INTRODUCTION

Asthma is a chronic airway disease resulting from an inflammatory process which generally affects 1-18% population, characterized by symptoms varying from wheezing, shortness of breath, feeling of heaviness in the chest and/or coughing as well as varying expiratory airflow limitation.[1] Asthma is estimated to affect around 262 million people worldwide in 2019 and causes 455,000 deaths.[2] The prevalence in Singapore reaches 11.9% (2021), Japan 10% (2022), Taiwan 5.1% (2019), and Korea 2.2% (2020).[3-6]

Asthma occupies the top ten causes of morbidity and mortality in Indonesia. Nationally, the 10 districts/cities with the highest prevalence of asthma are West Aceh (13.6%), Buol (13.5%), Pohuwato (13.0%), West Sumba (11.5%), Boalemo (11. .0%), South Sorong (10.6%), Kaimana (10.5%), Tana Toraja (9.5%), Banjar (9.2%), and Manggarai (9.2%).[7]

Achieving and maintaining controlled asthma is main goal of asthma management, namely optimal conditions that allow asthma patients to carry out their life activities like other healthy people. Indications of controlled asthma are no symptoms, no activity limitations, no symptoms at night, no need for relievers, normal lung function and no asthma attacks throughout the year.[1] The level of asthma control can be achieved with medical treatment and good self-management of asthma patients, where one of the factors that can affect asthma control level is knowledge about asthma, patients can recognize and carry out self-management of asthma effectively.[8]

In Atmoko study regarding asthma control level at Asthma Clinic, Friendship Hospital, Jakarta in 2011 using the Asthma Control Test (ACT), it was shown that out of 107 subjects studied, 81 subjects (75.5%) with uncontrolled asthma and 26 people ( 24.3%) with controlled asthma. This is in line with research conducted at Asthma Polyclinic, General Hospital Dr. M. Djamil Padang and General Hospital Dr. Achmad Mochtar Bukittinggi in 2013, which based on ACT score found 36 people (55.4%) with uncontrolled asthma, 18 people (27.7%) with partially controlled asthma, and 11 people with totally controlled asthma (16.9%).[9,10]

The Department of Pulmonology, Faculty of Medicine, University of North Sumatra has developed an application "Paru Sehat" which can be downloaded via PlayStore. This application aims to be a media for pulmonary disease education which contains educational content in the form of video and text which facilitates exchange information between patients and health professionals. This research aims to determine whether there is an effect of providing digital education through "Paru Sehat" smartphone application on asthma control level as measured through Asthma Control Test (ACT) questionnaire in asthma patients.

METHOD

The research design used was Quasy Experimental within subject (pre-post) which was carried out to determine asthma control level as measured by Asthma Control Test (ACT) before and after provision of digital education through the "Paru Sehat" smartphone application at Outpatient Clinic University of North Sumatra Hospital which was carried out for 3 months, starting from April to June 2023.

The sample of this research were asthmatic patients who met inclusion criteria and were not included in exclusion criteria. The sample selection used a non-probability sampling technique with consecutive sampling types. The minimum sample size required is 22 people. To anticipate the loss of research subjects to follow-up, the sample size was increased to 25 people

The inclusion criteria for this research were patients diagnosed with asthma and not in a state of exacerbation, aged over 18 years, asthma patients who came for control to Outpatient Clinic, patients who had received asthma treatment according to asthma degree, patients who were willing to be research sample and have signed an informed consent form, are able to use Android smartphone applications or companions who are able to use Android smartphone applications. While the exclusion criteria were asthmatic patients who were unable to read and write, patients who were not willing to be the research sample and did not sign informed consent and asthma patients who were unable to operate Android smartphone devices or did not have companions who were able to use Android smartphone applications. Each research subject who was included in this research understood and signed the consent form after explanation (informed consent). The research subjects filled out the ACT questionnaire sheet. The research subjects were introduced to "Paru Sehat" smartphone application and given time to understand the contents of the application regarding information about asthma. The time given is 4 weeks, the patient will be exposed to material about asthma once a week. The research subjects filled out the ACT questionnaire again after 4 weeks of using "Paru Sehat" smartphone application.

