Professional and patient attitudes to using mobile phone technology to monitor asthma: questionnaire survey

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RIGINAL RESEARCH

rofessional and patient attitudes to usingobile phone technology to monitor asthma:uestionnaire survey

ilary Pinnocka,∗, Roger Slackb, Claudia Pagliari a,avid Pricec, Aziz Sheikha

Division of Community Health Sciences: GP Section, University of Edinburgh,0 West Richmond St, Edinburgh EH8 9DX, UKSchool of Informatics, University of Edinburgh, 1 Buccleuch Place, Edinburgh EH8 9LW, UKDepartment of General Practice and Primary Care, Foresterhill Health Centre,estburn Road, Aberdeen AB25 2AY, UK

eceived 14 March 2006; accepted 27 March 2006

KEYWORDSAsthma;Mobile technology;Monitoring

SummaryAims: There is increasing international interest in using emerging technologies toenhance chronic disease management. We aimed to explore the attitudes of patientsand primary care professionals to using mobile technology in order to monitorasthma.Methods: A piloted questionnaire containing closed and open-ended questionsassessing attitudes to using electronic self-monitoring was posted to a randomsample of general practitioners, asthma nurses, and people with asthma (12 yearsand over) in Lothian and Kent, UK, with 2 reminders. In addition to descriptivestatistics, patient and clinician responses were compared using Chi-squared orindependent sample t-tests. Free-text responses were analysed thematically.Results: Responses were obtained from 130/300 professionals (43%) and 202/389patients (52%). Patients rated the technology positively and considered that it mayhelp clinicians to provide care, especially during acute attacks. Although rated

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similarly, professionals were more sceptical about benefits. Both professionals andpatients had concerns about the time and cost implications. Of the respondents,28 professionals (10%) and 62 patients (16%) returned uncompleted questionnairesciting lack of perceived relevance.Conclusions: The low completion rate probably reflects the current status of mobile

phone-facilitated care as a minority interest for ‘early adopters’ of technology. Evenfor the enthusiastic minor

∗ Corresponding author. Tel.: +44 (0) 131 651 4151; fax: +44 (0) 131E-mail address: [email protected] (H. Pinnock).

471-4418/$30.00 © 2006 General Practice Airways Group. Publishedoi:10.1016/j.pcrj.2006.03.001

Available online at http

ity, using mobile phone technology raised questions of

650 9119.

by Elsevier Ltd. All rights reserved.

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238 H. Pinnock et al.

clinical benefit, impact on self-management, and concerns about workload and cost,dresAirw

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Introduction

Modern forms of communication offer considerablepotential for enhancing medical care [1—3],particularly in ensuring timely access to emergencyadvice [4,5], and in the management of chronicdisease [6,7]. Mobile phones are now widelyavailable [8], and offer innovative opportunities formessaging which have been used to remind patientsof appointments [9] and to encourage compliancewith inhaled steroids in asthma [10].

Guided by written asthma action plans, somepatients accept the responsibility for monitoringand adjusting their own treatment [11], whilstothers fail to respond to cues for self-management[12,13] and delay important actions pending theadvice of a clinician [14—17]. Novel technologiesmay change the dynamics of monitoring and care.For example, linking an electronic peak flowmeter with a mobile phone has been successfullypiloted in teenagers and younger adults withasthma, improving compliance with monitoring,and improving confidence in self-management [18].

Widespread uptake, however, depends onprofessionals’ and patients’ attitudes to thepotential benefits as well as the ‘user-friendliness’and clinical appropriateness of the system. Therecognised life-cycle of technology adoption (seeFigure 1) suggests there will be ‘innovators’ and‘early adopters’ who will welcome the technology,readily identifying clinical situations in whichthey may benefit [19]. Others will be moresceptical, expressing practical concerns or feelinguncomfortable with unfamiliar systems. Identifyingcurrent perceptions, and the perceived barriersto more extensive adoption, is a prerequisite forbreaching the ‘chasm’ and enabling new ideasto be placed appropriately within a primary careservice [20].

Our survey aimed to explore the attitudes ofpatients and primary care professionals to usingmobile technology in order to monitor their asthma,and to assess the potential impact on their asthmamanagement.

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Methods

The survey was conducted in 2005, in Lothianand Kent, UK, with the approval of the MultiCentre Research Ethics Committee for Scotland.

