Background
Methods
Study design
Matrix order | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |
---|---|---|---|---|---|---|---|---|---|
RCI | 0 | 0 | 0.58 | 0.90 | 1.12 | 1.24 | 1.32 | 1.41 | 1.45 |
Participant recruitment
Procedure
Developing the initial index system
Dimensions | |
1. Goals and planning | |
2. Feedback and monitoring | |
3. Shaping knowledge | |
4. Social support | |
5. Reward and threat | |
6. Natural consequences | |
7. Improving the compliance | |
8. Asthma information | |
9. Patient skills training | |
10. Non-pharmacological interventions | |
Sub- dimensions | 1.1 Goal setting (outcome/behavior) |
1.2 Asthma action plans | |
2.1 Self-monitoring of behavior | |
2.2 Self-monitoring of outcomes of behavior | |
2.3 Feedback | |
3.1 Demonstration of the behavior | |
3.2 Behavior substitution | |
4.1 Practical social support | |
4.2 Emotional support | |
5.1 Social reward | |
5.2 Threat | |
6.1 Information about health consequences | |
6.2 Salience of consequences | |
7.1 Prompts | |
7.2 Regulation | |
8.1 The nature of asthma | |
8.2 Asthma medication | |
8.3 Management of asthma exacerbation | |
8.4 Management of comorbidities | |
9.1 Peak flow meter usage | |
9.2 Inhaler technique | |
10.1 Identifying and avoiding risk factors | |
10.2 Good life style | |
Items | 1.1.1 Ask patients to reflect on what they would consider as good asthma control |
1.1.2 The purpose of asthma control is to have good asthma control and no limited activities | |
1.1.3 Set specific behavior goals in terms of the behavior to be achieved | |
1.1.4 State the factors that influence the behavior, and generate strategies that overcome barriers and increase facilitators | |
1.1.5 Set goals in terms of a positive outcome | |
1.1.6 Re-set new goals in light of achievement | |
1.2.1 Patient should be provided with an asthma action plan, and updated in time | |
1.2.2 State that asthma action plan helps patient to recognize and response appropriately to worsening asthma | |
1.2.3 Set detailed planning of performance of the behavior | |
1.2.4 Patients need to affirm commitment to change the behavior | |
2.1.1 States that the valid approaches for self-monitoring are PEF monitoring and symptom recognition | |
2.1.2 Provides reminders to monitor PEF everyday, and can record details | |
2.1.3 Provides reminders to monitor symptoms everyday, and can record details | |
2.1.4 Provides a diary to record medication | |
2.1.5 Provides a diary to record patients’ feeling | |
2.1.5 Provides a diary to record return visit | |
2.2.1 Provides a diary to record lung function test | |
2.2.2 Provides a diary to record worsening asthma-related events | |
2.2.3 Provides a diary to record factors related to worsening asthma, such as weather | |
2.2.4 Provides asthma assessment tools | |
2.3.1 Monitors and provides informative or evaluative feedback on performance of the behavior | |
2.3.2 Provide professional feedback information based on patients’ inhaler technique | |
2.3.3 Provides evaluative feedback on asthma status | |
2.3.4 Provides informative feedback on asthma severity based on PEF values | |
2.3.5 Generates PEF/symptoms summary visualization | |
2.3.6 Provides result feedback through connecting medical devices | |
3.1.1 Provide video tutorials or animations of peak flow meter use | |
3.1.2 Provide video tutorials or animations of inhaler devices use | |
3.1.3 Provides video tutorials or animations to display instructions of spacer for patients | |
3.2.1 States wanted or neutral behavior to substitute the unwanted behavior | |
3.2.2 States repetition of the wanted behavior | |
4.1.1 Allows establishing a cooperative relationship between doctors and patients | |
4.1.2 Allows setting goals by patients and doctors | |
4.1.3 Provides video tutorials or animations about asthma information introduced by medical workers | |
4.1.4 Allows users to share health data with medical workers through email | |
4.1.5 Allows patients to communicate with patients with controlled asthma | |