The Department of Pulmonology, Faculty of Medicine, University of North Sumatra has developed a "Paru Sehat" application that can be downloaded via the playstore. This application aims to provide digital education to patients with Asthma, COPD, Pulmonary TB and treatment monitoring.

The features of the "Paru Sehat" application consist of the patient's personal data, namely name, date of birth, height, city/district, address, cellphone number, family name and family cellphone number. Then there are questions regarding the history of covid infection and the "mMRC Congestion Scale" which, if the answers have been selected, will provide suggestions for steps that should be taken going forward. There is also a "Smoking History" and "Pulmonary Disease History" which will raise other questions if had chosen. Info & Educational Videos at a Glance are divided into 3 sections based on pulmonary disease asthma, COPD, and post-TB infection. Each section has disease-related information and educational videos that briefly explain the disease. The content of “Benefits of Exercise for Lung Patients” is a brief explanation and guide regarding exercise that is beneficial for lung patients. there are also videos that can be played to guide sport movement.

Figure 1. Some features in "Paru Sehat" Application

Factors causing worsening symptoms include those that can precipitate exacerbations in COPD and asthma. Information on first treatment of worsening symptoms if an exacerbation occurs for patient and the patient's family also provided. However, if the complaint does not decrease, immediately take the patient to the nearest hospital. Healthy Lung Community which includes several other features such as: information, programs, and documentation of "Paru Sehat" Community. There is also a WhatsApp group/call center service available for the "Paru Sehat" Community. In the inhaler medicine section, there are various kinds of inhaler medicines and also video tutorials on how to use them. Besides that, this application also include reminders when it's time to use the inhaler. It is hoped that the use of inhalers in patients who need them will become more routine. This application also displays the location of the hospital on a map that is within the radius of where the patient is when opening the application and displays the tips needed to start smoking cessation.

In this research, the data that has been collected will be managed and analyzed using a computerized system with SPSS (Statistical Package for the Social Sciences) program. The data obtained was tested for normality using Shapiro Wilk test. If the data is normally distributed, the hypothesis test used to analyze data with nominal independent variables and numerical dependent variables in the same research subject is dependent t test (paired t test). Conversely, if the data is not normally distributed, the Wilcoxon test is used to test the hypothesis. The research results are said to be significantly different if statistical analysis found p value <0.05.

RESULTS

Table 1. Distribution of Respondents Based on Demographic Data

This research obtained a total of 25 patients, with 5 male patients and 20 female patients. After obtaining data, a descriptive analysis was carried out on each research variable. Then a different test was carried out to find differences between the two paired variables, namely asthma control level before and after receiving digital education through "Paru Sehat" application. Based on Table 1, it was found that majority patients was in age group of 26 to 45 years, namely 48% of all study subjects. As many as 20% of patients were male and 80% of patients were female. As many as 48% of patients were housewives, 16% of patients were self-employed, 12% of patients were female students, 8% of patients were lecturers, the rest were civil servants, high school teachers, nurses and architects each of 4%. As many as 52% of patients have a normal body mass index, but 36% of patients are overweight, and the remaining 12% are obese. Most of the patients did not have comorbidities, 4% of patients had heart failure, 12% of patients had grade I hypertension and 12% grade II hypertension, the remaining 4% had pulmonary TB. As many as 44% of patients had severe persistent asthma, 36% moderate persistent, 12% mild persistent, and 8% patients had intermittent asthma.

Table 2. The Distribution of Research Subjects Based on Control Level Before and After Using “Paru Sehat” Application

Based on Table 2, it was found that 56% of asthma patients were partially controlled, 40% of asthma patients were not controlled and only 4% of asthma patients were fully controlled before using “Paru Sehat” application, but the rate of controlled asthma patients increased to 20%, partially controlled decreased to 48%, and uncontrolled asthma decreased to 32% of patients after using “Paru Sehat” application.

Table 3. Comparison of Asthma Control Level

The Wilcoxon test was carried out on both variables, namely asthma control level before and after using the healthy lung application, and the results obtained were a better level of asthma control after using “Paru Sehat” application but these results were not statistically significant with p value = 0.058.

