2/e25811", url="http://www.ncbi.nlm.nih.gov/pubmed/33890861" } @Article{info:doi/10.2196/25060, author="Kowatsch, Tobias and Schachner, Theresa and Harperink, Samira and Barata, Filipe and Dittler, Ullrich and Xiao, Grace and Stanger, Catherine and v Wangenheim, Florian and Fleisch, Elgar and Oswald, Helmut and M{\"o}ller, Alexander", title="Conversational Agents as Mediating Social Actors in Chronic Disease Management Involving Health Care Professionals, Patients, and Family Members: Multisite Single-Arm Feasibility Study", journal="J Med Internet Res", year="2021", month="Feb", day="17", volume="23", number="2", pages="e25060", keywords="digital health intervention", keywords="intervention design", keywords="mHealth", keywords="eHealth", keywords="chatbot", keywords="conversational agent", keywords="chronic diseases", keywords="asthma", keywords="feasibility study", abstract="Background: Successful management of chronic diseases requires a trustful collaboration between health care professionals, patients, and family members. Scalable conversational agents, designed to assist health care professionals, may play a significant role in supporting this collaboration in a scalable way by reaching out to the everyday lives of patients and their family members. However, to date, it remains unclear whether conversational agents, in such a role, would be accepted and whether they can support this multistakeholder collaboration. Objective: With asthma in children representing a relevant target of chronic disease management, this study had the following objectives: (1) to describe the design of MAX, a conversational agent--delivered asthma intervention that supports health care professionals targeting child-parent teams in their everyday lives; and (2) to assess the (a) reach of MAX, (b) conversational agent--patient working alliance, (c) acceptance of MAX, (d) intervention completion rate, (e) cognitive and behavioral outcomes, and (f) human effort and responsiveness of health care professionals in primary and secondary care settings. Methods: MAX was designed to increase cognitive skills (ie, knowledge about asthma) and behavioral skills (ie, inhalation technique) in 10-15-year-olds with asthma, and enables support by a health professional and a family member. To this end, three design goals guided the development: (1) to build a conversational agent--patient working alliance; (2) to offer hybrid (human- and conversational agent--supported) ubiquitous coaching; and (3) to provide an intervention with high experiential value. An interdisciplinary team of computer scientists, asthma experts, and young patients with their parents developed the intervention collaboratively. The conversational agent communicates with health care professionals via email, with patients via a mobile chat app, and with a family member via SMS text messaging. A single-arm feasibility study in primary and secondary care settings was performed to assess MAX. Results: Results indicated an overall positive evaluation of MAX with respect to its reach (49.5\%, 49/99 of recruited and eligible patient-family member teams participated), a strong patient-conversational agent working alliance, and high acceptance by all relevant stakeholders. Moreover, MAX led to improved cognitive and behavioral skills and an intervention completion rate of 75.5\%. Family members supported the patients in 269 out of 275 (97.8\%) coaching sessions. Most of the conversational turns (99.5\%) were conducted between patients and the conversational agent as opposed to between patients and health care professionals, thus indicating the scalability of MAX. In addition, it took health care professionals less than 4 minutes to assess the inhalation technique and 3 days to deliver related feedback to the patients. Several suggestions for improvement were made. Conclusions: This study provides the first evidence that conversational agents, designed as mediating social actors involving health care professionals, patients, and family members, are not only accepted in such a ``team player'' role but also show potential to improve health-relevant outcomes in chronic disease management. ", doi="10.2196/25060", url="http://www.jmir.org/2021/2/e25060/", url="http://www.ncbi.nlm.nih.gov/pubmed/33484114" } @Article{info:doi/10.2196/25052, author="Chelabi, Khadidja and Balli, Fabio and Bransi, Myriam and Gervais, Yannick and Marthe, Clement and Tse, Man Sze", title="Validation of a Portable Game Controller to Assess Peak Expiratory Flow Against Conventional Spirometry in Children: Cross-sectional Study", journal="JMIR Serious Games", year="2021", month="Jan", day="29", volume="9", number="1", pages="e25052", keywords="asthma", keywords="pediatrics", keywords="serious game", keywords="peak expiratory flow", keywords="pulmonary function test, adherence, self-management", abstract="Background: International asthma guidelines recommend the monitoring of peak expiratory flow (PEF) as part of asthma self-management in children and adolescents who poorly perceive airflow obstruction, those with a history of severe exacerbations, or those who have difficulty controlling asthma. Measured with a peak flow meter, PEF represents a person's maximum speed of expiration and helps individuals to follow their disease evolution and, ultimately, to prevent asthma exacerbations. However, patient adherence to regular peak flow meter use is poor, particularly in pediatric populations. To address this, we developed an interactive tablet-based game with a portable game controller that can transduce a signal from the user's breath to generate a PEF value. Objective: The purpose of this study was to evaluate the concordance between PEF values obtained with the game controller and various measures derived from conventional pulmonary function tests (ie, spirometry) and to synthesize the participants' feedback. Methods: In this cross-sectional multicenter study, 158 children (aged 8-15 years old) with a diagnosis or suspicion of asthma performed spirometry and played the game in one of two hospital university centers. We evaluated the correlation between PEF measured by both the game controller and spirometry, forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25\%-75\% of pulmonary volume (FEF25-75), using Spearman correlation. A Bland-Altman plot was generated for comparison of PEF measured by the game controller against PEF measured by spirometry. A post-game user feedback questionnaire was administered and analyzed. Results: The participants had a mean age of 10.9 (SD 2.5) years, 44\% (71/158) were female, and 88\% (139/158) were White. On average, the pulmonary function of the participants was normal, including FEV1, PEF, and FEV1/forced vital capacity (FVC). The PEF measured by the game controller was reproducible in 96.2\% (152/158) of participants according to standardized criteria. The PEF measured by the game controller presented a good correlation with PEF measured by spirometry (r=0.83, P<.001), with FEV1 (r=0.74, P<.001), and with FEF25-75 (r=0.65, P<.001). The PEF measured by the game controller presented an expected mean bias of --36.4 L/min as compared to PEF measured by spirometry. The participants' feedback was strongly positive, with 78.3\% (123/157) reporting they would use the game if they had it at home. Conclusions: The game controller we developed is an interactive tool appreciated by children with asthma, and the PEF values measured by the game controller are reproducible, with a good correlation to values measured by conventional spirometry. Future studies are necessary to evaluate the clinical impact this novel tool might have on asthma management and its potential use in an out-of-hospital setting. ", doi="10.2196/25052", url="http://games.jmir.org/2021/1/e25052/", url="http://www.ncbi.nlm.nih.gov/pubmed/33512326" } @Article{info:doi/10.2196/23963, author="Kotcherlakota, Suhasini and Pelish, Peggy and Hoffman, Katherine and Kupzyk, Kevin and Rejda, Patrick", title="Augmented Reality Technology as a Teaching Strategy for Learning Pediatric Asthma Management: Mixed Methods Study", journal="JMIR Nursing", year="2020", month="Dec", day="2", volume="3", number="1", pages="e23963", keywords="augmented reality", keywords="graduate nursing", keywords="pediatric asthma management", keywords="flipped learning", keywords="nursing", keywords="asthma", keywords="chronic disease", keywords="nurse practitioner", keywords="nursing students", keywords="pediatric asthma", abstract="Background: Asthma is a major chronic disease affecting 8.6\% of children in the United States. Objective: The purpose of this research was to assess the use of clinical simulation scenarios using augmented reality technology to evaluate learning outcomes for nurse practitioner students studying pediatric asthma management. Methods: A mixed-methods pilot study was conducted with 2 cohorts of graduate pediatric nurse practitioner students (N=21), with each cohort participating for 2 semesters. Results: Significant improvements in pediatric asthma test scores (P<.001) of student learning were found in both cohorts at posttest in both semesters. Student satisfaction with the augmented reality technology was found to be high. The focus group discussions revealed that the simulation was realistic and helpful for a flipped classroom approach. Conclusions: The study results suggest augmented reality simulation to be valuable in teaching pediatric asthma management content in graduate nursing education. ", doi="10.2196/23963", url="https://nursing.jmir.org/2001/1/e23963/", url="http://www.ncbi.nlm.nih.gov/pubmed/34406970" } @Article{info:doi/10.2196/18977, author="Dawson, M. Robin and Heiney, P. Sue and Messias, Hilfinger DeAnne and Ownby, Dennis", title="A Patient-Centered Asthma Management Communication Intervention for Rural Latino Children: Protocol for a Waiting-List Randomized Controlled Trial", journal="JMIR Res Protoc", year="2020", month="Dec", day="1", volume="9", number="12", pages="e18977", keywords="asthma", keywords="mHealth", keywords="mobile app", keywords="Latino", keywords="pediatrics", keywords="family-centered care", keywords="school nursing", keywords="rural health", keywords="RCT", keywords="mobile phone", abstract="Background: Rural Latino children with asthma suffer high rates of uncontrolled asthma symptoms, emergency department visits, and repeat hospitalizations. This vulnerable population must negotiate micro- and macrolevel challenges that impact asthma management, including language barriers, primary care access, parental time off from work, insurance coverage, distance from specialty sites, and documentation status. There are few proven interventions that address asthma management embedded within this unique context. Objective: Using a bio-ecological approach, we will determine the feasibility of a patient-centered collaborative program between rural Latino children with asthma and their families, school-based nursing programs, and primary care providers, facilitated by the use of a smartphone-based mobile app with a Spanish-language interface. We hypothesize that improving communication through a collaborative, patient-centered intervention will improve asthma management, empower the patient and family, decrease outcome disparities, and decrease direct and indirect costs. Methods: The specific aims of this study include the following: (1) Aim 1: produce and validate a Spanish translation of an existing asthma management app and evaluate its usability with Latino parents of children with asthma, (2) Aim 2: develop and evaluate a triadic, patient-centered asthma intervention preliminary protocol, facilitated by the bilingual mobile app validated in Aim 1, and (3) Aim 3: investigate the feasibility of the patient-centered asthma intervention from Aim 2 using a waiting-list randomized controlled trial (RCT) to investigate the effects of the intervention on school days missed and medication adherence. Results: Mobile app translation, initial usability testing, and app software refinement were completed in 2019. Analysis is in progress. Preliminary protocol testing is underway; we anticipate that the waiting-list RCT, using the refined protocol developed in Aim 2, will commence in fall 2020. Conclusions: Tailored, technology-based solutions have the potential to successfully address issues affecting asthma management, including communication barriers, accessibility issues, medication adherence, and suboptimal technological interventions. Trial Registration: ClinicalTrials.gov NCT04633018; https://www.clinicaltrials.gov/ct2/show/NCT04633018 International Registered Report Identifier (IRRID): DERR1-10.2196/18977 ", doi="10.2196/18977", url="https://www.researchprotocols.org/2020/12/e18977", url="http://www.ncbi.nlm.nih.gov/pubmed/33258784" } @Article{info:doi/10.2196/21863, author="Pletta, H. Karen and Kerr, R. Bradley and Eickhoff, C. Jens and Allen, S. Gail and Jain, R. Sanjeev and Moreno, A. Megan", title="Pediatric Asthma Action Plans: National Cross-Sectional Online Survey of Parents' Perceptions", journal="JMIR Pediatr Parent", year="2020", month="Nov", day="9", volume="3", number="2", pages="e21863", keywords="pediatric asthma", keywords="asthma action plan", keywords="parent", keywords="online survey", keywords="self-efficacy", keywords="daily living factors", keywords="parental work", keywords="school absence", keywords="school management", keywords="caregiver management", keywords="child activity", keywords="primary care provider", keywords="pediatrician", keywords="asthma specialist", abstract="Background: Asthma Action Plans (AAPs) are recommended for pediatric patients to help improve asthma control. Studies have shown variable results for unscheduled doctor and emergency room visits. AAPs may have an impact on parental self-efficacy for asthma management as well as on other daily living factors that are valuable for patients and families, such as the number of missed school days and parental workdays, and on school and caregiver management. Objective: The purpose of this study is to understand parent perceptions of AAPs. The goals of this analysis were threefold, including examining (1) the association between pediatric AAPs and parental self-efficacy, (2) parent perceptions of the helpfulness of an AAP for daily living factors, and (3) associations with the type of provider who gave the AAP (a primary care provider or an asthma specialist). Methods: A national cross-sectional online survey was completed in October 2018 by parents of children with asthma aged 0-17 years. Survey questions included the presence or absence of a pediatric AAP, the Bursch Parental Self-efficacy for Asthma scale, parental perceptions