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RCTs - Protocols/Proposals (eHealth) (538)

Published on in Vol 2, No 2 (2013): Jul-Dec

An Internet Intervention to Improve Asthma Management: Rationale and Protocol of a Randomized Controlled Trial

An Internet Intervention to Improve Asthma Management: Rationale and Protocol of a Randomized Controlled Trial

An Internet Intervention to Improve Asthma Management: Rationale and Protocol of a Randomized Controlled Trial

Authors of this article:

Amaël Arguel1 ;   Annie YS Lau1 ;   Sarah Dennis2 ;   Siaw-Teng Liaw2, 3, 4 ;   Enrico Coiera1
Article Authors Cited by (9) Tweetations (3) Metrics

    Protocol

    1Centre for Health Informatics, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia

    2Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia

    3School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia

    4Academic General Practice Unit, Fairfield Hospital, Sydney, Australia

    Corresponding Author:

    Amaël Arguel, PhD

    Centre for Health Informatics

    Australian Institute of Health Innovation

    University of New South Wales

    AGSM building, level 1

    University of New South Wales

    Sydney, NSW 2052

    Australia

    Phone: 61 2 9385 8691

    Fax:61 2 9385 8692

    Email: a.arguel@unsw.edu.au


    Background: Many studies have shown the effectiveness of self-management for patients with asthma. In particular, possession and use of a written asthma action plan provided by a doctor has shown to significantly improve patients’ asthma control. Yet, uptake of a written asthma action plan and preventative asthma management is low in the community, especially amongst adults.

    Objective: A Web-based personally controlled health management system (PCHMS) called Healthy.me will be evaluated in a 2010 CONSORT-compliant 2-group (static websites verse PCHMS) parallel randomized controlled trial (RCT) (allocation ratio 1:1).

    Methods: The PCHMS integrates an untethered personal health record with consumer care pathways and social forums. After eligibility assessment, a sample of 300 adult patients with moderate persistent asthma will be randomly assigned to one of these arms. After 12 months of using either Healthy.me or information websites (usual care arm), a post-study assessment will be conducted.

    Results: The primary outcome measure is possession of or revision of an asthma action plan during the study. Secondary outcome measures include: (1) adherence to the asthma action plan, (2) rate of planned and unplanned visits to healthcare providers for asthma issues, (3) usage patterns of Healthy.me and attrition rates, (4) asthma control and asthma exacerbation scores, and (5) impact of asthma on life and competing demands, and days lost from work.

    Conclusions: This RCT will provide insights into whether access to an online PCHMS will improve uptake of a written asthma action plan and preventative asthma actions.

    Trial Registration: Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12612000716864; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362714 (Archived by WebCite at http://www.webcitation.org/6IYBJGRnW).

    JMIR Res Protoc 2013;2(2):e28

    doi:10.2196/resprot.2695

    Keywords

    asthma management; Internet intervention; personalized health record; personally controlled health management system; eHealth; asthma action plan 


    Background

    Around 300 million people worldwide currently suffer from asthma [1]. The mortality caused by asthma is significant since a global estimation attributes to this disease about 1 in every 250 deaths [1]. Living with asthma is also difficult. People with asthma report worse health and quality of life than those without asthma [2,3].

    Solutions have been developed to help people with asthma cope with their condition [4]. One of the key elements to optimal asthma management is to achieve good control of the disease. To achieve that, patients’ knowledge in recognizing asthma symptoms, identifying risk factors, using medication, and managing asthma exacerbations is important. Further, the relationship between patients with asthma and healthcare providers is crucial to develop an efficient asthma self-management plan [5].

    One of the most useful tools in facilitating effective asthma self-management is the use of an individualized written asthma action plan, which describes different tailored steps of actions for the patient to follow according to their asthma severity. Written asthma action plans are claimed to be one of the most effective means for asthma self-management in several systematic reviews [6-8]. A Cochrane review by Gibson and colleagues concludes that use of a written asthma action plan, combined with regular visits to the doctor and education about asthma, leads to fewer visits to the emergency department, less hospital admissions, better lung function, and improvement on symptoms [6]. Online social networks and personal health management systems represent an innovative intervention to help patients engage with clinicians, health services, and self-management [9]. Despite strong evidence for the efficacy of written asthma action plans, they are widely under-used. Even after over 20 years of recommendation, only about one in 5 people with asthma have a written asthma action plan [10].