DISCUSSION

This research evaluated effect of using “Paru Sehat” application to improve control level of asthma patients. The application can control patient compliance and also provide information and educational videos for asthma patients. Asthma patients were dominated by women in this

research. The literature says that gender differences exist in asthma prevalence. As adults, women have an increased prevalence of asthma compared to men. Furthermore, women are more likely to have severe asthma and later asthma onset compared to men. Gender differences exist in asthma and change throughout life.[11] As children, boys had an increased asthma prevalence compared with girls (11.9% vs 7.5%, respectively).[12] and boys are also twice as likely to be hospitalized for an asthma exacerbation.[13] However, during adolescence there is a decrease in asthma prevalence and morbidity in males along with an increase in females. By adulthood, women have an increased asthma prevalence compared with men (9.6% vs. 6.3%, respectively), and women are three times more likely than men to be hospitalized for an asthma-related event. This is attributed to the effect of the hormone estrogen increasing adhesion to endothelial cells in blood vessels, and combination of hormones estrogen and progesterone can increase eosinophil degranulation thereby facilitating bronchial asthma attacks. The increase of asthma prevalence in women compared to men is maintained until around the time of menopause, when the decrease Asthma prevalence was noted in women. The shift in asthma prevalence by sex coincides with changes in sex hormones and suggests that sex hormones modulate pathways associated with asthma pathogenesis.[14]

Data were collected on the patient's asthma control level before and 1 month after using “Paru Sehat” application, and it was found that there was an improvement in asthma control level after 1 month of using “Paru Sehat” application, but after conducting statistical tests, there was no significant difference (p>0 , 05). This could be due to the different conditions of research subjects, different co-morbidities, and the evaluation time span of 1 month which might be too short to get a significant improvement in patient's asthma control level. Mendozo et al found in asthma with a more severe degree or in long-standing asthma, the inflammatory process of the airways will cause remodeling. The exact mechanism underlying this process is still being studied. On the other hand, persistent asthma with a more severe degree of obstruction requires more intensive treatment, higher drug doses and tighter supervision. This is strongly related to patient compliance level to achieve controlled asthma.[15]

Research conducted by Setiahasti et al, regarding correlation of asthma knowledge level and asthma control level at the Pulmonary Clinic of Arifin Achmad Hospital Pekanbaru, obtained in patients with high level of knowledge, there were 14 samples (19.4%) with a controlled asthma level, while those who were not controlled were 58 (80.6%) samples. Otherwise, in patients with low level of knowledge, there were only 6 (24%) controlled samples, while 19 (76%) samples were not controlled. The statistical test results obtained p value 0.843 which concluded that there is no significant relationship between asthma knowledge level and asthma control level.[16]

Steady increases in global prevalence of asthma have been reported by World Allergy Organization, especially in countries such as Australia, United Kingdom, and United States.[17] The global burden of asthma is estimated to affect more than 300 million people.[18] There are serious challenges in day-to-day management of asthma, including medication adherence and symptom control. As with any long-term chronic disease, asthma self-management is an integral part of health care. Self-management can be defined as the tasks that individuals must perform to live with their chronic condition, such as medical management, role management and emotional management.[19] Self-management interventions encourage patients to actively participate in their care and increase their responsibility for controlling symptoms and complications of their disease.[20] Qur'an et al in their review suggested that intervention studies reported positive effects of smartphone applications on asthma control, medication adherence and self-efficacy. Smartphone applications can be an effective asthma control tool, especially among adolescents who are the main users of smartphones.[21] Baptist et al in their research revealed the same thing, that technology-based interventions have high levels of user satisfaction among minorities and urban/low-income individuals with asthma and can improve asthma outcomes.[22] This differs from the results of this research due to the smaller sample size and shorter time coverage, further large-scale studies are needed to assess whether these interventions can reduce health inequalities in asthma.

