[This is a preview of some of the exciting mHealth research being presented at the mHealth Summit on December 3-5, 2012. This abstract and others are candidates for the iMedicalApps-mHealth Summit Research Award]
By: Lola Awoyinka, iMedicalApps-mHealth Summit Award Finalist
The prevalence of asthma is on the rise in nearly every demographic category. The CDC estimates that in the United States, 8% of the population and 10% of children are currently suffering from asthma at an expense of nearly 60 billion dollars annually.
The numbers are even more striking for minorities and those of low socioeconomic status: 16% of African-American children suffer from asthma, and socioeconomic status has been found to increase the likelihood of being asthmatic when all other factors are accounted for.
Though fatality rates may not be as striking as other chronic diseases, poorly controlled asthma can result in lost productivity and inferior quality of life. Achieving well controlled asthma can be a difficult prospect, but many studies have shown that self-management education can improve asthma control.
Smartphone based technology has emerged as a promising tool for providing such education as well as facilitating behavioral change and promoting healthy choices. CHESS (Comprehensive Health Enhancement Support System) applications are extensively investigated eHealth systems designed to provide information, support, and decision making tools for individuals.
Mobile CHESS or M-CHESS was adapted for smartphones and tailored for use by teens with a current diagnosis of asthma. The M-CHESS application was designed to provide periodic asthma education, medication reminders, case management, an asthma action plan, and access to peers with the primary goal of helping the participants learn to better control their asthma symptoms. The hope was that this additional information and support would improve asthma outcomes.
For our research, 218 inner-city adolescent Medicaid recipients were recruited. Participants were randomized to either a control group (n = 87) which received a smartphone with access to an asthma education website and regular surveys or to an intervention group (n = 131) that received a smartphone pre-installed with M-CHESS. Several surveys – including the Asthma Control Test (ACT®), a clinically validated measure of how well an individual’s asthma symptoms are being managed – were administered throughout the intervention period to both the control and M-CHESS teens via the smartphones.
Before assessing the effect of the application we decided to examine the usage. We found that 55% of teens were still using M-CHESS at the end of the 12 month intervention period. This is notable because it has been demonstrated that use of most health apps has diminished by the end of the first month. When we examined the primary services used we found that the most popular aspect was the social networking pieces, accounting for more than 75% of pages viewed. Educational pages were accessed primarily during the early months of the intervention, just not to the same extent as the social networking content.
We next examined the ACT scores for both groups over time. We observed a distinct difference between the M-CHESS group and the control group midway through the study. The M-CHESS group had a roughly 2 point increase in reported scores at that time. By the end of the 12 month intervention, however, this difference was offset by increases in the control group. It appeared that over time, the improvements seen by the M-CHESS group had been matched by the controls.
This improvement by controls was not anticipated as we would expect that this group would not see any level of improvement. In both groups, the improvement seen was sufficient to decrease the number of participants deemed “uncontrolled” by the ACT and to increase the number of ‘perfect’ scores in both groups, though to a greater extent in the M-CHESS group.
We additionally examined the data to determine whether certain subgroups would benefit more from the M-CHESS system. Our data suggest that teens 11-14 showed more improvement than older teens, and that teens with a more obstructed lung function pattern (as assessed by evaluation of spirometric parameters) may also have benefited more. No difference was seen when examining gender.
So what is this telling us? First, that if you build an app like this, there are ways to get kids to use it. Just be aware that they may not use it the way you imagined . Second, it seems that there may be a role for an intervention like CHESS in some subgroups but it may not be the answer for everyone. Finally, it appears that there is some benefit to regular prompts regarding asthma. The unanticipated benefits of the control group suggest that just the act of filling out regular surveys asking about their asthma may be of some benefit. Perhaps the survey tool itself provides a level of education or behavioral awareness that is sufficient to promote modest levels of improvement in asthma control.
Much work remains to be done to more fully assess the usefulness of such a tool. Further exploration to determine whether there are direct correlations between levels of system engagement and outcomes is needed, as well as examination of whether any improvement persists after the intervention period has ended. Determining the characteristics of those who experienced more dramatic change could also help identify which populations might benefit most from this app. Finally, looking at the effect of the application on lung function parameters and quality of life measures may also provide useful insight into the true value of the tool.
Lola Awoyinka is a Research Specialist at the University of Wisconsin – Madison’s Center for Health Enhancement System Studies (CHESS). The CHESS team works to develop interactive health communication technologies that promote healthy behaviors, improve quality of life, and improve access to services. In her role at CHESS, Lola works primarily on content development, participant engagement and data analysis.