    In Australia, the prevalence of asthma is particularly high and represents one of the highest in the world [2,3]. More than 1 in 10 adults and children is estimated to be suffering from asthma, representing more than 2 million Australians [2]. Although prevalence of asthma has declined over the last decade, the mortality caused by this disease remains significant with 411 people reported to have died from asthma in 2009 in Australia. According to a survey from the Australian Council of Asthma Monitoring in 2007 and 2008, only 21.3% of all-age patients with asthma are reported to possess a written asthma action plan [2,3]. This rate dropped to 14.4% when considering a subgroup of people aged 15 years and over [2].

    There are a number of explanations for the under-usage of written asthma action plans by patients. Firstly, the diagnosis of asthma may not have been made in primary care where symptoms have been treated, if the disease is not labeled then patients may not be provided with long-term self-management tools [11]. When asthma is properly diagnosed, some health professionals provide patients with oral instruction instead of a formal written asthma action plan [12]. Others may consider asthma action plans as inefficient tools because of a lack of information and a difference of perception of asthma between patients and doctors [13,14]. From the patient’s point-of-view, asthma action plans can also be perceived as irrelevant or be under-used because of a passive attitude toward their asthma. This can prevent them from taking personal control of their asthma [15,16]. Finally, another reason could be that patients do not visit healthcare professionals to obtain or to update their asthma action plan, or do not ask for it when they see their general practitioner [15].

    For asthma, Internet-based self-management appears to be a promising approach to improve control of this condition [17-21]. The aim of this study is to test a Web-based personally controlled health management system (PCHMS), in supporting consumers with asthma to encourage the uptake and use of a personal written asthma action plan, and to proactively seek self-management advice and schedule planned general practitioner (GP) visits before experiencing an asthma exacerbation. The PCHMS, called Healthy.me, has been previously tested with patients undergoing in-vitro fertilization (IVF) [22], in a randomized controlled trial to improve uptake of influenza vaccination [23,24], and amongst university students about help-seeking behaviors for physical and emotional well-being [25,26].

    Study Aims and Hypotheses

    Specific hypotheses to be tested in this study are that:

    1. Consumers using a Web-based PCHMS with interactive and social features are more likely to follow evidence-based guideline recommendations for asthma management, as measured by the rates of obtaining or updating a written asthma action plan with their GP and the usage rates with the asthma action plan, measured by questionnaires;
    2. Use of a PCHMS will contribute to improved asthma control and reduced rates of asthma exacerbation compared to those using only static websites (usual care arm).

    Study Design

    A randomized controlled trial with a 2-group parallel design (with intervention allocation ratio 1:1) will be used to evaluate the efficacy of the Web-based PCHMS Healthy.me, reported in accordance to the 2010 CONSORT statements [27](ACTRN12612000716864). The PCHMS is not part of usual care but aims to improve usual care as measured by compliance to evidence-based guidelines.

    • Participants randomized to the intervention group will have immediate access to an interactive version of Healthy.me with full PCHMS features as described later, from the date they are recruited.
    • Participants randomized to the control group will receive access to a static webpage, without PCHMS features or any interactive component. This webpage will offer links to Australian information websites about asthma.

    Participants

    Participants meeting eligibility criteria will be invited to use Healthy.me for 12 months. Participants will be assigned to intervention (access to Healthy.me) or control (access to static website) by random allocation generated by a computerized random-number generator [28]. Participants may be randomly selected to attend a 1-hour interview (or focus group) to discuss their asthma management and feedback at the end of the study. The participant inclusion eligibility criteria are as follows: (1) aged 18 or above, (2) living in Australia at the time of the study, (3) easy access to the Internet and email on a regular basis, (4) doctor diagnosis of asthma, and (5) adequate English reading and written ability. Participants currently enrolled in other trials of Healthy.me are excluded.

