May 19, 2021

JMIR mHealth and uHealth This paper is in the following e-collection/theme issue: October 09, 2020 . Effective German and English Language mHealth Apps for Self-management of Bronchial Asthma in Children and Adolescents: Comparison Study Effective German and English Language mHealth Apps for Self-management of Bronchial Asthma in Children and Adolescents: Comparison Study Authors of this article: 2Sigmund Freud University, Vienna, Austria *these authors contributed equally Donau-City-Strasse 1 Fax:43 1 263 7979 Abstract Background: Mobile health (mHealth) apps hold great potential for asthma self-management. Data on the suitability of asthma apps intended for children are insufficient, and the availability of German language apps is still inadequate compared with English language apps. Objective: This study aims to identify functional asthma apps for children in German and to compare them with English language apps. In line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the Google Play Store and Apple App Store are systematically searched to preselect the most efficient apps, which are then compared according to a self-compiled criteria catalog. Methods: Both app stores were screened for the term asthma. Following a PRISMA preselection process, the apps that met the inclusion criteria (ie, available free of charge, German or English language, and suitable for children) were rated by 3 independent persons following a criteria catalog consisting of 9 categories, some conceived for this purpose (availability, child-friendly, learning factor, and range of functions) and some adopted from existing validated catalogs (functionality and design, ease of use, potential for improving asthma self-management, fun factor and incentives, and information management and medical accuracy). The highest rated apps in German and English were compared. Results: A total of 403 apps were identified on the Google Play Store and the Apple App Store. Finally, 24 apps that met the inclusion criteria were analyzed. In the first step of the quality assessment, only 4 available German language asthma apps were compared with 20 English language asthma apps. The 4 German language apps were then compared with the 4 highest rated English language apps. All selected apps, independent of the language, were comparable in the following categories: availability, functionality and design, ease of use, and information management and medical accuracy. The English language apps scored significantly higher in the following categories: potential for improving self-management, child-friendly, fun factor, learning factor, and range of function. English language apps (mean total points 34.164, SD 1.09) performed significantly better than German language asthma apps (mean total points 22.91, SD 2.898; P=.003). The best rated English language app was Kiss my asthma (36/42 points), whereas the best rated German language app Kata achieved only 27.33 points. Conclusions: The recommended English language apps are Kiss my asthma, AsthmaXcel, AsthmaAustralia, and Ask Me, AsthMe!, whereas the only recommended German language app is Kata. The use of apps plays an increasingly important role in patients’ lives and in the medical field, making mHealth a staple in the future of asthma treatment plans. Although validated recommendations on rating mHealth apps have been published, it remains a challenging task for physicians and patients to choose a suitable app for each case, especially in non–English-speaking countries. JMIR Mhealth Uhealth 2021;9(5):e24907 Background Asthma is the most common chronic disease in childhood, affecting 1 in 12 children. According to the World Health Organization, approximately 339 million [ 1 ] people worldwide are living with asthma. Asthma is not a harmless condition; according to the last World Health Organization survey in 2016, there were 417,918 deaths attributable to asthma [ 2 ]. Disease control is often difficult, especially in children, because of a poor understanding of the issue and misjudging the severity of the symptoms. According to the Global Initiative for Asthma, the treatment adjustment strategy includes education, skills training, and optimization of medications as pillars of personalized disease management. Mobile health (mHealth) apps have recently become a tool to better educate children about their illness and treatment management [ 3 ]. A systemic analysis by Farzandipour et al [ 4 ] proved the exceptional potential asthma apps have to improve the quality of life and control symptoms compared with conventional treatment methods. Routine care can benefit from functions such as medication intake reminders, symptoms tracking, transmission of peak flow measurements directly to the treating physician [ 5 ], and tailored education about the disease and its risks. The use of apps has increased significantly in recent years and, accordingly, the use of medical apps. By 2020, the number of smartphone users worldwide is expected to reach 6.1 billion or 