Psychological Factors, Digital Health Technologies and Best Asthma Management: Three Fundamental Factors in Modern Care

Review Not peer-reviewed version Psychological Factors, Digital Health Technologies and Best Asthma Management: Three Fundamental Factors in Modern Care Pasquale Caponnetto , Graziella Chiara Prezzavento * , Mirko Casu , Maria Catena Quattropani Posted Date: 2 February 2024 doi: 10.20944/preprints202402.0126.v2 Keywords: Asthma; eHealth; Mobile apps; Digital Health Interventions; Mixed Reality; Depression; Anxiety; Clinical Psychology Preprints.org is a free multidiscipline platform providing preprint service that is dedicated to making early versions of research outputs permanently available and citable. Preprints posted at Preprints.org appear in Web of Science, Crossref, Google Scholar, Scilit, Europe PMC. Copyright: This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Review Psychological Factors, Digital Health Technologies and Best Asthma Management: Three Fundamental Factors in Modern Care Pasquale Caponnetto 1,2, Graziella Chiara Prezzavento 1,*, Mirko Casu 1,3 and Maria Catena Quattropani 1 1 Department of Educational Sciences, Section of Psychology, University of Catania, 95123 Catania, Italy; 2 Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, 95121 Catania, Italy; 3 Department of Mathematics and Computer Science, University of Catania, Viale Andrea Doria 6, Catania, 95125, Italy. * Correspondence: [email protected] Abstract: New digital interventions have shown potential in managing asthma and improving patients' quality of life compared with conventional interventions. Our objective was to conduct an exhaustive survey of the application of digital health technologies in evaluating, treating, and selfmanaging psychological and psychopathological elements linked to asthma. We analyzed a compendium of research papers and systematic reviews pertaining to asthma, encompassing themes such as outdoor air pollution, early life wheezing disorders, atopic dermatitis, digital strategies for asthma self-management, psychiatric conditions and asthma, familial impacts on pediatric asthma, and the utilization of mobile health apps for managing asthma. We scrutinized eight chosen studies to evaluate the capacity of digital health technologies to enhance the management and treatment outcomes of psychological factors related to asthma. The studies under review indicate that eHealth interventions, mixed reality instruments, mHealth technologyaugmented nurse-led interventions, and smartphone apps incorporating Bluetooth-enabled sensors for asthma inhalers can markedly enhance self-management of symptoms, quality of life, and mental health outcomes, particularly in children and adolescents with asthma. Nonetheless, additional research is required to ascertain their efficacy and practicability across diverse populations and environments. Customized interventions that cater to the unique needs and preferences of asthma patients and associated psychological elements are vital to ensure the persistent and equitable adoption of these technologies. We underscore the significance of addressing psychological elements in the management and treatment of asthma and advocate for ongoing research and development in this domain. Keywords: asthma; eHealth; mobile apps; digital health interventions; mixed reality; depression; anxiety; clinical psychology 1. Introduction Asthma, a chronic respiratory ailment that afflicts both adults and children, is characterized by inflammation and constriction of the airways, resulting in difficulty in breathing. The World Health Organization (WHO) has highlighted that asthma is often inadequately diagnosed or managed, particularly in low to middle-income nations [1]. Globally, the disease affects an estimated 100 to 150 million individuals, with the annual death toll associated with the condition, as per WHO data, standing at approximately 180,000 [2]. In Italy, the prevalence of asthma is around 10% among children, with severe asthma affecting 2% of asthmatic children and adolescents [3,4]. Among the adult population in Italy, the prevalence of asthma is approximately 8.4% [5]. The primary causes and risk factors for asthma encompass genetic predispositions [6], environmental influences [7], Disclaimer/Publisher’s Note: The statements, opinions, and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions, or products referred to in the content. Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 © 2024 by the author(s). Distributed under a Creative Commons CC BY license. 2 respiratory infections [8], and atopy [9]. The emergence of novel technologies has facilitated the introduction of efficacious treatment methodologies in clinical environments, including SMS-based interventions [10], smartphone applications [11], virtual and augmented reality [12,13], and commercial video games [14]. These are encompassed within the categories of electronic Health (eHealth) and mobile Health (mHealth), defined as follows: eHealth involves the utilization of information and communication technologies for health, such as electronic health records, personal health records, and clinical decision support tools, while mHealth pertains to medical and public health practices supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices, including mobile health apps and wearables [15]. In the context of asthma, these novel digital interventions aim to enhance asthma management, self-monitoring, and adherence to treatment regimens. They have been positively received by patients, who generally