    Recruitment Strategy

    The recruitment of participants will be made possible with the assistance of Asthma Foundation Australia, the National Asthma Council Australia, and other consumer groups which have an online presence, to advertise our study using their existing participant engagement methods (ie, electronic newsletters and website). Because the study requires participants who are familiar with the use of the Internet, special emphasis will be given to Internet-based recruitment. Calls for research participants will be made on Google, Facebook, Twitter, and other online/social media on a regular basis, as well as on an online notice board (Gumtree Australia). It will also be possible that some participants will be recruited by others participants (snowballing sampling) via sharing in social networks, and thanks to the “invite a friend” feature they will be able to use on Healthy.me website.

    Interested participants will be directed to a website with detailed information about the study. All consenting participants (control and intervention) will then be directed to a secure website to complete an eligibility screening survey.

    Ethical Concerns and Consent

    Ethics approval for this study has been obtained from the University of New South Wales (UNSW) Human Research Ethics Committee (approval no. HC12213), and from the National Research and Evaluation Ethics Committee of the Royal Australian College of General Practitioners (RACGP) (approval no. NREEC 12-005). Eligible participants will complete their written consent form online; the revocation of consent form is also available online.

    Intervention and Control

    All participant volunteers responding to the invitation are required to register online by providing consent, completing a 3-minute eligibility questionnaire. Those eligible will then be invited to complete a 10-minute online pre-study survey and to watch a 3-minute online tutorial about Healthy.me. All eligible participants will also complete a 5-minute monthly survey during the study and a 10-minute post-study survey at 12 months. The control and intervention arms of the trial run concurrently, meaning that the randomly allocated participants of the trial will be exposed to the same environmental condition (eg, season), and the same background of public health campaigns.

    Description of Intervention

    Healthy.me consists of the following features:

    1. Personal Health Record (PHR). Allows for self-recording of medical test results and health measurements.
    2. Pillbox. Allows for self-recording of current medications and medication adherence.
    3. Schedule, to-do list, and reminders. An online schedule to self-record and keep track of health-related appointments, to-do items, which sends email reminders, and allows participants to book appointments with their health service providers.
    4. Team. A feature that allows the self-recording of clinical and non-clinical personnel looking after one’s health.
    5. Journeys. Consumer-specific care pathways that provide knowledge for health service engagement and self-management in an actionable way. These pathways describe the different stages in the management of health conditions that can be used to personalize other PHR sections in the system, and provides advice on what to expect and how to prepare for each stage (Participants in this study will have access to three asthma management journeys with content developed in collaboration with Asthma Foundation NSW, and adapted from its website [29]).
    6. Social communication spaces. Support rich interaction across the continuum of care between participants and clinicians. The features include: (1) a poll system in which participants will be able to answer simple health-related questions and compare their response with other participants’ aggregated and de-identified responses; (2) ability to send and receive email messages with other participants on Healthy.me; (3) diary which offers a private place (by default but with the possibility to share with other participants) for participants to write down their thoughts and feelings; and (4) forums (moderated by a GP and the research team).
    7. Online appointment booking service. This feature allows participants to be directly connected by telephone and at no charge with their health professional after clicking on a button. The 3 steps of the protocol are: First, participant clicks on a “book now” graphic button in Healthy.me and confirms his/her telephone number as well as health professional’s one; Second, participant and health professional receive an automatic ongoing call from the service, and Third, participant and health professional are connected each other and can book an appointment over the phone.
    Intervention Group and Exposure

    The period of access to Healthy.me will vary depending on the date of participant registration (from 9 to 12 months). During the study Healthy.me will provide participants in the intervention group with information and forward email reminders about asthma, indications for managing their asthma or other medical concerns, should they wish to use that service.

    The intervention will not modify in any way the standard procedures of healthcare provision by GP clinics.

    A pilot study has been conducted with 9 adults including 3 participants with asthma. Issues on system usability, journey content, surveys, study protocol, and advertisement material have been resolved before recruiting participants with asthma to participate in their normal setting.

    Control

    Participants in the control group will receive only a static webpage with links to external evidence-based materials written for consumers on asthma management available in Australia without the PCHMS features listed previously (ie, myDr.com.au, HealthInSite.gov.au, and asthmaaustralia.org.au), and delayed access to the full interactive version of Healthy.me by 12 months.