of the AAP's helpfulness with regard to daily living factors ranked on a 5-point Likert scale, and the provider type who gave the AAP. Survey responses were summarized in terms of percentages or means and standard deviations. A 2-sample t test and analysis of covariance were used to compare self-efficacy for asthma and parental-perception-of-helpfulness scores between subjects with an AAP versus subjects without an AAP. All reported P values were 2-sided. Results: A total of 704 parents with a child with asthma completed the survey. The parents had a mean age of 37.5 years (SD 10.9), and 82\% (577/704) were women and 18\% (127/704) were men. Most (564/704, 80\%) parents had an AAP for their child; 65\% (367/564) were written, 51\% (286/564) were online, and 84\% (474/564) were available at school. The Bursch Self-efficacy scale was significantly higher for parents with an AAP (mean 57.7, SD 8.6) versus no AAP (mean 55.1, SD 9.9; P<.001). Parents reported that they agreed/strongly agreed that an AAP was helpful for daily living factors, including managing asthma (446/544, 82\%), decreased parental missed workdays (367/544, 68\%), decreased child missed-school days (396/542, 73\%), and for when a child is at school (422/541 78\%), with other caregivers (434/543, 80\%), doing normal activities (421/540 78\%), and leading a normal life (437/540 81\%). Parents agreed/strongly agreed that an AAP was helpful from all provider types: a pediatric provider (583/704, 82.8\%), a family practice provider (556/704, 79\%), and an asthma specialist (594/704, 84.4\%). There was no significant difference (P=.53) between the type of provider who gave the AAP. Conclusions: Parents who had pediatric AAPs for their children reported increased parental self-efficacy compared to those who did not have AAPs. Parents found AAPs helpful for decreasing missed time from work and school, and for asthma management when at home, school, and with other caregivers. Significant AAP helpfulness was seen regardless of the provider who gave the AAP, the parent's education, and income level. Findings support the usefulness of pediatric AAPs for families and the development of easily sharable electronic AAPs for children. ", doi="10.2196/21863", url="https://pediatrics.jmir.org/2020/2/e21863", url="http://www.ncbi.nlm.nih.gov/pubmed/33164900" } @Article{info:doi/10.2196/15076, author="Camacho-Rivera, Marlene and Vo, Huy and Huang, Xueqi and Lau, Julia and Lawal, Adeola and Kawaguchi, Akira", title="Evaluating Asthma Mobile Apps to Improve Asthma Self-Management: User Ratings and Sentiment Analysis of Publicly Available Apps", journal="JMIR Mhealth Uhealth", year="2020", month="Oct", day="29", volume="8", number="10", pages="e15076", keywords="mHealth", keywords="asthma apps", keywords="sentiment analysis", keywords="user ratings", keywords="smartphone", keywords="mobile phone", abstract="Background: The development and use of mobile health (mHealth) apps for asthma management have risen dramatically over the past two decades. Asthma apps vary widely in their content and features; however, prior research has rarely examined preferences of users of publicly available apps. Objective: The goals of this study were to provide a descriptive overview of asthma mobile apps that are publicly available and to assess the usability of asthma apps currently available on the market to identify content and features of apps associated with positive and negative user ratings. Methods: Reviews were collected on June 23, 2020, and included publicly posted reviews until June 21, 2020. To characterize features associated with high or low app ratings, we first dichotomized the average user rating of the asthma app into 2 categories: a high average rating and a low average rating. Asthma apps with average ratings of 4 and above were categorized as having a high average rating. Asthma apps with average ratings of less than 4 were categorized as having a low average rating. For the sentiment analysis, we modeled both 2-word (bi-gram) and 3-word (tri-gram) phrases which commonly appeared across highly rated and lowly rated apps. Results: Of the 10 apps that met the inclusion criteria, a total of 373 reviews were examined across all apps. Among apps reviewed, 53.4\% (199/373) received high ratings (average ratings of 4 or 5) and 47.2\% (176/373) received low ratings (average ratings of 3 or less). The number of ratings across all apps ranged from 188 (AsthmaMD) to 10 (My Asthma App); 30\% (3/10) of apps were available on both Android and iOS. From the sentiment analysis, key features of asthma management that were common among highly rated apps included the tracking of peak flow readings (n=48), asthma symptom monitoring (n=11), and action plans (n=10). Key features related to functionality that were common among highly rated apps included ease of use (n=5). Users most commonly reported loss of data (n=14) and crashing of app (n=12) as functionality issues among poorly rated asthma apps. Conclusions: Our study results demonstrate that asthma app quality, maintenance, and updates vary widely across apps and platforms. These findings may call into question the long-term engagement with asthma apps, a crucial factor for determining their potential to improve asthma self-management and asthma clinical outcomes. ", doi="10.2196/15076", url="http://mhealth.jmir.org/2020/10/e15076/", url="http://www.ncbi.nlm.nih.gov/pubmed/33118944" } @Article{info:doi/10.2196/18506, author="Iio, Misa and Miyaji, Yumiko and Yamamoto-Hanada, Kiwako and Narita, Masami and Nagata, Mayumi and Ohya, Yukihiro", title="Beneficial Features of a mHealth Asthma App for Children and Caregivers: Qualitative Study", journal="JMIR Mhealth Uhealth", year="2020", month="Aug", day="24", volume="8", number="8", pages="e18506", keywords="children", keywords="caregivers", keywords="asthma", keywords="mobile app", keywords="proposed beneficial features", abstract="Background: mHealth and uHealth apps are available for children with asthma and their caregivers. However, previous studies on mHealth apps for children older than 7 years old with asthma are limited, and most studies on asthma apps do not consider interactions involving communication between children and caregivers. Therefore, a prototype mHealth child asthma app was developed for children and their caregivers, with features of tailored feedback messages in continuing self-management and interactions between children and caregivers. Objective: The aim of this study was to identify the beneficial features of a prototype mHealth app developed for children with asthma and their caregivers. Methods: Children diagnosed with persistent asthma by allergy specialists at the National Center for Child Health and Development were recruited. The features of a prototype mHealth app for children with asthma and their caregivers were investigated using semistructured interviews after they tried the app. Data were analyzed using thematic analysis. Content-characteristic words were named and grouped together as categories to explore themes. Results: We recruited 27 children with asthma aged 2 to 12 years and 26 their caregivers. Findings on the good aspects of the app for children older than 7 years old and caregivers suggested 4 themes (confirmation of asthma knowledge, child-caregiver interaction, design of the app, and child's interest), and 6 categories were identified. Findings on the good aspects of app for children 7 to 12 years old and caregivers suggested 5 themes (new knowledge, manga as a Japanese-style comic, child's interest, trigger of self-management, and design and operability), and 11 categories were identified. Findings on the beneficial features of app suggested 6 themes (asthma knowledge, elements for continuous, universal design, notification, monitoring, and functions), and 12 categories were identified. Conclusions: Children with asthma and their caregivers perceived that the good aspects of the app were learning asthma knowledge with fun, including manga; interaction between child and caregiver; and easy-to-read design, such as colors. They wanted not only the asthma knowledge but also the universal design and enhanced elements, monitoring, and notification functions of the app. ", doi="10.2196/18506", url="http://mhealth.jmir.org/2020/8/e18506/", url="http://www.ncbi.nlm.nih.gov/pubmed/32831181" } @Article{info:doi/10.2196/20350, author="Frima, Eirini-Sofia and Theodorakopoulos, Ilias and Gidaris, Dimos and Karantaglis, Nikolaos and Chatziparasidis, Grigorios and Plotas, Panagiotis and Anthracopoulos, Michael and Fouzas, Sotirios", title="Lung Function Variability in Children and Adolescents With and Without Asthma (LUV Study): Protocol for a Prospective, Nonrandomized, Clinical Trial", journal="JMIR Res Protoc", year="2020", month="Aug", day="7", volume="9", number="8", pages="e20350", keywords="asthma", keywords="lung function variability", keywords="fluctuation analysis", keywords="children", keywords="adolescents", abstract="Background: Variability analysis of peak expiratory flow (PEF) and forced expiratory volume at 1 second (FEV1) has been used in research to predict exacerbations in adults with asthma. However, there is a paucity of data regarding PEF and FEV1 variability in healthy children and adolescents and those with asthma. Objective: The objective of this study is the assessment of PEF and FEV1 variability in (1) healthy children and adolescents, to define the normal daily fluctuation of PEF and FEV1 and the parameters that may influence it, and (2) children and adolescents with asthma, to explore the differences from healthy subjects and reveal any specific variability changes prior to exacerbation. Methods: The study will include 100 healthy children and adolescents aged 6-18 years (assessment of normal PEF and FEV1 variability) and 100 children and adolescents of the same age with diagnosed asthma (assessment of PEF and FEV1 variability in subjects with asthma). PEF and FEV1 measurements will be performed using an ultraportable spirometer (Spirobank Smart; MIR Medical International Research) capable of smartphone connection. Measurements will be performed twice a day between 7 AM and 9 AM and between 7 PM and 9 PM and will be dispatched via email to a central database for a period of 3 months. PEF and FEV1 variability will be assessed by detrended fluctuation and sample entropy analysis, aiming to define the normal pattern (healthy controls) and to detect and quantify any deviations among individuals with asthma. The anticipated duration of the study is 24 months. Results: The study is funded by the ``C. Caratheodory'' Programme of the University of Patras, Greece (PN 47014/24.9.2018). It was approved by the Ethics Committee (decision 218/19-03-2019) and the Scientific Board (decision 329/02-04-2019) of the University Hospital of Patras, Greece. Patient recruitment started in January 2020, and as of June 2020, 100 healthy children have been enrolled (74 of them have completed the measurements). The anticipated duration of the study is 24 months. The first part of the study (assessment of lung function variability in healthy children and adolescents) will be completed in August 2020, and the results will be available for publication by October 2020. Conclusions: Healthy children and adolescents may present normal short- and long-term fluctuations in lung function; the pattern of this variability may be influenced by age, sex, and environmental conditions. Significant lung function variability may also be present in children and adolescents with asthma, but the patterns may differ from those observed in healthy children and adolescents. Such data would improve our understanding regarding the chronobiology of asthma and permit the development of integrated tools for assessing the level of control and risk of future exacerbations. Trial Registration: ClinicalTrials.gov NCT04163146; https://clinicaltrials.gov/ct2/show/NCT04163146 International Registered Report Identifier (IRRID): DERR1-10.2196/20350 ", doi="10.2196/20350", url="http://www.researchprotocols.org/2020/8/e20350/", url="http://www.ncbi.nlm.nih.gov/pubmed/32763874" } @Article{info:doi/10.2196/15295, author="Nichols, Michelle and Miller, Sarah and Treiber, Frank and Ruggiero, Kenneth and Dawley, Erin and Teufel II, Ronald", title="Patient and Parent Perspectives on Improving Pediatric Asthma Self-Management Through a Mobile Health Intervention: Pilot Study", journal="JMIR Form Res", year="2020", month="Jul", day="3", volume="4", number="7", pages="e15295", keywords="asthma", keywords="mobile health", keywords="ecological momentary assessment", keywords="adolescents", keywords="medication adherence", keywords="self-management", keywords="mobile phone", abstract="Background: Asthma is a common chronic pediatric disease that can negatively impact children and families. Self-management strategies are challenging to adopt but critical for achieving positive outcomes. Mobile health technology may facilitate self-management of pediatric asthma, especially as adolescents mature and assume responsibility for their disease. Objective: This study aimed to explore the perceptions of youths with high-risk asthma and their caregivers on the use of a smartphone app, Smartphone Asthma Management System, in the prevention and treatment of asthma symptoms, possible use of the app to improve self-management of asthma outside traditional clinical settings, and the impact of asthma on everyday life to identify potential needs for future intervention development. Methods: Key informant interviews were completed with parent-child dyads post participation in an asthma management feasibility intervention study to explore the perceptions of users on a smartphone app designed to monitor symptoms and medication use and offer synchronous and asynchronous provider encounters. A thematic qualitative analysis was conducted inductively through emergent findings and deductively based on the self-determination theory (SDT), identifying 4 major themes. Results: A total of 19 parent-child dyads completed the postintervention interviews. The major themes identified included autonomy, competence, relatedness, and the impact of asthma on life. The participants also shared their perceptions of the benefits and challenges associated with using the app and in the self-management of asthma. Both children and parents conveyed a preference for using technology to facilitate medication and disease management, and children demonstrated a strong willingness and ability to actively engage in their care. Conclusions: Our study included support for the app and demonstrated the feasibility of enhancing the self-management of asthma by youth