Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children

Pediatric emergency department-based asthma education tools and parent/child asthma knowledge

Asthma exacerbations are a leading cause of pediatric hospitalizations despite multiple efforts to educate patients and families on disease course and medication management. Asthma education in the pediatric emergency department (ED) is challenging, and although the use of written action plans has been associated with reduction in hospitalizations and ED visits, written tools may not be useful for individuals with low health literacy. Moreover, asthmatic children should participate in their asthma education. In this prospective randomized study of 53 families presenting to a pediatric ED with a child experiencing an asthma exacerbation, education on asthma was presented via an interactive mobile-based video-game versus a standard-of-care asthma education video (SAV). Median age was 10 years; 64% were males. Many patients had moderate-to-severe asthma, with 57% experiencing ≥ 2 asthma-related ED visits in the last year, 58% requiring hospitalization and 32% reporting a critical care admission. In this cohort, the mobile-based video-game was found to be a feasible, acceptable educational tool; 86% of parents and 96% of children liked the game, while 96% of parents and 76% of children preferred playing the game over watching a SAV. Despite a history of persistent asthma, only 34% of children used an inhaled corticosteroid while 70% required rescue inhaler use in the prior week. Basic asthma knowledge was sub-optimal with only 60% of parents and 43% of children correctly recognizing symptoms that should prompt immediate medical care. This reflects a major gap in asthma knowledge that coexists with parental misconceptions regarding optimal asthma management.

Design of Sports Training Simulation System for Children Based on Improved Deep Neural Network

With the development of AI technology, human-computer interaction technology is no longer the traditional mouse and keyboard interaction. AI and VR have been widely used in early childhood education. In the process of the slow development and application of voice interaction, visual interaction, action interaction, and other technologies, multimodal interaction technology system has become a research hotspot. In this paper, dynamic image capture and recognition technology is integrated into early childhood physical education for intelligent interaction. According to the basic movement process and final node matching in children's sports training to judge children's physical behavior ability, attention is paid to identify the accuracy and safety of movement. The input images and questions are from the abstract clipart dataset of dynamic image recognition and the self-made 3D dataset of Web3D dynamic motion scene with the same style, which is similar to the action content in the actual preschool training teaching. Therefore, according to the idea of process capture and target recognition, on the basis of the original conditions of the recognition model, a new recognition model is developed through Zheng's target detector. The modified model is characterized by higher accuracy. Weapons need to combine process recognition and result recognition. The experimental results show that the improved model has the obvious advantages of high precision and fast speed, which provides a new research idea for the development of children's physical training simulation.

Acceptability of Serious Games in Pediatric Asthma Education and Self-management: Pilot Study

BACKGROUND

Asthma is the most common chronic pediatric disease. Despite existing tools to manage asthma, 40%-55% of children with asthma experience uncontrolled asthma. Serious games (SGs) represent a novel approach in promoting asthma education and self-management for children.

OBJECTIVE

In this qualitative pilot study with an embedded quantitative design, we aim to use focus groups and questionnaires to describe the perceived role of SGs in different aspects of asthma self-management by children and their parents. These aspects include asthma perception and knowledge, the impact of asthma and barriers to asthma self-management, and the support system for asthma self-management.

METHODS

A total of 5 children with asthma and their parents were invited to participate in an organized gaming session. Children and their parents completed a pregaming questionnaire on their medical history and asthma knowledge. Then, they were invited to test 4 original SG prototypes, after which the children answered a postgaming questionnaire on their asthma knowledge and perception of the SGs. Children and their parents subsequently participated in parallel focus groups, which were video-recorded or audio-recorded, transcribed verbatim, and analyzed by reaching consensus among members of the research team.

RESULTS

The mean age of the children was 10.3 (SD 1.5) years, with 20% (1/5) of the children being male. Qualitative data from the transcripts were coded into three separate domains: asthma self-management perception and knowledge, impact of asthma and barriers to asthma self-management, and support system for asthma self-management. We specifically explored the perceived roles of SGs within each domain. A key takeaway message was identified for each of these three domains: heterogeneity of asthma knowledge and the ability of SGs to encourage knowledge transfer through games, consequences and limitations of asthma and the ability of SGs to allow for identification and management of real-life situations through games, and insufficient support system and the ability of SGs to encourage playing with others for support and shared knowledge.

CONCLUSIONS

Our pilot study explored the role of SGs in the self-management of asthma, as perceived by children and their parents. Our findings support the acceptability of SGs in asthma education and self-management in pediatrics and the necessity for future development in this field.

The Use of Puzzles in Inhaler Technique Training

Objective: Inhaled drugs are essential for the treatment of several chronic respiratory diseases. However, patient inhaler techniques are frequently suboptimal; here, educational games may enhance patients' understanding of educational interventions. In addition, patients may practice repetitively, learning in a more relaxed and fun environment. In this study we aimed to compare two methods of inhaler technique training: (1) face-to-face training only and (2) face-to-face training and a subsequent puzzle game.Methods: The participants in group 1 were provided only face-to-face training. In group 2, the participants were given a puzzle after receiving the face-to-face training. Subsequently, the inhaler technique scores of both groups were compared. The chi-squared (χ² ) test was used for categorical variables and the Mann-Whitney U test (non-parametric) or Student's t test (parametric) were employed to compare the numerical variables between the groups.Results: In total, 170 patients with asthma and their parents were included in the study. It was found that the median total scores for the inhaler technique (p < 0.001) and the number of correct users (p < 0.001) were higher in group 2, whereas the inhaler technique error rate in shaking the inhaler tube (p < 0.001) was higher in group 1.Conclusion: The present study revealed that the success rate of correct users and participants' total scores were higher in the puzzle game group. Therefore, a game may help patients to better remember and visualize the steps of the inhaler technique. Our study supports the use of puzzles as real-world applications to teach patients optimal inhaler technique.

The Let's Eat Healthy and Move at School program for adolescents in South Korea: Program design, implementation, and evaluation plan using intervention mapping

Purpose

This study aimed to systematically develop an obesity prevention program for adolescents to promote healthy eating and physical activity in schools.

Methods

The development of the Let's Eat Healthy and Move at School program for adolescents followed the six steps of intervention mapping (IM). IM is a widely used protocol for developing systematic and effective interventions based on theories and evidence.

Results

To better understand the problem and identify the needs of adolescents, interviews were conducted with teachers, school nurses, and students (step 1). In step 2, the desired behaviors and their determinants were established and combined into a matrix comprising 16 change objectives. In step 3, theoretical methods such as persuasive communication and consciousness-raising were chosen. The program was segmented into three educational activity sessions in step 4. In step 5, an implementation manual was developed for program instructors to ensure effective and accurate implementation. Finally, practices for evaluating the program's effectiveness and procedures were designed in step 6.

Conclusion

The Let’s Eat Healthy and Move at School program will provide adolescents with guidelines to promote healthy living and prevent obesity in everyday life using strategies for sustainable adolescent obesity prevention and management.

