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Methodological Literature Review: mHealth Intervention on Adolescents with Asthma

Jackie Cuellar

California State University, Channel Islands

Health 309: Health Science Research Method

Dr. Lydia Dixon

December 8, 2021
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Introduction

Asthma is a chronic respiratory disease that directly affects the lungs making it difficult

to breathe. Cases may vary among individuals as it can develop at any age and range from mild

to severe asthma. Due to the complications this disease may cause to our respiratory system,

individuals with asthma have to effectively manage their disease and adhere to medication when

needed. Looking at the population, adolescents face low adherence rates and poor

self-management of asthma. Barriers mainly revolve around a decrease in parental involvement,

forgetting to take medication, and lacking awareness of both symptoms and triggers (Kosse et al.,

2019). The increase in poor asthma management among adolescents negatively affects their

health, which is why implementing an effective intervention is of great importance. This

methodological literature review will analyze articles about mhealth intervention to determine

the impact it has on managing asthma among adolescents. The independent variable is mobile

health (mhealth) interventions such as mobile applications. While the dependent variable is

whether or not adolescents with asthma were able to effectively manage their asthma due to the

mhealth intervention.

Methods Used In Conducting Review

In conducting research for this methodological literature review, the databases used were

Pubmed and the Channel Islands Advance Search. Within both databases a variety of keywords

were used in order to find specific studies relating to the impact mhealth intervention has on

adolescents with asthma. Moreover, all studies were limited to those that were peer-reviewed and

created from the year 2011-2021. To begin the search, the key words mhealth and asthma were

used. Although this conducted a variety of studies, it did not specify the intervention among

adolescents. Therefore, the research was narrowed down to include the key words adolescents,
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young adults, and teenagers. In addition, a variation of the key words mhealth and asthma, such

as mobile health and asthma management, were added to generate more results. Lastly, studies

were narrowed down if they included children and focused on mhealth application development

rather than intervention. This resulted in five peer-reviewed studies being used for the

methodological literature review.

Sampling

To begin, four of the articles used convenient sampling methods to obtain participants for

their study. This was done by contacting individuals that participated in similar studies (Johnson

et al., 2015), directly recruiting participants from clinical appointments (Burbank et al., 2015;

Fedele et al., 2021) and displaying flyers in clinics and the community (Fedele et al., 2021;

Johnson et al., 2015; Rhee et al., 2014). Convenient sampling is an easy and inexpensive method

to gather participants, yet it could create biased results as it only represents a small sample of the

population. As a result, it is difficult to generalize findings for the entire target population. In

addition to convenience sampling, one article used snowball sampling as they used referrals from

medical centers to gain participants (Rhee et al., 2014). Snowball sampling is an easy and

cost-efficient method, nonetheless it can create a sampling bias as participants are not randomly

selected. Moreover, one article used a cluster sample by randomly selecting Dutch community

pharmacies, then randomly selecting participants that qualified within those pharmacies (Kosse

et al., 2019). The advantage of this method is the ability to create a larger sample size, but

sampling bias can still occur if each cluster is not equal in size. Lastly, all articles contained

requirements that individuals needed to meet in order to participate in the study. This included

having a prescription, access to a phone, participation of caregivers (Fedele et al., 2021; Johnson

et al., 2015; Rhee et al., 2014) and meeting the age requirement which varied across studies from
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ages 12 to 18 (Burbank et al., 2015; Fedele et al., 2021; Johnson et al., 2015; Kosse et al., 2019;

Rhee et al., 2014). Due to the similar requirements, all five articles were able to individually

achieve eligible samples to proceed with their study.