in the community. Participant feedback led to intervention refinement and app improvements, and the use of the SDT allowed insight into motivational drivers of behavioral change. The use of mobile apps among high-risk children with asthma and their parents shows promise in improving self-management, medication adherence, and disease awareness and in reducing overall disease morbidity. ", doi="10.2196/15295", url="https://formative.jmir.org/2020/7/e15295", url="http://www.ncbi.nlm.nih.gov/pubmed/32442127" } @Article{info:doi/10.2196/18185, author="De Simoni, Anna and Shah, T. Anjali and Fulton, Olivia and Parkinson, Jasmine and Sheikh, Aziz and Panzarasa, Pietro and Pagliari, Claudia and Coulson, S. Neil and Griffiths, J. Chris", title="Superusers' Engagement in Asthma Online Communities: Asynchronous Web-Based Interview Study", journal="J Med Internet Res", year="2020", month="Jun", day="23", volume="22", number="6", pages="e18185", keywords="social networks", keywords="eHealth", keywords="social media", keywords="peer-to-peer support", keywords="social support", keywords="online health communities", keywords="online forums", keywords="superusers", keywords="leadership", keywords="misinformation", keywords="asthma", keywords="self-management", abstract="Background: Superusers, defined as the 1\% of users who write a large number of posts, play critical roles in online health communities (OHCs), catalyzing engagement and influencing other users' self-care. Their unique online behavior is key to sustaining activity in OHCs and making them flourish. Our previous work showed the presence of 20 to 30 superusers active on a weekly basis among 3345 users in the nationwide Asthma UK OHC and that the community would disintegrate if superusers were removed. Recruiting these highly skilled individuals for research purposes can be challenging, and little is known about superusers. Objective: This study aimed to explore superusers' motivation to actively engage in OHCs, the difficulties they may face, and their interactions with health care professionals (HCPs). Methods: An asynchronous web-based structured interview study was conducted. Superusers of the Asthma UK OHC and Facebook groups were recruited through Asthma UK staff to pilot and subsequently complete the questionnaire. Open-ended questions were analyzed using content analysis. Results: There were 17 superusers recruited for the study (14 patients with asthma and 3 carers); the majority were female (15/17). The age range of participants was 18 to 75 years. They were active in OHCs for 1 to 6 years and spent between 1 and 20 hours per week reading and 1 and 3 hours per week writing posts. Superusers' participation in OHCs was prompted by curiosity about asthma and its medical treatment and by the availability of spare time when they were off work due to asthma exacerbations or retired. Their engagement increased over time as participants furthered their familiarity with the OHCs and their knowledge of asthma and its self-management. Financial or social recognition of the superuser role was not important; their reward came from helping and interacting with others. According to the replies provided, they showed careful judgment to distinguish what can be dealt with through peer advice and what needs input from HCPs. Difficulties were encountered when dealing with misunderstandings about asthma and its treatment, patients not seeking advice from HCPs when needed, and miracle cures or dangerous ideas. Out of 17 participants, only 3 stated that their HCPs were aware of their engagement with OHCs. All superusers thought that HCPs should direct patients to OHCs, provided they are trusted and moderated. In addition, 9 users felt that HCPs themselves should take part in OHCs. Conclusions: Superusers from a UK-wide online community are highly motivated, altruistic, and mostly female individuals who exhibit judgment about the complexity of coping with asthma and the limits of their advice. Engagement with OHCs satisfies their psychosocial needs. Future research should explore how to address their unmet needs, their interactions with HCPs, and the potential integration of OHCs in traditional healthcare. ", doi="10.2196/18185", url="http://www.jmir.org/2020/6/e18185/", url="http://www.ncbi.nlm.nih.gov/pubmed/32573463" } @Article{info:doi/10.2196/18400, author="Fedele, A. David and Cushing, C. Christopher and Koskela-Staples, Natalie and Patton, R. Susana and McQuaid, L. Elizabeth and Smyth, M. Joshua and Prabhakaran, Sreekala and Gierer, Selina and Nezu, M. Arthur", title="Adaptive Mobile Health Intervention for Adolescents with Asthma: Iterative User-Centered Development", journal="JMIR Mhealth Uhealth", year="2020", month="May", day="6", volume="8", number="5", pages="e18400", keywords="asthma", keywords="mobile health", keywords="adherence", keywords="adolescence", keywords="self-regulation", keywords="problem-solving", keywords="adolescent", keywords="youth", abstract="Background: Adolescents diagnosed with persistent asthma commonly take less than 50\% of their prescribed inhaled corticosteroids (ICS), placing them at risk for asthma-related morbidity. Adolescents' difficulties with adherence occur in the context of normative developmental changes (eg, increased responsibility for disease management) and rely upon still developing self-regulation and problem-solving skills that are integral for asthma self-management. We developed an adaptive mobile health system, Responsive Asthma Care for Teens (ReACT), that facilitates self-regulation and problem-solving skills during times when adolescents' objectively measured ICS adherence data indicate suboptimal rates of medication use. Objective: The current paper describes our user-centered and evidence-based design process in developing ReACT. We explain how we leveraged a combination of individual interviews, national crowdsourced feedback, and an advisory board comprised of target users to develop the intervention content. Methods: We developed ReACT over a 15-month period using one-on-one interviews with target ReACT users (n=20), national crowdsourcing (n=257), and an advisory board (n=4) to refine content. Participants included 13-17--year-olds with asthma and their caregivers. A total of 280 adolescents and their caregivers participated in at least one stage of ReACT development. Results: Consistent with self-regulation theory, adolescents identified a variety of salient intrapersonal (eg, forgetfulness, mood) and external (eg, changes in routine) barriers to ICS use during individual interviews. Adolescents viewed the majority of ReACT intervention content (514/555 messages, 93\%) favorably during the crowdsourcing phase, and the advisory board helped to refine the content that did not receive favorable feedback during crowdsourcing. Additionally, the advisory board provided suggestions for improving additional components of ReACT (eg, videos, message flow). Conclusions: ReACT involved stakeholders via qualitative approaches and crowdsourcing throughout the creation and refinement of intervention content. The feedback we received from participants largely supported ReACT's emphasis on providing adaptive and personalized intervention content to facilitate self-regulation and problem-solving skills, and the research team successfully completed the recommended refinements to the intervention content during the iterative development process. ", doi="10.2196/18400", url="https://mhealth.jmir.org/2020/5/e18400", url="http://www.ncbi.nlm.nih.gov/pubmed/32374273" } @Article{info:doi/10.2196/17863, author="Talwar, Deepak and Bendre, Salil", title="Health-Related Effects of Home Nebulization With Glycopyrronium on Difficult-to-Treat Asthma: Post-Hoc Analyses of an Observational Study", journal="Interact J Med Res", year="2020", month="Apr", day="29", volume="9", number="2", pages="e17863", keywords="difficult-to-treat asthma", keywords="exacerbation", keywords="glycopyrronium", keywords="home nebulization", keywords="uncontrolled asthma", keywords="vibrating mesh nebulizer", abstract="Background: Bronchial asthma remains a clinical enigma with poorly controlled symptoms or exacerbations despite regular use of inhaled corticosteroids. Home nebulization offers a simplified solution for the delivery of rescue and maintenance bronchodilators, which is especially true for patients with frequent exacerbations during management of uncontrolled or difficult-to-treat asthma. Objective: We aimed to assess the clinical impact and outcomes associated with home nebulization---delivered long-acting bronchodilators for uncontrolled or difficult-to-treat asthma. Methods: This observational, concurrent study was conducted with 60 patients at 2 centers during November 2018. Statistical analyses for prebronchodilator forced expiratory volume in one second (FEV1) and Global Initiative for Asthma (GINA) asthma control score in patients on long-acting bronchodilators and corticosteroids were conducted, with two-tailed P values <.05 considered statistically significant. Results: Per protocol analyses (53/60) for consecutive cases receiving home nebulization with long-acting bronchodilators and corticosteroids were conducted. The baseline demographics included a male-to-female ratio of 30:23 and mean values of the following: age, 60.3 years (SD 11.8 years); weight, 64 kg (SD 16.8 kg); FEV1, 43\% (SD 16\%); GINA asthma control score, 3.0 points (SD 0.8 points); serum eosinophil level, 4\% (SD 3\%); fractional exhaled nitric oxide (FeNO), 12.1 ppb (SD 6 ppb). Of the patients, 100\% (53/53) had uncontrolled symptoms, 69.8\% (37/53) had prior exacerbations, 100\% (53/53) used formoterol/budesonide, and 75.5\% (40/53) used glycopyrronium. The per protocol group (n=53) had significantly improved mean prebronchodilator FEV1 (23.7\%, SD 29.8\%; 0.46 L, SD 0.58 L; P<.001) and GINA asthma control score (2.1 points, SD 0.8 points, P<.001). At baseline, patients (n=40) receiving glycopyrronium/formoterol/budesonide (25/20/500 mcg) nebulization admixture had the following mean values: prebronchodilator FEV1, 38\% (SD 15\%); GINA asthma control score, 3.0 points (SD 0.8 points); reversibility, 12\% (SD 6\%); peripheral eosinophil level, 4\% (SD 3\%); FeNO, 12 ppb (SD 5.7 ppb). In the post hoc analyses, these patients had significantly improved mean prebronchodilator FEV1 of 27.7\% (SD 26.2\%; 0.54 L, SD 0.51 L; P<.001) at 8 weeks compared with baseline. At baseline, patients (n=13) receiving formoterol/budesonide (20/500 mcg) nebulization had the following mean values: FEV1, 55\% (SD 12\%); GINA asthma control score, 3.0 points (SD 1.2 points); reversibility, 14\% (SD 7\%); serum eosinophil level, 4\% (SD 3\%); FeNO, 13.3 ppb (SD 6.8 ppb). In the post hoc analyses, these patients showed a significant improvement in prebronchodilator FEV1 of 11.2\% (SD 13.1\%; 0.22 L, SD 0.25 L; P<.001) from baseline. Breathlessness of mild to moderate intensity was reported by 10 cases (10/53, 18.9\%), with no other treatment-emergent adverse events or serious adverse events. Conclusions: Home nebulization remains a viable option for symptomatic difficult-to-treat asthma cases with frequent use of rescue medications. Glycopyrronium as add-on therapy offers a synergistic response in patients on corticosteroids with difficult-to-treat asthma. Trial Registration: Clinical Trial Registry of India CTRI/2018/11/016319; https://tinyurl.com/y78cctm3 ", doi="10.2196/17863", url="http://www.i-jmr.org/2020/2/e17863/", url="http://www.ncbi.nlm.nih.gov/pubmed/32347812" } @Article{info:doi/10.2196/resprot.9585, author="Roberts, Claire and Lanning, Eleanor and Fogg, Carole and Bassett, Paul and Hughes, Alison and Chauhan, J. Anoop", title="Modern Innovative Solutions to Improve Outcomes in Severe Asthma: Protocol for a Mixed Methods Observational Comparison of Clinical Outcomes in MISSION Versus Current Care Delivery", journal="JMIR Res Protoc", year="2019", month="Oct", day="10", volume="8", number="10", pages="e9585", keywords="asthma", keywords="diagnosis", keywords="community health services", keywords="drug therapy", keywords="epidemiology", keywords="asthma treatment", abstract="Background: Asthma that is poorly controlled and undertreated can progress to more severe disease that is associated with high levels of unscheduled care that requires high-cost therapy, leading to a significant health economic burden. The identification and appropriate referral to a specialist asthma service is also often delayed by several months or years because of poor recognition and understanding of symptom severity. Current severe asthma services may take several months to provide a comprehensive multidisciplinary assessment, often necessitating multiple hospital visits and costing up to {\textsterling}5000 per patient. Objective: This study aims to evaluate whether a new service model could identify poorly controlled and potentially severe asthma much earlier in the patient pathway, and then compare clinical outcomes between this new care model with standard care. Methods: Modern Innovative Solutions to Improve Outcomes in (MISSION) Severe Asthma is a novel service model developed by asthma specialists from Portsmouth and Southampton severe asthma services. MISSION Severe Asthma identified patients with poorly controlled disease from general practice databases who had not been under secondary outpatient care in the last 12 months or who were not known to secondary care. In 1- or 2-stop assessments, a thorough review of diagnosis, disease phenotype, and control is undertaken, and clinical outcomes collected at baseline. Results: A variety of clinical outcomes will be collected to assess the service model. The results will be reported in February 2020. Conclusions: This protocol outlines a mixed methods study to assess the impact on disease control, unscheduled health care usage, and quality of life in patients seen in the MISSION clinic compared with a closely matched cohort who declined to attend. International Registered Report Identifier (IRRID): DERR1-10.2196/9585 ", doi="10.2196/resprot.9585", url="https://www.researchprotocols.org/2019/10/e9585", url="http://www.ncbi.nlm.nih.gov/pubmed/31603434" } @Article{info:doi/10.2196/14300, author="Venkataramanan, Revathy and Thirunarayan, Krishnaprasad and Jaimini, Utkarshani and Kadariya, Dipesh and Yip, Yung Hong and Kalra, Maninder and Sheth, Amit", title="Determination of Personalized Asthma Triggers From Multimodal Sensing and a Mobile App: Observational Study", journal="JMIR Pediatr Parent", year="2019", month="Jun", day="27", volume="2", number="1", pages="e14300", keywords="personalized digital health", keywords="medical internet of things", keywords="asthma