Published on in Vol 20, No 12 (2018): December

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/9666, first published .
Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review

Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review

Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review

Review

1Spoonful of Sugar Ltd, London, United Kingdom

2Pharmaceutical Technology & Development, AstraZeneca, Macclesfield, United Kingdom

3UCL School of Pharmacy, University College London, London, United Kingdom

*all authors contributed equally

Corresponding Author:

Helen J Lycett, BSc, MSc

Spoonful of Sugar Ltd

UCL Business PLC

97 Tottenham Court Road

London, W1T 4TP

United Kingdom

Phone: 44(0)20 3515 5550

Email: helen@sos-adherence.co.uk


Background: Asthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes.

Objective: The study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes.

Methods: Electronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study’s reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis.

Results: Fourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention.

Conclusions: These findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.

J Med Internet Res 2018;20(12):e293

doi:10.2196/jmir.9666

Keywords



Background

Approximately 235 million people worldwide are living with asthma [World Health Organization. 2017. Bronchial asthma   URL: http://www.who.int/en/news-room/fact-sheets/detail/asthma [WebCite Cache]1]. First-line treatment for this chronic disease consists of a combination of quick-reliever inhalers (short-acting beta-agonists) during exacerbations and daily use of preventer medication (mainly inhaled corticosteroids, ICS) to control the disease [Shahidi N, Fitzgerald JM. Current recommendations for the treatment of mild asthma. J Asthma Allergy 2010;3:169-176 [FREE Full text] [CrossRef] [Medline]2]. Asthma is usually self-managed at home by the patient or caregivers [Howell G. Nonadherence to medical therapy in asthma: risk factors, barriers, and strategies for improving. J Asthma 2008;45(9):723-729. [CrossRef] [Medline]3], therefore, its effective control depends upon the patient’s behavior [Horne R, Weinman J. Self-regulation and self-management in asthma: exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication. Psychol Health 2002;17(1):17-32. [CrossRef]4,Eakin MN, Rand CS. Improving patient adherence with asthma self-management practices: what works? Ann Allergy Asthma Immunol 2012;109(2):90-92 [FREE Full text] [CrossRef] [Medline]5].

Efficient self-management involves active commitment to follow a written asthma action plan, self-monitoring symptoms, controlling environmental factors and, importantly, adhering to treatment [Eakin MN, Rand CS. Improving patient adherence with asthma self-management practices: what works? Ann Allergy Asthma Immunol 2012;109(2):90-92 [FREE Full text] [CrossRef] [Medline]5-Pinnock H, Epiphaniou E, Pearce G, Parke H, Greenhalgh T, Sheikh A, et al. Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies. BMC Med 2015;13(1):127 [FREE Full text] [CrossRef] [Medline]7]. Adherence to medication is a major determinant of treatment success in long-term conditions [Gamble J, Stevenson M, McClean E, Heaney LG. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med 2009;180(9):817-822. [CrossRef] [Medline]8,Mokoka MC, Lombard L, MacHale EM, Walsh J, Cushen B, Sulaiman I, et al. In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial. BMJ Open 2017 Jun 15;7(6):e015367 [FREE Full text] [CrossRef] [Medline]9]. An adherence rate to ICS of >80% is needed to reduce asthma exacerbations [Santos PD, D'Oliveira Júnior A, Noblat LD, Machado AS, Noblat AC, Cruz ÁA. Preditores da adesão ao tratamento em pacientes com asma grave atendidos em um centro de referência na Bahia. J Bras Pneumol 2008;34:995-1002. [CrossRef]10], successfully control symptoms, and improve lung function [Mokoka MC, Lombard L, MacHale EM, Walsh J, Cushen B, Sulaiman I, et al. In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial. BMJ Open 2017 Jun 15;7(6):e015367 [FREE Full text] [CrossRef] [Medline]9,Kandane-Rathnayake RK, Matheson MC, Simpson JA, Tang ML, Johns DP, Mészáros D, et al. Adherence to asthma management guidelines by middle-aged adults with current asthma. Thorax 2009;64(12):1025-1031. [CrossRef] [Medline]11]. This level of adherence has also been shown to decrease hospital admissions by 30% [Mokoka MC, Lombard L, MacHale EM, Walsh J, Cushen B, Sulaiman I, et al. In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial. BMJ Open 2017 Jun 15;7(6):e015367 [FREE Full text] [CrossRef] [Medline]9].

Despite these benefits, adherence rates to asthma treatment remain low [Miller L, Schüz B, Walters J, Walters EH. Mobile technology interventions for asthma self-management: systematic review and meta-analysis. JMIR Mhealth Uhealth 2017;5(5):e57 [FREE Full text] [CrossRef] [Medline]12] and variable [Bender BG, Pedan A, Varasteh LT. Adherence and persistence with fluticasone propionate/salmeterol combination therapy. J Allergy Clin Immunol 2006;118(4):899-904. [CrossRef] [Medline]13]. In general, 30% to 70% of people on long-term preventer therapy do not maintain the high levels of adherence necessary for good asthma control. Suboptimal levels of adherence are found in adults [Kandane-Rathnayake RK, Matheson MC, Simpson JA, Tang ML, Johns DP, Mészáros D, et al. Adherence to asthma management guidelines by middle-aged adults with current asthma. Thorax 2009;64(12):1025-1031. [CrossRef] [Medline]11], children [Morton RW, Everard ML, Elphick HE. Adherence in childhood asthma: the elephant in the room. Arch Dis Child 2014;99(10):949-953. [CrossRef] [Medline]14,De Simoni A, Horne R, Fleming L, Bush A, Griffiths C. What do adolescents with asthma really think about adherence to inhalers? Insights from a qualitative analysis of a UK online forum. BMJ Open 2017;7(6):e015245 [FREE Full text] [CrossRef] [Medline]15], and adolescents [Morton RW, Everard ML, Elphick HE. Adherence in childhood asthma: the elephant in the room. Arch Dis Child 2014;99(10):949-953. [CrossRef] [Medline]14-Bender B, Wamboldt FS, O'Connor SL, Rand C, Szefler S, Milgrom H, et al. Measurement of children's asthma medication adherence by self report, mother report, canister weight, and Doser CT. Ann Allergy Asthma Immunol 2000;85(5):416-421. [Medline]16].