Methodological Approaches

In order to conduct the studies, all articles used a longitudinal approach. The time frame

for each article varied, three of them were two, three, and eight weeks (Burbank et al., 2015;

Johnson et al., 2015; Rhee et al., 2014) while the other two lasted six and nine months (Fedele et

al., 2021; Kosse et al., 2019). A weakness of longitudinal studies is that participants could drop

out over time. Yet, it allows researchers to detect changes over a longer period of time and

collect more data from the same group of participants. In addition, three articles used an

experimental design to carry out their study by having a control and intervention group (Fedele

et al., 2021; Johnson et al., 2015; Kosse et al., 2019). On the other hand, two articles were

feasibility studies that used within-subject design to expose all participants to the mhealth

intervention (Burbank et al., 2015; Rhee et al., 2014). Unlike an experimental design, the

within-subject design lacks random assortment and a control group which is useful for ensuring

results are not influenced by outside factors. Moreover, all studies used quantitative methods

(Burbank et al., 2015;Fedele et al., 2021; Johnson et al., 2015; Kosse et al., 2019; Rhee et al.,

2014) while mixed methods were only used within two articles (Fedele et al., 2021; Rhee et al.,

2014). The advantage of using mixed methods is that researchers can obtain numerical and

descriptive data which provides more depth and strengthens findings. Unfortunately, mixed

methods take longer to conduct and can be costly as expertise in this method is required to

collect and analyze data. Through the use of all these methodological approaches, every article

was able to structure the design of their study.

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Data Collection

Data from the articles was collected in a variety of ways, the most diverse being the

quantitative methods that were collected through the use of questionnaires, surveys, and tests.

Across all articles, these were distributed at the beginning of the study to establish a baseline and

at the end as a follow up (Burbank et al., 2015; Fedele et al., 2021; Johnson et al., 2015; Kosse et

al., 2019; Rhee et al., 2014). They all addressed asthma self-management and self-efficiency to

determine if there was a change after mhealth intervention. An example of this was the Asthma

Control Test (ACT) which was used in 4 of the articles (Burbank et al., 2015; Fedele et al., 2021;

Johnson et al., 2015; Rhee et al., 2014) and the Medication Adherence Report Scale (MARS)

questionnaire that was used in one article (Kosse et al., 2019). Although the use of quantitative

methods makes it easier to generalize findings, data can be biased as it is usually self-reported. In

addition, qualitative methods such as semi-structured focus groups and interviews were held for

participants and caregivers to collect data on their experience with the mhealth intervention

(Fedele et al., 2021; Rhee et al., 2014). Although qualitative methods take longer to collect, they

provide a deeper understanding due to the open-ended nature of the method. Ultimately, across

all studies the data was collected to evaluate the effectiveness of mhealth intervention.

Analytical Techniques

After concluding the studies, two articles used descriptive statistics, such as standard

deviation, to analyze their baseline and outcome data (Burbank et al., 2015; Fedele et al., 2021;

Johnson et al., 2015). The advantage of using this technique is that it will demonstrate how far

responses deviate from the mean, but it can be affected by extreme outliers. In addition, two

articles analyzed categorical variables using different methods. For example, one article used

frequency to determine the number of individuals within a category (Burbank et al., 2015). On
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the other hand, the other article used Pearson's chi-squared test to analyze and compare

categorical variables to determine an association (Johnson et al., 2015). A limitation to both

frequency and Pearson's chi-squared test is that they are sensitive to sample size as it can affect

the results. Moreover, a different article used the chi squared test, mixed-effects models, or the

fisher’s exact test, depending on the variable, in order to compare groups in the beginning of the

study (Kosse et al., 2019). Furthermore, the Wilcoxon signed-rank test was used by two articles

to find the difference between participant’s individual scores. Baseline and post-intervention

scores, such as the ACT, were determined using this analytical technique (Burbank et al., 2015;

Johnson et al., 2015) . A potential weakness of using the Wilcoxon signed-rank test can occur

when there are no differences between the values as it would create misleading results. Lastly,

two articles analyzed data from their interviews and focus groups by coding to determine

similarities and differences (Fedele et al., 2021; Rhee et al., 2014). This allows researchers to

gain a better understanding of the research findings as they inductively code the transcripts.

