39 Design of the persuasive game ‘Ademgenoot’ 2 there was no necessity to use the maintenance inhaler in the period they hardly felt any symptoms. Not experiencing symptoms or feeling “well enough” were reasons to not use their maintenance medication on a regular basis for the majority of the participants. Comparable results were seen in the online survey. Half of the participants agreed, or completely agreed with the statement “Asthma feels episodic to me”. Theme 2: Not wanting to feel like a patient Participants mentioned that using the inhaler made them feel like “a patient”. Two out of six participants mentioned that even filling in a symptom and asthma control questionnaires reminded them of “being a patient” and made them more conscious of their asthma, which they preferred to not be aware of. They explained that they rather “live in the moment” and not be reminded of having asthma. In line with these qualitative findings, 33.3% of the online survey participants strongly agreed with the statement “using my maintenance inhaler is not necessary when I feel well”. When asked how to deal with flare-up of symptoms, one interviewee answered that he would use the reliever inhaler more often, up to six times a day. Theme 3: Health and symptom burden as an important motivator to use a maintenance inhaler All participants experienced moments of worsening of their asthma. During these moments, all except one participant used their maintenance inhaler daily or occasionally. The increased burden of disease on everyday life activities was a reason to start using the maintenance inhaler after a period of non-adherence. For two participants, important sport performances, requiring optimal physical condition, were reasons to be medication adherent. During these periods of performance (e.g., an important hockey tournament) they were more consciously self-managing their asthma which meant using their maintenance inhaler daily (temporarily), stopping smoking and avoiding other triggers. Theme 4: (delayed) experienced effect of medication When discussing reasons why participants rather used the reliever medication, the fact that people did not feel an effect of maintenance medication but did feel the effect (i.e., being able to breath and feeling of relieve) of their reliever medication were the main reasons, as one participant explained: “I find it hard to feel the effect of the medication. I do notice it when I feel bad, but I don’t notice it when it goes well.” Another participant indicated that she found it difficult to distinguish between breathlessness as the result of asthma or ‘bad’ condition. Theme 5: Need for knowledge on inhaler differences Other reasons for not using the maintenance inhaler included participants’ limited
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