Effective self-management of asthma is dependent on multiple factors, including consideration of patients’ perceptual and practical barriers to their disease and treatment [Horne R, Weinman J. Self-regulation and self-management in asthma: exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication. Psychol Health 2002;17(1):17-32. [CrossRef]4]. Patients adopt self-management and adherence behaviors to cope with their illness, and these are influenced by their perceptions of their condition [Leventhal H, Diefenbach M, Leventhal EA. Illness cognition: Using common sense to understand treatment adherence and affect cognition interactions. Cogn Ther Res 1992;16(2):143-163. [CrossRef]17]. Nonadherence to asthma medication is influenced by perceptual barriers such as patients’ doubts about their need for treatment and treatment concerns (eg, fears about possible short- or long-term effects of treatment [Horne R. Compliance, adherence, and concordance: implications for asthma treatment. Chest 2006;130(1):65S-72S. [CrossRef] [Medline]18]) and/or as a result of practical barriers (eg, forgetting, bad inhaler technique).

Inadequate adherence to preventer medication can lead to overuse of relievers and the prescription of higher doses of medication than the patient needs [Mokoka MC, Lombard L, MacHale EM, Walsh J, Cushen B, Sulaiman I, et al. In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial. BMJ Open 2017 Jun 15;7(6):e015367 [FREE Full text] [CrossRef] [Medline]9]. Nonadherence has been associated with uncontrolled asthma, poor clinical outcomes, increased hospitalizations, decreased quality of life, absenteeism from work/school, and mortality in adults and children [Gamble J, Stevenson M, McClean E, Heaney LG. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med 2009;180(9):817-822. [CrossRef] [Medline]8,Williams LK, Pladevall M, Xi H, Peterson EL, Joseph C, Lafata JE, et al. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol 2004;114(6):1288-1293. [CrossRef] [Medline]19-Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. 2014.   URL: http://eprints.uwe.ac.uk/23453/1/why-asthma-still-kills-full-report.pdf [WebCite Cache]21]. Most patients do not inform their health care professional when they stop treatment [Gamble J, Stevenson M, McClean E, Heaney LG. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med 2009;180(9):817-822. [CrossRef] [Medline]8,Levine RJ. Monitoring for adherence: ethical considerations. Am J Respir Crit Care Med 1994;149(2):287-288. [CrossRef] [Medline]22]; therefore, there may be limited opportunities to support patients to get the most from their medicines.

There is a clear need for effective self-management interventions, yet, to date, interventions have had varying degrees of success [Ring N, Malcolm C, Wyke S, Macgillivray S, Dixon D, Hoskins G, et al. Promoting the use of Personal Asthma Action Plans: a systematic review. Prim Care Respir J 2007;16(5):271-283 [FREE Full text] [CrossRef] [Medline]23]. Digital support services (mobile and Web technologies) may increase the accessibility of interventions, given that most people now use electronic devices in their daily lives [Gould G, Nilforooshan R. WhatsApp Doc? BMJ Innov 2016;2(3):109-110 [FREE Full text] [CrossRef] [Medline]24] and are willing to self-manage their disease using mobile technology interventions [Fonseca JA, Costa-Pereira A, Delgado L, Fernandes L, Castel-Branco MG. Asthma patients are willing to use mobile and web technologies to support self-management. Allergy 2006;61(3):389-390. [CrossRef] [Medline]25]. Digital support services can be highly scalable, personalized to increase medication adherence in targeted patient populations, can be applied in real time, and have the potential to provide consistency and delivery at low cost.

Digital adherence interventions, from electronic monitoring to short message service (SMS)–based programs, have been evaluated across long-term conditions with varying degrees of success [Finitsis DJ, Pellowski JA, Johnson BT. Text message intervention designs to promote adherence to antiretroviral therapy (ART): a meta-analysis of randomized controlled trials. PLoS One 2014;9(2):e88166 [FREE Full text] [CrossRef] [Medline]26-Kannisto KA, Adams CE, Koivunen M, Katajisto J, Välimäki M. Feedback on SMS reminders to encourage adherence among patients taking antipsychotic medication: a cross-sectional survey nested within a randomised trial. BMJ Open 2015;5(11):e008574 [FREE Full text] [CrossRef] [Medline]28]. However, the literature has been dominated by small-scale feasibility and exploratory studies and pilot evaluations that lack statistical power [Finitsis DJ, Pellowski JA, Johnson BT. Text message intervention designs to promote adherence to antiretroviral therapy (ART): a meta-analysis of randomized controlled trials. PLoS One 2014;9(2):e88166 [FREE Full text] [CrossRef] [Medline]26,Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014(11):CD000011. [CrossRef] [Medline]29]. For patients with asthma, digital support services may provide a highly accessible and effective means of monitoring and improving adherence to treatment and disease control.