The effectiveness of the use of video games and software-based programs for asthma education and self-management for children and teenagers

Abstract Introduction: Asthma is a chronic disease of the lower airways characterized by usually reversible airflow obstruction, inflammation, and hyperreactivity to various types of stimuli. It is one of the most common chronic respiratory diseases among children and adults, with an incidence of 300 million people worldwide. Objective: To evaluate the quality of the existent evidence in the literature in order to support the use of videogames and software-based programson asthmatic children and teenager’s knowledge capacity and self-management compared with standard education. Methods: Search, selection and analysis (starting March 2016) of all the original articles on virtual reality (VR) concerning asthmatic children and adolescents (ages 3 to 18), published up to October 2017, in Portuguese, English and Spanish, at the electronic databases Pubmed, Web of Science, MedlLine and LILACS, obtained by using the descriptors: asthma, video game, virtual reality, pulmonary rehabilitation, physical training. Results: Only six original articles were obtained. Of these, five (80%) presented level of evidence A, and one (20%) presented level of evidence B. All authors point out the treatment of asthma from VR as a safe and innovative therapy considering that the motivation and intensity of treatment from the use of VR improves the self-management capacity and aerobic capacity of asthmatic patients. Conclusion: The present study seeks to contribute to the literature by demonstrating that videogames and other software-based systemscan be used to improve knowledge capacity and self-management skills in children and teenagers with asthma diagnosis.

Digital health interventions in children with asthma

Although healthcare providers are actively involved in offering education, information and interventions for asthmatic patients, medication and therapeutic adherence remain low in the paediatric population, with estimates suggesting that adherence rates hover below 50%. A range of available digital health interventions has been explored in paediatric asthma with promising but variable results, limiting their widespread adoption in clinical practice. They include emerging technologies that yield the advantage of tracking asthma symptoms and medications, setting drug reminders, improving inhaler technique and delivering asthma education, such as serious games (video games designed for medical‐ or health‐related purposes), electronic monitoring devices, speech recognition calls, text messaging, mobile apps and interactive websites. Some of the proposed digital interventions have used multiple components, including educational and behavioural strategies and interactions with medical professionals. Overall, the implementation of such interventions may offer the opportunity to improve adherence and asthma control. In a state of emergency as the COVID‐19 pandemic, telemedicine can also play a central role in supporting physicians in managing children with asthma. This review evaluates the published literature examining digital health interventions for paediatric asthma and explores the most relevant issues affecting their implementation in practice and the associated evidence gaps, research limitations and future research perspectives.

Analysis of real-world data on growth hormone therapy adherence using a connected injection device

Background

Poor adherence to long-term recombinant human growth hormone (r-hGH) treatment can lead to suboptimal clinical outcomes; consequently, supporting and monitoring adherence is a crucial part of patient management. We assessed adherence to r-hGH treatment in children with growth disorders over 48 months using a connected monitoring device (easypod™), which automatically transmits adherence data via an online portal (easypod™ connect); both sit within an adherence decision support system (ADSS). We also investigated the effect of age and sex on adherence.

Methods

Data from children transmitting over 10 injections between January 2007 and February 2019 were analyzed. Adherence (mg injected/mg prescribed) was categorized as high (≥85%), intermediate (> 56–84%) or low (≤56%) and assessed at seven time points from the start of treatment up to 48 months. Adherence was investigated over time and stratified by puberty status and sex. Mean transmission rate in each adherence category (total number of transmissions/total number of children) at each time point was calculated as a proxy measure of engagement in disease and treatment management. Descriptive analyses were performed.

Results

Longitudinal records were available for 13,553 children. Overall, 71% (n = 9578) had high adherence, 22% (n = 2989) intermediate and 7% (n = 986) low. The proportion of children with high adherence decreased over time from 87% (n = 12,964) to 65% (n = 957) and was higher in pre-pubertal than pubertal children (girls: 80% [n = 1270] vs 70% [n = 4496]; boys 79% [n = 2573] vs 65% [n = 5214]). Children with high adherence had a higher mean number of transmissions (12.5 [SD 24.9]) than children with intermediate (7.2 [SD 15.3]) or low (3.5 [SD 5.7]) adherence.

Conclusions

High adherence was seen in patients administering r-hGH using the connected device. Children with high adherence were most likely to regularly transmit data. Pubertal children showed lower adherence. We show the potential to develop an ADSS to analyze trends in real-world adherence data. This may prove useful to direct interventions to improve adherence while the ability to readily share data with healthcare professionals may itself improve adherence.

Therapeutic Patient Education with Learning Objects Improves Asthma Control in Mexican Children

One of the most common chronic diseases that causes missed school days and workdays is pediatric asthma, producing education, health and economic delays in low and middle-income countries. A patient-centered remarkable therapeutic strategy in the prevention and treatment of chronic diseases is the Therapeutic Patient Education (TPE) which denotes an outstanding difference in the outcomes, from the awareness, to the personal treatment adaption to prevent crises. In this paper, an intervention of TPE with learning objects (LOs) of a pediatric asthma course, designed to train the uncontrolled patient and the caregiver as a team on the specific knowledge to self-control the disease, was carried out at a health facility in Mexico. The Asthma Control Test (ACT) was used and the learning performance was evaluated with formative quizzes. A randomized controlled trial was designed, with pairs of children patients and caregivers during 60 days; the control group was trained with the usual approach, receiving general information about the disease. ACT measures showed statistical significance for the TPE group after the use of the LOs, achieving a controlled state, while the control group did not show difference. Also, the intervention group obtained a higher score in learning performance assessment. The users learned how to avoid risks, the personal triggers of the patient, how to correctly use the different treatments and accessories, consequently, they learned how to self-manage the disease. Our study also confirmed that control of asthma is not only a matter of knowledge, but financial issues to afford the treatment.

Comparing Three Measures of Self-Efficacy of Asthma Self-Management in Adolescents

OBJECTIVE

This study examines the relationships between 3 measures of asthma-related self-efficacy and compares them by their relationships to quality of life, medication adherence, asthma control, asthma knowledge, and attitudes in adolescents.

METHODS

Participants included 371 urban adolescents (age 12-20 years) with asthma. Three self-efficacy measures included the Asthma Outcome Expectation-self-efficacy subscale (AOE-SE), Asthma Management Index-self-efficacy subscale (AMI-SE), and the Asthma Self-Efficacy scale (ASE).

RESULTS

The sample included 50% male, predominantly African American (78.4%) participants. All 3 measures of self-efficacy were positively correlated with each other (r = 0.46-0.54, P < .001). After controlling for gender, age, race, and health insurance type, all 3 self-efficacy measures predicted the symptom domain of quality of life, adherence, asthma control, and knowledge. Activity limitation was predicted by AMI-SE (B = 0.19, P = .008) and ASE (B = 0.38, P < .001) but not by AOE-SE, while emotional function associated only with ASE (B = 0.37, P < 0.001). Attitudes were positively associated with AOE-SE and ASE (B = 1.83 and 2.87, respectively, P < 0.001 for both), but not with AMI-SE.

CONCLUSIONS

Medication adherence and symptom control in adolescents were predicted by self-efficacy measured by the 3 measures, while these measures differed in their performance in predicting psychosocial outcomes. ASE appears the measure of choice in measuring adolescents' self-efficacy given its association with all outcome measures of the study. Further research is needed to investigate the generalized use of the self-efficacy measures in populations with varying demographic or asthma characteristics.