4.2.1 States that friends, relatives and medical workers should provide emotional support | |
4.2.2 Provides encouragement and consultation from friends, relatives and medical workers | |
4.2.3 Provides self-incentive in performing the behavior | |
5.1.1 Send incentive information if there has been progress in performing the behavior | |
5.2.1 Do not send incentive information if patients with unwanted behavior | |
6.1.1 Provides information about health consequences of performing the behavior | |
6.1.2 Provides information about social and environmental consequences of performing the behavior | |
6.2.1 Provides methods specifically designed to emphasize the consequences of performing the behavior | |
7.1.1 Set environmental or social stimulus in order to prompt the behavior | |
7.1.2 Allows users to set reminder for medication/return visit | |
7.1.3 Provides reminders for checking inhaler to ensure inhalers are not empty | |
7.1.4 Provides reminders for checking inhaler to ensure inhalers are in date | |
7.2.1 Provides stress-reduction strategies to prevent symptoms from worsening | |
7.2.2 States the importance of avoiding use of multiple different inhaler types | |
8.1.1 Asthma is a chronic respiratory disease, together with airway hyperresponsiveness and airway inflammation | |
8.1.2 Asthma is caused by a combination of endogenous (genetic) and external (environment) causes. | |
8.1.3 Respiratory symptoms of asthma are wheeze, shortness of breath, chest tightness and cough | |
8.1.4 Asthma severity can be assessed as mild asthma, moderate asthma, and severe asthma | |
8.1.5 Asthma cannot be cured, but can be effectively controlled through effective management. | |
8.1.6 Early controller treatment of asthma is critical to achieving optimal outcomes | |
8.2.1 Asthma medications include controller medications and reliever medications | |
8.2.2 Controller medications can be used to reduce airway inflammation, control symptoms, and reduce future risks | |
8.2.3 Controller medications should be used for regular | |
8.2.4 Reliever medications are used to relief breakthrough symptoms | |
8.2.5 Reliever medications are used as needed | |
8.2.6 Local side-effects of ICS include oral thrush and dysphonia | |
8.2.7 Side-effects of oral corticosteroids include osteoporosis, hypertension, and diabetes, etc. | |
8.2.8 Side-effects of ß2-agoinsts include tachycardia and tremor | |
8.2.9 Patients need to carry asthma reliever medications (such as Ventolin solution) with them in case of emergency | |
8.3.1 Early signs and symptoms of worsening asthma are sneezing, runny nose, dry cough, shortness of breath, and chest tightness, etc. | |
8.3.2 Symptoms of asthma exacerbations are a progressive increase in symptoms of shortness of breath, cough, wheezing or chest tightness | |
8.3.3 It is important to adjust treatment plan and went to see the doctor in time | |
8.3.4 Patients were removed from the allergen environment, inhale ß2 agonist, and went to see the doctor in time | |
8.4.1 Complications should be treated, such as rhinitis, sinusitis, and symptomatic gastroesophageal reflux disease | |
8.4.2 Obese patient should lose weight | |
9.1.1 Operational criteria of peak expiratory flow meter: taking a deep breath; sealing your mouth tightly around the mouthpiece; blowing as hard and as fast as you soon; checking the number, re-setting the pointer to zero; and repeating two more times | |
9.1.2 A peak flow meter is used for monitoring lung function changes in patients | |
9.1.3 Patients should use the same meter each time | |
9.2.1 Patients should be encouraged to participate in the choice of inhaler device | |
9.2.2 Emphasizes the importance of correct inhaler technique | |
9.2.3 States that patients should breathe deeply and hold their breath for a few seconds for effective use of inhaler devices | |
9.2.4 Patients should rinse and spit the mouse after using the inhaled hormone | |