80% of the world’s population [ 6 ]. Approximately 62% of all smartphone owners have used their smartphone to find information about their health [ 7 ]. According to a study conducted in Hong Kong, one of the most hi-tech cities, approximately 24% of smartphone and tablet users installed a mHealth app [ 8 ]. In 2015, the available mHealth apps in the relevant stores were more than 100,000, with almost 3 trillion downloaded mHealth apps [ 9 ]. In Europe, approximately 46% of children already had a smartphone in 2019 and 41% used it every day [ 10 ]. These figures draw attention to a rising market, making further research necessary. Although the classification of mHealth apps for asthma in English has already been the focus of several studies [ 11 - 13 ], research has neglected German-speaking countries. Multiple tools shortlist and evaluate apps that are potentially useful in the management of chronic diseases. Some also include a guide for rating or creating a standardized user dummy, thus minimizing interindividual effects of various testers [ 14 - 16 ]. In Germany, more than 11 million minors are aged <14 years [ 17 ]. The prevalence of asthma among children is approximately 10% [ 18 ], indicating that the market for potential users of asthma apps for children in Germany exceeds the 1 million mark. Objectives Therefore, this study aims to identify functional asthma apps in German and to compare them with English language apps. In a 3-step system, the Google Play Store and Apple App Store were systematically searched to preselect the most efficient apps using a criteria catalog, which was in part self-generated and in part adopted from existing validated catalogs. The content was further analyzed for correctness according to the current guidelines. Methods Quantitative Comparison of Apps Two of the world’s leading mobile app platforms, the Google Play Store and Apple App Store, were used for the search. The preselection process following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines ( Figure 1 ), adapted from the study by Page et al [ 19 ], was performed by one of the authors according to the inclusion and exclusion criteria. In the case of questionable results, they were checked for validity and plausibility by the other authors to ensure an objective decision. The term asthma was searched in both app stores, and the apps eligible for inclusion were downloaded on a smartphone with a Google Android operating system or an Apple iPad with an iOS operating system. Inclusion (available free of charge, German or English language apps, and suitable for children and adolescents) and exclusion criteria (specific product needed; restrictions in the tested area; app forum as the only function; intended for adults, parents, or medical professionals; alternative treatments; and lack of pertinence; Multimedia Appendix 1 [ 3 , 18 , 20 ]; Figure 1 ) were applied to select relevant apps and compare German and English free offers for children and adolescents. As asthma affects all social classes, we only included free apps. Other studies have already pointed out that low- and middle-income populations have limited access to mHealth apps [ 7 ]. For these groups, free apps were the only viable option. As shown in Multimedia Appendix 1 , these criteria ruled out all apps irrelevant for comparison and restricted the choice to those catering to children and adolescents, those available in German and English, those available free of charge, and available following medical guidelines and recommendations. ‎ Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of app assessment. After applying the exclusion criteria, 27 apps were primarily included. Of these, 17 were available in both stores, 4 in the Apple App Store (depicted as n1), and 6 in the Google Play Store (depicted as n2). As 1 app (AsthmaXcel) had 4 different variants, it was considered as one single app, resulting in 24 apps for the final analysis. Qualitative Assessment of German and English Language Apps After the preselection process, all remaining apps that met the inclusion criteria were downloaded, and their functions were evaluated by 3 independent persons following a self-compiled criteria catalog. These 3 raters tested the apps independently and without any conflicts of interest. For an objective analysis, testing was performed following the same procedure. A private email address and contact details were used for logging in, when required, to access the functions of the apps. For a realistic approach, any minor age was selected, and, if necessary, realistic, arbitrary values about personal measurements and other data were selected. In total, 2 test dummies ( Multimedia Appendix 2 ) of different age groups (preschoolers and teenagers) were generated to test all available app features for each age group and gain a comprehensive insight into each app. A total of 27 apps meeting the inclusion and exclusion criteria, suitable for use by children and adolescents, were selected for evaluation and representative