Responsive Asthma Care for Teens (ReACT): development protocol for an adaptive mobile health intervention for adolescents with asthma

INTRODUCTION

Asthma is a leading cause of youth morbidity in the USA, affecting >8% of youth. Adherence to inhaled corticosteroids (ICS) can prevent asthma-related morbidity; however, the typical adolescent with asthma takes fewer than 50% of their prescribed doses. Adolescents are uniquely vulnerable to suboptimal asthma self-management due to still-developing executive functioning capabilities that may impede consistent self-regulation and weaken attempts to use problem solving to overcome barriers to ICS adherence.

METHODS AND ANALYSIS

The aims of this project are to improve adherence to ICS as an important step towards better self-management among adolescents aged 13-17 years diagnosed with asthma by merging the efficacious behaviour change strategies found in behavioural health interventions with scalable, adaptive mobile health (mHealth) technologies to create the Responsive Asthma Care for Teens programme (ReACT). ReACT intervention content will be developed through an iterative user-centred design process that includes conducting (1) one-on-one interviews with 20 teens with asthma; (2) crowdsourced feedback from a nationally representative panel of 100 adolescents with asthma and (3) an advisory board of youth with asthma, a paediatric pulmonologist and a behavioural health expert. In tandem, we will work with an existing technology vendor to programme ReACT algorithms to allow for tailored intervention delivery. We will conduct usability testing of an alpha version of ReACT with a sample of 20 target users to assess acceptability and usability of our mHealth intervention. Participants will complete a 4-week run-in period to monitor their adherence with all ReACT features turned off. Subsequently, participants will complete a 4-week intervention period with all ReACT features activated. The study started in October 2018 and is scheduled to conclude in late 2019.

ETHICS AND DISSEMINATION

Institutional review board approval was obtained at the University of Kansas and the University of Florida. We will submit study findings for presentation at national research conferences that are well attended by a mix of psychologists, allied health professionals and physicians. We will publish study findings in peer-reviewed journals read by members of the psychology, nursing and pulmonary communities.

Effect of disease management education on the quality of life and self-efficacy levels of children with asthma

PURPOSE

The aim of this study was to determine the effects of disease management education provided to children with asthma on their quality of life and self-efficacy levels.

METHODS AND DESIGN

The study design was a quasi-experimental design with The One Group Pretest-Posttest design. This study was conducted on 60 children with asthma between 10 and 18 years of age. Data were collected by "Information Form", "Pediatric Asthma Quality of Life Questionnaire", and "Self-Efficacy Scale for Children and Adolescents with Asthma". Children's quality of life and self-efficacy levels were assessed before receiving an individual asthma education intervention and then children were informed with an asthma management education book individually. Two months after the education intervention, the quality of life and self-efficacy levels of the children were re-evaluated.

RESULTS

The children's quality of life and self-efficacy levels increased significantly after education (p = 0.014). Maternal age, number of siblings, number of family members living in the same house, activity status, the frequency of experiencing symptoms, and the ability to use the inhalers on their own affected children quality of life. Child's age, knowledge about factors causing asthma, and ability to use medication on their own affected their self-efficacy ( p < 0.05).

PRACTICE IMPLICATIONS

According to these results, planned asthma education program and provided continuity of this education by nurses would be effective to improve the quality of life and levels of self-efficacy. Asthma management education for children with asthma by nurses after diagnosis is beneficial for improving the quality of life and levels of self-efficacy.

Health Care Provider Perceptions of Consumer-Grade Devices and Apps for Tracking Health: A Pilot Study

Background

The use of Web- or mobile phone–based apps for tracking health indicators has increased greatly. However, provider perceptions of consumer-grade devices have not been widely explored.

Objective

The purpose of this study was to determine primary care physicians’ and advanced practice registered nurses’ perceptions of consumer-grade sensor devices and Web- or mobile phone–based apps that allow patients to track physical activity, diet, and sleep.

Methods

We conducted a cross-sectional mailed survey with a random sample of 300 primary care physicians and 300 advanced practice registered nurses from Michigan, USA. Providers’ use and recommendation of these types of technologies, and their perceptions of the benefits of and barriers to patients’ use of the technologies for physical activity, diet, and sleep tracking were key outcomes assessed.

Results

Most of the respondents (189/562, 33.6% response rate) were advanced practice registered nurses (107/189, 56.6%). Almost half of the sample (93/189, 49.2%) owned or used behavioral tracking technologies. Providers found these technologies to be helpful in clinical encounters, trusted the data, perceived their patients to be interested in them, and did not have concerns over the privacy of the data. However, the providers did perceive patient barriers to using these technologies. Additionally, those who owned or used these technologies were up to 6.5 times more likely to recommend them to their patients.

Conclusions

Our study demonstrated that many providers perceived benefits for their patients to use these technologies, including improved communication. Providers’ concerns included their patients’ access and the usability of these technologies. Providers who encountered data from these technologies during patient visits generally perceive this to be helpful. We additionally discuss the barriers perceived by the providers and offer suggestions and future research to realize the potential benefits to using these data in clinical encounters.

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

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.

A Mobile Game for Patients With Breast Cancer for Chemotherapy Self-Management and Quality-of-Life Improvement: Randomized Controlled Trial

Background

The application of game-based learning in clinical practice has shown potential advantages in previous studies. However, there have been little efforts to use smartphone-based mobile games in the management of adult patients with cancer.

Objective

The objective of our study was to evaluate if patient education using a mobile game may increase drug compliance, decrease physical side effects of chemotherapy, and improve psychological status in breast cancer patients.

Methods

A total of 76 patients with metastatic breast cancer who were planned to receive cytotoxic chemotherapy were enrolled in this trial. Study participants were randomly assigned to a mobile game play group (game group, n=36) or a conventional education group (control group, n=40) in a ratio of 1:1. The patients were unblinded and followed prospectively for 3 weeks. Outcome measures included time spent for education, compliance to medication, physical side effects, and psychological side effects including quality of life (QoL).

Results

Overall, 72 out of 76 patients completed the study after 3 weeks (95%). The subjects in the game group showed high levels of satisfaction with the app. The time spent playing the mobile game in the game group was longer than that spent for self-education in the control group (mean 22.2, SD 6.1 vs mean 5.5, SD 4.0 minutes a day; P<.001). The mobile game group showed better drug adherence (Korean version of the Medication Adherence Rating Scale; mean 7.6, SD 0.7 vs mean 6.5, SD 0.5; P<.001). The use of the mobile game was associated with lower rates of chemotherapy-related side effects, such as nausea, fatigue, numbness of hand or foot, and hair loss, than the control group. The game group exhibited better QoL during chemotherapy (mean 74.9, SD 3.5 vs mean 72.2, SD 5.3; P=.01). However, there were no significant differences in terms of depression and anxiety scales.

Conclusions

This study suggests the feasibility and potentiality of the use of smartphone mobile games for patients with breast cancer receiving chemotherapy. Education using a mobile game led to better patient education, improved drug compliance, decreased side effects, and better QoL compared with conventional education. Mobile games can be used as easy, fun, and effective measures for patient education and have the potential to improve treatment outcomes.

Trial Registration

ClinicalTrials.gov NCT03205969; http://clinicaltrials.gov/ct2/show/NCT03205969 (Archived by WebCite at http://www.webcitation.org/71jfSBOq9).

A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial

Background

There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa.

Objective

To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change.

Methods

Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics.

