38 Chapter 2 2 list of improvements to identify necessary features and improvements. Phase 3 and 4: prototype and evaluation – iteration 2 Improvements were made to the paper prototype, which was then translated to a WhatsApp prototype. The prototype mimicked the use of the new concept in practice. Using WhatsApp as a communication tool between the investigator and the participant, the participants received the screens they would interact with if they were using the real app. This approach allowed participants to interact with the concept for a longer period of time, within their own setting (e.g., at home) and at the same time did not require the costly development of a functional app in this early phase. Participants were asked every day at a fixed time (12 pm) “Did you use your maintenance medication this morning (yes/no)”? and “Did you use your reliever medication yesterday (yes/no)”? Based on their answers, participants received the corresponding screen via WhatsApp. The participants did not receive any instructions on inhaler use. After the five-day testing period, participants were invited for a semistructured interview. The participants were asked to reflect on the screens they had received in terms of motivation to use their maintenance inhaler, usefulness, inhaler use and usability. During the interview, the other screens (e.g., those that were sent with a different combination of answers) were also presented and asked to provide feedback on. In total, the interviews lasted approximately 1.5 hours. The interviews were audio recorded and transcribed. Transcripts were analysed and used to formulate design recommendations. Results Phase 1: define All participants of the questionnaire (n = 20) expressed that they found it difficult to use their maintenance inhaler on a daily basis. While the initial answer of all participants was that they did not adhere to their inhaler, because they simply forgot, further questioning revealed additional reasons and motives. Based on the interview data and data from the online survey, five key themes were identified regarding reasons for non-adherence to maintenance medication. Each theme is described below. Demographics of the participants of the interviews and the online survey are depicted in Appendix 1. Although not a specific inclusion criteria, participants in the interviews (and subsequent study activities, as chosen design focus) included participants with mild asthma only. Theme 1: Asthma feels episodic and no need for medication when feeling well Participants found it difficult to use their inhaler daily because their asthma felt episodic rather than chronic, marked by periods where they hardly experienced any symptoms. During these periods, they did not use their maintenance inhaler until their symptoms increased. Participants initially indicated that they believed
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