    Sample Size

    A conservative estimate of at least 300 participants with 150 in each arm is needed to detect a 15% point difference in possession rate of a written asthma action plan between the control group (14.4%) and the intervention group (29.4%). This estimate is calculated at 5% level of significance, 80% power (2-sided test), with an anticipated participant dropout rate approximately 25%.

    The effect size estimate is based on previous studies using Healthy.me assessing the efficacy of Internet-based interventions on the uptake of preventative health actions [23], and on studies with interventions promoting the use of personal asthma action plans [13]. The base rate is the percentage of adults (ie, 15 years and over) with current asthma in Australia and possessing a written asthma action plan, reported in the Australia Centre for Asthma Monitoring analysis of the Australian Bureau of Statistics National Health Survey 2007-2008, and cited in the Australia Centre for Asthma Monitoring 2011 report [2].

    Outcome Measures

    The primary measure is the number of participants who have obtained, or have updated, their written asthma action plan with a GP within the 12 months of the study. The secondary outcomes concern actual use rate of the written asthma action plan, number of unplanned visit to healthcare for asthma, usage of Healthy.me, asthma symptoms, and competing demands on health and asthma. Please see Table 1 below.

    Table 1. Summary of outcome measures.
    Outcome measures
    		Measurement time points &
    methods
    		Time



    		BaselineMonthlyCompletion
    Primary outcome





    		Number of participants with a written asthma action planPre and post-study surveysX
    		X
    Secondary outcomes




    		Number of participants reported using their written asthma action plan, obtained, or updated during the studyPost-study surveyX
    		X

    		Rate of planned (non-urgent) visits to a healthcare professional (eg, GP) for routine asthma managementPost-study survey

    		X

    		Rate of unplanned visits to a GP, emergency department, caused by worsening asthmaPost-study survey

    		X

    		Website usage patterns (number and timing of hits, duration of access, uptake of specific functions) of Healthy.meHealthy.me system logs

    		X

    		Technology acceptance of Healthy.me

    		Measured via the “Scales for Perceived Usefulness and Perceived Ease of Use” [30]



    		X

    		Asthma controlMeasured via “Asthma Control Questionnaire” [31]


    		X

    		Asthma exacerbationsMeasured via the “Asthma Exacerbation Questionnaire” [32]


    		X

    		Number of days lost from work or schoolMeasured via an additional question after the “Asthma Control Questionnaire” [31]


    		X

    		Competing demands on health and asthmaLists of life priorities and top health issues, monthly made by participants.
    		X


















    Data Collection

    Firstly, self-reported responses are collected by use of Internet-based survey, accessed online, or sent to participants via email (Table 2). Surveys will be hosted by “KeySurvey”, an in-house survey infrastructure available at UNSW [33]. All completed responses will be stored securely in a server managed by UNSW. These surveys are:

    Secondly, during the study, participants’ actions on the Healthy.me system will be unobtrusively and automatically logged.

    Thirdly, a subset of participants (up to 10% of the sample) may be selected, according to their experiences and their patterns of behaviors using Healthy.me, for a post-study semi-structured interview/focus group, eliciting their feedback on Healthy.me and asthma self-management.

    Analysis Plan

    Statistical significance is defined as a P-value of less than .05 (determined using a two-tailed test). Data will be collected by online survey software KeySurvey [33] and analyzed using IBM SPSS Statistics 19 [34].

    Baseline Comparison

    Comparisons of baseline variables between PCHMS group and control group will be conducted using visual inspection, to verify the absence of abnormal measures and data. An assessment of the homogeneity of the variances of distributions from the two groups will be statistically verified before carrying out inferential statistical analyses.

    Primary Analysis

    Differences in proportions of participants visiting their GP to obtain/update their written asthma action plan during the study will be compared between control and PCHMS groups. All intervention recipients who had the opportunity to use the PCHMS but did not do so will be included in the primary analysis (intention-to-treat principle with Last Observation Carried Forward (LOCF) imputation procedure for missing values [35,36]). Differences in participant proportions between control and PCHMS groups will be analyzed using χ2test or Student’s t-test. Proportions will be reported with 95% confidence intervals. Adjustments for baseline characteristics and possible confounders, such as age and other demographics [2,3], smoking status [3], and asthma severity [2], will be made through the use of sequential logistic regression [37]. All baseline characteristics, and factors that may affect the written asthma action plan possession rate collected at post study (eg, past possession of an asthma action plan) will be entered at step 1 of the regression; and group allocation (PCHMS vs. control) will be entered at step 2.