9.2.5 States that appropriate use of spacer device can improve effect and reduce adverse drug reactions | |
10.1.1 States identifying risk factors that make asthma worse | |
10.1.2 States the importance of avoidance of environmental smoke exposure | |
10.1.3 States the importance of avoidance of occupational exposures | |
10.1.4 States the importance of avoidance of medications that may make asthma worse | |
10.1.5 States the importance of avoidance of allergens exposure | |
10.2.1 States the importance of consuming a diet high in fruit and vegetables | |
10.2.2 States the importance of avoidance of indoor air pollutants | |
10.2.3 States the importance of engaging in regular physical activity |
Round 1 of Delphi survey
Judgment Criterion | The Degree of Impact on Experts’ Judgement | ||
---|---|---|---|
Large | Medium | Small | |
Impact | Impact | Impact | |
Experience | 0.5 | 0.4 | 0.3 |
Theoretical analysis | 0.3 | 0.2 | 0.1 |
Knowledge of literature | 0.1 | 0.08 | 0.05 |
Instinct | 0.1 | 0.07 | 0.05 |
Round 2 of Delphi survey—determining the weight of each item through AHP
Definition | Intensity of importance | |
---|---|---|
0.25<Aij–Aik ≤ 0.50 | Aij is moderately more important than Aik | 3 |
0.75<Aij–Aik ≤ 1.00 | Aij is strongly more important than Aik | 5 |
1.25<Aij–Aik ≤ 1.50 | Aij is very strongly more important than Aik | 7 |
1.75<Aij–Aik | Aij is extremely more important than Aik | 9 |
Intermediate value between the two adjacent judgements | 2,4,6,8 |
Round 3 of Delphi survey
Round 1 (N = 25) N (%) | Round 2 (N = 24) N (%) | Round 3 (N = 11) N (%) | |
---|---|---|---|
Age (years) | |||
< 40 years old | 11 (44.0) | 11 (45.8) | 6 (54.5) |
40–50 years old | 10 (40.0) | 9 (37.5) | 3 (27.3) |
> 50 years old | 4 (16.0) | 4 (16.7) | 2 (18.2) |
Work experience (years) | |||
10 years or less | 12 (48.0) | 12 (50.0) | 7 (63.6) |
10–20 years | 10 (40.0) | 9 (37.5) | 2 (18.2) |
More than 20 years | 3 (12.0) | 3 (12.5) | 2 (18.2) |
Education | |||
Bachelor’s degree | 5 (20.0) | 5 (20.8) | 1 (9.1) |
Master’s degree | 13 (52.0) | 10 (41.7) | 7 (63.6) |
PhD | 7 (28.0) | 9 (37.5) | 3 (27.3) |
Professional Title | |||
Intermediate title | 11 (44.0) | 8 (33.3) | 4 (36.4) |
Senior vice title | 10 (40.0) | 11 (45.8) | 5 (45.4) |
Senior title | 4 (16.0) | 5 (20.8) | 2 (18.2) |
Affiliation | |||
Educational institution | 6 (24.0) | 5 (20.8) | 5 (45.5) |
Clinical practice | 19 (76.0) | 19 (79.2) | 6 (54.5) |
Data analysis
Results
Survey results
Items | Kendall’s W | χ2 |
P
| |
---|---|---|---|---|
Round 1 | Dimensions | 0.440 | 105.692 | < 0.001 |
Sub-Dimensions | 0.410 | 226.335 | < 0.001 | |
Items | 0.412 | 859.754 | < 0.001 | |
Round 2 | Dimensions | 0.569 | 104.780 | < 0.001 |
Sub-Dimensions | 0.548 | 239.506 | < 0.001 | |
Items | 0.507 | 758.071 | < 0.001 | |
Round 3 | Dimensions | 0.693 | 69.335 | < 0.001 |
Sub-Dimensions | 0.654 | 150.503 | < 0.001 | |
Items | 0.656 | 413.448 | < 0.001 |
Item modifications
Criterion | Round 1 | Round 2 | Round 3 |
---|---|---|---|
Percentage important | ≥42% | ≥44% | ≥65% |
Mean importance rating | ≥4.09 | ≥4.21 | ≥4.53 |
Coefficient of variation | <0.23 | <0.20 | <0.16 |
Dimension | Mean | CV | The percentage important | Decision |
---|---|---|---|---|
Asthma knowledge | 4.80 | 0.083 | 80% | Remaining |
Reward and threat | 3.28 | 0.371 | 20% | Removed |
Social support | 4.08 | 0.229 | 40% | Remaining after discussion |
Criterion | ≥4.09 | <0.23 | ≥42% |
Dimensions | Weight | Sub-Dimensions | Weight | Items | Criteria/Example | Weight | Overall Weight |
---|---|---|---|---|---|---|---|
The following knowledge is included in the apps (i.e., presented in words, pictures, video, etc.): | |||||||
Asthma knowledge | 0.105 | Basic fact about asthma | 0.182 | Definition of asthma | Asthma is a chronic respiratory disease, together with airway hyperresponsiveness and airway inflammation | 0.086 | 0.0016 |
Causes of asthma | Asthma is caused by a combination of endogenous (genetic) and external (environment) causes | 0.123 | 0.0024 | ||||
