This was a randomized controlled trial using a pre- and post-test design. The study was conducted from January 3 to March 28, 2019 at Tan Tock Seng Hospital and was approved by the National Healthcare Group Ethics Committee (2018/00960). Participants who were randomized to the control group received the manufacturer’s paper instruction guide for all devices studied to learn the inhaler technique. Participants who were randomized to the experimental group received the mobile app Fig. 1. A research assistant was on hand for both groups to assist with randomization and data collection. No direct instruction on inhalation techniques was given to the participants by the research assistant. A medical statistician generated the randomization numbers via randomization software. Randomized results were sealed in individual envelopes.
Participants were final-year nursing students in their pre-registration clinical placement (PRCP). The inclusion criteria were (1) Nursing students (2) > 18 years old (3) willing to participate in the study. Participants who (1) had previously worked as a registered nurse, (2) had an upper respiratory infection such as cough, runny nose, fever, and sore throat, (3) had asthma or any other chronic respiratory condition, (4) or had any medical condition that prevents them from participating, will be excluded from the study. Consent was obtained before the start of the study. All participants who completed the study received a SGD 10 gift card.
A mobile application was developed in English from June 2017 to December 2017 for the Android platform. It engaged learners through three learning styles (i.e. visual, auditory and kinesthetic), providing a multi-sensory approach to learning without the need for physical inhalers or human supervision.
The app recreated precise three-dimensional models of different types of inhalers and reconfigured the steps of using an inhaler on a mobile phone device. The design was to ensure an intuitive and interactive experience for learning how to use inhalers. These were achieved through touch manipulation, hand movement and breath sensing. The app detects touch and swipe gestures near different parts of the 3D inhaler models on the screen. The user can slide on the MDI inhaler canister to push it down. White smoke particles will be emitted from the mouth of the inhaler in response. The app also uses the mobile phone’s built-in microphone to detect a range of low frequency sounds, especially the sound produced by inhalation, within a constant delay, and reacts to the detection. Inhaling while the white smoke is emitted from the MDI inhaler model will accelerate the movement of the particles, which will represent the flow and give users a visual impression that they are inhaling the smoke. The Breezhaler model will produce a clicking noise when inhaling, mimicking the rattling of the medicine tab in the chamber of the inhaler in real life. Finally, the app uses the phone’s accelerometer to detect vertical shaking action. The MDI inhaler model will respond to the shake and shake by itself on the screen. The aim is to enable learners to freely handle inhalers while acquiring the correct technical inhaler skills. The screenshots and features of the application are shown in Fig. 2.
To ensure accuracy, visual guides show learners how to handle the inhalers step by step. These were reinforced with visual and audio cues, such as leaking gas on the wrong inhalation, providing positive reinforcement and constructive correction. A demo feature has been included to provide the ability to walk through the steps of using an inhaler. The functionality resides before the interactive inhaler tutorials, giving students the choice to learn by observing before trying it out.
Student assessment quiz has been included in the app to assess students’ knowledge of inhalers and related medications. The quiz contained multiple-choice questions, which allowed for immediate assessment and returned the appropriate answer to the student. At the end of the quiz, the results were displayed for recording by the evaluators.
The study consisted of a pre- and post-test assessment of inhaler technique and a post-intervention questionnaire at the end of the study. Six inhalers were used for this study, namely Metered Dose Inhalers, Turbuhaler, Accuhaler, Breezhaler, Ellipta and Respimat as these are the common inhalers prescribed in public hospitals and clinics in Singapore. An assessment checklist compiled from the manufacturers’ instruction leaflets was used for the pre- and post-test assessment of the inhaler Supplementary File 1. The assessors were 3 clinical pulmonologist trained nurses with over 5 years of experience in the field of respiratory medicine at the institution. Each inhaler step counts as 1 point and the total points for each inhaler are recorded before and after each intervention. A pre-test assessment was conducted and each participant was then given a minimum of 30 minutes up to 90 minutes to learn all 6 inhalers.
All participants had to complete a questionnaire at the end of the study. The questionnaire was divided into five sections: demographics, previous experience using mobile phones, previous experience using inhalers, self-reported confidence in inhaler use, and self-rated level of knowledge. Participants will score on a scale of not at all, not very, somewhat, very, and completely for self-reported level of trust, while self-rated level of knowledge was scored on a scale between strongly disagree, disagree, neutral, d agree and strongly agree.
In addition to the post-test survey, the experimental group was asked about the application. App-related questions were adopted from the Mobile App Rating Scale (MARs) questionnaire to assess app quality, functionality and graphic design . These were questions asking users about their perception of the app’s engagement, functionality, aesthetics, and information quality using a Likert scale from 1 to 5 (1 strongly disagree and 5 strongly agree). Participants were also asked about the subjective quality of the app.
By estimating the average level of knowledge of inhalation technique in the control group at 20% and the average level of knowledge of inhalation technique in the mobile inhaler application group at 50%, so that the difference in knowledge levels is normally distributed with a standard deviation of 0.5, we will need to study 90 subjects in total, to be able to reject the null hypothesis that there is no difference in the average level of knowledge of the inhalation technique between the control group and the experimental group, with a power of 80% and a type I error probability of 0.05. Continuous variables were expressed as mean (standard deviation; SD) or median (interquartile range; IQR) depending on the distribution, and categorical variables were expressed as frequency and percentage. We compared differences for continuous variables using two samples you distribution test, and χ2 test or Fisher’s exact test for categorical variables. χ2 and Fisher’s exact tests were applied to assess the effectiveness of the app on inhaler learning compared to the control group. Data analysis is performed against all stages of each module as well as each stage of each module. The Mann-Whitney U test was used to analyze the participants’ level of confidence and knowledge between the two groups. Analyzes were performed using Stata (version 13.1, College Station, TX: StataCorp LP).