Results

Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game’s value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk.

Conclusions

The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design.

Trial Registration

ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW)

Wearables in Medicine

Wearables as medical technologies are becoming an integral part of personal analytics, measuring physical status, recording physiological parameters, or informing schedule for medication. These continuously evolving technology platforms do not only promise to help people pursue a healthier life style, but also provide continuous medical data for actively tracking metabolic status, diagnosis, and treatment. Advances in the miniaturization of flexible electronics, electrochemical biosensors, microfluidics, and artificial intelligence algorithms have led to wearable devices that can generate real-time medical data within the Internet of things. These flexible devices can be configured to make conformal contact with epidermal, ocular, intracochlear, and dental interfaces to collect biochemical or electrophysiological signals. This article discusses consumer trends in wearable electronics, commercial and emerging devices, and fabrication methods. It also reviews real-time monitoring of vital signs using biosensors, stimuli-responsive materials for drug delivery, and closed-loop theranostic systems. It covers future challenges in augmented, virtual, and mixed reality, communication modes, energy management, displays, conformity, and data safety. The development of patient-oriented wearable technologies and their incorporation in randomized clinical trials will facilitate the design of safe and effective approaches.

Educational and home-environment asthma interventions for children in urban, low-income, minority families

OBJECTIVE

This review examined the impact of environmental change and educational interventions targeting young children from minority groups living in urban environments and who were from low-income families.

DATA SOURCES

A scoping methodology was used to find research across six databases, including CINAHL, ERIC, PsycINFO, PubMed, MEDLINE, and EMBASE.

STUDY SELECTION

299 studies were identified. Duplicates were removed leaving 159 studies. After reviewing for inclusion and exclusion criteria, 23 manuscripts were identified for this study: 11 featured home-environment change interventions and 12 emphasized education of children.

RESULTS

Studies were reviewed to determine key interventions and outcomes for children. Both environmental interventions and educational programs had positive outcomes. Interventions did not always impact health outcomes, such as emergency department visits.

CONCLUSIONS

Results indicated many of the environmental change and education interventions improved asthma management and some symptoms. A multipronged approach may be a good method for targeting both education and change in the home and school environment to promote the well-being of young children in urban areas. New research with careful documentation of information about study participants, dose of intervention (i.e., number and duration of sessions, booster sessions) and specific intervention components also will provide guidance for future research.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A systematic review of serious games in asthma education

BACKGROUND

Serious games may be useful tools for asthma education. The objectives of this systematic review were to identify the available articles on serious games designed to educate patients and the general public about asthma and to assess their impact on patient's knowledge, behavior, and clinical outcomes related to asthma.

METHODS

PubMed, EMBASE, Cochrane Library, PsychInfo, and Web of Science were systematically searched from January 1980 to December 2015 for studies investigating serious games in asthma education. Two investigators independently assessed studies against inclusion criteria and rated those included on indicators of quality. Investigators extracted data on serious games' content and learning objectives, and on outcomes following Kirkpatrick classification.

RESULTS

A total of 12 articles were found to be relevant, describing a total of 10 serious games. All serious games were directed toward children, with eight games for children with asthma and two for school-based intervention. The average Medical Education Research Study Quality Instrument score was 13.9 of 18, which is high. Most of the serious games were associated with high rates of satisfaction and improvement in children's knowledge. Seven studies evaluated the impact of serious games on clinical outcomes and found no significant difference relative to control groups.

CONCLUSIONS

Although serious games designed for asthma education have evolved with advances in technology, results of their evaluation remained similar across studies, with clear improvements in knowledge but little or no change in behaviors and clinical outcomes.

The Impact of an Interactive Computer Game on the Quality of Life of Children Undergoing Chemotherapy

Background:

Quality of life (QOL) of children with cancer reduces right from the diagnosis of disease and the start of treatment. Computer games in medicine are utilized to interact with patients and to improve their health-related behaviors. This study aimed to investigate the effect of an interactive computer game on the QOL of children undergoing chemotherapy.

Materials and Methods:

In this clinical trial, 64 children with cancer aged between 8 and12 years were selected through convenience sampling and randomly assigned to experimental or control group. The experimental group played a computer game for 3 hours a week for 4 consecutive weeks and the control group only received routine care. The data collection tool was the Pediatric Quality of Life Inventory (PedsQL) 3.0 Cancer Module Child self-report designed for children aged between 8 to 12 years. Data were analyzed using descriptive and inferential statistics in SPSS software.

Results:

Before intervention, there was no significant difference between the two groups in terms of mean total QOL score (p = 0.87). However, immediately after the intervention (p = 0.02) and 1 month after the intervention (p < 0.001), the overall mean QOL score was significantly higher in the intervention group than the control group.

Conclusions:

Based on the findings, computer games seem to be effective as a tool in influencing health-related behavior and improving the QOL of children undergoing chemotherapy. Therefore, according to the findings of this study, computer games can be used to improve the QOL of children undergoing chemotherapy.

An educational video game for nutrition of young people: Theory and design

BACKGROUND

Playing Escape from DIAB (DIAB) and Nanoswarm (NANO), epic video game adventures, increased fruit and vegetable consumption among a multi-ethnic sample of 10-12 year old children during pilot testing. Key elements of both games were educational mini-games embedded in the overall game that promoted knowledge acquisition regarding diet, physical activity and energy balance. 95-100% of participants demonstrated mastery of these mini-games suggesting knowledge acquisition.

AIM

This article describes the process of designing and developing the educational mini-games. A secondary purpose was to explore the experience of children while playing the games.

METHOD

The educational games were based on Social Cognitive and Mastery Learning Theories. A multidisciplinary team of behavioral nutrition, PA, and video game experts designed, developed, and tested the mini-games.

RESULTS

Alpha testing revealed children generally liked the mini-games and found them to be reasonably challenging. Process evaluation data from pilot testing revealed almost all participants completed nearly all educational mini-games in a reasonable amount of time suggesting feasibility of this approach.

CONCLUSIONS

Future research should continue to explore the use of video games in educating children to achieve healthy behavior changes.

Developing a mobile application to better inform patients and enable effective consultation in implant dentistry

The field of dentistry lacks satisfactory tools to help visualize planned procedures and their potential results to patients. Dentists struggle to provide an effective image in their patient's mind of the end results of the planned treatment only through verbal explanations. Thus, verbal explanations alone often cannot adequately help the patients make a treatment decision. Inadequate attempts are frequently made by dentists to sketch the procedure for the patient in an effort to depict the treatment. These attempts however require an artistic ability not all dentists have. Real case photographs are sometimes of help in explaining and illustrating treatments. However, particularly in implant cases, real case photographs are often ineffective and inadequate. The purpose of this study is to develop a mobile application with an effective user interface design to support the dentist-patient interaction by providing the patient with illustrative descriptions of the procedures and the end result. Sketching, paper prototyping, and wire framing were carried out with the actual user's participation. Hard and soft dental tissues were modeled using three dimensional (3D) modeling programs and real cases. The application enhances the presentation to the patients of potential implants and implant supported prosthetic treatments with rich 3D illustrative content. The application was evaluated in terms of perceived ease of use and perceived usefulness through an online survey. The application helps improve the information sharing behavior of dentists to enhance the patients' right to make informed decisions. The paper clearly demonstrates the relevance of interactive communication technologies for dentist-patient communication.