management", keywords="patient-generated health data", keywords="pediatric asthma", keywords="asthma control", keywords="medication adherence", keywords="childhood asthma", keywords="understanding and treatment of asthma", abstract="Background: Asthma is a chronic pulmonary disease with multiple triggers. It can be managed by strict adherence to an asthma care plan and by avoiding these triggers. Clinicians cannot continuously monitor their patients' environment and their adherence to an asthma care plan, which poses a significant challenge for asthma management. Objective: In this study, pediatric patients were continuously monitored using low-cost sensors to collect asthma-relevant information. The objective of this study was to assess whether kHealth kit, which contains low-cost sensors, can identify personalized triggers and provide actionable insights to clinicians for the development of a tailored asthma care plan. Methods: The kHealth asthma kit was developed to continuously track the symptoms of asthma in pediatric patients and monitor the patients' environment and adherence to their care plan for either 1 or 3 months. The kit consists of an Android app--based questionnaire to collect information on asthma symptoms and medication intake, Fitbit to track sleep and activity, the Peak Flow meter to monitor lung functions, and Foobot to monitor indoor air quality. The data on the patient's outdoor environment were collected using third-party Web services based on the patient's zip code. To date, 107 patients consented to participate in the study and were recruited from the Dayton Children's Hospital, of which 83 patients completed the study as instructed. Results: Patient-generated health data from the 83 patients who completed the study were included in the cohort-level analysis. Of the 19\% (16/83) of patients deployed in spring, the symptoms of 63\% (10/16) and 19\% (3/16) of patients suggested pollen and particulate matter (PM2.5), respectively, to be their major asthma triggers. Of the 17\% (14/83) of patients deployed in fall, symptoms of 29\% (4/17) and 21\% (3/17) of patients suggested pollen and PM2.5, respectively, to be their major triggers. Among the 28\% (23/83) of patients deployed in winter, PM2.5 was identified as the major trigger for 83\% (19/23) of patients. Similar correlations were not observed between asthma symptoms and factors such as ozone level, temperature, and humidity. Furthermore, 1 patient from each season was chosen to explain, in detail, his or her personalized triggers by observing temporal associations between triggers and asthma symptoms gathered using the kHealth asthma kit. Conclusions: The continuous monitoring of pediatric asthma patients using the kHealth asthma kit generates insights on the relationship between their asthma symptoms and triggers across different seasons. This can ultimately inform personalized asthma management and intervention plans. ", doi="10.2196/14300", url="http://pediatrics.jmir.org/2019/1/e14300/", url="http://www.ncbi.nlm.nih.gov/pubmed/31518318" } @Article{info:doi/10.2196/11733, author="Hynes, Lisa and Durkin, Kristine and Williford, N. Desire{\'e} and Smith, Hope and Skoner, David and Lilly, Christa and Kothari, Dilip Viral and Mc Sharry, Jenny and Duncan, L. Christina", title="Comparing Written Versus Pictorial Asthma Action Plans to Improve Asthma Management and Health Outcomes Among Children and Adolescents: Protocol of a Pilot and Feasibility Randomized Controlled Trial", journal="JMIR Res Protoc", year="2019", month="Jun", day="17", volume="8", number="6", pages="e11733", keywords="asthma", keywords="child", keywords="adolescent", keywords="education", keywords="self-management", abstract="Background: Asthma is an important focus for pediatric health research as management of asthma symptoms is a significant challenge, and morbidity and mortality among youths with asthma remain prevalent. Treatment guidelines for asthma recommend a written asthma action plan (WAAP) that summarizes individualized instructions for daily medication use. However, WAAPs are typically written at a seventh- to ninth-grade reading level, which can be a barrier to young people in understanding their treatment, having confidence in using a WAAP, and engaging with asthma education. Objective: Utilizing a feasibility and pilot randomized controlled trial (RCT) design, the objective of the Take Action for Asthma Control study is to test a symptom-based, computer-generated pictorial asthma action plan (PAAP) in comparison with a standard WAAP and assess the feasibility and acceptability of the asthma action plan (AAP) intervention and study procedures. The study has 3 aims: (1) estimate the effect sizes of PAAPs compared with WAAPs on outcomes (eg, AAP knowledge and medication adherence), (2) evaluate feasibility and acceptability of AAP intervention and RCT procedures from the perspectives of key stakeholders, and (3) establish whether parent and youth literacy levels are associated with treatment outcomes. Methods: This feasibility and pilot RCT is a block randomized, 2-arm, parallel-group clinical trial, lasting 6 months in duration. At baseline, participants will be randomly assigned to receive a PAAP or WAAP generated for them and reviewed with them by their asthma physician. Study procedures will take place over 4 separate time points: a baseline clinic appointment, 1-month telephone follow-up, and 3- and 6-month clinic-based follow-ups. At each time point, data will be collected related to the main outcomes: AAP knowledge, AAP satisfaction, asthma control, pulmonary function, and adherence to daily asthma medication. A sample size of up to 60 participants (aged 8-17 years) will be recruited. Feasibility and acceptability data will be collected via one-to-one qualitative interviews with providers involved in the study and a subgroup of families that participate in the study. Results: Recruitment and data collection began in May 2017 and were completed in October 2018. Conclusions: This pilot and feasibility study will test the potential efficacy, feasibility, and acceptability of an AAP intervention and study procedures. The findings will inform the design and delivery of a future definitive trial to assess the efficacy of PAAPs versus WAAPs in supporting asthma self-management among children and adolescents. International Registered Report Identifier (IRRID): DERR1-10.2196/11733 ", doi="10.2196/11733", url="https://www.researchprotocols.org/2019/6/e11733/", url="http://www.ncbi.nlm.nih.gov/pubmed/31210140" } @Article{info:doi/10.5210/ojphi.v11i1.9803, title="Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review", journal="Online J Public Health Inform", year="2019", volume="11", number="1", pages="e9803", doi="10.5210/ojphi.v11i1.9803", url="" } @Article{info:doi/10.5210/ojphi.v11i1.9814, title="Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review", journal="Online J Public Health Inform", year="2019", volume="11", number="1", pages="e9814", doi="10.5210/ojphi.v11i1.9814", url="" } @Article{info:doi/10.2196/12411, author="Kosse, C. Richelle and Bouvy, L. Marcel and Belitser, V. Svetlana and de Vries, W. Tjalling and van der Wal, S. Piet and Koster, S. Ellen", title="Effective Engagement of Adolescent Asthma Patients With Mobile Health--Supporting Medication Adherence", journal="JMIR Mhealth Uhealth", year="2019", month="Mar", day="27", volume="7", number="3", pages="e12411", keywords="adolescent", keywords="asthma", keywords="medication adherence", keywords="pharmacists", keywords="telemedicine", abstract="Background: Mobile health (mHealth) apps have the potential to support patients' medication use and are therefore increasingly used. Apps with broad functionality are suggested to be more effective; however, not much is known about the actual use of different functionalities and the effective engagement. Objective: The aim of this study was to explore the use and the effective engagement of adolescents (aged 12 to 18 years) with the Adolescent Adherence Patient Tool (ADAPT). Methods: The ADAPT intervention consisted of an app for patients, which was connected to a management system for their pharmacist. The aim of the ADAPT intervention was to improve medication adherence and, therefore, the app contained multiple functionalities: questionnaires to monitor symptoms and adherence, medication reminders, short movies, pharmacist chat, and peer chat. For this study, data of the ADAPT study and a cluster randomized controlled trial were used. Adolescents with asthma had 6 months' access to the ADAPT intervention, and all app usage was securely registered in a log file. Results: In total, 86 adolescents (mean age 15.0, SD 2.0 years) used the ADAPT app 17 times (range 1-113) per person. Females used the app more often than males (P=.01) and for a longer period of time (P=.03). On average, 3 different functionalities were used, and 13\% of the adolescents used all functionalities of the app. The questionnaires to monitor symptoms and adherence were used by most adolescents. The total app use did not affect adherence; however, activity in the pharmacist chat positively affected medication adherence (P=.03), in particular, if patients sent messages to their pharmacist (P=.01). Conclusions: mHealth apps for adolescents with asthma should contain different functionalities to serve the diverging needs and preferences of individual patients. Suggested key functionalities to promote use and effectiveness in adolescents with asthma are questionnaires to monitor symptoms and a health care provider chat. ", doi="10.2196/12411", url="http://mhealth.jmir.org/2019/3/e12411/", url="http://www.ncbi.nlm.nih.gov/pubmed/30916664" } @Article{info:doi/10.2196/11201, author="Li, Kenan and Habre, Rima and Deng, Huiyu and Urman, Robert and Morrison, John and Gilliland, D. Frank and Ambite, Luis Jos{\'e} and Stripelis, Dimitris and Chiang, Yao-Yi and Lin, Yijun and Bui, AT Alex and King, Christine and Hosseini, Anahita and Vliet, Van Eleanne and Sarrafzadeh, Majid and Eckel, P. Sandrah", title="Applying Multivariate Segmentation Methods to Human Activity Recognition From Wearable Sensors' Data", journal="JMIR Mhealth Uhealth", year="2019", month="Feb", day="07", volume="7", number="2", pages="e11201", keywords="machine learning", keywords="physical activity", keywords="smartphone", keywords="statistical data analysis wearable devices", abstract="Background: Time-resolved quantification of physical activity can contribute to both personalized medicine and epidemiological research studies, for example, managing and identifying triggers of asthma exacerbations. A growing number of reportedly accurate machine learning algorithms for human activity recognition (HAR) have been developed using data from wearable devices (eg, smartwatch and smartphone). However, many HAR algorithms depend on fixed-size sampling windows that may poorly adapt to real-world conditions in which activity bouts are of unequal duration. A small sliding window can produce noisy predictions under stable conditions, whereas a large sliding window may miss brief bursts of intense activity. Objective: We aimed to create an HAR framework adapted to variable duration activity bouts by (1) detecting the change points of activity bouts in a multivariate time series and (2) predicting activity for each homogeneous window defined by these change points. Methods: We applied standard fixed-width sliding windows (4-6 different sizes) or greedy Gaussian segmentation (GGS) to identify break points in filtered triaxial accelerometer and gyroscope data. After standard feature engineering, we applied an Xgboost model to predict physical activity within each window and then converted windowed predictions to instantaneous predictions to facilitate comparison across segmentation methods. We applied these methods in 2 datasets: the human activity recognition using smartphones (HARuS) dataset where a total of 30 adults performed activities of approximately equal duration (approximately 20 seconds each) while wearing a waist-worn smartphone, and the Biomedical REAl-Time Health Evaluation for Pediatric Asthma (BREATHE) dataset where a total of 14 children performed 6 activities for approximately 10 min each while wearing a smartwatch. To mimic a real-world scenario, we generated artificial unequal activity bout durations in the BREATHE data by randomly subdividing each activity bout into 10 segments and randomly concatenating the 60 activity bouts. Each dataset was divided into {\textasciitilde}90\% training and {\textasciitilde}10\% holdout testing. Results: In the HARuS data, GGS produced the least noisy predictions of 6 physical activities and had the second highest accuracy rate of 91.06\% (the highest accuracy rate was 91.79\% for the sliding window of size 0.8 second). In the BREATHE data, GGS again produced the least noisy predictions and had the highest accuracy rate of 79.4\% of predictions for 6 physical activities. Conclusions: In a scenario with variable duration activity bouts, GGS multivariate segmentation produced smart-sized windows with more stable predictions and a higher accuracy rate than traditional fixed-size sliding window approaches. Overall, accuracy was good in both datasets but, as expected, it was slightly lower in the more real-world study using wrist-worn smartwatches in children (BREATHE) than in the more tightly controlled study using waist-worn smartphones in adults (HARuS). We implemented GGS in an offline setting, but it could be adapted for real-time prediction with streaming data. ", doi="10.2196/11201", url="http://mhealth.jmir.org/2019/2/e11201/", url="http://www.ncbi.nlm.nih.gov/pubmed/30730297" } @Article{info:doi/10.2196/10956, author="Morita, Pelegrini Plinio and Yeung, S. Melanie and Ferrone, Madonna and Taite, K. Ann and Madeley, Carole and Stevens Lavigne, Andrea and To, Teresa and Lougheed, Diane M. and Gupta, Samir and Day, G. Andrew and Cafazzo, A. Joseph and Licskai, Christopher", title="A Patient-Centered Mobile Health System That Supports Asthma Self-Management (breathe): Design, Development, and Utilization", journal="JMIR Mhealth Uhealth", year="2019", month="Jan", day="28", volume="7", number="1", pages="e10956", keywords="smartphone", keywords="asthma", keywords="self report", keywords="self-management", keywords="patient compliance", keywords="telemedicine", keywords="risk reduction behavior", keywords="internet", keywords="monitoring, physiologic", keywords="mobile applications", abstract="Background: Uncontrolled asthma poses substantial negative personal and health system impacts. Web-based technologies, including smartphones, are novel means to enable evidence-based care and improve patient