Asthma is a chronic respiratory disease affecting 1 in 9 Australians and 262 million people globally [1,2]. Current asthma management guidelines recommend that all patients are provided with guided self-management education [3]. This includes monitoring of symptoms and lung function; having a written asthma action plan; and regular review by a health professional, which may involve the use of pamphlets with pictures and demonstrations of inhaler devices [3,4]. However, the literature suggests that patients who access health professional support do not necessarily receive an explanation about their disease or correction of management missteps during these encounters [5-7]. A study by AL-Jahdali et al [8], found that >50% of patients with asthma had no formal education about the disease, and a further 40% had obtained no official education about the medications or inhaler devices from any health professionals. This is evidenced by an estimated 70% to 80% of people with asthma being unable to use their inhaler medication correctly [9]. Common mistakes in inhaler technique include inability to hold the breath long enough, breathing in very deep or not breathing sufficiently deep, and inability to coordinate inhaler use [10-13]. Preventable consequences of poor understanding of asthma and inhaler technique include treatment failure, leading to poor clinical outcomes, increased health care use, increased morbidity, high medication dosages, and poor quality of life [14-17].

Improvement in poor disease control can occur through review of inhaler technique, with health professionals correcting mistakes as they observe [10-12]. However, they may not be able to provide this level of support [6,7,18,19]. Health professionals are time poor, are overburdened, and have variable uptake of evidence-based guidelines in clinical practice [5-7,20]. Literature also suggests that health care professionals may not have adequate knowledge of asthma and inhaler technique themselves [17]. A systematic review by Plaza et al [21] analyzed 55 studies with >6300 participants identified as health care professionals, and results showed that only 15.5% of participants were considered to be proficient in inhaler technique. Furthermore, a study by Basheti et al [6] explored 200 health professionals and determined that there was significant association between poor asthma knowledge and inhaler technique. In addition, perceptions held by patients with asthma about health professionals can affect the range of mistakes being made and the amount of information available to them [22,23]. Qualitative studies indicate that some patients perceive general practitioners (GPs) as the only avenue of support or believe that alternate health professionals, particularly pharmacists, are unable to deliver medication advice [22]. A study by Cheong et al [22] interviewed 47 patients with asthma to determine how their perceptions and choices may affect multidisciplinary care. In particular, they looked at perceptions that participants held on the role of health professionals, convenience of accessing health advice, and asthma itself [22]. Furthermore, many people with asthma who perceive themselves to be adept in using their inhaler, make more or as many mistakes as those identifying as less confident [23,24]. Contributing to confusion, in Australia, people with asthma may use ≥1 of the 22 different inhaler devices available, depending on the device they are prescribed; therefore, they would need to master 1 of 6 different techniques [25]. A way to address poor inhaler knowledge and technique and increase use of prescribed medications is through improving education for patients and health care professionals [15,17].

A simple stepwise video demonstration may enhance education, as proper inhaler technique may not be portrayed sufficiently from manufacturer leaflets [26,27]. Advantages of multimedia education are noted from as early as 1983 and include the following: takeaway resources, allowing independent application; entertaining audio-visual for patients; and a modality that is less reliant on those with limited literacy skills [27-30]. A review by Abed et al [27] discovered 3 asthma studies that found multimedia to be useful for asthma education, with participants in 10 of the 20 included studies showing improvement following video-assisted patient education. Studies assessing the effect that multimedia and technology have on inhaler technique showed improvement in skill and knowledge following short-term and long-term interventions [27,31-35]. Studies have also shown multimedia to be effective for improving self-efficacy in children with asthma and their caregivers [36,37].

Technology known as augmented reality (AR), used as interactive print (an innovative medium allowing dissemination of educational advice), allows for digital enhancement of paper-based resources. AR technology can overcome issues of limited health literacy [38,39]; allow for tailoring to individual populations (eg, age and language); increase engagement [40]; increase accessibility of education [41]; and allow for real-time updates of content, as new evidence becomes available.