Among all articles, common analytical techniques were used to analyze data and determine the

impact mhealth intervention had on asthma management in adolescents.

Conclusion

After the data analysis of the studies were completed, researchers were able to determine

the impact mhealth intervention had on asthma management in adolescents. All studies

concluded that mhealth intervention allows adolescents to be more independent with their asthma

care and is easy to integrate as a majority of them own a phone (Burbank et al., 2015l; Fedele et

al., 2021; Johnson et al., 2015; Kosse et al., 2019; Rhee et al., 2014). In addition, four sources

concluded that mhealth applications or techniques such as text messaging could improve

self-management in adolescents with asthma. This is due to an increase in medical adherence and
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self awareness of symptoms and triggers (Burbank et al., 2015; Fedele et al., 2021; Johnson et

al., 2015; Rhee et al., 2014). On the other hand, one article concluded that mhealth interventions

only improve adherence to medication among adolescents who had poor asthma control at

baseline (Kosse et al., 2019). Furthermore, two articles found that mhealth intervention improved

communication between adolescents and their caregiver which positively impacts their self

management of asthma (Fedele et al., 2021; Rhee et al., 2014). When looking at the methods

across the articles, a limitation within all studies was the response bias as most of the data was

self recorded (Burbank et al., 2015; Fedele et al., 2021; Johnson et al., 2015; Kosse et al., 2019;

Rhee et al., 2014). Also, four studies had small sample sizes that included participants from

similar areas, making it difficult to apply results to a wider population (Burbank et al., 2015;

Fedele et al., 2021; Johnson et al., 2015; Rhee et al., 2014). Additionally, two studies lacked

randomization which affects validity (Burbank et al., 2015; Rhee et al., 2014). As a result, future

studies should include longitudinal studies that follow a larger sample size of adolescents for a

few years as current studies were completed in a relatively short time. Additionally, experimental

designs aimed at incorporating randomization and mixed methods to collect numerical and

non-numerical data should be used.

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References

Burbank, A. J., Lewis, S. D., Hewes, M., Schellhase, D. E., Rettiganti, M., Hall-Barrow, J.,

Bylander, L. A., Brown, R. H., & Perry, T. T. (2015). Mobile-based Asthma Action Plans

for Adolescents. Journal of Asthma, 52(6), 583–586.

https://doi.org/10.3109/02770903.2014.995307

Fedele, D. A., Thomas, J. G., McConville, A., McQuaid, E. L., Voorhees, S., Janicke, D. M.,

Abu-Hasan, M., Chi, X., & Gurka, M. J. (2021). Using Mobile Health to Improve

Asthma Self-Management in Early Adolescence: A Pilot Randomized Controlled Trial.

Journal of Adolescent Health, 69(6), 1032–1040.

https://doi.org/10.1016/j.jadohealth.2021.06.011

Johnson, K. B., Patterson, B. L., Ho, Y.-X., Chen, Q., Nian, H., Davison, C. L., Slagle, J., &

Mulvaney, S. A. (2015). The Feasibility of Text Reminders to Improve Medication

Adherence in Adolescents with Asthma. Journal of the American Medical Informatics

Association, 23(3), 449–455. https://doi.org/10.1093/jamia/ocv158

Kosse, R. C., Bouvy, M. L., de Vries, T. W., & Koster, E. S. (2019). Effect of a mHealth

Intervention on Adherence in Adolescents with Asthma: A Randomized Controlled Trial.

Respiratory Medicine, 149, 45–51. https://doi.org/10.1016/j.rmed.2019.02.009

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Rhee, H., Allen, J., Mammen, J., & Swift, M. (2014). Mobile Phone-Based Asthma

Self-management Aid for Adolescents (mAsMAA): A Feasibility Study. Patient

Preference and Adherence, 63. https://doi.org/10.2147/ppa.s53504