The research was conducted by Ghozali et al in 2022, which was carried out by providing interventions in the form of education using applications and assessing the pretest and posttest to find out the increasement of asthma patient knowledge. The results showed that the pretest AGKQA values of the control group (minimum, maximum, and average) were 9, 25, and 19.04 ± 2.56, while the post-test values were 10, 27, and 18.79 ± 3, 59 (p=0.47). In the treatment group, the mean pre-test values were 13, 25, and 19.11 ± 2.87, while the post-test scores were 16, 31, 23.6 ± 3.95 (p = 0.01). There was a difference between the post-test scores of control and treatment groups, namely 4.81 (p=0.01). This shows that the educational content in the application significantly increases asthma knowledge level.[23]

Education plays a fundamental role in management of asthma patients with poor knowledge, skills and adherence. To address this problem, a comprehensive educational strategy aimed at promoting patient compliance and enhancing their self-management knowledge and skills must be adapted to meet the needs of individual patients.[12] Technology-based digital methods such as instant messaging, smart healthcare devices, and immersive websites have been received rapid attention in recent years. Many such methods have been devised and validated to improve patient adherence to disease management. Research has shown that digital interventions are successful in increasing asthma awareness and self-management such as application of action plans to improve quality of life and optimize medication adherence.[24] The literature suggests that poor knowledge will interfere with the quality of life of patients with asthma. Poor asthma control is a realized public health problem. This causes respiratory health problems and limits physical activity.[25]

Atmoko et al investigated risk factors that affect asthma control level in patients with uncontrolled asthma and found that based on a statistical comparison between general asthma awareness level and asthma management level, there was no significant effect.[17] This could be due to factors confounders who were not included in the study and could impact the findings. Confounding variables in the study could include elements related to general asthma knowledge level, such as inappropriate drug use, inappropriate drug selection, and inappropriate dosage. Theoretically this contradicts the study by Gecko B et al (p 0.0001), who came to the conclusion that level of patients awareness about their asthma contributes to a higher control level in these asthma patients.[18]

This research has several limitations that might cause hypothesis testing to be insignificant, such as the sample size being too small, patient data characteristics without smoking history data, history of drug use, therefore in future research, the sample should be chosen randomly so that it can represent a population. and further research on other risk factors for asthma control such as history of smoking, history of previous drug use, and assessment of treatment response were needed.

CONCLUSION

This study validated the C2HEST and mC2HEST scores as effective predictors of new-onset atrial fibrillation (FA) in patients with acute coronary syndrome (ACS), emphasising the significant role of age as a risk factor.

The modified mC2HEST score, which has improved age stratification, performed similarly to the original C2HEST score. Key factors such as age, chronic obstructive pulmonary disease (COPD), heart failure, and left atrial volume index (LAVI) were identified as important predictors of AF development in patients with ACS.

DECLARATIONS

This research was approved by the Health Research Ethics Committee of Universitas Sumatera Utara with the registered number 195/KEPK/USU/2023.

CONSENT FOR PUBLICATION

The Authors agree to publication in Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

The authors declare that there is no conflict of interest in this report.

AUTHORS’ CONTRIBUTIONS

All authors significantly contribute to the work reported execution, acquisition of data, analysis, and interpretation, or in all these areas. Contribute to drafting, revising, or critically reviewing the article. Approved the final version to be published, agreed on the journal to be submitted, and agreed to be accountable for all aspects of the work.

ACKNOWLEDGMENTS

None

REFERENCE

1. Indonesian Pulmonologist Association. Guidelines for Diagnosis and Management of Asthma in Indonesia. Jakarta. 2019; 1: 1-18.

2. Jeyagurunathan A, Abdin E, Shafie S, Sambasivam R, Zhang Y, Chua BY, et al. Asthma prevalence and its risk factors among a multi-ethnic adult population. Yale J Biol Med. 2021; 94: 417-427.

3. Hsieh CJ, Yu PY, Tai CJ, Jan RH, Wen TH, Lin SW, et al. Association between the first occurrence of asthma and residential greenness in children and teenagers in Taiwan. Int J Environ Res Public Health. 2019; 16: 1-2076.

4. Futamura M, Hiramitsu Y, Kamioka N, Yamaguchi C, Umemura H, Nakanishi R, et al. Prevalence of infantile wheezing and eczema in a metropolitan city in Japan: A complete census survey. PLoS One. 2022; 17: 4-268092.