outcomes. Objective: The aim of this study was to design, develop, and assess the utilization of an asthma collaborative self-management (CSM) platform (breathe) using content based on international evidence-based clinical guidelines. Methods: We designed and developed breathe as a Web-based mobile health (mHealth) platform accessible on smartphones, tablets, or desktop with user-centered design methods and International Organization for Standardization--certified quality development processes. Moreover, breathe was envisioned as a multifunctional, CSM mHealth platform, with content based on international clinical practice guidelines and compliant with national privacy and security specifications. The system enabled CSM (patient, provider, and breathe) and self-monitoring of asthma patients through (1) assessment of asthma control, (2) real-time access to a dynamic asthma action plan, (3) access to real-time environmental conditions, and (4) risk-reduction messaging. The data collection protocol collected user data for 12 months, with clinic visits at baseline and 6 and 12 months. Utilization outcomes included user interactions with the platform, user impressions, self-reported medication use, asthma symptom profile, reported peak flow measurement, and the delivery and impact of email reminders. Results: We enrolled 138 patients with a mean age of 45.3 years to receive the breathe intervention. Majority were female (100/138, 72.5\%), had a smartphone (92/138, 66.7\%), and had a mean Asthma Control Test score of 18.3 (SD 4.9). A majority reported that breathe helped in the management of their asthma. Moreover, breathe scored 71.1 (SD 18.9) on the System Usability Scale. Overall, 123 patients had complete usage analytics datasets. The platform sent 7.96 reminder emails per patient per week (pppw), patients accessed breathe 3.08 times, journaled symptoms 2.56 times, reported medication usage 0.30 times, and reported peak flow measurements 0.92 times pppw. Furthermore, breathe calculated patients' action plan zone of control 2.72 times pppw, with patients being in the green (well-controlled) zone in 47.71\% (8300/17,396) of the total calculations. Usage analysis showed that 67.5\% (83/123) of the participants used the app at week 4 and only 57.7\% (71/123) by week 45. Physician visits, email reminders, and aged 50 years and above were associated with higher utilization. Conclusions: Individuals with asthma reported good usability and high satisfaction levels, reacted to breathe notifications, and had confidence in the platform's assessment of asthma control. Strong utilization was seen at the intervention's initiation, followed by a rapid reduction in use. Patient reminders, physician visits, and being aged 50 years and above were associated with higher utilization. Trial Registration: ClinicalTrials.gov NCT01964469;?https://clinicaltrials.gov/ct2/show/NCT01964469 ", doi="10.2196/10956", url="http://mhealth.jmir.org/2019/1/e10956/", url="http://www.ncbi.nlm.nih.gov/pubmed/30688654" } @Article{info:doi/10.2196/11988, author="Jaimini, Utkarshani and Thirunarayan, Krishnaprasad and Kalra, Maninder and Venkataraman, Revathy and Kadariya, Dipesh and Sheth, Amit", title="``How Is My Child's Asthma?'' Digital Phenotype and Actionable Insights for Pediatric Asthma", journal="JMIR Pediatr Parent", year="2018", month="Nov", day="30", volume="1", number="2", pages="e11988", keywords="digital phenotype", keywords="actionable insights", keywords="asthma control level", keywords="asthma control test", keywords="digital phenotype score", keywords="controller compliance score", keywords="mobile health", abstract="Background: In the traditional asthma management protocol, a child meets with a clinician infrequently, once in 3 to 6 months, and is assessed using the Asthma Control Test questionnaire. This information is inadequate for timely determination of asthma control, compliance, precise diagnosis of the cause, and assessing the effectiveness of the treatment plan. The continuous monitoring and improved tracking of the child's symptoms, activities, sleep, and treatment adherence can allow precise determination of asthma triggers and a reliable assessment of medication compliance and effectiveness. Digital phenotyping refers to moment-by-moment quantification of the individual-level human phenotype in situ using data from personal digital devices, in particular, mobile phones. The kHealth kit consists of a mobile app, provided on an Android tablet, that asks timely and contextually relevant questions related to asthma symptoms, medication intake, reduced activity because of symptoms, and nighttime awakenings; a Fitbit to monitor activity and sleep; a Microlife Peak Flow Meter to monitor the peak expiratory flow and forced exhaled volume in 1 second; and a Foobot to monitor indoor air quality. The kHealth cloud stores personal health data and environmental data collected using Web services. The kHealth Dashboard interactively visualizes the collected data. Objective: The objective of this study was to discuss the usability and feasibility of collecting clinically relevant data to help clinicians diagnose or intervene in a child's care plan by using the kHealth system for continuous and comprehensive monitoring of child's symptoms, activity, sleep pattern, environmental triggers, and compliance. The kHealth system helps in deriving actionable insights to help manage asthma at both the personal and cohort levels. The Digital Phenotype Score and Controller Compliance Score introduced in the study are the basis of ongoing work on addressing personalized asthma care and answer questions such as, ``How can I help my child better adhere to care instructions and reduce future exacerbation?'' Methods: The Digital Phenotype Score and Controller Compliance Score summarize the child's condition from the data collected using the kHealth kit to provide actionable insights. The Digital Phenotype Score formalizes the asthma control level using data about symptoms, rescue medication usage, activity level, and sleep pattern. The Compliance Score captures how well the child is complying with the treatment protocol. We monitored and analyzed data for 95 children, each recruited for a 1- or 3-month-long study. The Asthma Control Test scores obtained from the medical records of 57 children were used to validate the asthma control levels calculated using the Digital Phenotype Scores. Results: At the cohort level, we found asthma was very poorly controlled in 37\% (30/82) of the children, not well controlled in 26\% (21/82), and well controlled in 38\% (31/82). Among the very poorly controlled children (n=30), we found 30\% (9/30) were highly compliant toward their controller medication intake---suggesting a re-evaluation for change in medication or dosage---whereas 50\% (15/30) were poorly compliant and candidates for a more timely intervention to improve compliance to mitigate their situation. We observed a negative Kendall Tau correlation between Asthma Control Test scores and Digital Phenotype Score as ?0.509 (P<.01). Conclusions: kHealth kit is suitable for the collection of clinically relevant information from pediatric patients. Furthermore, Digital Phenotype Score and Controller Compliance Score, computed based on the continuous digital monitoring, provide the clinician with timely and detailed evidence of a child's asthma-related condition when compared with the Asthma Control Test scores taken infrequently during clinic visits. ", doi="10.2196/11988", url="http://pediatrics.jmir.org/2018/2/e11988/", url="http://www.ncbi.nlm.nih.gov/pubmed/31008446" } @Article{info:doi/10.2196/pediatrics.9576, author="Bakker, Aafke and Janssen, Lindy and Noordam, Cees", title="Home to Hospital Live Streaming With Virtual Reality Goggles: A Qualitative Study Exploring the Experiences of Hospitalized Children", journal="JMIR Pediatr Parent", year="2018", month="Dec", day="13", volume="1", number="2", pages="e10", keywords="experiences", keywords="hospitalization", keywords="mobile phone", keywords="livestream", keywords="pediatrics", keywords="qualitative analysis", keywords="videoconferencing", keywords="virtual reality", abstract="Background: Being separated from home and relatives is a major stressor for children and adolescents when hospitalized. Children long for a manner to be distracted, pleasured, and socially connected during hospitalization. Different technological devices have been applied in health care to answer those needs. Both virtual reality (VR) and videoconferencing have proven their value in hospital wards and pediatrics. VisitU combines these 2 technologies innovatively. VisitU is a recently launched VR product enabling users to be virtually at home during hospitalization. Objective: This study aims to explore the experiences of hospitalized patients with the VR intervention of VisitU in addition to standard care. Methods: Over a 3-month period, a purposive sample of 10 patients hospitalized in the Radboudumc Amalia Children's Hospital was included in this qualitative study. Semistructured interviews were performed, one before and one after the use of the VR device. Patients were asked open-ended questions concerning their experiences with VisitU on practical, cognitive, emotional, and social domains. The interviews were audiorecorded and transcribed verbatim. Atlas.ti was used to support the qualitative analysis. Furthermore, the inductive thematic analysis was done according to the 6-step procedure described by Braun and Clarke. Results: The following 6 main themes were the result of the qualitative analysis: ``Being hospitalized,'' ``Expectations of VisitU,'' ``VisitU in use,'' ``VisitU, the benefits,'' ``The impact of VisitU,'' and ``Barriers when using VisitU.'' The way VisitU was used by patients varied. The main benefits of VisitU were being somewhere else, being at home, and facilitating social connection. Limitations were experienced on the technical abilities, physical side effects, and complexity of use. Despite that, patients were positive about VisitU and unanimous in the view that they would like to use it again and advise other patients to use it. Conclusions: This study shows the positive experiences of pediatric patients with VR live streaming. VisitU brings together the needs of patients and possibilities of VR and videoconferencing; it offers patients a way out of the hospital. Nevertheless, practical and technical obstacles must be overcome and side effects are an area of further research. ", doi="10.2196/pediatrics.9576", url="http://pediatrics.jmir.org/2018/2/e10/", url="http://www.ncbi.nlm.nih.gov/pubmed/31518293" } @Article{info:doi/10.2196/jmir.9245, author="van den Wijngaart, S. Lara and Geense, W. Wytske and Boehmer, LM Annemie and Brouwer, L. Marianne and Hugen, AC Cindy and van Ewijk, E. Bart and Koenen-Jacobs, Marie-Jos{\'e} and Landstra, M. Anneke and Niers, EM Laetitia and van Onzenoort-Bokken, Lonneke and Ottink, D. Mark and Rikkers-Mutsaerts, RVM Eleonora and Groothuis, Iris and Vaessen-Verberne, A. Anja and Roukema, Jolt and Merkus, JFM Peter", title="Barriers and Facilitators When Implementing Web-Based Disease Monitoring and Management as a Substitution for Regular Outpatient Care in Pediatric Asthma: Qualitative Survey Study", journal="J Med Internet Res", year="2018", month="Oct", day="30", volume="20", number="10", pages="e284", keywords="asthma", keywords="barriers and facilitators", keywords="eHealth", keywords="pediatric", keywords="Web-based monitoring", abstract="Background: Despite their potential benefits, many electronic health (eHealth) innovations evaluated in major studies fail to integrate into organizational routines, and the implementation of these innovations remains problematic. Objective: The purpose of this study was to describe health care professionals' self-identified perceived barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient care. Also, we assessed patients' (or their parents) satisfaction with this eHealth innovation. Methods: Between April and November 2015, we recruited 76 health care professionals (from 14 hospitals). During a period of 6 months, participants received 3 questionnaires to identify factors that facilitated or impeded the use of this eHealth innovation. Questionnaires for patients (or parents) were completed after the 6-month virtual asthma clinic (VAC) implementation period. Results: Major perceived barriers included concerns about the lack of structural financial reimbursement for Web-based monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of Web-based portal use on clinician workload, and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals toward eHealth, the possibility to tailor care to individual patients (``personalized eHealth''), easily deliverable care according to current guidelines using the VAC, and long-term profit and efficiency. Conclusions: The implementation of Web-based disease monitoring and management in children is complex and dynamic and is influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context, and economic and political context. Understanding and defining the barriers and facilitators that influence the context is crucial for the successful implementation and sustainability of eHealth innovations. ", doi="10.2196/jmir.9245", url="http://www.jmir.org/2018/10/e284/", url="http://www.ncbi.nlm.nih.gov/pubmed/30377147" } @Article{info:doi/10.2196/10771, author="Bashi, Nazli and Fatehi, Farhad and Fallah, Mina and Walters, Darren and Karunanithi, Mohanraj", title="Self-Management Education Through mHealth: Review of Strategies and Structures", journal="JMIR Mhealth Uhealth", year="2018", month="Oct", day="19", volume="6", number="10", pages="e10771", keywords="health education", keywords="mHealth", keywords="mobile apps", keywords="mobile phone", keywords="patient education", keywords="self-management education", abstract="Background: Despite the plethora of evidence on mHealth interventions for patient education, there is a lack of information regarding their structures and delivery strategies. Objective: This review aimed to investigate the structures and strategies of patient education programs delivered through smartphone apps for people with diverse conditions and illnesses. We also examined the aim of educational interventions in terms of health promotion, disease prevention, and illness management. Methods: We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and PsycINFO for peer-reviewed papers that reported patient educational interventions using mobile apps and published from 2006 to 2016. We explored various determinants of educational interventions, including the content, mode of delivery, interactivity with health