comparison of their quality. The AsthmaXcel app with its 4 different, complementary, and overlapping variants (AsthmaXcel, AsthmaXcel PRO, AsthmaXcel Adventures, and AsthmaXcelED) was considered as one single app for the evaluation. Thus, the final number of evaluated apps was 24. The resulting app selection is presented in more detail in the Results section. On authorization for this study, quality assessment was carried out by the 3 independent testers according to a criteria catalog consisting of 9 categories, some conceived for this purpose and some adopted from existing validated catalogs ( Multimedia Appendix 3 [ 3 , 14 - 16 , 18 , 20 ]). The categories availability, child-friendly, learning factor, and range of functions were analyzed using self-compiled criteria. The categories functionality and design, ease of use, potential for improving asthma self-management, fun factor and incentives, and information management and medical accuracy were adopted from existing catalogs [ 14 - 16 ]. As there are no official criteria for evaluating apps, particularly for asthma apps for children, the authors designed some specifically intended to assess apps’ suitability for children and integrated them with existing standards. The child-friendliness of an app was determined based on the provider’s recommendations, the design (visual incentives for children to use the app), the range of functions (games and understandable information about asthma), engagement creation (through a reward or score system and entertaining features for children), usability (by the child alone or with parental support), and the general impression of the app. The test dummies were created to simulate a child using an app as accurately as possible ( Multimedia Appendix 2 ). The category information management and medical accuracy was analyzed using the App Chronic DiseaseChecklist by Anderson et al [ 16 ]. In addition, the quality of the app and its medical accuracy were checked by the authors using the Global Initiative for Asthma [ 3 , 20 ] and German Airway League [ 18 ] guidelines to ensure medical guidelines were met and if the recommendations (eg, instructional videos) were correct. This category was not designed to check every single guideline recommendation but rather to analyze the correctness of the provided information in general (eg, asthma medications, time point of adapting the medication, how to access medical care, and how to use an inhaler). These factors influenced the rating scores by consensus [ 14 - 16 ]. As 4 of the questions in this category addressed the points of information management, data protection, and app provider, this category was named information management and medical accuracy. For the criteria catalog, we used a point system. Apps matching 8 categories were assigned a value between 1 and 5; those matching 1 category (availability) could score either 1 or 2 points, as illustrated in Multimedia Appendix 3 . The validated criteria catalog point system differed from the one we applied to the potential for improving asthma self-management [ 14 ] and fun factor and incentives [ 15 ] categories (0-26 and 0-31 points, including half points for partial compliance) and to the functionality and design [ 16 ], ease of use [ 16 ], and information management and medical accuracy [ 16 ] categories (0-6 points, including half points for partial compliance). Multimedia Appendix 3 provides the ratings for each class. Classes indicate an app rating for a category with a different point system to align it with our 5-point system. The App Chronic Disease Checklist version 1.0 according to Anderson et al [ 16 ] for the functionality and design, ease of use, and information management and medical accuracy [ 16 ] categories consists of 6 questions. Each response was assigned a value of 1 (full compliance), 0.5 (partial compliance), or 0 (no compliance), hence the maximum of 6 points. The points scored in the 6 questions were divided into 5 classes to ensure compatibility of the checklist protocol with our 5-point system. Half of the points were counted in the next higher class ( Multimedia Appendix 3 ). All 24 apps (4 versions of AsthmaXcel were considered as one and referred to as AsthmaXcel) that met the inclusion and exclusion criteria were evaluated, compared, and ranked based on the points achieved both cumulatively and in the single categories. A total of 3 testers individually assessed the apps and then determined the mean value of points both cumulatively and in the single categories. Therefore, apps were ranked according to the average of the total points of the 3 testers and the point system, with a maximum of 42 points. Statistical calculations on the same number of highest-ranking German and English language apps compared the quality of the apps. As only 4 of all eligible apps were in German, these were compared with the 4 highest ranked English language apps. Statistical Analysis The quantitative comparison between German and English language apps considered