Recent systematic reviews have found that digital interventions can improve adherence to asthma preventer medication and asthma control when compared with standard treatment [Miller L, Schüz B, Walters J, Walters EH. Mobile technology interventions for asthma self-management: systematic review and meta-analysis. JMIR Mhealth Uhealth 2017;5(5):e57 [FREE Full text] [CrossRef] [Medline]12,Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: a systematic review of reviews. Annu Rev Public Health 2015;36:393-415 [FREE Full text] [CrossRef] [Medline]30,McLean G, Murray E, Band R, Moffat KR, Hanlon P, Bruton A, et al. Interactive digital interventions to promote self-management in adults with asthma: systematic review and meta-analysis. BMC Pulm Med 2016;16(1):83 [FREE Full text] [CrossRef] [Medline]31]. Miller et al [Miller L, Schüz B, Walters J, Walters EH. Mobile technology interventions for asthma self-management: systematic review and meta-analysis. JMIR Mhealth Uhealth 2017;5(5):e57 [FREE Full text] [CrossRef] [Medline]12] conducted a recent review and meta-analysis of mobile health (mHealth) interventions for the self-management of asthma comparing mHealth interventions with usual care and found a moderate effect on adherence, a large effect on quality of life, but no significant effect on lung function. The authors also found mHealth interventions to be as effective as paper-based monitoring on adherence and clinical outcomes. However, the findings of individual studies have been inconsistent. Although telemonitoring (text messaging, Web systems, etc) was not associated with better control of asthma symptoms when compared with usual care [Kew KM, Cates CJ. Home telemonitoring and remote feedback between clinic visits for asthma. Cochrane Database Syst Rev 2016(8):CD011714. [CrossRef] [Medline]32], internet-based self-management support has been shown to improve asthma quality of life and asthma control [van Gaalen JL, Beerthuizen T, van der Meer V, van Reisen P, Redelijkheid GW, Snoeck-Stroband JB, SMASHING Study Group. Long-term outcomes of internet-based self-management support in adults with asthma: randomized controlled trial. J Med Internet Res 2013;15(9):e188 [FREE Full text] [CrossRef] [Medline]33].

Guidelines for the development of interventions recommend the use of a theoretical framework or model of behavior change [Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health 2010;31:399-418. [CrossRef] [Medline]34-Stavri Z, Michie S. Classification systems in behavioural science: current systems and lessons from the natural, medical and social sciences. Health Psychol Rev 2012;6(1):113-140. [CrossRef]37]. Theory can be used in various ways, for example, to identify modifiable determinants of health behaviors to be addressed within interventions (eg, illness perceptions), to select appropriate techniques to address behavioral determinants (eg, motivational interviewing), or to select people who are most likely to benefit from the intervention (eg, patients who have misconceptions about their illness or treatment). Many theory-based interventions used to explain health behavior have been based on social cognition theories [Stavri Z, Michie S. Classification systems in behavioural science: current systems and lessons from the natural, medical and social sciences. Health Psychol Rev 2012;6(1):113-140. [CrossRef]37,Holmes EA, Hughes DA, Morrison VL. Predicting adherence to medications using health psychology theories: a systematic review of 20 years of empirical research. Value Health 2014;17(8):863-876 [FREE Full text] [CrossRef] [Medline]38]. These include Social Cognitive Theory (SCT) [Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.39], the Health Belief Model (HBM) [Hochbaum G, Rosenstock I, Kegels S. Health Belief Model.: United States Public Health Service; 1952.   URL: http:/​/www.​infosihat.gov.my/​infosihat/​artikelHP/​bahanrujukan/​HE_DAN_TEORI/​DOC/​Health%20Belief%20Model.​doc [WebCite Cache]40], Theory of Reasoned Action (TRA) [Fishbein MA, Ajzen I. Belief, Attitude, Intention and Behaviour: An Introduction to Theory and Research. Reading, MA: Addison-Wesley; 1975.41], and Theory of Planned Behavior (TPB) [Azjen I. From intentions to actions: a theory of planned behavior. In: Kuhl J, Beckmann J, editors. Action Control: From Cognition to Behavior. Berlin, Heidelberg: Springer; 1985:11-39.42], all of which are based on the premise that people are rational decision makers who can weigh up the advantages and disadvantages of adopting a behavior.

Several reviews of behavior change interventions have shown that interventions that explicitly refer to a theoretical approach to their development are more effective than those that lack a theoretical base [Ammerman AS, Lindquist CH, Lohr KN, Hersey J. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Prev Med 2002;35(1):25-41. [Medline]43-Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull 2007;133(4):673-693. [CrossRef] [Medline]45]. A systematic review of interventions to improve adherence to asthma medicines showed that the use of theory was more common among effective than ineffective interventions [McCullough AR, Ryan C, Macindoe C, Yii N, Bradley JM, O'Neill B, et al. Behavior change theory, content and delivery of interventions to enhance adherence in chronic respiratory disease: a systematic review. Respir Med 2016;116:78-84 [FREE Full text] [CrossRef] [Medline]46], and another study reviewed the application of behavior change theory and clinical guidelines on internet-based asthma interventions [Al-Durra M, Torio MB, Cafazzo JA. The use of behavior change theory in Internet-based asthma self-management interventions: a systematic review. J Med Internet Res 2015;17(4):e89 [FREE Full text] [CrossRef] [Medline]47]. However, these reviews only indicated whether theory was cited within the paper, rather than the extent to which theory was used to guide the development of the intervention or its effect on clinical outcomes. A review of digital interventions across long-term conditions found that more extensive use of theory was associated with a larger effect on health-related behavior [Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12(1):e4 [FREE Full text] [CrossRef] [Medline]48]. To date, no systematic reviews of asthma self-management interventions have assessed how the use of theory impacts their effectiveness; therefore, little is known about how and to what extent theory has been applied, which theoretical models show promise, or which components of these models are most effective.

Objectives

This review was designed to address the following questions about how best to use theory in the development of digital self-management interventions for asthma: (1) are theory-based digital interventions to enhance asthma self-management effective at changing behavior and improving clinical outcomes and quality of life?; (2) which theories have been applied to the development of digital interventions to enhance asthma self-management, and which theoretical constructs and behavioral determinants have been addressed?; (3) how and to what extent have theoretical models been applied to the development of digital interventions to enhance asthma self-management?


Literature Search

Searches were conducted using CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and PsycINFO. Predetermined terms within titles, abstracts, and keywords were used to identify relevant studies. More detailed information about search terms used is available in

Multimedia Appendix 1

Search terms. Terms within columns were combined using the Boolean "OR" operator, terms between columns were then combined with "AND," that is, papers were retrieved if the title/abstract/keywords contained at least one term from each column.