value the usability of these tools and express a willingness to continue treatments [16–18], thereby improving adherence. Specifically, multifunctional mobile health applications (mHealth apps) have demonstrated potential in managing asthma and improving patients’ quality of life compared to conventional interventions [19]; additionally, digital inhaler health platforms, which employ digital inhalers to monitor dosage timing and dates, have proven effective in managing both asthma and medication [20]. These platforms have fostered a collaborative care environment between healthcare providers and patients and provide a more comprehensive understanding of actual inhaler usage, demonstrating potential, with evidence indicating positive effects on various outcomes, including knowledge, activity limitations, self-care, quality of life, and medication usage [21]. The development of digital interventions is often underpinned by psychological models and theories aimed at enhancing their impact and utilization, guiding their optimal design and delivery [22]. In fact, theory-based digital interventions can improve asthma selfmanagement outcomes, such as medication adherence, asthma control, and quality of life [23]. Within the realm of psychology, it is recognized that asthma can be influenced by a variety of psychological and psychopathological factors: individuals afflicted with asthma frequently exhibit comorbidities, demonstrating a higher incidence of anxiety and depressive disorders compared to the general populace [24]. These psychological elements can adversely affect asthma control, adherence to treatment protocols, and overall quality of life [25]. Stress has the potential to intensify asthma symptoms, and interventions aimed at managing stress may contribute to improved asthma outcomes [26]. Furthermore, the relationship between asthma and psychological factors can be bidirectional: while psychological factors can influence asthma symptoms, the symptoms of asthma can also precipitate increased psychological distress [27]. Parental psychological factors can also exert an impact on the outcomes of children’s asthma. Specifically, parental anxiety and depression have been linked to poorer asthma control in children [28]. Collectively, these studies underscore the intricate interplay between psychological and psychopathological factors and asthma, highlighting the necessity of addressing these factors in the management and treatment of asthma. Table 1 provides a summary of the paper’s contribution to the extant literature on digital health interventions for managing psychological factors related to asthma. Table 1. The table delineates the identified problem or issue, summarizes the existing knowledge on the subject, and articulates the novel contribution of the paper to the extant literature. Problem or Issue What is Already Known What This Paper Adds Addressin g psychologi cal aspects Prior studies have highlighted the potential Digital health technologies have been identified to significantly boost symptom self-management, enhance quality of life, and positively Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 3 linked to asthma through the use of digital health technologi es. benefits of eHealth approaches, mixed reality tools, and mobile applications in improving symptom management, quality of life, and mental health outcomes. influence mental health outcomes, particularly in children and adolescents with asthma. The analysis of selected studies indicates the potential efficacy of these digital interventions in tackling psychological factors in the management and treatment outcomes of asthma. The objective of our literature review is to explore the current advancements in digital health interventions, specifically pertaining to the evaluation and treatment of psychological aspects associated with asthma, such as stress, anxiety, depression, and coping mechanisms employed to mitigate the emotional distress induced by asthma. Additionally, we assess the feasibility of utilizing these cutting-edge technological tools for conducting observational clinical studies. We also examine the effectiveness and deployment of digital aids for self-management for both adult and pediatric asthma patients. 2. Materials and Methods 2.1. Research Guidelines This review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for Systematic Reviews [29], a set of guidelines that enhance the transparency, quality, and replicability of reviews, facilitate the assessment of the review’s strengths and weaknesses, and promote adherence to guidelines. We opted for a PRISMA diagram over a bibliometric analysis due to the specific requirements and objectives of the review. The PRISMA diagram serves as an effective tool for delineating the process of a systematic review or search, offering a clear and succinct visual depiction of the number of records identified, included, and excluded, along with the reasons for exclusions. This ensures a transparent and replicable methodology, which is essential. Conversely, while bibliometric analysis is useful in understanding publication patterns and impacts, it does not provide the same level of detail or clarity in the process of a literature review. It is more apt for analyzing the impact of a body of work rather than the process of reviewing it. Hence, for the purpose of conducting a comprehensive and transparent literature review, a PRISMA diagram was deemed the more suitable choice. Additional literature, not depicted in the flow diagram, has been sourced from full-text articles and is included in the references. 