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sed prior to wider acceptance.ays Group. Published by Elsevier Ltd. All rights reserved.

overnance approval was granted by NHS Lothiannd Kent Primary Care Trusts.

etting

othian (Central Scotland) and Kent (South Eastngland) include both city and rural environmentsnd represent populations with a diversityf demographic features including areas ofeprivation/affluence.

uestionnaire design [21]

e devised a structured questionnaire, adapted foroctors, nurses or people with asthma, including arief description of an asthma monitoring servicehich enables electronic peak flow readings to be

ransmitted to a central server which feeds backnformation on current control and reminders onelf-management [E-san Ltd, Oxford, UK: mmO2,xbridge, UK]. The questionnaire asked aboutttitudes to such innovative technology, focusingn its acceptability, practicability and impact onare (see associated with this article, located,n the online version, at Supplementary dataoi: 10.1016/j.pcrj.2006.03.001). Designed by aultidisciplinary team, our questions were based

n a detailed review of the literature on the usef mobile technology to monitor chronic disease1—3], the process of adoption of new technologies20], and the concepts of asthma self-management15—17]. Minor adjustments were made after initialiloting.

The relative importance of potential issuesas assessed by asking respondents to rate theirgreement with statements on a 5-point Likert-cale [1 = strongly agree; 5 = strongly disagree],r to choose between two opposing positionsn a scale of 1 to 10. Where appropriate,imilar questions were devised for patients androfessionals to allow for comparison. Closeduestions included an option for adding additionalomments in free-text, and a final open questionnvited more general opinions.

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50 general practitioners (GPs) and ‘the asthmaurse’ of 150 randomly selected practices inothian and Kent. We phoned non-respondingractices to check receipt of the mailing, and

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Professional and patient attitudes to using mobile phone technology to monitor asthma 239

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igure 1 The technology adoption life-cycle. Adapted fohn Wiley & Sons Ltd on behalf of Capstone Publishing L

ffered an electronic version of the questionnairef preferred. Two reminders were sent toon-responders.

Three Lothian and three Kent practicesdentified adults and teenagers with ‘activesthma’ (definition: aged 12 years and over; on theractice asthma register; and having received arescription for asthma therapy in the previous 12onths) registered with a randomly selected GP.

wo reminders were sent to non-responders.We provided an option for both patients and

rofessionals to indicate that they felt the topicas of no interest to them, and for them to returnn uncompleted questionnaire.

ata analysis

ategorical and continuous data were analysed

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ppropriately depending on type and distributionf data using SPSS version 11.5. A mean technologycore was calculated by combining the scores fromhe four questions assessing general attitude to

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Moore [20]. This figure is reproduced with permission of

echnology. In addition to descriptive statistics,atient and clinician responses were comparedsing Chi-squared or independent sample t-tests.

A multidisciplinary group analysed free-textesponses by developing a coding frame anddentifying key emerging themes [22—23].

esults

e received responses from 66/150 GPs (44%),4/150 nurses (42%), and 202/389 patients (52%).f the respondents, 20 GPs (13%), nine nurses

6%) and 62 patients (16%) indicated that they felthe questionnaire was of no relevance or of nonterest to them, some adding free-text commentso explain their decision not to complete theuestionnaire. The 140/389 (36%) patients whoeturned completed questionnaires had a similar

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emographic profile (mean age 44.0 years (SD8.5), 39% male) to the eligible sample (meange 43.1 years (SD 19.5) 42% male). The 46/150Ps (31%) and 55/150 nurses (36%) who returned

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240 H. Pinnock et al.

Table 1 Demography of respondents

Doctors Nurses

Total number of GPs/practices GPs: 896 Practices: 222Randomly selected 150 Male: 79/139 (53%) 150 Not knownResponded 66 (44%) 64 (42%)Completed questionnaires 46 (31%) Male: 22 (48%) 55 (36%) Male: 4/54 (7%)Age groups

20 to 29 years 1 030 to 39 years 9 840 to 49 years 22 2550 to 59 years 14 19over 60 years 0 3

Practice demographyMean list size (SD) 8,735 (SD 3,009) 7,327 (SD 3,962)Inner city 3 (7%) 10 (18%)Urban 34 (74%) 28 (51%)Rural 9 (20%) 11 (20%)Remote 0 0Deprived 4 (9%) 7 (13%)