PDF File (Adobe PDF File), 111KBMultimedia Appendix 1 Searches were completed on June 22, 2017. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097 [FREE Full text] [CrossRef] [Medline]49].

Selection of Papers

Titles, abstracts, and keywords from the electronic searches were screened independently by 2 researchers (HJL, EKW) and coded as “include” or “exclude” with both researchers screening all studies (100% overlap). Discrepancies were resolved by a third researcher (VC). Full texts of relevant papers were subjected to further scrutiny, and reference lists within relevant papers were hand-searched for significant titles, which were screened following the same process above. Final papers were selected based on the inclusion and exclusion criteria presented in Textbox 1. The selection process of papers for the review is summarized in Figure 1.

Quality Assessment

The Cochrane Collaboration tool [Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928 [FREE Full text] [Medline]50] was used to assess bias in the studies reporting on randomized controlled trials (RCTs). The item blinding participants and personnel was excluded because it would not be possible to blind participants to the use of the digital intervention. Each of the remaining 6 items was rated independently (low/high/unclear) by 2 researchers (HJL, EKW). Any disagreements were resolved through discussion.

Data Extraction and Synthesis

Study Characteristics

Data were extracted by 2 independent researchers (HL, EKW). Data extracted on characteristics of the interventions included country, study design (RCT or pre-post design), inclusion criteria of participants, sample size, percentage of females, and mean age (or range). Details can be found in

Multimedia Appendix 2

Study characteristics: Study design, population characteristics, and intervention engagement.

PDF File (Adobe PDF File), 126KBMultimedia Appendix 2.

Mode of Digital Delivery

Interventions were classified as fully digital or partly digital (digital and nondigital components). Data were extracted on the type of digital platform (eg, SMS, smart device app) and the type of nondigital component (eg, telephone call, paper-based). Full details are available in

Multimedia Appendix 3

Details of mode of delivery of the intervention.

PDF File (Adobe PDF File), 118KBMultimedia Appendix 3.

Outcomes

To be able to compare the efficacy of the interventions on self-management, and as studies reported on different outcomes, only outcomes relevant to the study were extracted (EKW, EMR; eg, knowledge was not included) and classified under one of these overall themes: adherence to medication, self-management and asthma control, clinical markers of health, quality of life, other quality of life outcomes and health care utilization (Table 1). The intervention was considered to be effective on a specific outcome if the study reported a statistically significant (P<.05) improvement in the outcome. This included a significantly improved outcome in the intervention group relative to the control group for RCTs or a significant positive change in the outcome in pre-post studies. A score based on the study’s reported significance level was assigned to each outcome (2=if reported as a significant P value, 1=if reported as a marginally significant P value, and 0=if reported as not significant). An average score was applied when different suboutcomes of the same outcome were reported in the same study (eg, both symptom days and symptom nights were reported as clinical markers of health [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51]). Finally, an average score was calculated for each study by adding the average outcome scores and dividing this result by the total number of outcomes. Therefore, interventions were deemed to be fully effective if they were associated with an outcome average score of 2.0, partially effective if they were in the range of 1.0 to 1.9, and not effective if the score was in the range of 0 to 0.9.

Inclusion and exclusion criteria.

Inclusion criteria

  • Paper in English
  • Patients with asthma
  • Empirical study (pilot, feasibility, or evaluative study)
  • Intervention focused on patient (rather than physician or carer)
  • Digital intervention (eg, online intervention, smart phone app, electronic monitor, short message service (SMS), interactive voice recognition, or wearable
  • Intervention designed to enhance adherence or persistence with asthma medication or self-management
  • Explicit mention of the use of theory to design the self-management intervention or to increase engagement with the intervention

Exclusion criteria

  • Conference abstracts
  • Paper not in English
  • Review or letter
  • Intervention is delivered to parent(s) of children with asthma
  • Not an empirical study
  • Clinician focus (clinician attitude, behavior, or diagnostic tool)
  • Intervention not designed to enhance self-management or adherence or persistence with asthma medication
  • Intervention was not electronic
  • Full-text paper not available
Textbox 1. Inclusion and exclusion criteria.
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the selection process of studies included in the review.
View this figure
Table 1. Application of theory according to the Theory Coding Scheme (TCS) and effectiveness scores for study outcomes.
Authors, yearNBehavior change model/theoryTheory Coding Scheme (Item number)% theory appliedAdherenceSelf-management and controlClinical markers of healthQuality of lifeOther Quality of life outcomesHealth care utilizationOutcomes average score
Bartholomew, 2000 [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54]133SRMa; SCTb1; 3; 5; 636N/Ac22N/AN/A11.67
Bartlett, 2002 [Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62]16SLTd1; 2; 3; 5; 6; 7; 8; 9732N/AN/AN/AN/AN/A2
Huss, 2003 [Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56]101PRECEDE-PROCEED model; Developmental; Social Support and learning theories1; 2; 527N/AN/A00N/A N/A0
Krishna, 2003 [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58]228SRTe19N/AN/A1.33010.670.78
Joseph, 2007 [Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57]315Transtheoretical Model; HBMf1; 2; 5; 6; 11451N/A201.331.51.17
Bender, 2010 [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55]50Benefit-Risk Model of Health Behavior1; 2; 3; 53620N/A0N/AN/A0.68
Petrie, 2012 [Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60]148Extended SRM1; 2; 3; 4; 5; 6; 7;11732N/AN/AN/AN/AN/A2
Burns, 2013 [Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63]51TPBg1; 318N/A1N/A2N/AN/A1.5
Joseph, 2013 [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51]422HBM1; 2; 5; 6; 1145N/A21N/A0.6700.92
Lau, 2015 [Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59]330HBM; SCT; SETh; Transtheoretical change1; 2; 5; 8; 1145N/A00N/A000
Wiecha, 2015 [Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61]58SCT191N/A0N/A0.2500.31
Ahmed, 2016 [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53]98Behavior change; SET; Motivational Theory1; 218N/A0 1N/A00.33
Speck, 2016 [Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64]44SCT1; 2; 3; 5; 6; 8; 1164N/A2 2N/AN/A2
Warren, 2016 [Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65]12SRT1; 2; 327N/A020N/AN/A0.67

aSRM: Self-Regulatory Model.

bSCT: Social Cognitive Theory.

cN/A: not applicable.

dSLT: Social Learning Theory.

eSRT: Self-Regulation Theory.

fHBM: Health Belief Model.

gTPB: Theory of Planned Behavior.

hSET: Self-Efficacy Theory.