the corresponding offers on the Google Play Store and Apple App Store. The analysis was performed using Microsoft Excel and IBM SPSS Statistics 25.0. Descriptive statistics were used to calculate and compare the results. For normally distributed results, the mean was calculated with SD, and for nonnormally distributed results, the median was determined between the maximum and minimum values. Normal distribution was tested using the Shapiro-Wilk test and confirmed for total points and all categories except availability, for which other variables nonparametric tests were used. The significant difference in the results was calculated using the two-tailed t test or, in the case of nonparametric results, using the Mann-Whitney U test. Statistical significance was set at P<.05. Results Quantitative Comparison of German and English Language Asthma Apps for Children and Adolescents In total, 403 apps were identified under the term asthma in both app stores ( Figure 1 ), including 238 (59.1%) on the Google Play Store and 165 (40.9%) on the Apple App Store. Of 403 apps, 27 (6.7%) met the inclusion and exclusion criteria. Of these, 17 (17/27, 63%) were available in both stores, 4 (4/27, 15%) only on the Apple App Store, and 6 (6/27, 22%) only on the Google Play Store. As the AsthmaXcel app has 4 different, complementary, and overlapping variants (AsthmaXcel, AsthmaXcel PRO, AsthmaXcel Adventures, and AsthmaXcelED) separately available for download, they were considered as one single app for the evaluation. Therefore, the final number of apps downloaded for the analysis was 24. Of these 24 apps, 20 (83%) were available in English but not in German, and 4 (17%) apps were available in both German and English. None of the apps were available only in German. The most common exclusion criterion was the lack of pertinence to the topic, although it was listed under the term asthma. The reasons for exclusion are listed in Table 1 and Figure 1 . Table 1. Exclusion criteria for the asthma apps. Exclusion criteria Categorial Analysis of Asthma Apps Availability As all 4 English language apps and 4 German language apps were available on the Google Play Store and the Apple App Store, they were awarded a maximum score of 2 points (median 2, minimum 2, and maximum 2) without showing any differences. Functionality and Design For the evaluation of this category, the functionality subitem in the App Chronic Disease Checklist version 1.0 according to Anderson et al [ 16 ] was used. The English language apps KmAsthma and Ask Me, AsthMe! and the German language app Kata scored the highest (5 points). Points were deducted for other apps because of the lack of the possibility of sending data such as peak flow values and the lack of warnings for out-of-range values. The design and performance power were very satisfactory in all 8 apps; hence, all apps received at least three points in this category. The average score of all 8 apps was 4.25 (SD 0.7), the average score of apps in English was 4.7 (SD 0.41) and the average score of apps in German was 3.8 (SD 0.76). The difference between the German and English language apps was not significant (P=.16). Ease of Use The App Chronic Disease Checklist version 1.0 according to Anderson et al was also used for the evaluation of this category [ 16 ]. Km Asthma was the only app that achieved 5 points in the ease of use subitem [ 16 ], as it is the only one that allows users to perform all self-management tasks easily, creates a user profile with a log-in option, and offers a reminder function. Points were deducted from all other apps for not offering these features. Nevertheless, all apps in this category performed very well, with a minimum score of 3.33, as all apps can be used offline and are intuitive. The average score for all 8 apps was 4.08 (SD 0.54), with the English language apps performing slightly, but not significantly, better (P=.11). The average of the English language apps was 4.4 (SD 0.49), and of the German language apps was 3.74 (SD 0.34). Potential for Improving Asthma Self-management Evaluation for this category was carried out with the help of the “Exemplary rating criteria for behavior change techniques in mHealth asthma apps” according to Abraham and Michie [ 14 ]. On the basis of the points achieved, 5 classes were conceived to align the rating in this category with the alternative 1-5-point system. None of the apps were awarded 5 points in this category. The apps Km Asthma and Ask Me, AsthMe! achieved 4 points in this category and thus the highest score among all apps. The German language app AllergyMonitor only achieved a minimum score of 1 point in this category. English language apps performed significantly better (P=.02), with an average score of 3.6 (SD 0.44), whereas German language apps’ average score was 1.8 (SD 0.72). The mean score of all 8 apps was 2.7 (SD 1.05). Child-Friendly Factor The results diverged widely in this category. Only the English language app Asthma Australia achieved the highest score, closely followed