This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.
Mobile health (mHealth) apps hold great potential for asthma self-management. Data on the suitability of asthma apps intended for children are insufficient, and the availability of German language apps is still inadequate compared with English language apps.
This study aims to identify functional asthma apps for children in German and to compare them with English language apps. In line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the Google Play Store and Apple App Store are systematically searched to preselect the most efficient apps, which are then compared according to a self-compiled criteria catalog.
Both app stores were screened for the term
A total of 403 apps were identified on the Google Play Store and the Apple App Store. Finally, 24 apps that met the inclusion criteria were analyzed. In the first step of the quality assessment, only 4 available German language asthma apps were compared with 20 English language asthma apps. The 4 German language apps were then compared with the 4 highest rated English language apps. All selected apps, independent of the language, were comparable in the following categories:
The recommended English language apps are
Asthma is the most common chronic disease in childhood, affecting 1 in 12 children. According to the World Health Organization, approximately 339 million [
A systemic analysis by Farzandipour et al [
The use of apps has increased significantly in recent years and, accordingly, the use of medical apps. By 2020, the number of smartphone users worldwide is expected to reach 6.1 billion or 80% of the world’s population [
In Germany, more than 11 million minors are aged <14 years [
Therefore, this study aims to identify functional asthma apps in German and to compare them with English language apps. In a 3-step system, the
Two of the world’s leading mobile app platforms, the Google Play Store and Apple App Store, were used for the search. The preselection process following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (
The term
As shown in
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of app assessment. After applying the exclusion criteria, 27 apps were primarily included. Of these, 17 were available in both stores, 4 in the Apple App Store (depicted as n1), and 6 in the Google Play Store (depicted as n2). As 1 app (AsthmaXcel) had 4 different variants, it was considered as one single app, resulting in 24 apps for the final analysis.
After the preselection process, all remaining apps that met the inclusion criteria were downloaded, and their functions were evaluated by 3 independent persons following a self-compiled criteria catalog. These 3 raters tested the apps independently and without any conflicts of interest.
For an objective analysis, testing was performed following the same procedure. A private email address and contact details were used for logging in, when required, to access the functions of the apps. For a realistic approach, any minor age was selected, and, if necessary, realistic, arbitrary values about personal measurements and other data were selected.
In total, 2 test dummies (
A total of 27 apps meeting the inclusion and exclusion criteria, suitable for use by children and adolescents, were selected for evaluation and representative comparison of their quality. The
On authorization for this study, quality assessment was carried out by the 3 independent testers according to a criteria catalog consisting of 9 categories, some conceived for this purpose and some adopted from existing validated catalogs (
As there are no official criteria for evaluating apps, particularly for asthma apps for children, the authors designed some specifically intended to assess apps’ suitability for children and integrated them with existing standards. The child-friendliness of an app was determined based on the provider’s recommendations, the design (visual incentives for children to use the app), the range of functions (games and understandable information about asthma), engagement creation (through a reward or score system and entertaining features for children), usability (by the child alone or with parental support), and the general impression of the app. The test dummies were created to simulate a child using an app as accurately as possible (
The category
For the criteria catalog, we used a point system. Apps matching 8 categories were assigned a value between 1 and 5; those matching 1 category (availability) could score either 1 or 2 points, as illustrated in
All 24 apps (4 versions of
A total of 3 testers individually assessed the apps and then determined the mean value of points both cumulatively and in the single categories.
Therefore, apps were ranked according to the average of the total points of the 3 testers and the point system, with a maximum of 42 points. Statistical calculations on the same number of highest-ranking German and English language apps compared the quality of the apps. As only 4 of all eligible apps were in German, these were compared with the 4 highest ranked English language apps.
The quantitative comparison between German and English language apps considered the corresponding offers on the Google Play Store and Apple App Store. The analysis was performed using Microsoft Excel and IBM SPSS Statistics 25.0. Descriptive statistics were used to calculate and compare the results. For normally distributed results, the mean was calculated with SD, and for nonnormally distributed results, the median was determined between the maximum and minimum values. Normal distribution was tested using the Shapiro-Wilk test and confirmed for total points and all categories except
In total, 403 apps were identified under the term
Of these 24 apps, 20 (83%) were available in English but not in German, and 4 (17%) apps were available in both German and English. None of the apps were available only in German.