Technology-Based Interventions for Asthma-Can They Help Decrease Health Disparities?

Asthma is a condition that has consistently demonstrated significant health outcome inequalities for minority populations. One approach used for care of patients with asthma is the incorporation of technology for behavioral modification, symptom monitoring, education, and/or treatment decision making. Whether such technological interventions can improve the care of black and inner-city patients is unknown. We reviewed all randomized controlled trial technological interventions from 2000 to 2015 performed in minority populations. A total of 16 articles met inclusion and exclusion criteria; all but 1 was performed in a childhood or adolescent age group. The interventions used MPEG audio layer-3 players, text messaging, computer/Web-based systems, video games, and interactive voice response. Many used tailored content and/or a specific behavior theory. Although the interventions were based on technology, most required additional special staffing. Subject user satisfaction was positive, and improvements were noted in asthma knowledge, medication adherence, asthma symptoms, and quality of life. Unfortunately, health care utilization (emergency department visits and/or hospitalizations) was typically not improved by the interventions. Although no single intervention modality was vastly superior, the computer-based interventions appeared to have the most positive results. In summary, technology-based interventions have a high level of user satisfaction among minority and urban/low-income individuals with asthma, and can improve asthma outcomes. Further large-scale studies are needed to assess whether such interventions can decrease health disparities in asthma.

The Rise of Consumer Health Wearables: Promises and Barriers

Lukasz Piwek and colleagues consider whether wearable technology can become a valuable asset for health care.

Interactive media for parental education on managing children chronic condition: a systematic review of the literature

Background

Although some research has examined the use of games for the education of pediatric patients, the use of technology for parental education seems like an appropriate application as it has been a part of the popular culture for at least 30 years. The main objective of this systematic review is to examine the literature for research evaluating the use of interactive media in the education of parents of children with chronic conditions.

Methods

We searched the MEDLINE, PSYCHINFO, CINAHL, Cochrane database of systematic reviews and EMBASE databases from 1986 to 2014 seeking original investigations on the use of interactive media and video games to educate parents of children with chronic conditions. Cohort studies, randomized control trials, and observational studies were included in our search of the literature.

Two investigators reviewed abstracts and full texts as necessary. The quality of the studies was assessed using the GRADE guidelines.

Overall trend in the results and the degree of certainty in the results were considered when assessing the body of literature pertaining to our focused questions.

Results

Our initial search identified 4367 papers, but only 12 fulfilled the criterion established for final analysis, with the majority of the studies having flaws that reduced their quality. These papers reported mostly positive results supporting the idea that parent education is possible through interactive media.

Conclusion

We found limited evidence of the effectiveness of using serious games and or interactive media to educate parents of children with chronic conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0517-2) contains supplementary material, which is available to authorized users.

A taxonomy of behaviour change methods: an Intervention Mapping approach

In this paper, we introduce the Intervention Mapping (IM) taxonomy of behaviour change methods and its potential to be developed into a coding taxonomy. That is, although IM and its taxonomy of behaviour change methods are not in fact new, because IM was originally developed as a tool for intervention development, this potential was not immediately apparent. Second, in explaining the IM taxonomy and defining the relevant constructs, we call attention to the existence of parameters for effectiveness of methods, and explicate the related distinction between theory-based methods and practical applications and the probability that poor translation of methods may lead to erroneous conclusions as to method-effectiveness. Third, we recommend a minimal set of intervention characteristics that may be reported when intervention descriptions and evaluations are published. Specifying these characteristics can greatly enhance the quality of our meta-analyses and other literature syntheses. In conclusion, the dynamics of behaviour change are such that any taxonomy of methods of behaviour change needs to acknowledge the importance of, and provide instruments for dealing with, three conditions for effectiveness for behaviour change methods. For a behaviour change method to be effective: (1) it must target a determinant that predicts behaviour; (2) it must be able to change that determinant; (3) it must be translated into a practical application in a way that preserves the parameters for effectiveness and fits with the target population, culture, and context. Thus, taxonomies of methods of behaviour change must distinguish the specific determinants that are targeted, practical, specific applications, and the theory-based methods they embody. In addition, taxonomies should acknowledge that the lists of behaviour change methods will be used by, and should be used by, intervention developers. Ideally, the taxonomy should be readily usable for this goal; but alternatively, it should be clear how the information in the taxonomy can be used in practice. The IM taxonomy satisfies these requirements, and it would be beneficial if other taxonomies would be extended to also meet these needs.

An Electronic Asthma Self-Management Intervention for Young African American Adults

BACKGROUND

Health disparities are seen in many chronic conditions including asthma. Young African American adults represent a population at high risk for poor asthma outcomes due to both their minority status and the difficult transition from adolescence to adulthood. Recruitment and retention has been challenging in this demographic stratum, and traditional asthma education is often not feasible.

OBJECTIVE

The objective of this study was to develop and assess the feasibility of an electronic asthma self-management program for young African American adults.

METHODS

A total of 44 African American adults (age 18-30 years) with uncontrolled persistent asthma were enrolled in an asthma self-management program. The 6-week Breathe Michigan program (predicated on the social cognitive theory) was tailored specifically to the concerns and preferences of young African American adults. The entire program was completed electronically, without any specialized human support. At 2 weeks and 3 months after program completion, participants were contacted for follow-up.

RESULTS

A total of 89% of enrolled subjects completed the 6-week intervention, and 77% were available for evaluation at 3 months. All subjects completing the 2-week postprogram survey reported that the program was helpful, and 97% would recommend it to others. Asthma control as measured by the Asthma Control Test improved from 16.1 to 19.3 (P < .01), and asthma quality of life as measured by the Mini Asthma Quality of Life Questionnaire improved from 4.0 to 5.1 (P < .01).

CONCLUSIONS

The Breathe Michigan program is feasible for recruitment and retention, and demonstrated an improvement in asthma control and quality of life for young African American adults.

Using indirect comparisons to compare interventions within a Cochrane review: a tool for comparative effectiveness research

AIM

Assessing relative performance among competing interventions is an important part of comparative effectiveness research. Bayesian indirect comparisons add information to existing Cochrane reviews, such as which intervention is likely to perform best. However, heterogeneity variance priors may influence results and, potentially, clinical guidance.

METHODS

We highlight the features of Bayesian indirect comparisons using a case study of a Cochrane review update in asthma care. The probability that one self-management educational intervention outperforms others is estimated. Simulation studies investigate the effect of heterogeneity variance prior distributions.

RESULTS

Results suggest a 55% probability that individual education is best, followed by combination (39%) and group (6%). The intervention with few trials was sensitive to prior distributions.

CONCLUSION

Bayesian indirect comparisons updates of Cochrane reviews are valuable comparative effectiveness research tools.

Videogames and Health Improvement: A Literature Review of Randomized Controlled Trials

OBJECTIVE

There are potential benefits of playing videogames for health improvement such as increasing knowledge about health-related issues by playing educational games and fighting a sedentary lifestyle by playing exergames. The number of systematic review articles about "videogames" and "health improvement" is limited. Therefore, the purpose of this study is to review those randomized controlled trials (RCTs) with the topic of "videogames" and "health improvement."

