Qualitative findings
The process of double coding by an external researcher as well as discussions of the coding process within the research team did not present any discrepancies in the findings.
The main themes emerging from the interview data were:
patients’ transition from being uncertain about their ability to use the technology to being confident to use it;
the way in which the mHealth intervention addressed patient concerns about fragmented care by offering a sense of continuity of care and, thereby, reassurance;
increased patient awareness of the variability of symptoms; and
the way the mHealth intervention appeared to support patients’ self-management behaviour.
From ‘uncertainty of ability to use technology’ to ‘ease of use’
Patients had a varied previous experience in using computers and mobile phone technology, ranging from none to everyday use of smart phones and tablet computers. Unsurprisingly, those who had little or no previous experience in using computers were more likely to express concerns over using the mHealth application:
‘First of all when, because I kept saying, “I’m never going to cope” I didn’t really want to do it after I said I would. Only because my sister said, “Go on, you can do it”. But I am not, I’ve never been on these things or whatever.’
(PR034)
Interestingly, the perceived ‘inability to cope’ with using the mHealth application did not only relate to their lack of experience but also to age:
‘I said, “no, I wouldn’t cope with something like that. I’m too old to bother”.’
(PR034)
‘But [uh] it’s a job when you’re old, you get, you know the family says, “Oh, have a laptop, have a ...” [breathless] I get muddled up with my television, don’t, remote controls so Yes, I am quite happy to be where I am. I can’t be bothered with new stuff.’
(HA004)
Yet despite these initial concerns, patients in this study were able to use the mHealth application regardless of their previous experience. In addition, even those who initially expressed concern over their age reported during the second interview that they were able to use the mHealth application effectively:
‘So I know exactly what to do with that. So I’m quite good. I’m quite pleased with myself.’
(PR034)
‘Well, I was all right ... I was all right.’
(HA004)
It appeared that despite initial concerns about both age and ability to use the mHealth application effectively, none of the patients in this study had significant problems in using the application.
From ‘disruption of care’ to ‘reassurance and perceived continuity of care’
Patients expressed satisfaction with their current care but indicated a sense of disrupted care in terms of their contact with healthcare professionals. This was not necessarily attributed to the behaviour of professionals but more to their own reluctance in making contact with them. These perceptions appeared to relate to patients not wanting to be ‘burdensome’ and ‘bothering’ nurses, who were perceived to be busy, resulting in feelings of ‘being left out there’:
‘I don’t like to bother them [nurses] to be honest, you know if I can cope.’
(HA007)
‘“Oh we’ll come and see you such and such.” And they never come ... I mean I know they’re busy, don’t get me wrong, I do know they’re busy, but I just feel a bit like, left out there.’
(HA001)
Another reason for patients to avoid seeking contact with healthcare professionals was the potential of unnecessary visits, and therefore these were often delayed:
‘I’m not a great one for to-ing and fro-ing to the doctor unnecessarily.’
(HA006)
During the second interview, a sense of reassurance and continuity of care through mHealth monitoring was identified. Patients were aware that data were not monitored by the research nurse on a daily basis and were advised (both in written form and verbally prior to taking written consent) to contact healthcare services in the usual way in an emergency. Yet the virtual link offered by the mHealth intervention appeared to reassure patients and gave a sense of continuity of care:
‘It’s nice to know that you’ve got it ... you’re being monitored you know, and it gives a sense, you know, this is all getting back to some central computer and it’s all being monitored. So somebody’s actually looking at how you are, without me actually going to the doctors, so you get that feeling that you’re being looked after.’
(HA014)
The main aspect that underpinned this sense of continuity appeared to relate to the sharing of patients’ self-monitoring data with the research nurse, even though this was infrequent and did not replace current care:
‘I think having the system that will monitor it, and somebody’ll have a record.’
(HA015)
‘You’re being looked after really, looked over and there is someone who is looking at your condition ... I did like the idea that someone would be looking over me.’