The most common exclusion criterion was the lack of pertinence to the topic, although it was listed under the term asthma. The reasons for exclusion are listed in
Exclusion criteria for the asthma apps.
Exclusion criteria | Google Play Store (n=215), n (%) | Apple App Store (n=144), n (%) |
Lack of pertinence | 123 (57.2) | 52 (36.1) |
Alternative treatment methods | 22 (10.2) | 13 (9.0) |
Language | 14 (6.5) | 2 (1.4) |
Cost | 8 (3.7) | 11 (7.6) |
Intended for medical staff | 20 (9.3) | 17 (11.8) |
Intended for parents | 6 (2.8) | 6 (4.2) |
Impossible download, registration, or use | 11 (5.1) | 8 (5.5) |
Medical device or specific product required | 8 (3.7) | 16 (11.1) |
Asthma forum | 0 (0) | 1 (0.7) |
Limited functions in some areas | 3 (1.4) | 6 (4.1) |
Intended for adults | 0 (0) | 12 (8.3) |
All 24 apps that met the inclusion and exclusion criteria were rated by the 3 app testers. Average single category point values and total points were calculated (
Average of the 3 testers’ evaluation (individual categories and overall points of English and German language apps).
App | Categoriesa | ||||||||||
|
Language | Availability | Functionality and design | Ease of use | Potential for improving asthma self-management | Child-friendly | Fun factor and incentives | Learning factor | Information management and medical accuracy | Range of function | Total |
Maximum points | —b | 2.0 | 5.0 | 5.0 | 5.0 | 5.0 | 5.0 | 5.0 | 5.0 | 5.0 | 42.0 |
KmAsthma | English | 2.0 | 5.0 | 5.0 | 4.0 | 3.3 | 3.0 | 4.7 | 4.3 | 4.7 | 36.0 |
AsthmaXcel | English | 2.0 | 4.0 | 4.3 | 3.3 | 4.7 | 3.3 | 5.0 | 4.0 | 4.0 | 34.6 |
Asthma Australia | English | 2.0 | 4.7 | 3.7 | 3.0 | 5.0 | 2.3 | 4.7 | 3.7 | 4.3 | 33.4 |
Ask Me, AsthMe! | English | 2.0 | 5.0 | 4.7 | 4.0 | 4.3 | 2.0 | 4.0 | 3.7 | 3.7 | 33.4 |
AsthmaMD | English | 2.0 | 4.7 | 5.0 | 3.3 | 3.0 | 2.0 | 4.3 | 4.7 | 4.0 | 33.0 |
Elfy | English | 2.0 | 4.7 | 4.7 | 2.3 | 3.3 | 1.0 | 4.0 | 4.0 | 3.3 | 29.3 |
Kata | German and English | 2.0 | 5.0 | 3.7 | 3.0 | 2.0 | 1.0 | 2.3 | 5.0 | 3.3 | 27.3 |
Wizdypets | English | 2.0 | 3.7 | 3.3 | 2.3 | 5.0 | 3.0 | 3.0 | 2.3 | 2.3 | 26.9 |
Asthmadodge | English | 2.0 | 3.3 | 2.7 | 1.7 | 5.0 | 2.3 | 3.3 | 2.7 | 2.7 | 25.7 |
Asthma Eclub | English | 1.0c | 3.3 | 3.0 | 2.0 | 4.3 | 1.0 | 4.7 | 3.7 | 2.3 | 25.3 |
SaniQ | German and English | 2.0 | 4.0 | 4.3 | 1.7 | 2.3 | 1.3 | 1.7 | 3.3 | 3.0 | 23.6 |
Asthma Tracker | German and English | 2.0 | 3.3 | 3.7 | 1.7 | 2.0 | 1.0 | 1.0 | 3.3 | 2.7 | 20.7 |
Breathcount | English | 1.0d | 4.3 | 3.7 | 1.7 | 2.3 | 1.3 | 1.7 | 2.7 | 1.7 | 20.4 |
Allergymonitor | German and English | 2.0 | 3.0 | 3.3 | 1.0 | 2.7 | 1.0 | 2.3 | 2.7 | 2.0 | 20.0 |
Rightbreath | English | 1.0c | 3.0 | 3.0 | 1.7 | 2.0 | 1.0 | 3.0 | 2.7 | 2.3 | 19.7 |
InhalerCounter | English | 1.0c | 3.7 | 3.7 | 1.7 | 1.7 | 1.0 | 1.7 | 2.3 | 2.7 | 19.5 |
AsthmaActionhero | English | 1.0c | 3.7 | 3.0 | 1.0 | 4.0 | 1.0 | 1.7 | 2.3 | 1.7 | 19.4 |
ASTHMA | English | 1.0c | 3.7 | 3.3 | 1.7 | 2.3 | 1.0 | 2.0 | 1.7 | 2.0 | 18.7 |
