Table 1 Defining and understanding the problem

Task 1: Define and quantify the problem

Optimum self-management of asthma is an underused, yet proven treatment strategy that improves a range of asthma outcomes (fewer visits to emergency room, hospitalisations, unscheduled visits to doctors, and days off work and school, reduces nocturnal asthma and improves quality of life) [7]. People with asthma have:

1) Suboptimal use of preventative therapies. Adherence to therapies in long term conditions is around 50 % [39]. Low use of preventative (inhaled corticosteroids (ICS)) therapies and high use of short acting beta agonists (SABA) reliever inhalers, is a pattern commonly seen which is associated with poorer asthma control [29].

2) High levels of symptom burden (46 % daytime symptoms and 30 % nocturnal symptoms) [30], with lack of recognition of scope for improvement: 50 % of patients reporting severe persistent symptoms report their own asthma as being completely or well controlled [30]. This results in people with uncontrolled or deteriorating asthma not seeking timely medical advice.

3) Suboptimal attendance at asthma reviews with low use of asthma action plans (AAPs) [13, 32] as evidenced by the National Review of Asthma Deaths (NRAD) where only 23 % of those who died having been provided with an AAP [32], and attendance at asthma reviews in Scotland was only 65 %.

Task 2: Identify and quantify the population most affected, most at risk, or most likely to benefit from the intervention

The Global Initiative for Asthma (GINA) guidelines lists risk factors for poor asthma outcomes [8]:

• Uncontrolled asthma symptoms

• Increased use of short acting beta agonist (SABA) e.g. reliever therapy

• Inadequate inhaled corticosteroids (ICS), including poor technique.

• Low FEV₁ (especially if <60 % predicted)

• Major psychological or socioeconomic problems

• Smoking

• Comorbidities: obesity, rhino-sinusitis, food allergy

• Previous exacerbations or intensive care admissions for asthma

The majority of these factors are related to uncontrolled asthma symptoms, and therefore a key way of identifying those most likely to benefit is to target those with uncontrolled asthma symptoms.

Task 3: Understand the pathways by which the problem is caused

With reference to problems outlined in task 1:

1) Reasons for low adherence to asthma therapies are often related to concerns about side effects, or perceptions that they don’t need to be on treatments [12].

2) The global asthma insights and reality surveys [29] provides evidence of suboptimal asthma control and suggests reasons for it. First, people with asthma overestimate how controlled their asthma is, therefore don’t consider themselves to be candidates for gaining improvement with asthma treatments. Second, those who do acknowledge they have symptoms and limitation of activities accept them as unavoidable consequences of having asthma.

3) Patients reasons for not attending asthma reviews revolve around feelings that their asthma is not serious enough [9]. Asthma Action plans are underused for several reasons [31]:

i) Differences in beliefs and attitudes between health care professionals and people with asthma.

ii) Perceived irrelevance of AAPs of the part of those who would potentially benefit from them

iii) Health professionals only offer AAPs to select groups of patients (e.g. with well controlled asthma, or those with higher levels of educational achievement).

In summary, people with asthma often underestimate their symptoms and overestimate their control, not making use of available therapeutic options (medications, AAPs and advice from health professionals). Those who do recognise they have symptoms may not adhere to prescribed medications due to misunderstandings around medication side effects, or perceived benefits of using AAPs.

Task 4: Explore whether these pathways may be amenable to change and, if so, at which points

With specific reference to the three ‘problems’ outlined in Task 1:

1) Prompting users to consider reasons why they don’t take medications regularly (barriers) and consider strategies to overcome these barriers. Providing information about benefits of inhaled corticosteroids, challenging misconceptions and negative beliefs. Focussing on benefits meaningful to individuals such as fewer days off work, managing that exercise class etc. Providing instructions (ideally including videos) to demonstrate correct inhaler technique.

2) Promoting the message that users should be aiming for no symptoms. Providing information to challenge the belief that having asthma symptoms is normal, and asking validated questions to determine if users are currently putting up with symptoms, providing feedback on response. Prompting users to recognise if they avoid activities due to their asthma, or are limited in everyday tasks such as housework, gardening, visiting friends. Turn these limitations into ‘goals’ to aim towards, and describing how these goals are achievable for them.

3) Provide information that people who use AAPs and attend for reviews have fewer symptoms and fewer asthma attacks. Provide quotes from practice nurses encouraging attendance for reviews. Remove physical barrier to using AAPs by providing a template that can be taken to health professionals (identical to those provided by local health board).

The expert panel will ensure that behaviour change theory is incorporated into the web page contents and full analysis of behaviour change techniques will be done on final website (Table 6).

Task 5: Quantify the potential for improvement

An estimated 300 million people worldwide have asthma and its prevalence appears to be increasing with an estimated additional 100 million people with asthma by 2025 [16]. Depending on criteria used to define poor control evidence suggests that levels of uncontrolled asthma range from at least 25 %, and probably higher [29, 30, 36]. Our primary outcomes in a full scale RCT would be symptom level using a questionnaire. A good candidate would be the Asthma Control Questionnaire and we would aim for a drop of 0.5 in score which is the minimally important clinical difference [14]