by AsthmaXcel with 4.67. A distinctive element of these 2 apps was the age-appropriate educational videos on asthma and its treatment. German language apps received less than 3 points in this category. Among these, AllergyMonitor was the best rated in this category, with 2.67 points. The principal reasons for points deduction were the lacking content and functions suitable for children (Kata, AllergyMonitor, Asthma Tracker, and SaniQAsthma) along with a poorly captivating design for the younger ones (Kata and SaniQAsthma). The average score was 3.28 (SD 1.15), with a significant difference (P=.007 between English language apps (average score 4.3, SD 0.63) and German language apps (average score 2.2, SD 0.3). Fun Factor and Incentive to Use the App This category was assessed using the “Exemplary rating criteria for gamification components in mHealth asthma apps” according to Thiebes et al [ 15 ]. On the basis of the points achieved, 5 classes were conceived to align the rating in this category with the alternative 1- to 5-point system. The app AsthmaXcel scored 3.33 points in this category, the highest among all apps. The average of all 8 apps was only 1.87 (SD 0.88). Although 3 of the 4 German language apps received only 1 point, with a mean value of 1.075 (SD 0.13), the mean value of the English language apps was 2.67 (SD 0.53), indicating a significant difference between the 2 language groups (P=.02). Learning Factor Only AsthmaXcel achieved 5 points because videos about asthma and its treatment and games with questions about the topics contribute to the app’s learning factor. In this category, points were deducted because of inadequate information (Km Asthma, Ask Me, AsthMe!, and AllergyMonitor), no child-friendly delivery of information (Kata) or lacking content (Asthma Tracker and SaniQAsthma) about asthma and its treatment. The mean score of the 8 apps in this category was 3.2 (SD 1.45). The mean value of apps in German language was 1.83 (SD 0.55), whereas the mean value of apps in English language was 4.59 (SD 0.36). With P<.001, there was a significant difference in this category between the 2 language groups. Information Management and Medical Accuracy The accuracy of medical content is undoubtedly crucial [ 3 , 18 , 20 ]. This category was the only one with a German app (Kata) outperforming the English apps for following the German Respiratory Society website medical guidelines [ 18 ] and providing references. Points were deducted because of a lack of references (Asthma Australia, Km Asthma, and AsthmaXcel). An additional point was deducted for Ask Me, AsthMe!, AllergyMonitor, Asthma Tracker, and SaniQAsthma because of poor content and missing references. The average score of all 8 apps was 3.7 points (SD 0.63). The mean value of English language apps was 3.84 (SD 0.165), whereas the mean value of German language apps was 3.58 (SD 0.86). The difference in points achieved in this category by English and German language apps was not significant (P=.65). Range of Functions As none of the apps incorporated all the beneficial functions (general asthma information, games, diary, medication reminder, and pollen calendar), none of them achieved the highest score. The gaming app AsthmaXcel and the information app Asthma Australia lack diary and medication reminder functions, whereas diary apps (Km Asthma, Ask Me, AsthMe!, Kata, AllergyMonitor, Asthma Tracker, and SaniQAsthma) do not provide a game function. The broadest array of functions was offered by the apps Km Asthma (diary and medication reminder functions, asthma action plan, and information), AsthmaXcel (games, information, and video quiz), and Asthma Australia (information, videos, quizzes, asthma control tests, and asthma action plans). These apps scored more than 4 out of 5 points. The best rated German app Kata (diary, medication reminder, asthma control test, inhalation instructions, pollen calendar, and general asthma information) achieved 3.33 points. Among the English language apps, most points were deducted in this category for the Ask Me, AsthMe! app (diary, asthma action plan, asthma control test score, inhalation videos, and inadequate general information). The German language apps Asthma Tracker (diary, medication reminder, and asthma control test) and SaniQAsthma (diary and medication reminder) scored 3 and 2.67 points, respectively, whereas AllergyMonitor incorporated the diary function only, thus totaling 2 points. The mean value of the 8 apps in this category was 3.46 (SD 0.82). The mean value of the English language apps was 4.16 (SD 0.37), and the mean value of the German language apps was 2.75 (SD 0.49). The difference in points achieved between the 2 language groups was significant (P=.007). Total Points and Overall Ranking The evaluation of the quality of the apps using the criteria catalog determined that the English language asthma apps performed significantly better than the German language apps ( Table 3 ). Table 3. Total score of English and German language apps. Rank