Respiratory symptoms of asthma | Repeated episodes of wheeze, shortness of breath, chest tightness and cough | 0.177 | 0.0034 | ||||
Prognosis of asthma | Asthma cannot be cured, but can be effectively controlled through effective management | 0.253 | 0.0048 | ||||
Early treatment | Early controller treatment of asthma is critical to achieving optimal outcomes | 0.361 | 0.0069 | ||||
Asthma medications | 0.439 | Categories of asthma medications | Asthma medications include controller medications and reliever medications | 0.138 | 0.0063 | ||
Roles and usage of controller medications | Controller medications can be used to reduce airway inflammation, control symptoms, and reduce future risks, which must be used regularly | 0.240 | 0.0110 | ||||
Roles and usage of reliever medications | Reliever medications can be used to relief breakthrough symptoms, which must be used as needed | 0.182 | 0.0084 | ||||
Side-effects of asthma medications | Local side effects of ICS include oral thrush and dysphonia; osteoporosis, hypertension, and diabetes, etc. in high dose steroids; tachycardia and tremor in ß2-agoinsts | 0.096 | 0.0044 | ||||
Carrying reliever medications | Patients need to carry asthma reliever medications (such as Ventolin solution) with them in case of emergency | 0.344 | 0.0158 | ||||
Management of asthma exacerbations | 0.241 | Early signs and symptoms of worsening asthma | The app describes early signs and symptoms of worsening asthma (sneezing, runny nose, dry cough, shortness of breath, and chest tightness, etc.) | 0.138 | 0.0035 | ||
Symptoms of asthma exacerbations | The app describes symptoms of asthma exacerbations (a progressive increase in symptoms of shortness of breath, cough, wheezing or chest tightness) | 0.195 | 0.0049 | ||||
Management of asthma exacerbations | For example, patients were removed from the allergen environment, inhale ß2 agonist, and went to see the doctor in time | 0.391 | 0.0098 | ||||
Management after asthma exacerbations | Seek the cause of acute attack actively, check medication compliance, and adjust treatment plan | 0.276 | 0.0070 | ||||
Asthma with comorbidities and triggers | 0.138 | Comorbidities of asthma | The app describes comorbidities of asthma, such as, rhinitis, sinusitis, and symptomatic gastroesophageal reflux disease, etc. | 0.249 | 0.0036 | ||
Management of comorbidities | The app provides details of treatment of rhinitis, sinusitis, and symptomatic gastroesophageal reflux disease, and psychological intervention, etc. | 0.157 | 0.0023 | ||||
Triggers of asthma | The app describes triggers of asthma, such as, occupational factors, environmental factors, weather changes, drug and sports | 0.594 | 0.0086 | ||||
Skills training for effective self-management | 0.203 | Peak flow meter use and monitoring | 0.667 | The purpose of using peak flow meter | A peak flow meter is used for monitoring lung function changes in patients | 0.195 | 0.0264 |
Operational criteria for peak flow meter | Take a deep breath, seal your mouth tightly around the mouthpiece and then blow as hard and as fast as you soon. Check the number, re-set the pointer to zero, and repeat two more times | 0.391 | 0.0527 | ||||
The same peak flow meter | The patient should use the same peak flow meter each time | 0.276 | 0.0373 | ||||
The best time to use peak flow meter | PEF is measured in the morning, and then in the evening (after 10-12 h of the first time) | 0.138 | 0.0186 | ||||
Inhaler devices use | 0.333 | Common inhaler devices | The app describes common inhaler devices, such as pressurized metered dose inhalers (pMDI), pMDI +spacer and dry power inhalers (DPIs) | 0.140 | 0.0094 | ||
The importance of correct inhaler technique | Correct inhaler technique can enhance the medication into lung, reduce asthma attack, and obtain the best clinical effect | 0.528 | 0.0356 | ||||
Operational criteria for different inhaler devices | For example, usage of Diskus is that remove mouthpiece cover, position inhaler mouthpiece in mouth and seal lips, inward breath steady and deeply, remove inhaler, hold breath for a few seconds, and rinse mouth | 0.332 | 0.0225 | ||||