Although multimedia has shown to be able to improve inhaler technique compared with traditional standard print, use in the form of AR has not been tested before. In addition, as with any new technology or innovation, it is necessary to ensure that it meets the demands of the main user—for example, health professionals, patients with asthma, and key community stakeholders such as the Asthma Foundation of South Australia. Therefore, the aim of this study was to obtain the perspectives of health professionals, patients with asthma, and key community stakeholders on the feasibility of innovative technology in the form of AR, particularly, current inhaler technique education level, technology use level, and potential of AR.

The Human Research Ethics Committee of The Queen Elizabeth Hospital (TQEH) granted both ethics approval (July 13, 2016) and governance approval (July 29, 2016; Q20160614). Acceptance of approval (July 25, 2016) and relevant insurance (July 26, 2016) from the Human Research Ethics Committee and Legal and Risk Branch of The University of Adelaide were also obtained.

Following review of research evidence, in addition to recommendations from national and international asthma guidelines [8,9,12,24,25,42], a prototype poster (Multimedia Appendix 1) for patient information around inhaler technique was developed. A senior scientist on the Medical and Scientific Advisory Committee for the Asthma Foundation of South Australia examined the prototype for relevance and applicability for use by health professionals and patients with asthma. A digital version of the poster was uploaded to a web-based Layar server and superimposed with educational inhaler technique videos provided by the Lung Foundation of Australia [42]. After publishing the AR version of the poster, the free Layar application could be used to scan printed versions of the paper-based poster, thus triggering pattern recognition. Then, the educational videos were activated, thereby initiating the print-based poster to activate on a smartphone screen. Layar allows digital media to be added to paper-based resources, augmenting them and providing the observer with a direct view of correct inhaler technique video demonstration [43]. The free smartphone app allowed demonstration of the technology throughout interviews and further aided in gaining perspectives from participants and potential users.

Inclusion criteria for all participants were based on the current gap in the literature for inhaler technique. Participant recruitment commenced in August 2016 and continued until sufficient data saturation was achieved in September 2016. All potential participants were contacted to assess willingness of participation. Participant information sheets and consent forms were distributed following agreement for consideration, with 24 hours allowed to discuss enrollment in the study with friends and family members. Interviews were scheduled following reading and understanding of participant information sheets and verbal and written agreement of participation.

Health professionals were recruited through existing contacts of the Respiratory Medicine Department at TQEH, SA Health, and Asthma Foundation of South Australia. Health professionals intended for interviewing included respiratory specialists, GPs, respiratory nurses, and pharmacists, who are currently consulting patients with asthma [5,6,44,45]. Overall, 8 semistructured, one-on-one interviews (n=2, 25% with each profession) were considered feasible to reach data saturation, inclusively with patient with asthma and key community stakeholder interviews [46]. Health professionals who did not meet the inclusion criteria were excluded from participation. Specific health professional inclusion criteria comprised the following:

1. Providing consultation or assistance for patients with asthma over a minimum 12-month period, with at least one consult per week or equivalent

Recruitment of patients with asthma occurred through existing contacts throughout the Respiratory Department at TQEH via respiratory specialists. Semistructured, one-on-one interviews with 50% (3/6) male patients and 50% (3/6) female patients were considered feasible for data saturation, inclusively with health professionals and key community stakeholders [46]. Patients with asthma were recruited through purposive selection ensuring diversity of demographic characteristics and, in particular, sourcing patients who experience difficulty with inhaler technique [47]. For example, recruiting someone who is regularly admitted to hospital for inadequate asthma management, at least once per year, compared with someone with well-controlled asthma [9]. Inclusion criteria for patients with asthma comprised the following:

Patients with COPD can use different inhalers to manage their condition compared with patients who purely have asthma [25]. Therefore, to avoid confusion, people with COPD-asthma overlap syndrome were excluded.

In total, 4 key community stakeholders, identified through existing contacts of the principal investigator, were considered for recruitment from the Asthma Foundation of South Australia. They were chosen because their key role in delivering resources and training is particularly focused on health professionals and patients with asthma. Semistructured, one-on-one interviews were conducted with participants involved in asthma education including asthma researchers, policy makers, and asthma health workers. Overall, 4 interviews were considered feasible in obtaining data saturation, inclusively with health professional and patient interviews. Key community stakeholder inclusion criteria comprised the following:

Interview data were deidentified for coding, analysis, and publication purposes. Participants were also given the opportunity to review their transcript before publication and dissemination.