Use of Theory

Data extracted included the theory(ies) reported in the intervention and the theoretical construct(s) addressed by the intervention. The Theory Coding Scheme (TCS) [Michie S, Prestwich A. Are interventions theory-based? Development of a theory coding scheme. Health Psychol 2010;29(1):1-8. [CrossRef] [Medline]52] was used to assess the extent to which theory had been applied. This instrument consists of 19 items, from which items 1 to 11 were relevant to this review, as items 12 to 19 do not measure the use of theory in the development of the interventions [Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12(1):e4 [FREE Full text] [CrossRef] [Medline]48]. Items 1 to 11 assessed whether theory was mentioned in the paper, the use of theory to select participants, intervention techniques, or tailoring of the intervention and whether theoretical constructs or behavioral determinants were explicitly linked to intervention techniques [Michie S, Prestwich A. Are interventions theory-based? Development of a theory coding scheme. Health Psychol 2010;29(1):1-8. [CrossRef] [Medline]52]. For each study, a percentage score was calculated representing the proportion of relevant TCS items applied to the intervention ([number of TCS items applied divided by number of relevant TCS items] × 100).

Data Synthesis

Narrative synthesis was used to describe the impact of the interventions on the study outcomes and the application of theory in the development of the interventions. Pearson correlation coefficients were used to calculate the correlation between the effectiveness of interventions and the percentage score for the use of theory.


Characteristics of the Interventions

From 1136 papers originally identified, 14 met the inclusion criteria (Figure 1).

Multimedia Appendix 2

Study characteristics: Study design, population characteristics, and intervention engagement.

PDF File (Adobe PDF File), 126KBMultimedia Appendix 2 shows full details of the studies’ design and population characteristics. Of the 14 studies, 71% (10/14) reported on RCTs [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53-Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61]), and 29% (4/14) were feasibility studies employing a pre-post design [Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62-Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65]. In all, 71% (10/14) of studies were undertaken in the United States. Studies included children (36%, 5/14) [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65]), adolescents (14%, 2/14) [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57]), adults (43%, 6/14); [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64]), and mixed samples (7%, 1/14) [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58]). Between 35% and 82% of the samples were female. Sample sizes ranged from 16 to 422 and included a total of 1856 participants.

Multimedia Appendix 3

Details of mode of delivery of the intervention.

PDF File (Adobe PDF File), 118KB
Multimedia Appendix 3
shows details of the type of digital platforms, the frequency of the interventions, details of the nondigital component, if applicable, and control conditions. None of the included studies incorporated measures to prevent dropout, with details of adoption and engagement with the interventions shown in

Multimedia Appendix 2

Study characteristics: Study design, population characteristics, and intervention engagement.

PDF File (Adobe PDF File), 126KB
Multimedia Appendix 2
. A total of 2 studies involved patients in the development of the interventions [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63].

Effectiveness of Theory-Based Digital Interventions to Enhance Asthma Self-Management

Effect of Interventions on Behavioral Outcomes
Medication Adherence

Five studies (36%, 5/14) reported on adherence to preventer medications (Table 1), from which 3 studies measured adherence using electronic monitoring [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62], and 2 used self-report [Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60]. This included 4 RCTs [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61] and the single pre-post study [Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62]. A total of 3 studies reported a significant positive effect of the intervention on adherence [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62]. Moreover, 2 studies were considered as having a partial effect, 1 reported controller medication adherence improved significantly from baseline for the subgroup of subjects with low (<75%) adherence on the intervention group only but also reported no significant differences in change between the intervention group and control group (P=.10) [Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61]; the other study [Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57] described their result as only marginally significant (P=.09; see Table 1).

Self-Management and Control

A total of 8 studies (57%; 8/14) measured self-management and control outcomes (

Multimedia Appendix 4

Behavioral (adherence, self-management, and control) and clinical outcomes of studies. Randomized control trials’ (RCT) values reported in this table refer to the differences between intervention (IG) and control groups (CG); values for pre-post intervention studies report changes from baseline.

PDF File (Adobe PDF File), 223KBMultimedia Appendix 4). Each of the 8 studies (5 RCTs and 3 pre-post studies) that measured self-management behavior and control [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53-Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63-Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65] used a different measure. In terms of self-management, these included the Partners in Health Scale [Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63], a validated measure of self-management behaviors [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54] and the Asthma Belief survey [Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65]. Asthma control was measured by the Asthma Control Questionnaire (ACQ) [Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59], the Asthma Control Test (ACT) [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64], potential overuse of rescue fast-acting bronchodilators [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53], indicators of uncontrolled asthma [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51], and the Royal College of Physicians 3-questions screening tool [Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63]. In addition, 3 studies reported a significant positive effect of the intervention on self-management behavior [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54], 2 studies reported a significant positive effect on asthma control [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64], and 1 study [Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63] reported the intervention had a significant positive outcome on asthma control but not on self-management (Table 1). Only 1 [Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] of the 2 pre-post studies showing a significant effect of the intervention on asthma control reported that the improvement of over 3 points on the ACT at 3 months was greater than the minimally important difference.