    Secondary and Ancillary Analysis

    Differences in proportions of participants between different groups (eg, control vs. PCHMS) will be examined using χ2test based on data collected from pre-, monthly, and post-intervention questionnaires, for each of the following activities experienced at least once during the study: (1) visited a GP (or a healthcare professional) for an unplanned asthma visit; (2) used medications or remedy; and (3) experienced performance impairment. Differences in average number of days of absence per participant and differences in score distributions from questionnaires will be compared between control and PCHMS groups using Student’s t-test or non-parametric statistics. Reasons for receiving (or not receiving) written asthma action plan will be reported using descriptive statistics. Attrition rate for the use of Healthy.me will be assessed with system logs. Technology acceptance of Healthy.me will be measured via the “Scales for Perceived Usefulness and Perceived Ease of Use” [30,38]. Participants’ satisfaction and utilization of Healthy.me will be reported. Cost effectiveness of health service utilization [39] (upon availability and feasibility) will also be considered as well as economic costs from days lost from work/school. If any post-hoc comparison would need to be performed between unplanned groups of participants, a Holm’s sequential Bonferroni procedure [40] will be used in order to control a familywise error rate FWER inferior or equal to level α = .05.

    Study Procedure

    Table 3 below summarizes participant procedures in the study. The duration of the study is expected to be 12 months.

    Email will be the primary channel to communicate with participants for study information and reminders about survey completion. From the time participants are recruited until study completion, all participants (control and intervention) will receive an email each month to complete a 5-minute survey about their health in the past month. At study completion, all participants will receive an email asking them to complete a post-study survey. In order to ensure the completeness of data collection, there will be 2 follow-up emails sent 5 days apart from each other to remind those who have not completed each survey.

    Table 2. Surveys used in the study.
    SurveyPurpose
    Screening surveyEliciting participants’ eligibility criteria.
    Pre-trial survey

    		To obtain participants’ demographics and experiences of asthma management at study enrolment.
    Monthly follow-up questions

    		To obtain participants’ self-reported symptoms of asthma (ie, asthma control and exacerbation), impact on work and study due to asthma symptoms, and competing demands and health throughout the study.
    Post-trial survey (12 months after the beginning of the study)To obtain participants’ state of asthma control and asthma management. For those who receive the PCHMS version of Healthy.me, their perceived usefulness of Healthy.me will also be assessed.
    Table 3. Stages of study procedure.


    Stage of study

    		Procedure
    Online registration

    		Eligibility screening survey

    		Participant registration, study consent and Healthy.me tutorial (self-completed online)
    Baseline data

    		Pre-study survey (self-completed online)
    Participant follow-up procedures

    		Monthly 5-minute surveys (self-completed online)

    		Post-study survey (self-completed online)

    		Patterns of Healthy.me use (computer logs and data entered by participants)
    Randomization

    After consent each participant is randomly allocated to the intervention or control group, stratified by gender and level of asthma severity (intermittent vs. persistent), according to a sequence generated by a computerized random-number generator [28] using permutated blocks of 2, 4, and 8. The randomization sequence generation, participant enrolment and group allocation processes in this study are computerized online and do not involve interference from the investigators.

    Allocation Concealment and Assessment

    Since Healthy.me is a behavioral intervention it is not possible to completely blind participants to the intervention. However, allocation of participants is automatically randomized, then coded within the Internet-based survey tool “KeySurvey”. The surveys are automatically sent by the system to participants, so investigators involved in the study are blinded to group allocation until completion of the quantitative analyses. The group allocation is revealed to participants only after they consent to participate in the study following completion of the pre-study questionnaire. To minimize contamination of control participants who might interact closely with participants who are part of the intervention group, participants in the intervention group are asked not to share their Healthy.me access details with other people.


    The recruitment of participants is ongoing and first results are expected in early 2014. The data collection should be complete by mid-2014.


    Limitations

    There are several potential limitations in this study. Firstly, the number of participants meeting inclusion criteria at study completion might be low because the study will focus recruitment only in Australia. The other inclusion criteria such as age, Internet access, and English speaking skills, might be also restrictive for recruiting participant in the targeted population.