(HA002)
Increased awareness of variability of symptoms
Patients also indicated an increased awareness of the variability of their symptoms. Although they acknowledged the often unpredictable nature of their COPD-related symptoms during the first interview, during the second interview they emphasised a much more structured approach to reviewing their condition and how they felt not just over a number of days but also within a 24-hour period. As patients were answering questions about their symptoms as well as monitoring their oxygen saturation on a daily basis, they felt encouraged to think more about how they were feeling each day and throughout the day:
‘It makes me think about the problem more during the day ... you know you’re sort of analysing yourself how you’re feeling.’
(HA007)
‘It makes you stop and think about ... how things are.’
(HA002)
This appeared particularly beneficial as patients reported they would often ignore their symptoms or be less aware of a symptom change, as explained during the second interview:
‘I think it’s, it’s probably just a good thing to be aware because I might start not bothering to become aware, if I wasn’t now that I’m not using it [mHealth intervention].’
(HA002)
‘I am the sort of person who ignores my own, whatever it is I’ve had that are too nasty things. I tend to ignore it. [um] And I don’t think, “How am I feeling today?”. The only time I thought about how I’m feeling today was when I filled it in. “How have I felt today?” And then I would assess how I felt today.’
(HA006)
As part of the mHealth application, patients were asked to monitor their oxygen saturations on a daily basis, and initially patients were uncertain how to interpret oxygen levels:
‘I’m not quite sure what it should be. [er] Yes, I don’t know what’s bad. Say it went down to 80 ... I mean I’d probably be dead by then, but I don’t know. You see I’ve no idea.’
(HA013)
However, after having used the application for 6 months, they appeared to develop an understanding of their individual ‘normal’ levels, despite not receiving any additional information or training about oximetry and normal oxygen saturation levels:
‘When I am feeling alright it’s [oxygen saturation] about 90.’
(PR034)
‘It seems to vary between 94 and 97.’
(HA011)
Although not all patients paid the same amount of attention to their oxygen saturation levels, there was a sense of ‘wanting to know’ oxygen saturation levels as this would aid their decision-making process when feeling unwell:
‘Definitely I’d want to know because then I might be able to do something about it.’
(HA012)
The patients in this interview study welcomed the self-monitoring of oxygen saturation levels and perceived this as beneficial in managing their COPD.
Supporting self-management behaviour
As well as using the oxygen saturation data provided by the mHealth application as an aid to self-manage COPD, patients also perceived the tablet computer, as a whole, as supporting their self-management behaviour. It reminded patients of the need to engage in self-management:
‘It’s a presence in the home, it encourages me to do what I call breathing exercises.’
(HA006)
It also reinforced routines that included adherence to regular medication:
‘Because, I knew I’d got to do that ... do my puffers and then I go and have my shower and then I do my thing. I’d got it all in, and I think it was because of that that I’d got to do, that I done it so regular. And took my tablets as well.’
(PR034)
Patients expressed the view that using the mHealth application was beneficial to their self-management, not just in terms of monitoring and adherence to medication, but also engaging with mood issues. Patients expressed feelings of low mood but explained that using the symptom diary (which included a general question of wellbeing) made them realise they were in a better frame of mind than they initially thought:
‘It’s a good thing to be aware [of COPD changes] and become aware ... and also if you’re feeling a bit down ... and you got to say how you feel, you stop and think and think I don’t have to feel down and then you think “I feel good”.’
(HA002)
Yet some patients perceived the mHealth application as less useful. It is interesting to note that those who ‘felt it was a waste of time,’ (PR032) appeared to be less engaged with managing their COPD, and stated that:
‘They [respiratory nurses] tell me to do this when I’m not well and they [respiratory nurses] come and see me,’
(HA001).
Thus they appeared to rely more on healthcare professionals to make decisions about treating exacerbations and often suffered from comorbidities that impacted equally if not more on their health. Other characteristics, such as COPD severity, length of diagnosis or familiarity with communication technologies appeared to be less strongly linked to level of engagement with the mHealth intervention.