Effect of the Interventions on Clinical Outcomes
Clinical Markers of Health

A total of 8 studies (57%, 8/14: 7 RCTs and 1 pre-post study) reported on clinical markers of health (

Multimedia Appendix 4

Behavioral (adherence, self-management, and control) and clinical outcomes of studies. Randomized control trials’ (RCT) values reported in this table refer to the differences between intervention (IG) and control groups (CG); values for pre-post intervention studies report changes from baseline.

PDF File (Adobe PDF File), 223KBMultimedia Appendix 4). Measures included asthma symptoms, symptom days or symptom nights [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58], forced expiratory volume [Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56], functional status measure [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54], severe asthma exacerbation [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58], worsening of asthma needing treatment changes [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58], reported days of wheezing [Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61], peak expiratory flow rate [Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65], days of reliever use, and average daily dose of ICS [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58]. Moreover, 3 studies reported a significant effect of the intervention on all of their clinical markers measured [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65] (Table 1).

Quality of Life

A total of 8 studies (57%, 8/14: 5 RCTs and 3 pre-post studies) reported on quality of life [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55-Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63-Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65] (

Multimedia Appendix 4

Behavioral (adherence, self-management, and control) and clinical outcomes of studies. Randomized control trials’ (RCT) values reported in this table refer to the differences between intervention (IG) and control groups (CG); values for pre-post intervention studies report changes from baseline.

PDF File (Adobe PDF File), 223KBMultimedia Appendix 4). Validated measures included the Asthma Quality of Life Questionnaire (AQLQ) [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64], the Paediatric Asthma Quality of Life Questionnaire [Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65], and the mini AQLQ [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53]. Two studies developed a quality of life measure specific to their study [Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63]. In addition, 2 studies [Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] reported a significant positive effect of the intervention on quality of life (Table 1). One study [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53] reported a significant improvement from baseline to 3 months, but this effect was not significant at 6- and 9-month follow-ups.

Other Quality of Life Outcomes

A total of 5 studies (36%; 5/14) reported on factors influencing quality of life [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57-Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61] (

Multimedia Appendix 4

Behavioral (adherence, self-management, and control) and clinical outcomes of studies. Randomized control trials’ (RCT) values reported in this table refer to the differences between intervention (IG) and control groups (CG); values for pre-post intervention studies report changes from baseline.

PDF File (Adobe PDF File), 223KBMultimedia Appendix 4). These included nights of sleep disturbance or patient awakening [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61], days of activity limitation/restricted activity [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61], number of school days missed [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61], number of work days missed [Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59], days of changed plans [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57], and number of days the patient had to slow down [Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61]. Two studies were partly effective in improving these outcomes [Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58] (Table 1). For example, although in 1 study [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58], days of activity limitation and number of school days missed significantly decreased in the intervention group only (P<.01), there were no significant differences between the control and intervention groups.

Health Care Utilization

A total of 7 studies (50%, 7/14, all being RCTs) reported on health care utilization [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57-Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61] (

Multimedia Appendix 4

Behavioral (adherence, self-management, and control) and clinical outcomes of studies. Randomized control trials’ (RCT) values reported in this table refer to the differences between intervention (IG) and control groups (CG); values for pre-post intervention studies report changes from baseline.

PDF File (Adobe PDF File), 223KBMultimedia Appendix 4). All measured the number of emergency department visits or hospitalizations over a given time. A total of 3 studies also reported the total number of urgent visits to a health care professional, general practitioner, or physician [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61]. In all, 2 studies reported a significant decrease in hospitalizations following the intervention but no significant differences in emergency room visits [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57]. One study found a significant decrease in emergency department annual visits in the intervention group but not for the number of hospitalizations or urgent visits to physicians [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58]. A total of 4 studies did not find any significant effect of the intervention on health care utilization outcomes (Table 1).

Theories That Have Been Applied to Intervention Development

Details of the theoretical basis of the intervention are shown in Table 1. Theories included Social Cognitive Theory [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64], Health Belief Model [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59], Theory of Planned Behavior [Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63]; Social Learning Theory [Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62], the Transtheoretical Model [Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57], the PRECEDE-PROCEED model [Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56], developmental and social support and learning theories [Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56], Behavior Change theory and Motivational theory [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53], the Benefit-Risk Model of Health Behavior [Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55], and Self-Efficacy Theory [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59]. A total of 5 of the interventions referenced the Self-Regulatory Model, Common Sense Model of Self-Regulation, Extended Common Sense Model of Self-Regulation, Illness Perceptions, or Necessity Concerns Framework in the development of the intervention [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65].

Theoretical Constructs That Have Been Addressed

Theoretical constructs/behavioral determinants specified within the models and addressed in the interventions included illness perceptions, which specifically explored identity, consequences, timeline, personal control, treatment control, concern, understanding, and emotional response to the illness [Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60]; beliefs about medicines were addressed in 3 interventions by targeting patients’ beliefs about the necessity of their medication and their concerns about taking their medication [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60]. General control beliefs [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] and self-efficacy beliefs looked at how confident patients felt in areas such as self-management, which is taking medicines as prescribed, and self-awareness, which includes recognizing and acting on the symptoms [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65].

The Extent Theoretical Models Have Been Applied

Responses to the TCS are shown in Table 1, and the frequency each item was reported in the studies is illustrated in Figure 2. In line with the study inclusion criteria, all studies (100%, 14/14) mentioned theory (item 1), and 10 studies (71%, 10/14) [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55-Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59-Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] mentioned a target construct as a predictor of behavior (item 2). Theory was explicitly used to select or develop intervention techniques (item 5) in 9 studies (64%, 9/14) [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54-Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64]. A total of 7 studies (50%, 7/14) [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62-Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65] referred to the application of a single theory rather than a combination of different theories (Item 3). A total of 6 studies (43%, 6/14) [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] used theory or predictors to tailor intervention techniques to participants (item 6). A total of 3 studies (21%, 3/14) [Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] linked at least 1 intervention technique to a theory-relevant construct/ predictor (item 8), 2 studies (14%, 2/14) [Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62] linked all intervention techniques to at least 1 theory-relevant predictor (item 7), and 1 study [Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62] (7%, 1/14) linked a group of techniques to a group of clusters/predictors (item 9). Only 1 study (7%, 1/14) [Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60] screened or selected participants based on a particular score or level on a theory-relevant construct or predictor (item 4). No studies linked every theoretical construct within a stated theory to an intervention technique (item 10); however, 5 studies (36%, 5/14) [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] linked at least 1 theoretical construct to at least 1 intervention technique (item 11).