NVivo Pro 11 (QSR International) allowed qualitative data (interview transcripts) to be analyzed by 2 independent coders. Analysis and coding occurred under thematic categories based on the Triandis model of interpersonal behavior (explained in the following sections), and they were further divided into positive and negative participant perspectives to reduce confirmation bias [48].

Scores on 10-point Likert scales assessing attitudes, knowledge, perceptions, and beliefs of inhaler use and education were collected during interviews and expressed as means and SDs. Other quantitative data including demographics, inhaler use, asthma education, and more were also collected. Use of both qualitative and quantitative data enhances triangulation of information, which is important to improve strength and dependability of findings [49]. Moreover, it allows comparison of the 3 participant groups’ responses through 3 levels of the Triandis model, leading to improved reliability and validity [49,50].

The Triandis model of interpersonal behavior belongs to a school of cognitive models and considers intentions and habits as immediate precursors of behavior. Both are influenced by facilitating conditions [50]. According to Triandis, facilitating conditions including social and affective factors and rationale considerations (eg, incorrect inhaler technique causing decreased asthma management, leading to patients stopping the use of their inhalers) influence intentions [51]. This can indicate that no action is either fully deliberate or automatic, and therefore, behavior is believed to be influenced by intentions, habits, and facilitating conditions. The impact of this can be further limited by both emotional and cognitive function [50].

An alternative way to consider the influences within the Triandis model is the trilevel explanation developed by Egmond and Bruel [48]. The study applied this form of the model throughout [48]. The model starts with investigating the behavior (inhaler technique) itself and working backward from that point. The third level explains intentions when influenced by facilitating conditions, that is, difficulty in understanding written instructions. It also explains habits such as using inhaler incorrectly to predict whether an individual will perform a particular behavior. The second level considers how cognition, affect (being pure emotion), and personal normative beliefs influence the creation of intentions regarding a specific or general behavior. Finally, the first level relates to personal characteristics that focus on past experiences, which shape perceived consequences, affect, and social factors related to behavior. Ultimately, the Triandis model offers a framework that provides explanations to understand complex human behaviors, particularly those influenced by affective and social factors (Figure 1).

A total of 21 participants were recruited into the study, and data saturation was achieved. The sample consisted of 33% (7/21) male patients and 62% (13/21) female patients, aged between 21 and 64 years. The characteristics of all participants are reported in Table 1; however, raw age and gender information has been removed for confidentiality purposes.

Similarities were observed between quantitative and qualitative results among the 3 groups and 3 levels of the Triandis model on triangulating the results. There is a strongly held belief that the app or technology has the capacity for improving inhaler technique. Furthermore, it is believed that all users of the technology would benefit by using it, owing to the importance of patient inhaler technique.

As per the evidence in Table 2 and responses from the qualitative results, patients with asthma are very confident with their inhaler technique, which is represented by the mean score of 9.17 (SD 1.33) out of 10. However, health professionals and key community stakeholders believe that patients with asthma are typically not confident (mean 7.25, SD 1.39, and mean 4.5, SD 0.71, for health professionals and key community stakeholders, respectively).

Further adding to this incongruency, patients with asthma do not believe that they experience stress, anxiety, or worries when using their inhalers (mean 1.83, SD 2.51), whereas health professionals and key community stakeholders report that patients with asthma experience stress, are anxious, or report being worried when using their inhaler device (mean 5.38, SD 1.19, and mean 5, SD 1.41, respectively). Frequency of smartphone technology use is another instance where a divergence in views among groups can be observed, as shown in Table 2. Health professionals and key community stakeholders see themselves using the technology more often (mean 7.63, SD 0.92, and mean 8.25, SD 0.35, respectively) than the patients with asthma (mean 5.17, SD 1.75). The final discrepancy reported among the 3 groups was regarding the amount of education and help available for patient’s inhaler use. Patients with asthma believed that there was sufficient education or help available, with mean score of 6.5 (SD 2.71), whereas health professionals and key community stakeholders believed that there could be more education (mean 5.5, SD 2.07, and mean 5.5, SD 0.71, respectively). Additional findings related to attitudes, knowledge, and beliefs around inhaler technique for each of the 3 groups of participants are reported in Table 2.