5. Lee E, Kim A, Ye YM, Choi SE, Park HS. Increasing prevalence and mortality of asthma with age in Korea, 2002–2015: A nationwide, population-based study. Allergy Asthma Immunol Res. 2020; 12: 467–484.

6. Ministry of Health of the Republic of Indonesia. Indonesia Health Profile 2020. Jakarta. 2021; 1: 1-15.

7. Imran NH, Khairani R, Susanti H. Relationship between control level and peak expiratory flow in asthma patients. J Biomed Health. 2018; 2: 1 –10.

8. Wahyudi. Adherensi pengobatan asma anak dan tingkat kontrol asma di RSUD H. Abdul Manan Simatupang Asahan. Anatomica Med J.1997; 1: 1–10.

9. Katerine I, Medison I, Rustam E. Hubungan tingkat pengetahuan mengenai asma dengan tingkat kontrol asma. J Kesehatan Andalas. 2015; 3: 1–20.

10. Zein JG, Erzurum SC. Asthma is different in women. Curr Allergy Asthma Rep. 2015; 15: 1-28.

11. Ghozali MT, Satibi S, Ikawati Z, Lazuardi L. The efficient use of smartphone apps to improve the level of asthma knowledge. J Med Life. 2022; 15: 625–630.

12. Centers for Disease Control and Prevention. Vital Signs. 2011;1: 1–13.

13. Kynyk JA, Mastronarde JG, McCallister JW. Asthma, the sex difference. Curr Opin Pulm Med. 2011; 17: 6–11.

14. Moorman JE, Zahran H, Truman BI, Molla MT. Current asthma prevalence - United States, 2006–2008. MMWR Suppl. 2011; 60: 84–86.

15. Syahira, Indra Yovi, Miftah Azrin. Hubungan tingkat pengetahuan asma dengan tingkat kontrol asma di Poliklinik Paru RSUD Arifin Pekanbaru. JOM FK. 2015; 1: 1–33.

16. Gerald LB, Gerald JK, Zhang B, McClure LA, Bailey WC, Harrington KF. Can a school-based hand hygiene program reduce asthma exacerbations among elementary school children? J Allergy Clin Immunol. 2012; 130: 1317–1324.

17. Atmoko W, Khairina H, Faisal P, Bobian T, Adisworo MW, Yunus F. Prevalens asma tidak terkontrol dan faktor-faktor yang berhubungan dengan tingkat kontrol asma di Poliklinik Asma Rumah Sakit Persahabatan, Jakarta. J Respir Indo. 2011; 31: 1–19.

18. Pawankar R, Canonica G, Holgate S, Lockey RF. World Allergy Organisation (WAO) White Book on Allergy. Milwaukee: World Allergy Organization; 2013 1: 1: 1-10.

19. Taylor SJC, Pinnock H, Epiphaniou E, Pearce G, Parke HL, Schwappach A, et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS—Practical systematic Review of Self-Management Support for long-term conditions. Health Serv Deliv Res. 2014; 2: 1–17.

20. Mansouri PM, Ghadami MM, Najafi SSM, Yektatalab S. The effect of self-management training on self-efficacy of cirrhotic patients referring to transplantation center of Nemazee Hospital: A randomized controlled clinical trial. Int J Community Based Nurs Midwifery. 2017; 5: 256–263.

21. Alquran A, Lambert KA, Farouque A, Holland A, Davies J, Lampugnani ER, et al. Smartphone applications for encouraging asthma self-management in adolescents: A systematic review. Int J Environ Res Public Health. 2018; 15: 1-2403.

22. Baptist AP, Islam N, Joseph CL. Technology-based interventions for asthma: Can they help decrease health disparities? J Allergy Clin Immunol Pract. 2016; 4: 1135–1142.

23. Al Kindi Z, McCabe C, McCann M. School nurses' available education to manage children with asthma at schools: A scoping review. J Pediatr Nurs. 2021; 60: 46–57.

24. Ramsey RR, Plevinsky JM, Kollin SR, Gibler RC, Guilbert TW, Hommel KA. Systematic review of digital interventions for pediatric asthma management. J Allergy Clin Immunol Pract. 2020; 8: 1284–1293.