care providers, theoretical basis, duration, and follow-up. The reporting quality of studies was evaluated according to the mHealth evidence and reporting assessment criteria. Results: In this study, 15 papers met the inclusion criteria and were reviewed. The studies mainly focused on the use of mHealth educational interventions for chronic disease management, and the main format for delivering interventions was text. Of the 15 studies, 6 were randomized controlled trials (RCTs), which have shown statistically significant effects on patients' health outcomes, including patients' engagement level, hemoglobin A1c, weight loss, and depression. Although the results of RCTs were mostly positive, we were unable to identify any specific effective structure and strategy for mHealth educational interventions owing to the poor reporting quality and heterogeneity of the interventions. Conclusions: Evidence on mHealth interventions for patient education published in peer-reviewed journals demonstrates that current reporting on essential mHealth criteria is insufficient for assessing, understanding, and replicating mHealth interventions. There is a lack of theory or conceptual framework for the development of mHealth interventions for patient education. Therefore, further research is required to determine the optimal structure, strategies, and delivery methods of mHealth educational interventions. ", doi="10.2196/10771", url="https://mhealth.jmir.org/2018/10/e10771/", url="http://www.ncbi.nlm.nih.gov/pubmed/30341042" } @Article{info:doi/10.2196/pediatrics.9796, author="Teufel II, John Ronald and Patel, K. Sachin and Shuler, B. Anita and Andrews, L. Anne and Nichols, Michelle and Ebeling, D. Myla and Dawley, Erin and Mueller, Martina and Ruggiero, J. Kenneth and Treiber, A. Frank", title="Smartphones for Real-time Assessment of Adherence Behavior and Symptom Exacerbation for High-Risk Youth with Asthma: Pilot Study", journal="JMIR Pediatr Parent", year="2018", month="Oct", day="5", volume="1", number="2", pages="e8", keywords="children", keywords="ecological momentary assessment", keywords="medication adherence", keywords="medication monitoring device", keywords="mHealth", keywords="mobile phone", keywords="symptoms", keywords="youth", abstract="Background: Youth with asthma who have poor medication adherence, have limited access to care, and are frequently seen in the acute care setting are often termed ``high risk.'' Objective: This study aimed to design and test the feasibility of using smartphone technology to assess contextual factors that may impact changes in daily medication adherence and to identify new symptom episodes among high-risk youth with asthma in their home environment. Methods: Youth aged 8-17 years with high-risk asthma from 2 children's hospitals were eligible for the 2-month study. An app was downloaded on participants' phones at enrollment. Daily text message (short message service) reminders were sent to complete ecological momentary assessment of asthma symptoms and other contextual factors such as emotional state using the app. Bluetooth inhaler devices were used to record timestamps of inhaler use with the ability to review and manually enter data. The acceptability was assessed with surveys, key informant interviews (KII), and frequency of days with asthma data. KII data were used in an iterative design approach to identify challenges, strengths, and suggestions for maximizing use. Generalized linear mixed modeling was used to preliminarily explore contextual factors associated with changes in daily adherence. Results: We enrolled 14 children aged 8-16 years (13/14, 93\% were African Americans). Over the 2-month study period, participants reported coughing (42/110, 38\%), wheezing (8/111, 7\%), chest tightness (9/109, 8\%), boredom (57/109, 52\%), and 10 new asthma symptom episodes. The controller medication adherence was 30\%, which increased significantly on days with asthma symptoms or boredom. Data were received on 89\% (606/681) of study days. Surveys and KIIs suggest acceptability among youth and their caregivers. Challenges reported during the study included lost or damaged phones and available memory. Conclusions: Youth and their caregivers reported the acceptability of using smartphones for real-time asthma monitoring. Overall, the controller medication adherence was low but increased significantly on days with reported asthma symptoms or boredom, suggesting that daily contextual factors may be associated with a change in the adherence behavior. ", doi="10.2196/pediatrics.9796", url="http://pediatrics.jmir.org/2018/2/e8/", url="http://www.ncbi.nlm.nih.gov/pubmed/31518299" } @Article{info:doi/10.2196/10055, author="Roberts, Courtney and Sage, Adam and Geryk, Lorie and Sleath, Betsy and Carpenter, Delesha", title="Adolescent Preferences and Design Recommendations for an Asthma Self-Management App: Mixed-Methods Study", journal="JMIR Formativ Res", year="2018", month="Sep", day="13", volume="2", number="2", pages="e10055", keywords="asthma", keywords="mHealth", keywords="mobile app", keywords="patient engagement", keywords="self-management", keywords="usability", abstract="Background: Approximately 10\% of adolescents in the United States have asthma. Adolescents widely use apps on mobile phones and tablet technology for social networking and gaming purposes. Given the increase in recreational app use among adolescents, leveraging apps to support adolescent asthma disease management seems warranted. However, little empirical research has influenced asthma app development; adolescent users are seldom involved in the app design process. Objective: The aim of this mixed-methods study was to assess adolescent preferences and design recommendations for an asthma self-management app. Methods: A total of 20 adolescents with persistent asthma (aged 12-16 years) provided feedback on two asthma self-management apps during in-person semistructured interviews following their regularly scheduled asthma clinic visit and via telephone 1 week later. Interviews were audiorecorded, transcribed verbatim, analyzed using SPSS v24, and coded thematically using MAXQDA 11. Results: Regarding esthetics, app layout and perceived visual simplicity were important to facilitate initial app use. Adolescents were more likely to continually engage with apps that were deemed useful and met their informational needs. Adolescents also desired app features that fit within their existing paradigm or schema and included familiar components (eg, medication alerts that appear and sound like FaceTime notifications and games modeled after Quiz Up and Minecraft), as well as the ability to customize app components. They also suggested that apps include other features, such as an air quality tracker and voice command. Conclusions: Adolescents desire specific app characteristics including customization and tailoring to meet their asthma informational needs. Involving adolescents in early stages of app development is likely to result in an asthma app that meets their self-management needs and design preferences and ultimately the adoption and maintenance of positive asthma self-management behaviors. ", doi="10.2196/10055", url="http://formative.jmir.org/2018/2/e10055/", url="http://www.ncbi.nlm.nih.gov/pubmed/30684424" } @Article{info:doi/10.2196/resprot.8872, author="MacDonell, Karen and Naar, Sylvie and Gibson-Scipio, Wanda and Bruzzese, Jean-Marie and Wang, Bo and Brody, Aaron", title="The Detroit Young Adult Asthma Project: Proposal for a Multicomponent Technology Intervention for African American Emerging Adults With Asthma", journal="JMIR Res Protoc", year="2018", month="May", day="07", volume="7", number="5", pages="e98", keywords="asthma", keywords="telemedicine", keywords="medication adherence", keywords="young adults", keywords="health equity", abstract="Background: Racial and ethnic minority youth have poorer asthma status than white youth, even after controlling for socioeconomic variables. Proper use of asthma controller medications is critical in reducing asthma mortality and morbidity. The clinical consequences of poor asthma management include increased illness complications, excessive functional morbidity, and fatal asthma attacks. There are significant limitations in research on interventions to improve asthma management in racial minority populations, particularly minority adolescents and young adults, although illness management tends to deteriorate after adolescence during emerging adulthood, the unique developmental period beyond adolescence but before adulthood. Objective: The objective of the pilot study was to test the feasibility, acceptability, and signals of efficacy of an intervention targeting adherence to controller medication in African American youth (ages 18-29) with asthma. All elements of the protocol were piloted in a National Heart, Lung, and Blood Institute (NHLBI)--funded pilot study (1R34HL107664 MacDonell). Results suggested feasibility and acceptability of the protocol as well as proof of concept. We are now ready to test the intervention in a larger randomized clinical trial. Methods: The proposed study will include 192 African American emerging adults with moderate to severe persistent asthma and low controller medication adherence recruited from clinic, emergency department, and community settings. Half of the sample will be randomized to receive a multicomponent technology-based intervention targeting adherence to daily controller medication. The multicomponent technology-based intervention consists of 2 components: (1) 2 sessions of computer-delivered motivational interviewing targeting medication adherence and (2) individualized text messaging focused on medication adherence between the sessions. Text messages will be individualized based on ecological momentary assessment. The remaining participants will complete a series of computer-delivered asthma education modules matched for length, location, and method of delivery of the intervention session. Control participants will also receive text messages between intervention sessions. Message content will be the same for all control participants and contain general facts about asthma (not tailored). Results: It is hypothesized that youth randomized to multicomponent technology-based intervention will show improvements in medication adherence (primary outcome) and asthma control (secondary outcome) compared with comparison condition at all postintervention follow-ups (3, 6, 9, and 12 months). The proposed study was funded by NHLBI from September 1, 2016 through August 31, 2021. Conclusions: This project will test a brief, technology-based intervention specifically targeting adherence to asthma controller medications in an under-researched population, African American emerging adults. If successful, our multicomponent technology-based intervention aimed at improving adherence to asthma medications has the potential to improve quality of life of minority emerging adults with asthma at relatively low cost. It could eventually be integrated into clinical settings and practice to reach a large number of emerging adults with asthma. Trial Registration: ClinicalTrials.gov NCT03121157; https://clinicaltrials.gov/ct2/show/NCT03121157 (Archived by WebCite at http://www.webcitation.org/6wq4yWHPv) ", doi="10.2196/resprot.8872", url="http://www.researchprotocols.org/2018/5/e98/", url="http://www.ncbi.nlm.nih.gov/pubmed/29735474" } @Article{info:doi/10.2196/mhealth.8849, author="McWilliams, Andrew and Reeves, Kelly and Shade, Lindsay and Burton, Elizabeth and Tapp, Hazel and Courtlandt, Cheryl and Gunter, Andrew and Dulin, F. Michael", title="Patient and Family Engagement in the Design of a Mobile Health Solution for Pediatric Asthma: Development and Feasibility Study", journal="JMIR Mhealth Uhealth", year="2018", month="Mar", day="22", volume="6", number="3", pages="e68", keywords="engagement", keywords="pediatric asthma", keywords="shared decision-making", keywords="health information technology", abstract="Background: Asthma is a highly prevalent, chronic disease with significant morbidity, cost, and disparities in health outcomes. While adherence to asthma treatment guidelines can improve symptoms and decrease exacerbations, most patients receive care that is not guideline-based. New approaches that incorporate shared decision-making (SDM) and health information technology (IT) are needed to positively impact asthma management. Despite the promise of health IT to improve efficiency and outcomes in health care, new IT solutions frequently suffer from a lack of widespread adoption and do not achieve desired results, as a consequence of not involving end-users in design. Objective: To describe a case study of a pediatric asthma SDM health IT solution's development and demonstrate a methodology for engaging actual patients and families in IT development. Perspectives are shared from the vantage point of the research team and a parent of a child with asthma, who participated on the development team. Methods: We adapted user-centric design principles to engage actual users across three main development phases: project initiation, ideation, and usability testing. To facilitate the necessary level of user engagement, our approach included: (1) a Development Workgroup consisting of patients, caregivers, and providers who met regularly with the research team; and (2) ``real-world users'' consisting of patients, caregivers, and providers recruited from a variety of care locations, including safety-net clinics. Results: Using this methodology, we successful partnered with asthma patients and families to create an interactive, digital solution called Carolinas Asthma Coach. Carolinas Asthma Coach incorporates SDM principles to elicit patient information, including goals and preferences, and provides health-literate, tailored education with specific guideline-based recommendations for patients and their providers. Of the patients, caregivers, and providers surveyed, 100\% (n=60) said they would recommend Carolinas Asthma Coach to a friend or colleague. Qualitative feedback from users provided support for the usability and engaging nature of the app. Conclusions: This project demonstrates the feasibility and benefits of deploying user-centric design methods that engage real patients and caregivers throughout the health IT design process. ", doi="10.2196/mhealth.8849", url="http://mhealth.jmir.org/2018/3/e68/", url="http://www.ncbi.nlm.nih.gov/pubmed/29567637" } @Article{info:doi/10.2196/jmir.6994, author="Peters, Dorian and Davis, Sharon and Calvo, Alejandro Rafael and Sawyer, M. Susan and Smith, Lorraine and Foster, M. Juliet", title="Young People's Preferences for an Asthma