A randomized controlled trial is needed to evaluate the effectiveness of the AR resource in the clinical care setting. Combined with a brief training program, the physical poster-based resource overlaid with AR technology should be compared with implementation of usual care across multiple sites. Outcomes to evaluate include the following: assessment of correct inhaler technique among patients, number of patients shown inhaler technique by their health professional at each visit, asthma exacerbations, need to use reliever medication, emergency department presentation or hospitalization, and reported use of the electronic resource outside outpatient or hospital visits.

Recruitment was more difficult than initially predicted owing to the paucity of patients with asthma admitted to TQEH who met all the inclusion criteria and were willing to participate. Therefore, more participants with well-controlled asthma were recruited. These participants had fewer exacerbations and better controlled asthma than those originally targeted; however, in the final phase of recruitment, 3 participants fulfilling all the original inclusion criteria were identified and agreed to participate, thus improving generalizability of the findings. For these reasons, the number of recruited patients with asthma is a larger cohort than initially intended. Although unexpected, this broadens the scope of the study to include patients with asthma with well-controlled symptoms and those with frequent hospitalizations.

Another limitation for this study includes the limited representation of diversity in the sample. The sample included people who resided within urban areas of Adelaide, with limited ethnic diversity; had English as a first language; had middle to high socioeconomic status; and were employed. This study would be strengthened with recruitment of a more diverse range of participants from across multiple hospitals and different locations (urban, regional, and rural and across states and territories). Of note, participants were not excluded based on smoking status or time of last lung function assessment. Therefore, a potential exists for some recruited patients with asthma to have undiagnosed early-stage COPD. However, it is unlikely that having undiagnosed COPD will affect the results of the evaluation because patient’s self-identity as a person with asthma will not change.

Purposive sampling used throughout recruitment of patients with asthma poses a risk of participant selection bias that is difficult to measure or control [57]. However, considering that the purpose of this evaluation was to gain insight into specific populations, the targeted sample cohort evaluated in this study is typical of qualitative research. An attempt was made to reduce researcher bias by using 2 independent researchers to code the qualitative data.

As the scope of the paper was limited to themes directly related to the use of new technology as an intervention to improve inhaler technique, it only indirectly addressed the broad strategies for improving asthma inhaler technique, such as pamphlets, face-to-face assessments, and other resources or dynamics used when educating patients.

Methodology used in this study did not incorporate quantitative assessment of inhaler technique used by patients with asthma according to guidelines. Moreover, interviews were conducted using a semistructured guide permitting flexibility in wording and flow of interview. Throughout initial interviews with health professionals, patients with asthma, and key community stakeholders, responses were not as expected in some cases. In these instances, adjustments to the moderator guides occurred, generating more in-depth responses that better addressed the gap in evidence. Counts could not be conducted to quantify responses on any one particular issue. Supplementing this, 10-point Likert scales were used to provide quantitative outputs or key issues that were also used to triangulate data collection.

Inhaler technique is an important part of asthma management that is frequently overlooked. There is a widely held perception of confidence in inhaler technique among most patients with asthma that may be masking issues of incorrect technique. These perceptions lead to a false sense of security as patients do not ask their health professionals to check inhaler technique, they do not seek resources for confirmation, and health professionals request to see inhaler technique less often. These factors may be exacerbating the high rates of incorrect inhaler technique that are contributing to suboptimal disease management and subsequently escalating hospital use. AR technology was perceived by all participants (21/21, 100%) to be a potentially valuable tool to aid in the education of correct inhaler technique and as a means of prompting health professionals to check inhaler use. The ability to update the digital content easily and cost-effectively without the need to change the printed document is a valuable asset, as is the capacity for videos to negate issues surrounding poor health literacy. Barriers to uptake were identified for the older population who may not know how to use the technology and for people without smartphones. Underevaluation of poor inhaler technique by health professionals was also identified as a potential barrier resulting in reduced uptake of the technology by patients with asthma. As this is a qualitative study, research data cannot be generalized beyond the sample. Therefore, a randomized controlled trial to evaluate efficacy in the clinical setting is required.