MATERIALS AND METHODS

Several electronic databases were searched for RCTs testing videogames on health outcomes that were published in English between January 2000 and April 2012.

RESULTS

Forty-five articles met the eligibility criteria and were categorized into five groups: (1) videogames and patient pain and stress reduction (nine articles), (2) videogames and patient behavioral change (19 articles), (3) videogames and patient rehabilitation (eight articles), (4) videogames as diagnostic tools (three articles), and (5) videogames and cognitive ability (six articles).

CONCLUSIONS

Most of the articles have shown promising results in using videogames within various fields of healthcare. Although exergames are the most prominent choice regarding health improvement, videogames have the potential to be used as a pain management tool, diagnostic tool, or educational tool. They also can be used as a facilitator in physical rehabilitation or cognitive loss prevention. More RCTs are needed to fully uncover the benefits of using videogames for improving patients' health.

Serious games for improving knowledge and self-management in young people with chronic conditions: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials assessing the effectiveness of serious games in improving knowledge and/or self-management behaviors in young people with chronic conditions.

MATERIALS AND METHODS

The authors searched the databases PubMed, Cochrane Library, Web of Sciences, and PsychINFO for articles published between January 1990 and January 2014. Reference lists were hand-searched to retrieve additional studies. Randomized controlled trials that compared a digital game with either standard education or no specific education in a population of children and/or adolescents with chronic conditions were included.

RESULTS

The authors identified 9 studies in which the effectiveness of serious games in young people with chronic conditions was evaluated using a randomized controlled trials design. Six studies found a significant improvement of knowledge in the game group from pretest to posttest; 4 studies showed significantly better knowledge in the game group than in the control group after the intervention. Two studies reported significantly better self-management in the game group than in the control group after the intervention. Seven studies were included in the meta-analysis. For knowledge, pooled estimate of Hedges' gu was 0.361 (95% confidence intervals, 0.098-0.624), demonstrating that serious games improve knowledge in patients. For self-management, pooled estimate of Hedges' gu was 0.310 (95% confidence intervals, 0.122-0.497), showing that gaming improves self-management behaviors.

CONCLUSIONS

The authors' meta-analysis shows that educational video games can be effective in improving knowledge and self-management in young people with chronic conditions.

National standards for asthma self-management education

BACKGROUND

Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that "if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease." Without a standardized curriculum, reimbursement from payers is beyond reach.

OBJECTIVE

Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement.

METHODS

The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document.

RESULTS

This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014.

CONCLUSION

This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.

Impact of symptom management training among asthmatic children and adolescents on self-efficacy and disease course

PURPOSE

The study was conducted to examine the effect of a training program provided to asthmatic children/adolescents on disease course and self-efficacy.

METHODS

This prospective study consisted of both experimental and control subjects. The study population was composed of children/adolescents aged 10-18 years, who presented at Health Centers within Tokat province with asthma and who were currently using inhaler treatments. The study sample included 40 patients each in both the control and experimental groups. Asthmatic Child Information Form, Disease Evaluation Form, Peak Expiratory Flow Rate Evaluation Form and an Asthmatic Child/Adolescent Self-Efficacy Scale were used to collect data on research outcomes. Data were statistically analyzed with paired sample t-test, McNemar's test, independent samples t-test.

RESULTS

A significant increase in mean self-efficacy score was observed in the experimental group following training sessions. The experimental training was also associated with a reduction in asthma symptoms, less limitations to daily function and fewer attacks following physical activity relative to the control subjects. The children/adolescents in the experimental group were more conscious of the symptoms of asthma attacks and used preventive and rescue medications regularly, and reported fewer absences from school and fewer emergency room visits (p < 0.05). The average peak expiratory flow rate was 62.5% in the experimental group. After training, there were significant decreases in the number of attacks and the need of increasing inhaler doses in the experimental group.

CONCLUSIONS

The study results show that the training program is effective in increasing self-efficacy and improving asthma symptoms among children/adolescents. Nurses should offer the training program to support children/adolescents during asthma attacks, and encourage the development of self-efficacy.

Intervention Mapping Protocol for Developing a Theory-Based Diabetes Self-Management Education Program

Development of behavior theory–based health promotion programs is encouraged with the paradigm shift from contents to behavior outcomes. This article describes the development process of the diabetes self-management program for older Koreans (DSME-OK) using intervention mapping (IM) protocol. The IM protocol includes needs assessment, defining goals and objectives, identifying theory and determinants, developing a matrix to form change objectives, selecting strategies and methods, structuring the program, and planning for evaluation and pilot testing. The DSME-OK adopted seven behavior objectives developed by the American Association of Diabetes Educators as behavioral outcomes. The program applied an information-motivation-behavioral skills model, and interventions were targeted to 3 determinants to change health behaviors. Specific methods were selected to achieve each objective guided by IM protocol. As the final step, program evaluation was planned including a pilot test. The DSME-OK was structured as the 3 determinants of the IMB model were intervened to achieve behavior objectives in each session. The program has 12 weekly 90-min sessions tailored for older adults. Using the IM protocol in developing a theory-based self-management program was beneficial in terms of providing a systematic guide to developing theory-based and behavior outcome–focused health education programs.

A meta-analysis of serious digital games for healthy lifestyle promotion

Several systematic reviews have described health-promoting effects of serious games but so far no meta-analysis has been reported. This paper presents a meta-analysis of 54 serious digital game studies for healthy lifestyle promotion, in which we investigated the overall effectiveness of serious digital games on healthy lifestyle promotion outcomes and the role of theoretically and clinically important moderators. Findings showed that serious games have small positive effects on healthy lifestyles (g=0.260, 95% CI 0.148; 0.373) and their determinants (g=0.334, 95% CI 0.260; 0.407), especially for knowledge. Effects on clinical outcomes were significant, but much smaller (g=0.079, 95% CI 0.038; 0.120). Long-term effects were maintained for all outcomes except for behavior. Serious games are best individually tailored to both socio-demographic and change need information, and benefit from a strong focus on game theories or a dual theoretical foundation in both behavioral prediction and game theories. They can be effective either as a stand-alone or multi-component programs, and appeal to populations regardless of age and gender. Given that effects of games remain heterogeneous, further explorations of which game features create larger effects are needed.

Knowledge, instruction and behavioural change: building a framework for effective eczema education in clinical practice

AIMS

A discussion on the reasons educational interventions about eczema, by nurses, are successful, with the subsequent development of a theoretical framework to guide nurses to become effective patient educators.

BACKGROUND

Effective child and parent education is the key to successful self-management of eczema. When diagnosed, children and parents should learn to understand the condition through clear explanations, seeing treatment demonstrations and have ongoing support to learn practical skills to control eczema. Dermatology nurses provide these services, but no one has proposed a framework of the concepts underpinning their successful eczema educational interventions.

DESIGN

A discussion paper.

DATA SOURCES

A literature search of online databases was undertaken utilizing terms 'eczema OR atopic dermatitis', 'education', 'parent', 'nurs*', 'framework', 'knowledge', motivation', in Scopus, CINAHL, Web of Science, Medline and Pubmed. Limits were English language and 2003-2013.

IMPLICATIONS FOR NURSING

The framework can inform discussion on child and parent education, provide a scaffold for future research and guide non-specialist nurses, internationally, in providing consistent patient education about eczema.