The use of theory as assessed by the TCS ranged from 9% to 73%. Three studies applied >60% of the different uses of theory based on the items of the TCS (6 items) [Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60,Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64] (Table 1). All 3 of these studies (100%) showed a significant positive effect of the intervention on all behavioral and clinical outcomes measured (average score 2.0; Table 1). Comparably, from the 11 studies that incorporated ≤60% of theory, no study was fully effective, but 3 interventions were partially effective (average score range 1.0-1.9) [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Burns P, Jones SC, Iverson D, Caputi P. AsthmaWise - a field of dreams? The results of an online education program targeting older adults with asthma. J Asthma 2013;50(7):737-744. [CrossRef] [Medline]63]. All other studies yielded average scores of <1.0. There was a significant correlation between the percentage of theory applied to the interventions and the effectiveness of the intervention (outcomes average score) (r=.657; P=.01). To assess whether sample size had an influence on the results, correlations were recalculated excluding Bartlett et al [Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39(1):47-54. [Medline]62], with a small sample size of n=16. Results showed correlations were still highly significant, indicating theory and effectiveness were not biased by sample size (r=.581; P=.04). None of the studies reported using theory to promote engagement with the intervention.

Figure 2. Frequency items from the Theory Coding Scheme used in the studies.
View this figure
Figure 3. Risk of bias across interventions.
View this figure

Risk of Bias Assessment

Risk of bias assessment was performed on the 10 RCTs included in the review. The results are shown in Figure 3, and complete details are provided in

Multimedia Appendix 5

Risk of Bias table.

PDF File (Adobe PDF File), 158KBMultimedia Appendix 5. A total of 6 studies reported using appropriate random sequence generation methods; of these all used computer-generated random allocation [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55-Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60]. Four studies did not specify the method of randomization [Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61]. Only 1 study reported concealment of allocation [Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60], while this was unclear for the remaining 9 studies. None of the studies specified whether there had been blinding of the outcome assessment. Three studies were considered to have high risk of incomplete outcome data [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care 2003;17(2):72-78. [CrossRef] [Medline]56,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59] due to high rates of attrition, whereas the remainder were considered to have low risk. A total of 9 studies were assessed as having low-risk of selective reporting, while this was unclear in 1 study [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58] as measures had not been stated at the outset.


Summary of Findings

This review identified 14 studies that evaluated theory-based digital interventions in RCTs or pre-post studies. A range of different theories had been used in the development of these interventions, most frequently Social Cognitive Theory, the Health Belief Model, and the Common-Sense Model of Self-Regulation [Joseph CL, Ownby DR, Havstad SL, Saltzgaber J, Considine S, Johnson D, et al. Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach. J Adolesc Health 2013;52(4):419-426 [FREE Full text] [CrossRef] [Medline]51,Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns 2000;39(2-3):269-280. [Medline]54,Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med 2010;23(2):159-165 [FREE Full text] [CrossRef] [Medline]55,Joseph CL, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, et al. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007;175(9):888-895 [FREE Full text] [CrossRef] [Medline]57-Wiecha JM, Adams WG, Rybin D, Rizzodepaoli M, Keller J, Clay JM. Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial. BMC Pulm Med 2015;15(1):17-27 [FREE Full text] [CrossRef] [Medline]61,Speck AL, Hess M, Baptist AP. An electronic asthma self-management intervention for young African American adults. J Allergy Clin Immunol Pract 2016;4(1):89-95. [CrossRef] [Medline]64,Warren CM, Dyer A, Blumenstock J, Gupta RS. Leveraging mobile technology in a school-based participatory asthma intervention: Findings from the Student Media-Based Asthma Research Team (SMART) study. J Health Educ 2016;47(2):59-70. [CrossRef]65]. The findings indicate that the use of psychological theory can enhance the effectiveness of digital interventions, as interventions that incorporated a more extensive use of theory were more likely to achieve successful outcomes. These findings are consistent with those of previous systematic reviews showing that digital self-management interventions can be effective at improving clinical outcomes in asthma [Miller L, Schüz B, Walters J, Walters EH. Mobile technology interventions for asthma self-management: systematic review and meta-analysis. JMIR Mhealth Uhealth 2017;5(5):e57 [FREE Full text] [CrossRef] [Medline]12,Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: a systematic review of reviews. Annu Rev Public Health 2015;36:393-415 [FREE Full text] [CrossRef] [Medline]30,Tran N, Coffman JM, Sumino K, Cabana MD. Patient reminder systems and asthma medication adherence: a systematic review. J Asthma 2014;51(5):536-543. [CrossRef] [Medline]66] and suggest that theory-based interventions may be more effective than interventions that have not used theory in their development [McCullough AR, Ryan C, Macindoe C, Yii N, Bradley JM, O'Neill B, et al. Behavior change theory, content and delivery of interventions to enhance adherence in chronic respiratory disease: a systematic review. Respir Med 2016;116:78-84 [FREE Full text] [CrossRef] [Medline]46]. A previous meta-analytic review of internet- based interventions also found that extensive use of theory was associated with larger effect sizes on health behavior change [Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12(1):e4 [FREE Full text] [CrossRef] [Medline]48].