Role in asthma careInterest in asthma? 14 (32%) 50 (91%)See asthma patients 31 (67%) (Has asthma diploma) 44 (80%)Rarely see asthma patients 0 0

Specialist rolesG/P with Special Interest 2 (4%) 11 (44%)Member specialist society: 1 (2%) 2 (4%)Advisor Primary Care Organisation: 0 2 (4%)Practice respiratory lead: 11 (24%) 21 (38%)Practice Q&O lead: 8 (17%) 5 (9%)

Patients

Number (%) Mean age (SD) Male (%)

Total eligible population: from 6 practices. 408Excluded by GP 19Total sent questionnaires 389 43.1 (19.5) 163 (42%)Responded 202 (52%)Completed questionnaires 140/389 (36%) 44.0 (18.5) 54 (39%)

Current asthma treatmentNone 2/140 (1%)Reliever (blue inhaler) 116/140 (83%)Preventer (brown/orange/maroon) 86/140 (61%)Add on (green inhaler or tablets) 21/140 (15%)

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Combination inhaler (purple/red)Other

completed questionnaires worked in a broad rangeof practices (see Table 1). Nurse and GP responsesto all the questions were similar and were thereforecombined as ‘professional’ responses.

Current attitudes to peak flow charting andself-management

Home peak flow monitoring is widely encouragedwith 84/101 professionals (84%) routinely

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140 (27%)140 (12%)

rescribing peak flow meters for adults withsthma, and 98/140 patients (70%) agreeing thathey had a peak flow meter at home, though only2/91 of these patients kept a record of their peakows.

Professionals were positive about encouraging

elf-management, scoring their agreement with thetatement ‘I would like most of my asthma patientso have a written self-management plan’ at 1.9 (SD.8) By contrast, patients were undecided about

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Professional and patient attitudes to using mobile phone technology to monitor asthma 241

Table 2 Attitudes to technology

Variable Patientsmean (SD)

Professionalsmean (SD)

Mean difference p

Mean overall technology score 7.1 (2.4) 6.9 (1.8) −0.3 (95% CI −0.8 to 0.3) 0.38Trying out new technology 7.2 (2.7) 6.8 (1.9) −0.4 (95% CI −1.0 to 0.3) 0.26Learning to use technology 7.0 (2.7) 6.5 (2.2) −0.6 (95% CI −1.2 to 0.) 0.09Exploring the potential of technology 7.0 (2.6) 6.6 (2.0) −0.4 (95% CI −1.0 to 0.3) 0.25

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Technology as part of life 6.9 (3.0)

Scale of 1 to 10 (1 avoids technology, 10 embraces technology

heir preference for self-management, scoringneutral 3.1 (SD 1.1) in agreement with the

tatement ‘I prefer to look after my own asthmand would not want to bother my doctor or nurse’.

ttitudes to technology in general

oth patients and professionals were positive inheir attitude to new technology with similar meanechnology scores (professionals 6.9 (SD 1.8) vs.atients 7.1 (SD 2.4) mean difference −0.3 (95%CI0.8 to 0.3) p = 0.38), though patients’ attitudes

o technology were more polarised than those ofrofessionals. Responses to the individual questionsre given in Table 2. Free-text comments confirmedhe range of attitudes, from the very enthusiastico those having no interest in communicationechnology.

‘What a fantastic idea!’’ Patient 33 F

‘The technology is available. It makes sense to uset.’’ Patient 42 F

‘No mobile phone hard of hearing. No website orobile phone not on internet.’’ Patient 74 M

Lack of technical expertise was one of theeasons given by patients who decided againstompleting the questionnaire.

‘I am sorry I cannot be more helpful in answeringhe questionnaire I received recently, as I do notnderstand anything about modern technology.’’atient 82 F who declined to complete theuestionnaire.

ttitudes to electronic peak flow monitoring

atients were keener than professionals to try theobile technology with a positive mean score of

.1 (SD 1.2) in agreement with the statement ‘I

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ould like to try out this monitoring technology’ompared to the relatively neutral 2.8 (SD 1.1)cored by the professionals (mean difference 0.695% CI 0.3 to 0.9), p < 0.01).