2.2. Research Question The guiding research question for this review was: “How do digital technologies for selfmanagement and treatment (such as mobile apps, virtual reality, and wearable technology) compare to traditional asthma management methods in terms of psychological factors (stress, anxiety, depression) and their impact on asthma in adults and youth?” This question was framed using the PICO framework [30] to guide the exploration of the effectiveness of digital technologies in addressing psychological and psychopathological factors associated with asthma in both adult and youth populations. Each article included met the following criteria: the study Population comprised adults and youth with asthma of any sex and socioeconomic status; the Intervention involved Digital technologies for self-management or treatment of asthma-related psychological and psychopathological factors (mobile apps, virtual reality, and wearable technology); some research Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 4 Compared traditional asthma management methods with those incorporating digital technologies; the Outcome evaluated the effectiveness of digital technologies for self-management and/or treatment of psychological and psychopathological factors related to asthma. 2.3. Literature Search From March to June 2023, we conducted several searches on our internal search engine Summon [31] using different search terms combinations. We analyzed articles from the PubMed, PubMed Central, Health & Medical Collection, and Web of Science databases, focusing on results that discussed the relationship between asthma and digital technologies, such as mobile applications, virtual reality, and wearable devices, and their correlation with psychological factors like stress, anxiety, and depression. The first search was conducted using the terms "(asthma) AND ((smartphone applications) OR (mobile apps)) AND ((psychological factors) OR (psychopathological factors))". Out of the 12 papers found, 9 were duplicates and 2 were irrelevant, leaving 1 paper for further analysis. The second search used the terms "(asthma) AND ((smartphone applications) OR (mobile apps)) AND ((stress) OR (anxiety) OR (depression))". Out of the 99 papers found, 68 were duplicates, leaving 3 papers for further analysis. The third search used the terms "(asthma) AND ((virtual reality) OR (video games)) AND ((psychological factors) OR (psychopathological factors))". Out of the 23 papers found, 16 were duplicates, leaving 1 paper for further analysis. The fourth search used the terms "(asthma) AND ((virtual reality) OR (video game)) AND ((stress) OR (anxiety) OR (depression))". Out of the 27 papers found, 15 were duplicates, leaving 1 paper for further analysis. The fifth search used the terms "(asthma) AND ((Wearable technology) OR (Telemedicine)) AND ((psychological factors) OR (psychopathological factors))". Out of the 24 papers found, 15 were duplicates and none were selected for further analysis. The sixth and final search used the terms "(asthma) AND ((Wearable technology) OR (Telemedicine)) AND ((stress) OR (anxiety) OR (depression))". Out of the 164 papers found, 104 were duplicates, leaving 2 papers for further analysis. All the studies published since 2015 were included. There were no limitations based on language. The reference lists of the included studies underwent additional scrutiny to identify additional potential studies. Two authors of the review independently examined and chose studies from the conducted searches. 2.4. Eligibility Criteria We included every article that met the following criteria: a) All studies and reviews that were published in indexed journals and listed in PubMed, PubMed Central, Health & Medical Collection, and Web of Science databases. b) Studies related to digital technologies associated with asthma's psychological and psychopathological factors, such as stress, anxiety, and depression. c) Studies published from 2015 to the present. 2.5. Exclusion Criteria We excluded every article meeting the following criteria: a) Studies not related to digital technologies associated with asthma's psychological and psychopathological factors, such as stress, anxiety, and depression. b) Studies that focus on the clinical management of asthma, such as pharmacological interventions. c) Studies that do not examine the psychological factors associated with the use of digital technologies for asthma. d) Studies published in non-scientific or non-peer-reviewed sources. e) Studies published prior to 2015. Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 5 2.6. Data Extraction The data extraction process was independently carried out by two reviewers. Any discrepancies that arose were addressed through dialogue or with the aid of a third reviewer. 3. Results 3.1. Characteristics of the Included Studies The search process resulted in a total of eight full-text articles, following which 10 full-text articles were evaluated for eligibility. The term "full-text articles" in the PRISMA diagram denotes the number of articles that were considered potentially relevant after screening at the abstract level and were subjected to a detailed review of the full text. This constitutes a crucial step in the PRISMA process as it ensures the inclusion of only the most pertinent and suitable studies in the final review. The article selection procedure, as reported in the PRISMA and compiled in line with the guidelines for updates of systematic reviews, is depicted in Figure 1. The primary characteristics of the included studies are elucidated below. Figure 1. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram representing the article selection process in accordance with the guidelines for systematic reviews [29]. The articles encompassed in this review delve into the utilization of eHealth interventions and digital health technologies for the assessment, treatment, and self-management of psychological and psychopathological facets linked to asthma in children, adolescents, and young adults. The review includes systematic reviews, qualitative protocols, participatory studies, and articles. The studies were subjected to qualitative analysis, and the findings were amalgamated to furnish an overview of the contemporary state of research in this domain. A synopsis of these studies is presented in Table Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 6 2. The constraints of the studies and the ramifications for prospective research are also deliberated upon. Table 2. Summary of Studies Included in the Results Section. Authors Year Type of Intervention/Tool Type of Paper Outcome McGar et al. (32) 2019 eHealth interventions Systematic Review The efficacy of eHealth strategies in ameliorating psychological outcomes in children with health conditions Thabrew et al. (33) 2018 eHealth interventions Systematic Review The efficacy of eHealth strategies in addressing anxiety and depression in children and adolescents with chronic health conditions Nichols et al. (34) 2020 mHealth intervention Study Protocol The efficacy of the mHealth strategy (MATADORS) in aiding symptom self-regulation among young individuals with asthma Peters et al. (35) 2017 Preferences for an asthma selfmanagement app Participatory Study Determining the psychological requirements and preferences of young individuals for an asthma self-regulation application Neves et al. (37) 2021 Health and fitness mobile apps Secondary analysis of observational studies Factors influencing the utilization of health and fitness mobile applications by individuals with asthma Dzubur et al. (38) 2015 Smartphone application that integrates sensors for asthma inhalers A letter to the editor The application can facilitate comprehension of real-time experiences of adolescent asthma patients, enhance adherence to treatment, customize therapies, and improve communication between patients and providers Shah et al. (41) 2022 Digital Health Interventions Scoping review DHIs are predominantly utilized for treatment, with a primary emphasis on depression, and are typically disseminated through web-based platforms. Nonetheless, their integration into routine care is restricted Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 7 Sharrad et al. (42) 2021 Mixed reality technology Qualitative protocol The manuscript presents a project aimed at creating and evaluating mixed reality instruments for administering cognitive and behavioral therapies to young individuals with asthma. The outcomes of the project are currently unavailable 3.2. eHealth and mHealth Strategies: Tackling Psychological Elements in Children and Adolescents with Asthma and Persistent Health Conditions In this segment, we will scrutinize articles that delve into the utilization of eHealth and mHealth tools for the treatment, management, or self-monitoring of psychological factors associated with asthma or similar chronic physical conditions in young individuals, ranging from children to adolescents. The inaugural study we examine is the one spearheaded by McGar et al. [32], which undertook a systematic review of 22 studies that assessed the efficacy of eHealth interventions designed to prevent or treat psychological sequelae (such as anxiety, depression, posttraumatic stress symptoms, and quality of life) in youth with medical conditions and their caregivers. They discovered mixed but promising results, suggesting that eHealth interventions may aid in enhancing psychological and functional outcomes in certain pediatric populations, particularly those with traumatic brain injury and other potentially traumatic injuries. Among the 22 studies reviewed, three were centered on children with persistent asthma. These studies employed eHealth interventions that offered selfmanagement education, interactive asthma monitoring, and tailored feedback to ameliorate asthma control and quality of life. The authors reported that these interventions achieved at least one targeted outcome, indicating that eHealth interventions may be beneficial for augmenting disease management and reducing psychological distress in children with asthma. eHealth interventions have the potential to expand the reach and accessibility of psychological interventions for children with medical conditions and their caregivers, suggesting that future eHealth interventions should be grounded on evidence-based theoretical frameworks, such as cognitive behavioral therapy or problem-solving therapy, and should be tailored to the specific needs and challenges of each medical population. Thabrew et al. [33] conducted a systematic review of eHealth interventions for anxiety and depression in children and adolescents with long-term physical conditions, such as asthma. They incorporated five trials of three interventions (Breathe Easier Online, Web-MAP, and multimodal cognitive behavioral therapy), which involved 463 participants aged 10 to 18 years. They found very low-quality evidence that eHealth interventions were not clearly superior to any comparator (such as attention placebo, treatment as usual, or waiting list) in reducing symptoms of anxiety and depression, improving quality of life, functioning, or