To our knowledge, this is the first systematic review to examine the extent to which theory has been applied to the development of digital self-management interventions for asthma. We found substantial differences between studies in terms of their use of theory. Although most of the studies that mentioned theory referred to the use of theory in the development of their interventions, fewer studies explicitly reported the use of theory to select recipients for the intervention or indicated how they had linked intervention techniques, relevant constructs or predictors. Our findings suggest that interventions that incorporated these items in their development were more likely to be effective; however, only a small number of studies utilized these constructs. Further research is, therefore, required to ascertain how the application of theory in the development of interventions impacts their effectiveness.

Other factors, such as the delivery channel (eg, via different digital platforms), the context in which the intervention is delivered (eg, via hospital or routine assessments), and the type of user (eg, children vs adults) may also influence outcomes. The fact that interventions that applied theory to a similar extent could have varying degrees of effectiveness implies that the use of theory is necessary, but not sufficient, for a successful intervention.

Strengths and Limitations

The strengths of this review include the systematic approach, inclusion of a range of interventions focusing on many different self-management behaviors, and the use of a reliable instrument to determine the extent to which theory had been used to inform the design of the interventions. The heterogeneity in outcomes measured precluded the use of meta-analysis, therefore, we were not able to determine the size of the effect. Although the findings indicate an increasing number of researchers are utilizing theory in the development of digital interventions for asthma, there were insufficient numbers of studies referencing each theoretical model to determine whether any one theory showed promise over another.

Limitations of the individual studies included a lack of information describing the interventions. Often it was not possible to determine which behavioral determinants had been targeted or how they had been addressed by the intervention. This could be improved in future studies through the use of a framework such as the Template for Intervention Description and Replication checklist [Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014;348:g1687. [Medline]67] to describe the intervention. This would not only aid replication but also allow a more reliable and thorough assessment of the process by which digital self-management interventions exert their effect. In addition, there was a lack of information on methods of randomization and concealment in many of the studies, meaning that the risk of bias was often unclear. Eysenbach [Krishna S, Francisco BD, Balas EA, König P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111(3):503-510. [Medline]58] stated there is a need to address the “law of attrition,” which relates to the dropout and nonengagement in electronic health users. A high dropout rate was observed in the interventions included within this review [Ahmed S, Ernst P, Bartlett SJ, Valois MF, Zaihra T, Paré G, et al. The effectiveness of web-based asthma self-management system, My Asthma Portal (MAP): a pilot randomized controlled trial. J Med Internet Res 2016;18(12):e313 [FREE Full text] [CrossRef] [Medline]53,Lau AY, Arguel A, Dennis S, Liaw ST, Coiera E. “Why didnt it work?” Lessons from a randomized controlled trial of a web-based personally controlled health management system for adults with asthma. J Med Internet Res 2015;17(12):e283 [FREE Full text] [CrossRef] [Medline]59,Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients' illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17(1):74-84. [CrossRef] [Medline]60]. However, none of the included studies incorporated measures to engage participants in the intervention and prevent dropout, and none of the studies mentioned they used theory to increase engagement with the interventions. The short duration of some studies means that individual studies may have been underpowered or overpowered for individual outcomes. Further research is needed to explore how theory could specifically target engagement behavior to achieve effective engagement.

Implications of Our Findings for Clinical Care and Future Research

Our findings suggest that theory-based digital interventions to enhance asthma self-management can be effective at improving adherence and self-management and that more extensive use of theory in the development and application of digital interventions for asthma self-management may enhance their effectiveness. However, although a number of theories have been applied to the development of asthma digital interventions, it is not clear whether any particular theory is more effective. Furthermore, most studies lack details on the theoretical constructs used and behavioral determinants addressed by the intervention, and whether or how these have been applied to the design or application of the intervention. The systematic recording and reporting on the use of theory in the development of future interventions is, therefore, important. It is not sufficient to merely state theory has been used; there should be specific reference to exactly how it has informed the design of the intervention. The TCS can be used to inform the design of an intervention, ensuring that the theoretical basis of an intervention is adequately and clearly described so that the use of theory can be evaluated.

Acknowledgments

AstraZeneca commissioned and funded Spoonful of Sugar to undertake this review. The funders have had no influence on the content of the review.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Search terms. Terms within columns were combined using the Boolean "OR" operator, terms between columns were then combined with "AND," that is, papers were retrieved if the title/abstract/keywords contained at least one term from each column.

PDF File (Adobe PDF File), 111KB

Multimedia Appendix 2

Study characteristics: Study design, population characteristics, and intervention engagement.

PDF File (Adobe PDF File), 126KB

Multimedia Appendix 3

Details of mode of delivery of the intervention.

PDF File (Adobe PDF File), 118KB

Multimedia Appendix 4

Behavioral (adherence, self-management, and control) and clinical outcomes of studies. Randomized control trials’ (RCT) values reported in this table refer to the differences between intervention (IG) and control groups (CG); values for pre-post intervention studies report changes from baseline.

PDF File (Adobe PDF File), 223KB

Multimedia Appendix 5

Risk of Bias table.

PDF File (Adobe PDF File), 158KB

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ACT: Asthma Control Test
AQLQ: Asthma Quality of Life Questionnaire
HBM: Health Belief Model
ICS: inhaled corticosteroids
mHealth: mobile health
RCT: randomized controlled trials
SCT: Social Cognitive Theory
SET: Self-Efficacy Theory.
SLT: Social Learning Theory
SMS: short message service
SRM: Self-Regulatory Model
SRT: Self-Regulation Theory
TCS: Theory Coding Scheme
TPB: Theory of Planned Behavior


Edited by G Eysenbach; submitted 15.01.18; peer-reviewed by L Morrison, E Arden-Close, D Carpenter, A Kotlo; comments to author 22.03.18; revised version received 03.08.18; accepted 07.08.18; published 12.12.18

Copyright

©Helen J Lycett, Eva M Raebel, Emilie K Wildman, Jordi Guitart, Thomas Kenny, Jon-Paul Sherlock, Vanessa Cooper. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 12.12.2018.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.


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