Feasibility and Acceptability of an Asthma App to Monitor Medication Adherence: Mixed Methods Study
Authors: Jácome Cristina , Almeida Rute , Pereira Ana Margarida , Amaral Rita , Mendes Sandra , Alves-Correia Magna , Vidal Carmen , López Freire Sara , Méndez Brea Paula , Araújo Luís , Couto Mariana , Antolín-Amérigo Darío , de la Hoz Caballer Belén , Barra Castro Alicia , Gonzalez-De-Olano David , Todo Bom Ana , Azevedo João , Leiria Pinto Paula , Pinto Nicole , Castro Neves Ana , Palhinha Ana , Todo Bom Filipa , Costa Alberto , Chaves Loureiro Cláudia , Maia Santos Lilia , Arrobas Ana , Valério Margarida , Cardoso João , Emiliano Madalena , Gerardo Rita , Cidrais Rodrigues José Carlos , Oliveira Georgeta , Carvalho Joana , Mendes Ana , Lozoya Carlos , Santos Natacha , Menezes Fernando , Gomes Ricardo , Câmara Rita , Rodrigues Alves Rodrigo , Moreira Ana Sofia , Bordalo Diana , Alves Carlos , Ferreira José Alberto , Lopes Cristina , Silva Diana , Vasconcelos Maria João , Teixeira Maria Fernanda , Ferreira-Magalhães Manuel , Taborda-Barata Luís , Cálix Maria José , Alves Adelaide , Almeida Fonseca João 
Published: April 2021

Background
Poor medication adherence is a major challenge in asthma, and objective assessment of inhaler adherence is needed. The InspirerMundi app aims to monitor adherence while providing a positive experience through gamification and social support.

Objective
This study aimed to evaluate the feasibility and acceptability of the InspirerMundi app to monitor medication adherence in adolescents and adults with persistent asthma (treated with daily inhaled medication).

Methods
A 1-month mixed method multicenter observational study was conducted in 26 secondary care centers from Portugal and Spain. During an initial face-to-face visit, physicians reported patients’ asthma therapeutic plan in a structured questionnaire. During the visits, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients registered the intake (inhaler, blister, or other drug formulation) by using the image-based medication detection tool. At 1 month, patients were interviewed by phone, and app satisfaction was assessed on a 1 (low) to 5 (high) scale. Patients were also asked to point out the most and least preferred app features and make suggestions for future app improvements.

Results
A total of 107 patients (median 27 [P25-P75 14-40] years) were invited, 92.5% (99/107) installed the app, and 73.8% (79/107) completed the 1-month interview. Patients interacted with the app a median of 9 (P25-P75 1-24) days. At least one medication was registered in the app by 78% (77/99) of patients. A total of 53% (52/99) of participants registered all prescribed inhalers, and 34% (34/99) registered the complete asthma therapeutic plan. Median medication adherence was 75% (P25-P75 25%-90%) for inhalers and 82% (P25-P75 50%-94%) for other drug formulations. Patients were globally satisfied with the app, with 75% (59/79) scoring ≥4,; adherence monitoring, symptom monitoring, and gamification features being the most highly scored components; and the medication detection tool among the lowest scored. A total of 53% (42/79) of the patients stated that the app had motivated them to improve adherence to inhaled medication and 77% (61/79) would recommend the app to other patients. Patient feedback was reflected in 4 major themes: medication-related features (67/79, 85%), gamification and social network (33/79, 42%), symptom monitoring and physician communication (21/79, 27%), and other aspects (16/79, 20%).

Conclusions
The InspirerMundi app was feasible and acceptable to monitor medication adherence in patients with asthma. Based on patient feedback and to increase the registering of medications, the therapeutic plan registration and medication detection tool were redesigned. Our results highlight the importance of patient participation to produce a patient-centered and engaging mHealth asthma app.