Non- pharmacological strategies | 0.094 | Measures to treat asthma triggers | 0.667 | Identifying risk factors that make asthma worse | The app describes factors that make asthma worse, such as allergens exposure, physical and chemical irritants, psychosocial factors, etc. | 0.160 | 0.0100 |
Avoidance of environmental smoke exposure | The app provides advice about avoidance of active smoking and passive smoking | 0.106 | 0.0066 | ||||
Avoidance of occupation exposures | The app provides advice about avoidance of plant dust, animal dust, etc. | 0.255 | 0.0159 | ||||
Avoidance of medications that may make asthma worse | The app provides advice about avoidance of aspirin, NSAIDs, and ß-blockers, etc. | 0.255 | 0.0159 | ||||
Avoidance of allergen exposure | The app provides advice about avoidance of domestic mites, furred animals, fungi, and pollen, etc. | 0.160 | 0.0100 | ||||
Avoidance of indoor and outdoor air pollution | The app provides advice about avoidance of domestic coal burning, cooking, and traffic pollution, etc. | 0.064 | 0.0040 | ||||
Lifestyles | 0.333 | Avoidance of emotional stress | The app provides advice about relieving emotional stress and encouraging breathing exercises, etc. | 0.667 | 0.0209 | ||
Regular moderate physical activity | Patients should exercise regularly and given appropriate exercise advice | 0.333 | 0.0104 | ||||
The following behavioral change strategies are employed in apps: | |||||||
Goals and planning | 0.068 | Goal setting (outcome/behavior) | 0.667 | Allow users to set behavior goals or provide behavior goals | The app allows users to record symptoms and PEF values daily, and assess asthma control level periodically, etc. | 0.667 | 0.0300 |
Allows users to set outcome goals or provide outcome goals | The app allows users to set the goals of asthma control | 0.333 | 0.0150 | ||||
Action plans | 0.333 | Explain the purpose of an asthma action plan | An asthma action plan helps patients to identify early symptoms of asthma attacks and respond appropriately to improve asthma control | 0.500 | 0.0113 | ||
Allow making individualized asthma action plan, and updated in time | The app allows doctors to program asthma action plan directly into their phone or users type in manually | 0.500 | 0.0113 | ||||
Feedback and monitoring | 0.084 | Feedback | 0.250 | Provide result feedback information based on patients’ health data | The app can provide advice based on changing PEF, symptoms or ACT scores | 0.185 | 0.0039 |
Provide professional feedback information based on patients’ inhaler technique | The app allows users to upload the patients’ inhaler technique video through user-end, and then clinicians check inhaler technique in order to identify problematic steps | 0.245 | 0.0051 | ||||
Provide feedback information based on patients’ changing asthma status | The app can provide feedback about severity of asthma based on symptoms or PEF, etc. | 0.323 | 0.0068 | ||||
Allow storing and summarizing patients’ recent health data, and generating summary visualization automatically | The app allows storing patients’ data, such as symptoms, PEF or medicine use | 0.141 | 0.0030 | ||||
Allow connecting medical devices or wearables to upload data and provide feedback information to patients | For example, after the sensor collecting the patients’ vital signs, the app can send the data to end-users and judge whether the patients’ health is in the normal range | 0.106 | 0.0022 | ||||
Self-monitoring of behavior | 0.500 | Provide a diary to record PEF readings and predicted PEFR will be calculated automatically | The app allows users to type in manually or supports pair to the patients’ Bluetooth device automatically for data exchange | 0.195 | 0.0082 | ||
Provide a diary to record patients’ symptoms. | The app provides a diary to record details about wheezing/shortness of breath/sleep, etc. | 0.391 | 0.0164 | ||||