Self-Management App Highlight Psychological Needs: A Participatory Study", journal="J Med Internet Res", year="2017", month="Apr", day="11", volume="19", number="4", pages="e113", keywords="asthma", keywords="mobile applications", keywords="quality of life", keywords="mental health", keywords="adolescents", keywords="chronic disease", keywords="mhealth", keywords="participatory design", abstract="Background: Although the prevalence of mental illness among young people with asthma is known to be twice the rate of the wider population, none of the asthma apps reported have acknowledged or attempted to include psychological support features. This is perhaps because user involvement in the development of asthma apps has been scarce. User involvement, facilitated by participatory design methods, can begin to address these issues while contributing insights to our understanding of the psychological experience associated with asthma and how technology might improve quality of life. Objective: The goal of this participatory user research study was to explore the experience, needs, and ideas of young people with asthma while allowing them to define requirements for an asthma app that would be engaging and effective at improving their well-being. Methods: Young people aged 15-24 years with doctor-diagnosed asthma were invited to participate in a participatory workshop and to complete a workbook designed to elicit their thoughts and ideas about living with asthma, technology use, and the design of an app. Participants generated a number of artifacts (including collages, concept maps, and paper prototypes) designed to reify their ideas, tacit knowledge, and experience. Results: A total of 20 participants (mean age 17.8 years; 60\%, 12/20 female) representing a range from inadequately to well-controlled asthma completed a workbook and 13 of these also took part in a workshop (four workshops were held in total), resulting in 102 participant-generated artifacts. Theoretical thematic analysis resulted in a set of personal needs, feature ideas, and app characteristics considered relevant by young people for an asthma support app. The data revealed that psychological factors such as anxiety, and impediments to autonomy, competence, and relatedness (as consistent with self-determination theory [SDT]), were considered major influences on quality of life by young people with asthma. Furthermore, the incorporation of features pertaining to psychological experience was particularly valued by participants. Conclusions: In addition to practical features for asthma management, an app for young people with asthma should include support for the mental health factors associated with lived experience (ie, anxiety, lack of autonomy, and social disconnectedness). We show how support for these factors can be translated into design features of an app for asthma. In addition to informing the development of asthma-support technologies for young people, these findings could have implications for technologies designed to support people with chronic illness more generally. ", doi="10.2196/jmir.6994", url="http://www.jmir.org/2017/4/e113/", url="http://www.ncbi.nlm.nih.gov/pubmed/28400353" } @Article{info:doi/10.2196/resprot.6674, author="Adams, A. Sarah and Leach, Chan Michelle and Feudtner, Chris and Miller, A. Victoria and Kenyon, Collin Ch{\'e}n", title="Automated Adherence Reminders for High Risk Children With Asthma: A Research Protocol", journal="JMIR Res Protoc", year="2017", month="Mar", day="27", volume="6", number="3", pages="e48", keywords="asthma", keywords="pediatrics", keywords="child", keywords="child, preschool", keywords="adolescent", keywords="metered dose inhalers", keywords="medication adherence", keywords="text messaging", keywords="pilot projects", keywords="randomized controlled trial", keywords="clinical protocols", abstract="Background: The use of inhaled corticosteroid (ICS) medications has been shown to improve asthma control and reduce asthma-related morbidity and mortality. Two recent randomized trials demonstrated dramatic improvements in ICS adherence by monitoring adherence with electronic sensors and providing automated reminders to participants to take their ICS medications. Given their lower levels of adherence and higher levels of asthma-related emergency department (ED) visits, hospitalizations, and death, urban minority populations could potentially benefit greatly from these types of interventions. Objective: The principal objective of this study will be to evaluate the feasibility, acceptability, and limited efficacy of a text message (short message service, SMS) reminder intervention to enhance ICS adherence in an urban minority population of children with asthma. We will also assess trajectories of ICS adherence in the 2 months following asthma hospitalization. Methods: Participants will include 40 children aged 2-13 years, who are currently admitted to the Children's Hospital of Philadelphia (CHOP) for asthma, and their parent or legal guardian. Participants will be assigned to intervention and control arms using a 1:1 randomization scheme. The intervention arm will receive daily text message reminders for a 30-day intervention phase following hospitalization. This will be followed by a 30-day follow-up phase, in which all participants may choose whether or not to receive the text messages. Feasibility will be assessed by measuring (1) retention of the participants through the study phases and (2) perceived usefulness, acceptability, and preferences regarding the intervention components. Limited efficacy outcomes will include percent adherence to prescribed ICS regimen measured using Propeller Health sensors and change in parent-reported asthma control. We will perform an exploratory analysis to assess for discrete trajectories of adherence using group-based trajectory modeling (GBTM). Results: Study enrollment began in December 2015 and the intervention and follow-up phases are ongoing. Results of the data analysis are expected to be available by December 2016. Conclusions: This study will add to the literature by providing foundational feasibility data on which elements of a mobile health text-message reminder intervention may need to be modified to suit the needs and constraints of high-risk urban minority populations. Trial Registration: Clinicaltrials.gov NCT02615743; https://www.clinicaltrials.gov/ct2/show/study/NCT02615743 (Archived with WebCite at http://www.webcitation.org/6ji59rAXN) ", doi="10.2196/resprot.6674", url="http://www.researchprotocols.org/2017/3/e48/", url="http://www.ncbi.nlm.nih.gov/pubmed/28347975" } @Article{info:doi/10.2196/humanfactors.7133, author="Sage, Adam and Roberts, Courtney and Geryk, Lorie and Sleath, Betsy and Tate, Deborah and Carpenter, Delesha", title="A Self-Regulation Theory--Based Asthma Management Mobile App for Adolescents: A Usability Assessment", journal="JMIR Hum Factors", year="2017", month="Feb", day="01", volume="4", number="1", pages="e5", keywords="mHealth", keywords="asthma", keywords="mobile", keywords="usability", abstract="Background: Self-regulation theory suggests people learn to influence their own behavior through self-monitoring, goal-setting, feedback, self-reward, and self-instruction, all of which smartphones are now capable of facilitating. Several mobile apps exist to manage asthma; however, little evidence exists about whether these apps employ user-centered design processes that adhere to government usability guidelines for mobile apps. Objective: Building upon a previous study that documented adolescent preferences for an asthma self-management app, we employed a user-centered approach to assess the usability of a high-fidelity wireframe for an asthma self-management app intended for use by adolescents with persistent asthma. Methods: Individual interviews were conducted with adolescents (ages 11-18 years) with persistent asthma who owned a smartphone (N=8). Adolescents were asked to evaluate a PDF app wireframe consisting of 76 screen shots displaying app features, including log in and home screen, profile setup, settings and info, self-management features, and graphical displays for charting asthma control and medication. Preferences, comments, and suggestions for each set of screen shots were assessed using the audio-recorded interviews. Two coders reached consensus on adolescent evaluations of the following aspects of app features: (1) usability, (2) behavioral intentions to use, (3) confusing aspects, and (4) suggestions for improvement. Results: The app wireframe was generally well received, and several suggestions for improvement were recorded. Suggestions included increased customization of charts and notifications, reminders, and alerts. Participants preferred longitudinal data about asthma control and medication use to be displayed using line graphs. All participants reported that they would find an asthma management app like the one depicted in the wireframe useful for managing their asthma. Conclusions: Early stage usability tests guided by government usability guidelines (usability.gov) revealed areas for improvement for an asthma self-management app for adolescents. Addressing these areas will be critical to developing an engaging and effective asthma self-management app that is capable of improving adolescent asthma outcomes. ", doi="10.2196/humanfactors.7133", url="http://humanfactors.jmir.org/2017/1/e5/", url="http://www.ncbi.nlm.nih.gov/pubmed/28148471" } @Article{info:doi/10.2196/resprot.5932, author="Geryk, L. Lorie and Roberts, A. Courtney and Sage, J. Adam and Coyne-Beasley, Tamera and Sleath, L. Betsy and Carpenter, M. Delesha", title="Parent and Clinician Preferences for an Asthma App to Promote Adolescent Self-Management: A Formative Study", journal="JMIR Res Protoc", year="2016", month="Dec", day="06", volume="5", number="4", pages="e229", keywords="asthma", keywords="self-management", keywords="social support", keywords="mHealth", keywords="mobile apps", keywords="adolescents", keywords="parents", keywords="clinicians", abstract="Background: Most youth asthma apps are not designed with parent and clinician use in mind, and rarely is the app development process informed by parent or clinician input. Objective: This study was conducted to generate formative data on the use, attitudes, and preferences for asthma mHealth app features among parents and clinicians, the important stakeholders who support adolescents with asthma and promote adolescent self-management skills. Methods: We conducted a mixed-methods study from 2013 to 2014 employing a user-centered design philosophy to acquire feedback from a convenience sample of 20 parents and 6 clinicians. Participants were given an iPod Touch and asked to evaluate 10 features on 2 existing asthma apps. Participant experiences using the apps were collected from questionnaires and a thematic analysis of audio-recorded and transcribed (verbatim) interviews using MAXQDA. Descriptive statistics were calculated to characterize the study sample and app feature feedback. Independent samples t tests were performed to compare parent and clinician ratings of app feature usefulness (ratings: 1=not at all useful to 5=very useful). Results: All parents were female (n=20), 45\% were black, 20\% had an income ?US \$50,000, and 45\% had a bachelor's degree or higher education. The clinician sample included 2 nurses and 4 physicians with a mean practice time of 13 years. Three main themes provided an understanding of how participants perceived their roles and use of asthma app features to support adolescent asthma self-management: monitoring and supervision, education, and communication/information sharing. Parents rated the doctor report feature highest, and clinicians rated the doctor appointment reminder highest of all evaluated app features on usefulness. The peak flow monitoring feature was the lowest ranked feature by both parents and clinicians. Parents reported higher usefulness for the doctor report (t(10)=2.7, P<.02), diary (t(10)=2.7, P<.03), and self-check quiz (t(14)=2.5, P<.02) features than clinicians. Specific participant suggestions for app enhancements (eg, a tutorial showing correct inhaler use, refill reminders, pop-up messages tied to a medication log, evidence-based management steps) were also provided. Conclusions: Parent and clinician evaluations and recommendations can play an important role in the development of an asthma app designed to help support youth asthma management. Two-way asthma care communication between families and clinicians and components involving families and clinicians that support adolescent self-management should be incorporated into adolescent asthma apps. ", doi="10.2196/resprot.5932", url="http://www.researchprotocols.org/2016/4/e229/", url="http://www.ncbi.nlm.nih.gov/pubmed/27923777" } @Article{info:doi/10.2196/resprot.5362, author="Kenyon, Collin Ch{\'e}n and Chang, Joyce and Wynter, Sheri-Ann and Fowler, C. Jessica and Long, Jin and Bryant-Stephens, C. Tyra", title="Electronic Adherence Monitoring in a High-Utilizing Pediatric Asthma Cohort: A Feasibility Study", journal="JMIR Res Protoc", year="2016", month="Jun", day="22", volume="5", number="2", pages="e132", keywords="electronic medication monitoring", keywords="adherence", keywords="beta-agonists", keywords="inhaled steroids", keywords="motivational interviewing", keywords="community health workers", abstract="Background: Inner-city, minority children with asthma have the highest rates of morbidity and death from asthma and the lowest rates of asthma controller medication adherence. Some recent electronic medication monitoring interventions demonstrated dramatic improvements in adherence in lower-risk populations. The feasibility and acceptability of such an intervention in the highest-risk children with asthma has not been studied. Objective: Our objective was to assess the feasibility and acceptability of a community health worker-delivered electronic adherence monitoring intervention among the highest utilizers of acute asthma care in an inner-city practice. Methods: This was a prospective cohort pilot study targeting children with the highest frequency of asthma-related emergency department and hospital care within a local managed care Medicaid plan. The 3-month intervention included motivational interviewing, electronic monitoring of controller and rescue inhaler use, and outreach by a community health worker for predefined medication alerts. We measured acceptability by using a modified technology acceptability model and changes in asthma control using the Asthma Control Test (ACT). Given prominent feasibility issues, we describe qualitative patterns of medication use at baseline