Asthma:Management | English | 1.0d | 1.7 | 3.3 | 1.7 | 1.7 | 1.0 | 3.0 | 2.7 | 1.7 | 17.8 |
mypeakflow | English | 1.0d | 3.3 | 2.7 | 1.3 | 1.7 | 1.0 | 1.7 | 3.0 | 1.7 | 17.4 |
Inhaler | English | 1.0d | 1.7 | 2.0 | 1.0 | 2.7 | 1.0 | 2.3 | 3.0 | 1.7 | 16.4 |
Peak Flow | English | 1.0d | 3.3 | 2.0 | 1.7 | 1.7 | 1.0 | 1.3 | 2.7 | 1.7 | 16.4 |
Asthma | English | 1.0d | 2.3 | 2.0 | 1.3 | 1.7 | 1.0 | 2.7 | 2.3 | 2.0 | 16.3 |
Inhaler diary | English | 1.0d | 2.7 | 2.3 | 1.0 | 1.3 | 1.0 | 1.3 | 2.0 | 1.3 | 14.0 |
aAverage points of the 3 testers presented with one decimal.
bCells do not add points to the scoring system but reflect the available language (English or German) and the score provided at the end after applying the total points.
cApple.
dAndroid.
The best rated apps (
Quality was evaluated and compared according to the points assigned cumulatively and in single categories of the criteria catalog (
SaniQ Asthma
Asthma Tracker
Kata
AllergyMonitor
Kiss my asthma (KmAsthma)
AsthmaXcel
Asthma Australia
Ask Me, AsthMe!
As all 4 English language apps and 4 German language apps were available on the Google Play Store and the Apple App Store, they were awarded a maximum score of 2 points (median 2, minimum 2, and maximum 2) without showing any differences.
For the evaluation of this category, the
The
Evaluation for this category was carried out with the help of the “Exemplary rating criteria for behavior change techniques in mHealth asthma apps” according to Abraham and Michie [
On the basis of the points achieved, 5 classes were conceived to align the rating in this category with the alternative 1-5-point system. None of the apps were awarded 5 points in this category. The apps
The results diverged widely in this category. Only the English language app
This category was assessed using the “Exemplary rating criteria for gamification components in mHealth asthma apps” according to Thiebes et al [
The average of all 8 apps was only 1.87 (SD 0.88). Although 3 of the 4 German language apps received only 1 point, with a mean value of 1.075 (SD 0.13), the mean value of the English language apps was 2.67 (SD 0.53), indicating a significant difference between the 2 language groups (
Only
The accuracy of medical content is undoubtedly crucial [
As none of the apps incorporated all the beneficial functions (general asthma information, games, diary, medication reminder, and pollen calendar), none of them achieved the highest score. The gaming app
The broadest array of functions was offered by the apps
The mean value of the 8 apps in this category was 3.46 (SD 0.82). The mean value of the English language apps was 4.16 (SD 0.37), and the mean value of the German language apps was 2.75 (SD 0.49). The difference in points achieved between the 2 language groups was significant (
The evaluation of the quality of the apps using the criteria catalog determined that the English language asthma apps performed significantly better than the German language apps (
Total score of English and German language apps.