status of long-term physical condition. They also found very low-quality evidence that eHealth interventions were less acceptable than any comparator. They concluded that the effects of eHealth interventions for this population are uncertain, and that more research is needed to develop and evaluate effective and acceptable e-health interventions. Despite this uncertainty, considering the increasing number of these interventions and the worldwide enhancement in technology accessibility, there seems to be potential for the development and assessment of suitable and effective technology-based treatments tailored for children and adolescents with long-term physical conditions. Nichols et al. [34] delineated the development and feasibility testing of a mHealth intervention, termed MATADORS, aimed at enhancing symptom self-management among youth (ages 10–17) with asthma and obesity. The intervention amalgamates motivational enhancement and behavioral activation strategies within a family-centric model and an innovative mobile app that encompasses educational content, symptom Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2 8 monitoring, activity tracking, and photo/video/voice diaries. The authors reported the outcomes of a pilot study that randomized 30 youth with asthma and obesity to either MATADORS or a control condition. The intervention group partook in a six-week nurse-guided mHealth program, while the control group received standard care. The feasibility outcomes encompassed recruitment, reach, adherence, satisfaction, and participant burden. The preliminary outcomes included fatigue, pain, self-efficacy, anxiety, sleep, depression, and quality of life, measured at baseline, six, and 12 weeks. The authors concluded that MATADORS is a feasible and acceptable intervention with the potential to enhance symptom self-management and quality of life for youth with asthma and obesity. However, they did not report the statistical significance of the preliminary outcomes, rendering it unclear whether MATADORS was effective in terms of reducing these symptoms and improving these outcomes. Subsequently, Peters and colleagues [35] conducted a participatory study to comprehend the experiences, needs, and ideas of young individuals with asthma. The objective was to identify the prerequisites for an asthma app that would be engaging and effective in augmenting their well-being. The study comprised 20 participants aged between 15 and 24 years who completed a workbook and participated in a workshop, culminating in the creation of 102 participant-generated artifacts. The data underscored that psychological aspects such as anxiety and impediments to autonomy, competence, and relatedness were perceived by young individuals with asthma as significant influences on their quality of life. The study proposes that an app designed for young individuals with asthma should provide support for mental health factors associated with lived experience, in conjunction with practical features for managing asthma. These findings could potentially influence the design of technologies intended to assist individuals with chronic illnesses more broadly. 3.3. mHealth Strategies: Factors Influencing the Use of Health and Fitness Applications by Individuals with Asthma Fitness applications can exert a significant influence on psychological health by offering several key advantages [36]. They provide motivation and support, assisting users in setting objectives, tracking progress, and receiving feedback and encouragement for their physical activity. This can result in an enhancement in self-esteem and a sense of achievement. Fitness applications also foster engagement and enjoyment by aiding users in selecting the most effective and enjoyable forms of physical activity tailored to their needs, thereby promoting increased engagement and a more positive relationship with exercise. Moreover, the convenience and accessibility of fitness applications facilitate the incorporation of regular physical activity into users' lives, which can ameliorate mood and alleviate symptoms of stress, anxiety, and depression. However, it's crucial to note that while fitness applications can contribute to psychological well-being, they do not serve as a substitute for professional mental health care [36]. In this context, Neves and colleagues [37] conducted a study to assess the usage of general health and fitness applications among individuals with asthma and to identify the factors that influence their usage. The majority of the participants reported having good overall health. However, the incidence of anxiety and depression was found to be 34.3% and 11.9%, respectively. Approximately 41.1% of the participants reported using health and fitness mobile applications. The research revealed that individuals who were single and those with more than 10 years of education were more predisposed to use these applications. Furthermore, participants with higher digital literacy scores were more likely to use the applications. Interestingly, participants exhibiting symptoms of depression were less likely to use health and fitness applications. The study underscores the importance of understanding the barriers and motivators for application usage among patients with lower education levels, lower digital literacy, or depressive symptoms. This understanding is crucial for devising tailored interventions that ensure sustained and equitable use of these technologies. Preprints.org (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 February 2024 doi:10.20944/preprints202402.0126.v2