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7.6 (2.0) 0.7 (95% CI 0.0 to 1.4) 0.05

The free-text comments reflect some patients’nthusiasm to try out new technology forhemselves, compared to an (unsurprisingly) morecademic interest on the part of the professionals.

‘It would be very helpful to me and I would like tose it.’’ Patient 14 F

‘I would really like to try out this new systemspecially if it helps with my asthma.’’ Patient 33

‘Interesting concept: Are there papers on doinghis in asthma/other already?’’ GP M (age notiven)

mplications for care

able 3 compares professional and patient scoreso statements about the implications of usingobile technology for monitoring asthma care.

n general, patients thought that the monitoringechnology would help their doctor or asthma nurseook after their asthma, especially in the eventf an acute attack. Professionals, however, wereore sceptical both in their scoring and free-text

omments.

‘I think the technology could save my life and thats a good thing.’’ Patient 41 F

‘Excellent idea, I personally think this could helpsthmatics and their doctors/nurses to preventajor asthma attacks.’’ Patient 62 F

‘There are some others who don’t care and doothing when feeling fine and present in extremisnd I suspect they will still do exactly thategardless.’’ GP 30-39 F

‘Would need to observe/have demo/read upiterature/evidence etc before making any furtherecisions about benefits to patient care.’’ Asthma

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Opinions of both professionals and patients wereivided on how the technology would impact onhe professional/patient relationship—–facilitating

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communication or reducing face-to-face contact,increasing dependence or facilitating self-management. Confidentiality was not highlightedas a major issue by either group.

‘‘I would not have to explain to my GP or PracticeNurse if they have this info on tap.’’ Patient 71 F

‘‘I am very much in favour of trying any advances,technological or otherwise, but I am slightlyworried that this proposed phone monitoring maylessen face-to-face contact between patient anddoctor/nurse.’’ Patient 62 F

‘‘I would like to have something that would notonly monitor my peak flow but give me a warningwhen my breathing/asthma may be becoming aproblem.’’ Patient 24 F

‘‘By receiving patients’ peak flow readings, Iexpect I would then be responsible for actingon them. This would be difficult to implementand take some responsibility from the patient tomanage their own care.’’ GP 50-59 M

‘‘My main concern would be that patients feel weare interfering with their day to day lives andbecome irritated.’’ GP 30-39 F

One GP was concerned about the medico-legalimplications if he failed to act on readings that hadbeen transmitted to his surgery.

‘‘Places further burden of responsibility onclinician if results are forwarded to GP who failsto deal with them → litigation.’’ GP 40-49 F

Practical issues

Concerns about the time and cost implications werevoiced by both professionals and patients in thefree-text comments.

‘‘This system would only be successful ifdoctor/nurse hours are allocated on a dailybasis. My problem is that I don’t think thatthis will happen. If there was complete buy-inby doctors/nurses then the system has a goodchance.’’ Patient 56 M

‘‘I am not sure how this would work, who or howyou would monitor incoming patient information,who would be responsible on a 24 h, 365 day a

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year?’’ Asthma nurse 50—59 F

‘‘What additional charges are incurred when usingthis — is it chargeable to us?’’ Patient 26 F

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rofessional and patient attitudes to using mobile p

iscussion

ur questionnaire on using mobile technologyo monitor asthma attracted the interest ofbout a third of patients and professionals. Thedea was thus greeted with enthusiasm by aignificant minority of the patients, consideredith interest by some professionals, but raisedrange of issues for both groups. In general,

atients were optimistic about the potentialenefits of the system for the care of theirsthma, though they questioned who would meethe cost. Professionals were generally neutralbout the impact on care and were concernedbout workload implications. For some people,nfamiliarity with the technology was a significantarrier.

imitations of this study

he completion rate of 35% is low and reduceseneralisability, although responders had a similaremography to that of the eligible population,mplying that our questionnaire had interested thenthusiasts across the full demographic range. Theumber of additional respondents who explicitlyeclined to complete the questionnaire because oflack of interest in technology, no available mobilehone or internet access, or a perception that theystem was not applicable to them, support thisnterpretation.