Rank | App | Language | Points, mean (SD) |
1 |
|
English | 36.00 (0.82) |
2 |
|
English | 34.00 (1.41) |
3 |
|
English | 33.33 (1.25) |
4 |
|
English | 33.33 (1.25) |
5 |
|
German | 27.33 (0.94) |
6 |
|
German | 23.67 (1.25) |
7 |
|
German | 20.67 (4.03) |
8 |
|
German | 20.00 (2.94) |
The mean value of all the 8 apps was 28.54 points (SD 6.03). The average of the 4 English language apps was 34.165 points (SD 1.09). The average of the 4 German language apps was 22.91 points (SD 2.898). All English language apps ranked above the overall mean, whereas German language apps were below that value. The difference in the total number of points in the criteria catalog between German and English language apps was highly significant (
This study aims to identify the quality and quantity of mHealth apps for English- and German-speaking children with bronchial asthma. Our analysis and evaluation following a criteria catalog that was in part self-compiled and in part applying analysis scores for mHealth apps [
This study is the first to compare German and English language asthma apps for children and adolescents, and generally, little information exists about asthma apps dedicated to these age groups or, more specifically, about apps developed in German. The assortment of asthma apps on the Google Play Store and Apple App Store is large, but only a few are child-friendly, and providing comprehensive medical recommendations remains a difficult task, as none of the available options integrate all the necessary functions. As other studies also underlined, asthma self-management requires a combination of at least two apps to access all features [
Children with high-risk asthma seem to be inclined to use asthma apps [
However, mHealth apps are not suitable for all patient groups. Not all families might have the financial means of purchasing a smartphone for their children. Social and language barriers may hinder the use of mHealth apps. These patient groups will benefit from continuing to use conventional, manually recorded asthma diaries.
The approach to using the apps typically differs depending on age group. Primary school children will prefer playful apps that can significantly nurture their enthusiasm and motivation to learn. For instance,
Studies conducted on numerous diseases have already confirmed the potential of apps to support self-management and be instrumental in the treatment plan [
Considering the growing mHealth apps market in German-speaking countries, a German version of the
Some studies have also evaluated the quality of asthma apps and issued recommendations for the use of suitable asthma apps [
Although app evaluation followed objective criteria, the ratings in each category were determined by 3 persons, thus the likelihood of a biased perspective. Moreover, apps were used over a limited period, and potential updates or apps issued after the completion of this study were not included. Four apps for each language were selected as the most suitable for quality comparison; however, as the array of apps for German speakers was limited, apps in German in addition to English were included in this group.
As asthma is a disease that affects all social classes worldwide, only free-of-charge apps were included in the evaluation. This choice represents a limitation because a free app typically does not have a full range of functions and a corresponding technical implementation.
As not all apps indicate an age limit, the app provider recommendation was used to select the apps. As adolescents are considered to be children up to the age of 17 years, all apps that are not explicitly labeled as intended for adults were included. Another limiting factor is that teenagers’ preferences tend to be closer to those of adults’ preferences. Hence, the apps were rated based on their suitability for toddlers and school-aged children.
As not every app offers an asthma diary with the entry of peak flow values, the diary feature was not defined as a separate category, and warnings for out-of-range values were not tested. This aspect was included as a question in the
Every German language app in this study is also available in English.
The use of apps plays an increasingly important role in patients’ lives and in the medical field, making mHealth a staple in the future of asthma treatment plans. Although validated recommendations on rating mHealth apps have been published, it remains a challenging task for physicians and patients to choose a suitable app for each case, especially in non–English-speaking countries. Hence, further studies are required on this topic. In addition, developers should address the necessary features’ improvements to allow a more efficient use of this tool in the future.
Inclusion and exclusion criteria or identification of suitable asthma apps.
Test dummies for preschoolers and teenagers.
Criteria catalog for each category and its description and rating.
Single test results of each rater.
mobile health
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
None declared.