Table 4 Changes made during phase 2

1 (13 pages)

Introduction pages^b Home page

Original one page introduction became 13+ page section.

• Both TA participants and expert panel highlighted that people with asthma are well known for underestimating their asthma severity, and suggested it was important to challenge this idea right at the start and illustrate to users how this resource could benefit them.

• First page presented user with questions designed to tease out limitations due to asthma. Then feedback provided for each question user ticked, along with tailored advice about which sections of the resource might benefit them most.

• Subsequent pages focused on identifying lifestyle goals relevant to users.

• Other changes included addition of a ‘landing’ page, combining links to sections to reduce the ‘buttons’ in the navigation bar from 11 down to 7, and rearranging the home page.

2 (24 pages)

My Asthma^b

Initially just one section, but became apparent that resource needed to be more tailored, and preventer therapy use was a good method of stratifying users, so users had to choose one of three options:

1) I have never used/been prescribed a preventer

2) I have been prescribed a preventer but don’t really use it

3) I mostly/always take my preventer inhaler as prescribed

The think aloud study confirmed the contents of this section, with most changes focusing on improving readability, removing repetition and trying to achieve the right balance when explaining negative side effects versus potential benefits of inhaled steroids.

3 (14 pages)

Treatments

Organization of this section completely altered. It initially took the form of 6 pages users worked through with sideway steps for more information about different treatments.

Section changed to have:

• its own homepage (i.e. spoke and wheel layout) which allowed users to go directly to a treatment type without having to work through potentially irrelevant pages.

• a visual representation of the asthma treatment ladder adapted from the BTS/Sign guidelines.

We were unable to meet requests to have pictures of individual inhalers.

4 (21 pages)

Asthma Reviews

• Focused on modifying the language used and simplifying messages.

• Altering layout of both individual pages and order of pages.

• Main message was to “aim for no symptoms” and this was very well received by users.

• Included a quiz covering what put people at risk of attacks—this was streamlined and made optional.

5 (5 pages)

Action Plans

• Altered layout and clarity of wording, and quotes added to dilute the very factual nature of the information provided.

• Added a template to a blank action plan that users could print out and take to their health professional.

6 (17 pages)

Physical Activity

• Initially one generic section with the aim of promoting physical activity but was altered to become tailored to the individual’s activity status.

7 (18 pages)

Common concerns and queries

• Originally had 8 concerns and queries, and a further 7 were added addressing topics originally not included as were felt to be covered elsewhere, or had seemed ‘too basic’.

• Reviewing this section served as a reminder that people quickly forget (or have never been told) even basic information about their asthma, and that having it here for those who need it was essential.

• Another major change was the wording of questions. One user commented that questions were just statements and didn’t make it clear than scenarios were amenable to change. So for example ‘I don’t exercise because of my asthma’ was changed to ‘I don’t exercise because of my asthma. Could I?’

8 (5 pages)

Stress & Anxiety

• Received mainly positive feedback.

• Links to online resources aimed at reducing stress and anxiety (e.g. online CBT) added.

9 (8 pages)

Take the 4 week Challenge

• This section was specifically for users who had chosen option 1 or 2 during the ‘My Asthma’ section.

• Initially much confusion about the nature of the challenge with some users misunderstanding it completely. Thus pages were modified and more explanation added.

• Layout of pages were altered, in particular, to make it clear that there were 4 steps to work through, and it was made clearer how you were progressing through them (e.g. colour strip across the top, which illustrated progress).

• One of the steps to the four week challenge was to anticipate barriers to taking preventer medication regularly and consider some solutions. Template barriers and solutions were provided, and these were added to by the think aloud participants.

10

Like to stop smoking?

• This section was a link to an external site called ‘StopAdvisor’[19] and therefore not covered during the think aloud studies.

11 (1 page)

Useful info and links

• Expanded during the think aloud to include more links to online mental health resources and information about the GP exercise referral scheme.