CONCLUSION

Founded on an understanding of knowledge, the framework utilizes essential elements of cognitive psychology and social cognitive theory leading to successful self-management of eczema. This framework may prove useful as a basis for future research in child and parent education, globally, in the healthcare community. A framework has been created to help nurses understand the essential elements of the learning processes at the foundation of effective child and parent education. The framework serves to explain the improved outcomes reported in previous nurse-led eczema educational interventions.

Brief approaches to developmental-behavioral promotion in primary care: updates on methods and technology

Well-child visits are a critical opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, enhance the development and well-being of children and their families, identify problems not amenable to brief in-office counseling, and refer for services when needed. This article outlines the communication skills, instructional methods, and resource options that enable clinicians to best assist families. Also covered is how to monitor progress and outcomes. A total of 239 articles and 52 Web sites on parent/patient education were reviewed for this study. Providers require a veritable armamentarium of instructional methods. Skills in nonverbal and verbal communication are needed to elicit the parent/patient agenda, winnow topics to a manageable subset, and create the "teachable moment." Verbal suggestions, with or without standardized spoken instructions, are useful for conveying simple messages. However, for complex issues, such as discipline, it is necessary to use a combination of verbal advice, written information, and "teach-back," aided by role-playing/modeling or multimedia approaches. Selecting the approaches most likely to be effective depends on the topic and family characteristics (eg, parental literacy and language skills, family psychosocial risk and resilience factors, children's developmental-behavioral status). When providers collaborate well (with parents, patients, and other service providers) and select appropriate educational methods, families are better able to act on advice, leading to improvements in children's well-being, health, and developmental-behavioral outcomes. Provided are descriptions of methods, links to parenting resources such as cell phone applications, Web sites (in multiple languages), interactive technology, and parent training courses.

Digital asthma self-management interventions: a systematic review

BACKGROUND

Many people with asthma tolerate symptoms and lifestyle limitations unnecessarily by not utilizing proven therapies. Better support for self-management is known to improve asthma control, and increasingly the Internet and other digital media are being used to deliver that support.

OBJECTIVE

Our goal was to summarize current knowledge, evidenced through existing systematic reviews, of the effectiveness and implementation of digital self-management support for adults and children with asthma and to examine what features help or hinder the use of these programs.

METHODS

A comprehensive search strategy combined 3 facets of search terms: (1) online technology, (2) asthma, and (3) self-management/behavior change/patient experience. We undertook searches of 14 databases, and reference and citation searching. We included qualitative and quantitative systematic reviews about online or computerized interventions facilitating self-management. Title, abstract, full paper screening, and quality appraisal were performed by two researchers independently. Data extraction was undertaken using standardized forms.

RESULTS

A total of 3810 unique papers were identified. Twenty-nine systematic reviews met inclusion criteria: the majority were from the United States (n=12), the rest from United Kingdom (n=6), Canada (n=3), Portugal (n=2), and Australia, France, Spain, Norway, Taiwan, and Greece (1 each). Only 10 systematic reviews fulfilled pre-determined quality standards, describing 19 clinical trials. Interventions were heterogeneous: duration of interventions ranging from single use, to 24-hour access for 12 months, and incorporating varying degrees of health professional involvement. Dropout rates ranged from 5-23%. Four RCTs were aimed at adults (overall range 3-65 years). Participants were inadequately described: socioeconomic status 0/19, ethnicity 6/19, and gender 15/19. No qualitative systematic reviews were included. Meta-analysis was not attempted due to heterogeneity and inadequate information provision within reviews. There was no evidence of harm from digital interventions. All RCTs that examined knowledge (n=2) and activity limitation (n=2) showed improvement in the intervention group. Digital interventions improved markers of self care (5/6), quality of life (4/7), and medication use (2/3). Effects on symptoms (6/12) and school absences (2/4) were equivocal, with no evidence of overall benefits on lung function (2/6), or health service use (2/15). No specific data on economic analyses were provided. Intervention descriptions were generally brief making it impossible to identify which specific "ingredients" of interventions contribute most to improving outcomes.

CONCLUSIONS

Digital self-management interventions show promise, with evidence of beneficial effects on some outcomes. There is no evidence about utility in those over 65 years and no information about socioeconomic status of participants, making understanding the "reach" of such interventions difficult. Digital interventions are poorly described within reviews, with insufficient information about barriers and facilitators to their uptake and utilization. To address these gaps, a detailed quantitative systematic review of digital asthma interventions and an examination of the primary qualitative literature are warranted, as well as greater emphasis on economic analysis within trials.

A systematic review of interactive multimedia interventions to promote children's communication with health professionals: implications for communicating with overweight children

BACKGROUND

Interactive multimedia is an emerging technology that is being used to facilitate interactions between patients and health professionals. The purpose of this review was to identify and evaluate the impact of multimedia interventions (MIs), delivered in the context of paediatric healthcare, in order to inform the development of a MI to promote the communication of dietetic messages with overweight preadolescent children. Of particular interest were the effects of these MIs on child engagement and participation in treatment, and the subsequent effect on health-related treatment outcomes.

METHODS

An extensive search of 12 bibliographic databases was conducted in April 2012. Studies were included if: one or more child-participant was 7 to 11-years-of-age; a MI was used to improve health-related behaviour; child-participants were diagnosed with a health condition and were receiving treatment for that condition at the time of the study. Data describing study characteristics and intervention effects on communication, satisfaction, knowledge acquisition, changes in self-efficacy, healthcare utilisation, and health outcomes were extracted and summarised using qualitative and quantitative methods.

RESULTS

A total of 14 controlled trials, published between 1997 and 2006 met the selection criteria. Several MIs had the capacity to facilitate engagement between the child and a clinician, but only one sought to utilise the MI to improve communication between the child and health professional. In spite of concerns over the quality of some studies and small study populations, MIs were found useful in educating children about their health, and they demonstrated potential to improve children's health-related self-efficacy, which could make them more able partners in face-to-face communications with health professionals.

CONCLUSIONS

The findings of this review suggest that MIs have the capacity to support preadolescent child-clinician communication, but further research in this field is needed. Particular attention should be given to designing appropriate MIs that are clinically relevant.

Developing an interactive story for children with asthma

Despite advancements in asthma treatment and diagnosis, asthma still remains the number 1 cause for hospitalizations in school-aged children. This usability study aimed to develop a child-friendly interactive narrative, Okay with Asthma v2.0, based on the Biopsychosocial Family Model using feedback from children. This fun and kid-friendly program encourages children to manage their own asthma with the help of peers, families, communities, and health care services. With these support structures, children can identify and avoid triggers, monitor their asthma, manage their condition with medications based on an action plan, and learn to live happily with asthma.

Electronic media-based health interventions promoting behavior change in youth: a systematic review

IMPORTANCE

Little research has been done on the efficacy of electronic media-based interventions, especially on their effect on health or safety behavior. The current review systematically identified and evaluated electronic media-based interventions that focused on promoting health and safety behavior change in youth.

OBJECTIVE

To assess the type and quality of the studies evaluating the effects of electronic media-based interventions on health and safety behavior change.

EVIDENCE REVIEW

Studies were identified from searches in MEDLINE (1950 through September 2010) and PsycINFO (1967 through September 2010). The review included published studies of interventions that used electronic media and focused on changes in behavior related to health or safety in children aged 18 years or younger.