    Secondly, there is a possible high attrition rates. The study’s outcomes will rely on data from participants’ self-reports. Due to the long duration of the study, over 12 months, it is possible to observe a high rate of attrition from participants and thus, a significant loss of data. To limit this, all participants will be actively requested to complete questionnaires by receiving monthly reminders via emails. Furthermore, the questionnaires used on a monthly-basis will be easy and convenient complete (short questionnaires with an online completion using multiple-choice questions).

    Thirdly, there may not be representative of consumers with asthma. The study may be more appealing to younger participants who are interested or literate in computers, the Internet, or asthma self-management topics. These participants may be more enthusiastic about health and the Internet than the general asthma population.

    Fourthly, as this is a pragmatic trial of a multifaceted intervention in a complex environment, it is possible that baseline variables associated with participants might also influence the outcome. For example, having a prior history of obtaining a written asthma action plan may predict future planned visits to GP, independent of any additional intervention. We will identify potential baseline variables that might influence outcomes, including age and smoking status, and test for unequal variance in the distribution of these variables in the intervention and control populations.

    Concluding Remarks

    Most of the features used in the study have been recently tested in a Healthy.me trial on help-seeking behaviors for physical and emotional well-being in a university student population [25]. The results of that study have shown that some bundles of features could lead to behavioral changes in university health service utilization and reported help-seeking for physical and/or emotional concerns. These results were consistent with theoretical expectations of behavioral changes generated from the use of features in Healthy.me. Particularly, the Health Belief Model (HBM) provides insights on how information may be transformed into action when informational cues in the environment are linked to action [41]. In the present study, we expect that the use of the online appointment booking service will be significantly associated with visits to health professionals, and consequently with a high rate in obtaining an asthma action plan. Another lever of behavioral change in accord with the principle of self-monitoring, may be operate thanks to features which encourage self-refection and self-awareness, such as the Personal Health Record, the Pillbox, the Diary, and the Poll [42]. In addition, the social and interactive features used in Healthy.me (Forums, Poll, Message) should play an important role in minimizing attrition and in promoting utilization of the platform amongst participants during the 12 months of the study [9].

    Our design of the present randomized controlled trial (RCT) focuses on the comparison of outcomes that unequivocally reflect a change in consumer behavior, and takes into account the complexity of intervention. Results of this study will offer new insights about the utility of a Personally Controlled Health Management System (PCHMS) for consumer engagement with e-health services and self-management. Our findings will provide specific answers to whether using a Web-based PHCMS, containing information and self-management tools that facilitate consumers to engage with health services, will improve the uptake of preventive asthma management actions such as the possession and use of a written asthma action plan.

    Acknowledgments

    The authors thank Jingbo Liu, Vitaliy Kim, Farshid Anvari, and Jay Liu for their contributions to software development, as well as Sara Morgan from Asthma Foundation New South Wales for her support in the development of journey content.

    This research is supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Informatics and E-Health (1032664).

    Authors' Contributions

    Study conceptualization: AL, EC, STL, SD, AA; Study design: AL, AA, SD, STL, EC; Journey design: AA, AL, SD, STL, EC; First draft: AA, AL; Draft revision: AA, AL, SD, STL, EC.

    Conflicts of Interest

    The university and some of the researchers involved in this project could in the future benefit from any commercialization of Healthy.me or its technologies.

    ‎

    Multimedia Appendix 1

    CONSORT-EHEALTH checklist V1.6.2 [43].

