51 Design of the persuasive game ‘Ademgenoot’ 2 Ademgenoot as a fully functional prototype to assess its long-term usage, impact on inhaler usage, and the expected shift from external to internal motivation, and include people with limited (health)literacy (59). Long-term evaluation should in addition provide more understanding of the degree of adherence to the app to acquire the desired behaviour (60). Eventually, effectiveness on clinical outcomes (e.g., asthma control) and medication adherence should be evaluated by including considering study design appropriate for summative evaluation of eHealth interventions (e.g., step-wedged-design). While the involvement of healthcare professionals within this study ensured that Ademgenoot fits with care processes, feasibility in practice should also be assessed through pilot studies, taking into account the perspectives of patients, healthcare professionals in both first (i.e., general practitioners and practice nurses) and secondary care (i.e., respiratory physicians), and decision makers. Finally, considering that smart inhalers are a relatively new field of research, further research is needed to determine which patients would benefit the most from these programs (39). Hence, we encourage that studies into the effectiveness of smart asthma inhalers include patient characteristics (e.g., beliefs about medication and eHealth literacy) to gain insight into which smart inhaler programs benefit which patients based on these characteristics and reasons for non-adherence (57). Conclusion Combining a participatory user-centred design with behaviour change principles and persuasive game theory, we developed an innovative six-week challengebased persuasive game that was evaluated as user-friendly and useful and has the potential to increase motivation to be medication adherent. Active involvement of all stakeholders throughout the design process ensured that our solution does not only meet the end-users needs but is also technically, commercially, and practically feasible and has the potential to improve medication adherence among people with mild asthma and other chronic conditions in which non-adherence is a common challenge.
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