FINDINGS

Nineteen studies met the criteria and focused on at least 1 behavior change outcome. The focus was interventions related to physical activity and/or nutrition in 7 studies, on asthma in 6, safety behaviors in 3, sexual risk behaviors in 2, and diabetes mellitus in 1. Seventeen studies reported at least 1 statistically significant effect on behavior change outcomes, including an increase in fruit, juice, or vegetable consumption; an increase in physical activity; improved asthma self-management; acquisition of street and fire safety skills; and sexual abstinence. Only 5 of the 19 studies were rated as excellent.

CONCLUSIONS AND RELEVANCE

Our systematic review suggests that interventions using electronic media can improve health and safety behaviors in young persons, but there is a need for higher-quality, rigorous interventions that promote behavior change.

Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach

PURPOSE

Asthma interventions targeting urban adolescents are rare, despite a great need. Motivating adolescents to achieve better self-management of asthma is challenging, and the literature suggests that certain subgroups are more resistant than others. We conducted a school-based, randomized controlled trial (RCT) to evaluate Puff City, a Web-based, tailored asthma intervention, which included a referral coordinator, and incorporated theory-based strategies to target urban teens with characteristics previously found to be associated with lack of behavior change.

METHODS

To identify eligible teens, we administered questionnaires on asthma diagnoses and symptoms to ninth through 12th graders of participating schools during a scheduled English class. We randomized eligible, consenting students to Puff City (treatment) or generic asthma education (control).

RESULTS

We randomized 422 students (98% African-American, mean age = 15.6 years). At 12-month follow-up, adjusted odds ratios (aORs) (95% confidence intervals) indicated intervention benefit for treatment teens for symptom-days and restricted activity days (analyzed as categorical variables) as aOR = .49 (.24-.79), p = .006 and .53 (.32-.86), p = .010, respectively. Among teens meeting baseline criteria for rebelliousness, treatment teens reported fewer symptom-days, symptom-nights, school absences, and restricted activity days: aOR = .30 (.11-.80), .29 (.14-.64), .40 (.20-.78), and .23 (.10-.55); all p < .05. Among teens reporting low perceived emotional support, treatment students reported only fewer symptom-days than controls: aOR = .23 (.06-.88), p = .031. We did not observe statistically significant differences in medical care use.

CONCLUSIONS

Results suggest that a theory-based, tailored approach, with a referral coordinator, can improve asthma management in urban teens. Puff City represents a viable strategy for disseminating an effective intervention to high-risk and hard-to-reach populations.

Evaluation of a peer-led asthma self-management program and benefits of the program for adolescent peer leaders

BACKGROUND

Asthma is the leading chronic condition in adolescents. Nonetheless, research efforts to address adolescent asthma morbidity by applying a developmentally appropriate self-management intervention have been limited. Recently a peer-led asthma self-management program has been developed and implemented for adolescents. The purpose of the study was to assess the acceptability of a peer-led asthma program for adolescents based on participant feedback and to examine the program's impact on asthma outcomes in peer leaders.

METHODS

Adolescents with persistent asthma (n = 91, 13-17 years) participated in a camp-based asthma program led by peer leaders (the intervention group) or healthcare professionals (the control group), and completed a set of program evaluation forms. Peer leaders (n = 14, 16-20 years) completed study questionnaires measuring asthma knowledge, self-efficacy, asthma control, and quality of life at baseline, immediately after camp, and 3, 6, and 9 months post-camp.

RESULTS

The peer-led group reported more positive experience with the program than the adult-led group (P = .01, Cohen's d = 0.53), particularly in its usefulness in dealing with asthma. Peer leaders were rated by participants highly on knowledge (98%), attitudes (93-96%), personal skills (91%), and perceived similarities (80-86%). Significant improvements were found in peer leaders' knowledge (P < .001, η(2) = 0.87), self-efficacy (P < .001, η(2) = 0.74), asthma control (P = .01, η(2) = 0.66), and quality of life in emotional functioning (P = .002, η(2) = 0.82) and activity (P = .003, η(2) = 0.62).

CONCLUSIONS

A peer-led asthma self-management program was successfully implemented and well received by adolescent learners. Asthma outcomes in peer leaders appear to have improved as a result of the program, although caution should be exercised in determining clinical meaningfulness, given the modest changes in mean scores. ClinicalTrials.gov registration NCT01161225.

Role of video games in improving health-related outcomes: a systematic review

CONTEXT

Video games represent a multibillion-dollar industry in the U.S. Although video gaming has been associated with many negative health consequences, it also may be useful for therapeutic purposes. The goal of this study was to determine whether video games may be useful in improving health outcomes.

EVIDENCE ACQUISITION

Literature searches were performed in February 2010 in six databases: the Center on Media and Child Health Database of Research, MEDLINE, CINAHL, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials. Reference lists were hand-searched to identify additional studies. Only RCTs that tested the effect of video games on a positive, clinically relevant health consequence were included. Study selection criteria were strictly defined and applied by two researchers working independently. Study background information (e.g., location, funding source); sample data (e.g., number of study participants, demographics); intervention and control details; outcomes data; and quality measures were abstracted independently by two researchers.

EVIDENCE SYNTHESIS

Of 1452 articles retrieved using the current search strategy, 38 met all criteria for inclusion. Eligible studies used video games to provide physical therapy, psychological therapy, improved disease self-management, health education, distraction from discomfort, increased physical activity, and skills training for clinicians. Among the 38 studies, a total of 195 health outcomes were examined. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 46% of clinician skills outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. Study quality was generally poor; for example, two thirds (66%) of studies had follow-up periods of <12 weeks, and only 11% of studies blinded researchers.

CONCLUSIONS

There is potential promise for video games to improve health outcomes, particularly in the areas of psychological therapy and physical therapy. RCTs with appropriate rigor will help build evidence in this emerging area.

Community-based approaches to controlling childhood asthma

The prevalence and burden of childhood asthma remain high and are increasing. Asthma hot spot neighborhoods around the country face particular challenges in controlling the effects of the condition. Increasing attention is being paid to developing interventions that recognize the child and family as the primary managers of disease and to introducing assistance that reaches beyond the clinical care setting into the places where families live and work. A range of types of community-focused interventions has been assessed in the past decade in schools, homes, and community health clinics, and programs using electronic media and phone links have been evaluated. Stronger evidence for all these approaches is needed. However, school-based programs and community coalitions designed to bring about policy and systems changes show particular promise for achieving sustainable improvements in asthma control. Research is needed that emphasizes comparisons among proven asthma control interventions, translation of effective approaches to new settings and communities, and institutionalization of effective strategies.

Dropout from computer-based interventions for children and adolescents with chronic health conditions

Dropout is a frequent problem in face-to-face psychological interventions. However, little is known regarding dropout in computer-based interventions (CBIs). It is important to understand the extent to which children and adolescents drop out of CBIs, so we can ensure that more people complete the programmes to gain maximum benefit. A systematic review of current research on dropout from CBIs identified 15 studies. Dropout rate ranged from 0 per cent to 54 per cent with a median of 15 per cent. There is a need for more rigorous investigation of the extent of, and reasons for, dropout from CBIs with children and adolescents with chronic health conditions.