    PDF File (Adobe PDF File), 988KB
    1. Masoli M, Fabian D, Holt S, Beasley R. Global Burden of Asthma.: Global Initiative for Asthma; 2004.   URL: http://www.ginasthma.org/local/uploads/files/GINABurdenReport.pdf
    2. Australian Centre for Asthma Monitoring. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Canberra: Australian Institute of Health and Welfare; 2011 Oct 18.   URL: http://www.aihw.gov.au/publication-detail/?id=10737420159
    3. Asthma Management Handbook 2006. Asthma Management Handbook 2006. Melbourne: National Asthma Council Australia; 2006.   URL: http://www.nationalasthma.org.au/handbook
    4. Pocket guide for asthma management and prevention.: Global Initiative for Asthma; 2011.   URL: http://www.ginasthma.org/local/uploads/files/GINA_Pocket_April20_1.pdf
    5. Love MM, Mainous AG, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract 2000 Nov;49(11):998-1004. [Medline]
    6. Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003(1):CD001117. [CrossRef] [Medline]
    7. Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev 2003(1):CD004107. [CrossRef] [Medline]
    8. Freedman DL, Gossett JM. Biodegradation of dichloromethane and its utilization as a growth substrate under methanogenic conditions. Appl Environ Microbiol 1991 Oct;57(10):2847-2857 [FREE Full text] [Medline]
    9. Bennett GG, Glasgow RE. The delivery of public health interventions via the Internet: actualizing their potential. Annu Rev Public Health 2009;30:273-292. [CrossRef] [Medline]
    10. Gibson PG. Asthma action plans: use it or lose it. Prim Care Respir J 2004 Mar;13(1):17-18 [FREE Full text] [CrossRef] [Medline]
    11. Dennis SM, Zwar NA, Marks GB. Diagnosing asthma in adults in primary care: a qualitative study of Australian GPs' experiences. Prim Care Respir J 2010 Mar;19(1):52-56 [FREE Full text] [CrossRef] [Medline]
    12. Sulaiman ND, Barton CA, Abramson MJ, Liaw T, Harris C, Chondros P, et al. Factors associated with ownership and use of written asthma action plans in North-West Melbourne. Prim Care Respir J 2004 Dec;13(4):211-217 [FREE Full text] [CrossRef] [Medline]
    13. 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 Oct;16(5):271-283 [FREE Full text] [CrossRef] [Medline]
    14. Ring N, Jepson R, Hoskins G, Wilson C, Pinnock H, Sheikh A, et al. Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature. Patient Educ Couns 2011 Nov;85(2):e131-e143. [CrossRef] [Medline]
    15. Lamarre Y, Bioulac B, Jacks B. Activity of pre-entral neurones in conscious monkeys: effects of deafferentation and cerebellar ablation. J Physiol (Paris) 1978;74(3):253-264. [Medline]
    16. Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000 Dec 16;321(7275):1507-1510 [FREE Full text] [Medline]
    17. McLean S, Chandler D, Nurmatov U, Liu J, Pagliari C, Car J, et al. Telehealthcare for asthma: a Cochrane review. CMAJ 2011 Aug 9;183(11):E733-E742 [FREE Full text] [CrossRef] [Medline]
    18. Rasmussen LM, Phanareth K, Nolte H, Backer V. Internet-based monitoring of asthma: a long-term, randomized clinical study of 300 asthmatic subjects. J Allergy Clin Immunol 2005 Jun;115(6):1137-1142. [CrossRef] [Medline]
    19. van der Meer V, Bakker MJ, van den Hout WB, Rabe KF, Sterk PJ, Kievit J, SMASHING (Self-Management in Asthma Supported by Hospitals‚ ICT‚ Nurses and General Practitioners) Study Group. Internet-based self-management plus education compared with usual care in asthma: a randomized trial. Ann Intern Med 2009 Jul 21;151(2):110-120. [Medline]
    20. Sherr L. Fear arousal and AIDS: do shock tactics work? AIDS 1990 Apr;4(4):361-364. [Medline]
    21. Johansen H, Olsen I, Kerekes K. Differentiation between Bacteroides gingivalis, Bacteroides endodontalis and Bacteroides asaccharolyticus by means of HPLC analysis of non-derivatized free metabolic acids. Oral Microbiol Immunol 1988 Mar;3(1):42-45. [Medline]
    22. Lau AY, Parker A, Early J, Sacks G, Anvari F, Coiera E. Comparative usage of a web-based personally controlled health management systemnormal support: a case study in IVF. electronic Journal of Health Informatics 2012;7(2) [FREE Full text]