only. Results: We enrolled 14 non-Hispanic black children with a median age of 3.5 years. Participants averaged 7.8 emergency or hospital visits in the year preceding enrollment. We observed three distinct patterns of baseline controller use: 4 patients demonstrated sustained use, 5 patients had periodic use, and 5 patients lapsed within 2 weeks. All participants initiated use of the electronic devices; however, no modem signal was transmitted for 5 or the 14 participants after a mean of 45 days. Of the 9 (64\% of total) caregivers who completed the final study visit, all viewed the electronic monitoring device favorably and would recommend it to friends, and 5 (56\%) believed that the device helped to improve asthma control. ACT scores improved by a mean of 2.7 points (P=.05) over the 3-month intervention. Conclusions: High-utilizer, minority families who completed a community health worker-delivered electronic adherence intervention found it generally acceptable. Prominent feasibility concerns, however, such as recruitment, data transmission failure, and lost devices, should be carefully considered when designing interventions in this setting. ", doi="10.2196/resprot.5362", url="http://www.researchprotocols.org/2016/2/e132/", url="http://www.ncbi.nlm.nih.gov/pubmed/27335355" } @Article{info:doi/10.2196/resprot.5261, author="Cave, J. Andrew and Sharpe, Heather and Anselmo, Mark and Befus, Dean A. and Currie, Gillian and Davey, Christina and Drummond, Neil and Graham, Jim and Green, A. Lee and Grimshaw, Jeremy and Kam, Karen and Manca, P. Donna and Nettel-Aguirre, Alberto and Potestio, L. Melissa and Rowe, H. Brian and Scott, D. Shannon and Williamson, Tyler and Johnson, W. David", title="Primary Care Pathway for Childhood Asthma: Protocol for a Randomized Cluster-Controlled Trial", journal="JMIR Res Protoc", year="2016", month="Mar", day="08", volume="5", number="1", pages="e37", keywords="asthma", keywords="child", keywords="chronic disease management", keywords="primary care", keywords="clinical pathway", keywords="asthma education", abstract="Background: Asthma is the most common chronic condition in children. For many, the disease is inadequately controlled, which can burden the lives of children and their families as well as the health care system. Improved use of the best available scientific evidence by primary care practitioners could reduce the need for hospital care and improve quality of life and asthma control, thereby reducing overall costs to society and families. Objective: The Primary Care Pathway for Childhood Asthma aims to improve the management of children with asthma by (1) providing primary care practitioners with an electronic guide (a clinical pathway) incorporated into the patient's electronic medical record, and (2) providing train-the-trainer education to chronic disease management health professionals to promote the provision of asthma education in primary care. Methods: The research will utilize a pragmatic cluster-controlled design, quantitative and qualitative research methodologies, and economic evaluation to assess the implementation of a pathway and education intervention in primary care. The intervention will be analyzed for effectiveness, and if the results are positive, a strategy will be developed to implement delivery to all primary care practices in Alberta. Results: The research has been successfully funded and ethics approvals have been obtained. Practice recruitment began fall 2015, and we expect all study-related activities to be concluded by March 2018. Conclusions: The proposed pathway and education intervention has the potential to improve pediatric asthma management in Alberta. The intervention is anticipated to result in better quality of care for equal or lesser cost. ClinicalTrial: ClinicalTrials.gov NCT02481037; https://clinicaltrials.gov/ct2/show/NCT02481037 (Archived by WebCite at http://www.webcitation.org/6fPIQ02Ma). ", doi="10.2196/resprot.5261", url="http://www.researchprotocols.org/2016/1/e37/", url="http://www.ncbi.nlm.nih.gov/pubmed/26955763" } @Article{info:doi/10.2196/jmir.4975, author="Rhee, Hyekyun and Belyea, J. Michael and Sterling, Mark and Bocko, F. Mark", title="Evaluating the Validity of an Automated Device for Asthma Monitoring for Adolescents: Correlational Design", journal="J Med Internet Res", year="2015", month="Oct", day="16", volume="17", number="10", pages="e234", keywords="asthma", keywords="adolescent", keywords="ambulatory monitoring", keywords="device", keywords="cough", keywords="validity", abstract="Background: Symptom monitoring is a cornerstone of asthma self-management. Conventional methods of symptom monitoring have fallen short in producing objective data and eliciting patients' consistent adherence, particularly in teen patients. We have recently developed an Automated Device for Asthma Monitoring (ADAM) using a consumer mobile device as a platform to facilitate continuous and objective symptom monitoring in adolescents in vivo. Objective: The objectives of the study were to evaluate the validity of the device using spirometer data, fractional exhaled nitric oxide (FeNO), existing measures of asthma symptoms/control and health care utilization data, and to examine the sensitivity and specificity of the device in discriminating asthma cases from nonasthma cases. Methods: A total of 84 teens (42 teens with a current asthma diagnosis; 42 without asthma) aged between 13 and 17 years participated in the study. All participants used ADAM for 7 consecutive days during which participants with asthma completed an asthma diary two times a day. ADAM recorded the frequency of coughing for 24 hours throughout the 7-day trial. Pearson correlation and multiple regression were used to examine the relationships between ADAM data and asthma control, quality of life, and health care utilization at the time of the 7-day trial and 3 months later. A receiver operating characteristic (ROC) curve analysis was conducted to examine sensitivity and specificity based on the area under the curve (AUC) as an indicator of the device's capacity to discriminate between asthma versus nonasthma cases. Results: ADAM data (cough counts) were negatively associated with forced expiratory volume in first second of expiration (FEV1) (r=--.26, P=.05), forced vital capacity (FVC) (r=--.31, P=.02), and overall asthma control (r=--.41, P=.009) and positively associated with daily activity limitation (r=.46, P=.01), nighttime (r=.40, P=.02) and daytime symptoms (r=.38, P=.02), and health care utilization (r=.61, P<.001). Device data were also a significant predictor of asthma control ($\beta$=--.48, P=.003), quality of life ($\beta$=--.55, P=.001), and health care utilization ($\beta$=.74, P=.004) after 3 months. The ROC curve analysis for the presence of asthma diagnosis had an AUC of 0.71 (95\% CI 0.58-0.84), which was significantly different from chance ($\chi$21=9.7, P=.002), indicating the device's discriminating capacity. The optimal cutoff value of the device was 0.56 with a sensitivity of 51.3\% and a specificity of 72.7\%. Conclusions: This study demonstrates validity of ADAM as a symptom-monitoring device in teens with asthma. ADAM data reflect the current status of asthma control and predict asthma morbidity and quality of life for the near future. A monitoring device such as ADAM can increase patients' awareness of the patterns of cough for early detection of worsening asthma and has the potential for preventing serious and costly future consequences of asthma. ", doi="10.2196/jmir.4975", url="http://www.jmir.org/2015/10/e234/", url="http://www.ncbi.nlm.nih.gov/pubmed/26475634" } @Article{info:doi/10.2196/mhealth.3118, author="Rhee, Hyekyun and Miner, Sarah and Sterling, Mark and Halterman, S. Jill and Fairbanks, Eileen", title="The Development of an Automated Device for Asthma Monitoring for Adolescents: Methodologic Approach and User Acceptability", journal="JMIR mHealth uHealth", year="2014", month="Jun", day="19", volume="2", number="2", pages="e27", keywords="asthma", keywords="adolescents", keywords="symptom monitoring", keywords="symptom algorithm", keywords="mobile device", abstract="Background: Many adolescents suffer serious asthma related morbidity that can be prevented by adequate self-management of the disease. The accurate symptom monitoring by patients is the most fundamental antecedent to effective asthma management. Nonetheless, the adequacy and effectiveness of current methods of symptom self-monitoring have been challenged due to the individuals' fallible symptom perception, poor adherence, and inadequate technique. Recognition of these limitations led to the development of an innovative device that can facilitate continuous and accurate monitoring of asthma symptoms with minimal disruption of daily routines, thus increasing acceptability to adolescents. Objective: The objectives of this study were to: (1) describe the development of a novel symptom monitoring device for teenagers (teens), and (2) assess their perspectives on the usability and acceptability of the device. Methods: Adolescents (13-17 years old) with and without asthma participated in the evolution of an automated device for asthma monitoring (ADAM), which comprised three phases, including development (Phase 1, n=37), validation/user acceptability (Phase 2, n=84), and post hoc validation (Phase 3, n=10). In Phase 1, symptom algorithms were identified based on the acoustic analysis of raw symptom sounds and programmed into a popular mobile system, the iPod. Phase 2 involved a 7 day trial of ADAM in vivo, and the evaluation of user acceptance using an acceptance survey and individual interviews. ADAM was further modified and enhanced in Phase 3. Results: Through ADAM, incoming audio data were digitized and processed in two steps involving the extraction of a sequence of descriptive feature vectors, and the processing of these sequences by a hidden Markov model-based Viterbi decoder to differentiate symptom sounds from background noise. The number and times of detected symptoms were stored and displayed in the device. The sensitivity (true positive) of the updated cough algorithm was 70\% (21/30), and, on average, 2 coughs per hour were identified as false positive. ADAM also kept track of the their activity level throughout the day using the mobile system's built in accelerometer function. Overall, the device was well received by participants who perceived it as attractive, convenient, and helpful. The participants recognized the potential benefits of the device in asthma care, and were eager to use it for their asthma management. Conclusions: ADAM can potentially automate daily symptom monitoring with minimal intrusiveness and maximal objectivity. The users' acceptance of the device based on its recognized convenience, user-friendliness, and usefulness in increasing symptom awareness underscores ADAM's potential to overcome the issues of symptom monitoring including poor adherence, inadequate technique, and poor symptom perception in adolescents. Further refinement of the algorithm is warranted to improve the accuracy of the device. Future study is also needed to assess the efficacy of the device in promoting self-management and asthma outcomes. ", doi="10.2196/mhealth.3118", url="http://mhealth.jmir.org/2014/2/e27/", url="http://www.ncbi.nlm.nih.gov/pubmed/25100184" } @Article{info:doi/10.2196/jmir.2413, author="Mulvaney, A. Shelagh and Ho, Yun-Xian and Cala, M. Cather and Chen, Qingxia and Nian, Hui and Patterson, L. Barron and Johnson, B. Kevin", title="Assessing Adolescent Asthma Symptoms and Adherence Using Mobile Phones", journal="J Med Internet Res", year="2013", month="Jul", day="17", volume="15", number="7", pages="e141", keywords="asthma", keywords="adherence", keywords="mobile technology", keywords="adolescent", keywords="assessment", abstract="Background: Self-report is the most common method of measuring medication adherence but is influenced by recall error and response bias, and it typically does not provide insight into the causes of poor adherence. Ecological momentary assessment (EMA) of health behaviors using mobile phones offers a promising alternative to assessing adherence and collecting related data that can be clinically useful for adherence problem solving. Objective: To determine the feasibility of using EMA via mobile phones to assess adolescent asthma medication adherence and identify contextual characteristics of adherence decision making. Methods: We utilized a descriptive and correlational study design to explore a mobile method of symptom and adherence assessment using an interactive voice response system. Adolescents aged 12-18 years with a diagnosis of asthma and prescribed inhalers were recruited from an academic medical center. A survey including barriers to mobile phone use, the Illness Management Survey, and the Pediatric Asthma Quality of Life Questionnaire were administered at baseline. Quantitative and qualitative assessment of asthma symptoms and adherence were conducted with daily calls to mobile phones for 1 month. The Asthma Control Test (ACT) was administered at 2 study time points: baseline and 1 month after baseline. Results: The sample consisted of 53 adolescents who were primarily African American (34/53, 64\%) and female (31/53, 58\%) with incomes US\$40K/year or lower (29/53, 55\%). The majority of adolescents (37/53, 70\%) reported that they carried their phones with them everywhere, but only 47\% (25/53) were able to use their mobile phone at school. Adolescents responded to an average of 20.1 (SD 8.1) of the 30 daily calls received (67\%). Response frequency declined during the last week of the month (b=-0.29, P<.001) and was related to EMA-reported levels of rescue inhaler adherence (r= 0.33, P=.035). Using EMA, adolescents reported an average of 0.63 (SD 1.2) asthma symptoms per day and used a rescue inhaler an average of 70\% of the time (SD 35\%) when they experienced symptoms. About half (26/49, 53\%) of the instances of nonadherence took place in the presence of friends. The EMA-measured adherence to rescue inhaler use correlated appropriately with asthma control as measured by the ACT (r=-0.33, P=.034). Conclusions: Mobile phones provided a feasible method to assess asthma symptoms and adherence in adolescents. The EMA method was consistent with the ACT, a widely established measure of asthma control, and results provided valuable insights regarding the context of adherence decision making that could be used clinically for problem solving or as feedback to adolescents in a mobile or Web-based support system. ", doi="10.2196/jmir.2413", url="http://www.jmir.org/2013/7/e141/", url="http://www.ncbi.nlm.nih.gov/pubmed/23864345" }