Answers to closed questions and free textesponses can only provide limited insights intottitudes to the adoption of mobile technology.nformation about the technology was restrictedo a brief description of the monitoring systemhich may have influenced responses. Familiarityith both peak flow monitoring and mobilehone technology, however, will have reduced theossibility of significant misconceptions.

ain strengths of this study

he survey was undertaken in two areas ofhe UK, encompassing city, urban, and ruralreas including a range of deprived and affluentopulations. Our piloted questionnaire appeared toe acceptable to both patients and professionals

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nd we identified no problems with completion.ntegration of quantitative and qualitative analysesncreases the validity of our findings [24], whilsthe involvement of clinicians and social scientistsnabled multidisciplinary interpretation of thendings.

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e technology to monitor asthma 243

nterpretation of findings in relation toreviously published work

he use of mobile technology to monitor asthmand other long-term conditions is currentlyxperimental in the UK, and the attitudes ofany of our respondents are consistent with

hose of ‘Innovators’ and the ‘Early Adopters’see Figure 1) [20]. The patient who wantedo use the technology because it ‘‘is available’’ay be acting as an ‘Innovator’, while ‘Earlydopters’ are motivated to adopt it to addressn issue of personal importance. For example,everal patients identified how the system mightelp them ‘‘manage the situation better’’ or even‘save my life’’. By contrast, the professionals wereore guarded in their enthusiasm, recognising that

echnology didn’t necessarily change behaviournd wanting more evidence before concludinghat such systems would improve care. Thisautious attitude of readiness to consider thedvantages is more typical of the ‘Early Majorityragmatists’ whose adoption of a new technologys critical to successful widespread acceptance20].

Practical concerns were raised about themplications for professional workload and cost tohe patients. Whilst these issues did not appearo dampen the enthusiasm of the ‘Innovators’nd ‘Early Adopters’, they will need to beully addressed before mobile technology gainsidespread acceptance.Current asthma guidelines promote self-

anagement [25], and a key strategy for meetinghe challenge of long-term diseases is theevelopment of empowered ‘expert patients’26]. It is of some concern, therefore, thatoth professionals and patients were uncertainbout the impact on self-management, and a keyenefit for patients was that mobile technologyould ‘help their doctor or nurse look after theirsthma’.

The doctor who was concerned that byccepting the transmission of these peak floweadings she was accepting additional responsibilityith incumbent medico-legal risks echoes the

ecognised professional concerns about liabilityssociated with using innovative technology [3,27].edical defence organisations currently provideinimal guidance for clinicians on safe practiceith mobile technology, effectively discouragingidespread adoption.

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Government policy encourages remoteonsultation as a means of improving accesso primary care services [28]. Some respondentsere impressed that web-based peak flow records

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could facilitate communication with a clinicianduring remote consultations, while others wereconcerned that the technology ‘‘may lessen face-to-face contact’’. These perspectives echo surveysof patients’ preference for alternative modesof consultation which suggest that while manywelcome telephone consultations, about a sixthprefer the reassurance of face-to-face contact[3,29].

Conclusions

Although greeted with enthusiasm by a significantminority, using mobile technology to monitorasthma raised many important questions forboth patients and professionals. Widespreadimplementation will depend on demonstratingclinical effectiveness, assessing the impact onpatients’ self-management skills, and addressingimportant practical concerns about workload, costand professional liability. Future studies shouldexplore these concerns.

Conflicts of interestNone known.

Acknowledgments

We thank the practices from the Lothian andBorders Primary Care Research Network, and Kentand Medway Primary Care Research Network whomailed questionnaires to people on their asthmaregisters: Mildmay Surgery, Ramsgate; Church LaneSurgery, New Romney; Thames Avenue Surgery,Rainham; Ashgrove Health Centre, Blackburn;McKenzie Medical Practice, Edinburgh; MuriestonMedical Practice, Livingston. We also wish to thankcolleagues from the Whitstable Medical Practice,and Ms Wendy Halley, from the Edinburgh ‘Breathe-Easy’ group who piloted and offered adviceon the questionnaire design. Lastly, we recordour appreciation to Alison Tait who undertookthe mailing of the questionnaires and dataentry.

HP led the development of the protocol,securing of funding, study administration, dataanalysis, interpretation of results and writing of thepaper. RS undertook the data collection and dataanalysis, and with AS, CP and DP contributed tothe securing of funding, interpretation of data and

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the writing of the paper. All authors reviewed thefinal manuscript. HP and RS are study guarantors.

Funding: British Lung Foundation Grant no.O2-02.

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H. Pinnock et al.

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