Provide a diary to record medication. | The app provides a diary to record details about medication use, such as categories and frequency, etc. | 0.276 | 0.0116 | ||||
Provide a diary to record return visit. | The app provides a diary to record details about return visit, such as frequency and results, etc. | 0.138 | 0.0058 | ||||
Self-monitoring of outcomes of behavior | 0.250 | Provide a diary to record lung function test. | The app provides a diary to record details about lung function test, such as FEV1, FVC, etc. | 0.0065 | |||
Provide a diary to record worsening asthma-related events. | The app provides a diary to record details about worsening asthma-related events, such as attack symptoms, duration of symptoms, and complications, etc. | 0.196 | 0.0041 | ||||
Provide asthma assessment tools | The app provides asthma assessment tools to assess patient progress, such as Asthma Control Test (ACT) | 0.493 | 0.0104 | ||||
Shaping knowledge | 0.105 | Demonstration of behavior | 1.000 | Provide video tutorials or animations of peak flow meter use | The app provides video tutorials or animations to display instructions of peak flow meter for patients | 0.500 | 0.0524 |
Provide video tutorials or animations of inhaler devices use | The app provides video tutorials or animations to display instructions of inhaler device for patients | 0.500 | 0.0524 | ||||
Social support | 0.049 | Practical support | 0.667 | Allow establishing a cooperative relationship between doctors and patients, and providing patient-doctor communication platform or interactive consultation service | For example, the app offers online consulting service | 0.100 | 0.0324 |
Emotional support | 0.333 | Provide functions of interactive communication among patients | For example, the app provides functions of sharing information and comment, etc. | 0.100 | 0.0162 | ||
Prompts | 0.084 | Reminder | 0.333 | Allow users to set reminders for asthma tests. | The app provides details of asthma tests reminder | 0.139 | 0.0039 |
Allow users to set medication reminder | The app provides details of medication reminder, such as medication name and dosage, etc. | 0.393 | 0.0110 | ||||
Allow users to set reminders for return visit | The app can send information regularly to remind return visit | 0.234 | 0.0066 | ||||
Provide reminders for checking inhalers | The app provides reminders for checking the date and medications dosage of inhalers | 0.234 | 0.0066 | ||||
Warnings | 0.667 | Provide alert based on patients’ changing health data | The app can send warning information automatically when there is abnormal data | 1.000 | 0.0561 | ||
The following design principles are implemented in the apps: | |||||||
Ease of use | 0.105 | Accessibility | 0.429 | The app can be easily accessed and obtained information | The app and its contents are accessible to all users (including all kinds of users with access barriers, such as visual impairment, hearing impairment, etc.) | 1.000 | 0.0449 |
Automation | 0.429 | The app can retrieve patients’ data automatically | The app can connect to health apparatuses to improve efficiency of data collection | 1.000 | 0.0449 | ||
User-friendly interface | 0.142 | All components/screens, menu labels/icons of apps are clear, intuitive, and able to use immediately | Interface design (including menu, background, colors, fonts, etc.) is scientific and reasonable. The operation steps are simple and can be operated according to window prompts without user guide. Navigation is logical and intuitive, and internal and external links are valid | 1.000 | 0.0150 | ||
Usability | 0.105 | Usefulness of knowledge | 0.250 | Information released by apps is for patient’s needs and value | Information contained within apps is accurate and comprehensive, with high utilization rate | 1.000 | 0.0262 |
Rate of update | 0.750 | The app is updated regularly and timely | The app (including its contents, functions and technology) is updated regularly and timely | 1.000 | 0.0786 |