    23. Lau AY, Sintchenko V, Crimmins J, Magrabi F, Gallego B, Coiera E. Impact of a web-based personally controlled health management system on influenza vaccination and health services utilization rates: a randomized controlled trial. J Am Med Inform Assoc 2012;19(5):719-727. [CrossRef] [Medline]
    24. Konno M, Kirikae T, Suzuki KS, Yoshida M, Mori KJ, Wakusawa R. Increased lethality and delay in the recovery of hemopoietic stem cells after irradiation in mice exposed to nitrous oxide. Acta Anaesthesiol Scand 1988 Apr;32(3):213-217. [Medline]
    25. Clavé M. [Imagination and reality]. Rev Infirm 1987 Jun;37(12):18-19. [Medline]
    26. Lau A, Dunn AG, Mortimer N, Proudfoot J, Andrews A, Liaw ST, et al. Consumers' Online Social Network Topologies and Health Behaviours. Presented at: 14th World Congress on Medical and Health Informatics; August 20-23, Copenhagen, Denmark. Copenhagen, Denmark: IMIA; 2013.
    27. The lymphatic filariases. Lancet 1985 May 18;1(8438):1135-1136. [Medline]
    28. Dallal GE. 2008; by WebCite® at Accessed 02 January, 2013   URL: http://www.randomization.com/ [accessed 2013-04-28] [WebCite Cache]
    29. Asthma Foundation. 2012;   URL: http://www.asthmafoundation.org.au/ [accessed 2013-04-28] [WebCite Cache]
    30. Davis FD. Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology. MIS Quarterly 1989;13(3):319-340.
    31. Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999 Oct;14(4):902-907 [FREE Full text] [Medline]
    32. Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, American Thoracic Society/European Respiratory Society Task Force on Asthma Control and Exacerbations. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009 Jul 1;180(1):59-99. [CrossRef] [Medline]
    33. KeySurveycomputer program. Braintree MA.   URL: http://www.keysurvey.com/ [accessed 2013-07-30] [WebCite Cache]
    34. IBM SPSS Statistics Version 19 [computer program]. Armonk, NY.   URL: http://www-01.ibm.com/software/analytics/spss/ [accessed 2013-07-30] [WebCite Cache]
    35. Somana R, Walberg F. Cerebellar afferents from the paramedian reticular nucleus studied with retrograde transport of horseradish peroxidase. Anat Embryol (Berl) 1978 Sep 27;154(3):353-368. [Medline]
    36. Little R, Yau L. Intent-to-treat analysis for longitudinal studies with drop-outs. Biometrics 1996 Dec;52(4):1324-1333. [Medline]
    37. Tabachnick BG, Fidell LS. Using multivariate statistics. Boston: Pearson/Allyn & Bacon; 2007.
    38. Venkatesh V, Davis FD. A Theoretical Extension of the Technology Acceptance Model: Four Longitudinal Field Studies. Management Science 2000 Feb;46(2):186-204. [CrossRef]
    39. Ortega JJ, Javier G, Olivé T. Treatment of high-risk acute lymphoblastic leukemia with protocols PETHEMA LAL 7/78 and LAL 17/84. An Esp Pediatr 1988 Oct;29 Suppl 34:72-83. [Medline]
    40. Holm S. A Simple Sequentially Rejective Multiple Test Procedure. Scandinavian Journal of Statistics 1979;6(2):65-70.
    41. Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q 1984;11(1):1-47. [Medline]
    42. Eversole LR, Laipis PJ. Oral squamous papillomas: detection of HPV DNA by in situ hybridization. Oral Surg Oral Med Oral Pathol 1988 May;65(5):545-550. [Medline]
    43. Eysenbach G, CONSORT-EHEALTH Group. CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res 2011;13(4):e126 [FREE Full text] [CrossRef] [Medline]

    ‎
    GP: general practitioner
    HBM: Health Belief Model
    IVF: in-vitro fertilization
    LOCF: Last Observation Carried Forward
    PCHMS: personally controlled health management system
    RCT: randomized controlled trial
    UNSW: University of New South Wales

    Edited by G Eysenbach; submitted 01.05.13; peer-reviewed by D Kroemker, K Huckvale; comments to author 28.05.13; revised version received 11.06.13; accepted 12.06.13; published 13.08.13

    Copyright

    ©Amaël Arguel, Annie YS Lau, Sarah Dennis, Siaw-Teng Liaw, Enrico Coiera. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 13.08.2013.

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