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Analysis of patterns of breathing over time may provide novel information on respiratory function and dysfunction. Devices that continuously record and analyze breathing rates may provide new options for the management of respiratory diseases. However, there is a lack of information about design characteristics that would make such devices user-friendly and suitable for this purpose.
Our aim was to determine key device attributes and user requirements for a wearable device to be used for long-term monitoring of breathing.
An online survey was conducted between June and July 2016. Participants were predominantly recruited via the Woolcock Institute of Medical Research database of volunteers, as well as staff and students. Information regarding the survey, a consent form, and a link to a Web-based questionnaire were sent to participants via email. All participants received an identical survey; those with doctor-diagnosed asthma completed an extra questionnaire on asthma control (Asthma Control Test). Survey responses were examined as a group using descriptive statistics. Responses were compared between those with and without asthma using the chi-square test.
The survey was completed by 134 participants (males: 39%, median age group: 50-59 years, asthma: 57%). Of those who completed the Asthma Control Test, 61% (47/77) had suboptimal asthma control. Of the 134 participants, 61.9% (83/134) would be willing to wear a device to monitor their breathing, in contrast to 6.7% (9/134) who would not. The remaining 31.3% (42/134) stated that their willingness depended on specific factors. Participants with asthma most commonly cited their asthma as motivation for using a wearable; the most common motivation for use in those without asthma was curiosity. More than 90% of total participants would use the device during the day, night, or both day and night. Design preferences among all users included a wrist watch (nominated by 92.5% [124/134] for both day and night use, out of four body sites), the ability to synchronize breathing data with a mobile phone or tablet (81.3%, 109/134), overnight power charging (33.6%, 45/134), and a cost of ≤Aus $100 (53.7%, 72/134).
We have explored the motivations and likelihood for adopting wearable technologies for the purpose of monitoring breathing and identified user preferences for key design features. We found participants were motivated to adopt a wearable breathing monitor irrespective of health status, though rationale for use differed between those with and without asthma. These findings will help inform the design of a user-acceptable wearable device that will facilitate its eventual uptake in both healthy and asthma populations.
Asthma is a serious public health problem affecting over 300 million people globally. Management challenges include the early prediction or warning of asthma attacks and optimizing the pharmaceutical management of the disease.
Monitoring of lung function over time is a widely accepted component of the assessment of asthma, both in clinical management of the disease as well as in research trials [
Several studies have investigated desirable features for a wearable device for health monitoring, from both a technical [
The purpose of this study is to (1) explore the reasons why participants with or without asthma would potentially adopt new technologies to monitor breathing over time, and (2) evaluate device-specific attributes that would meet the expectation of users within these two groups. We chose to additionally study healthy individuals, not only as a basis for comparison with those with asthma to identify those preferences that are specific to asthma, but also due to the increasing interest in personal health monitoring in the general population as evidenced by the uptake of wearable devices that measure activity and other physiological life signs.
An online survey was conducted between June and July 2016. A link to the survey was sent electronically to a subset (n=569) of the Woolcock Institute of Medical Research Volunteers Database based on the availability of a valid email address on record, as well as to staff and students at the Woolcock Institute. During the recruitment period, two rounds of recruitment emails were sent to the two lists, followed by a subsequent reminder email for each round. The Volunteers Database consists of members of the public who have previously given consent to be contacted about participation in research. The database comprises both healthy individuals (n=256) as well as those with asthma (n=1173). The exact number reached may differ due to constant additions or withdrawals from the database and the possibility of family members sharing a common email address. Inclusion criteria were (1) provision of informed consent, (2) completion of all responses, (3) no respiratory illness reported (for the healthy group), and (4) self-reported doctor’s diagnosis of asthma (for the asthma group). No incentives were offered for participation. The protocol for this study was approved by Northern Sydney Local Health District Human Research Ethics Committee (ethics approval #LNR/16/HAWKE99).
After clicking on the link to the survey, participants who provided informed consent proceeded to fill out an online questionnaire (see
The survey also included demographic questions such as age, gender, educational and socioeconomic status, and doctor-diagnosed health conditions. Those who reported having a doctor diagnosis of asthma completed the Asthma Control Test (ACT) [
Participant demographics were summarized using descriptive statistics. Results were compared between participants with self-reported doctor-diagnosed asthma versus those without asthma, using
In total, 156 participants responded but 2 did not provide informed consent and 20 failed to complete more than 50% of the survey and were omitted from analysis. Of the 134 participants who completed the survey (ie, 85.9% completion rate), 131 provided demographic information as shown in
A total of 61.2% (76/134) participants reported doctor-diagnosed asthma: mean (SD) ACT score was 17.4 (5.2). Nearly two-thirds (62%, 47/76) of these had suboptimal asthma control based on the ACT.
Participants demonstrated a high level of technology use: 88.8% (119/134) used a smart phone, 29.9% (40/134) used health monitoring devices such as a Fitbit, and a small percentage of participants used smart watches (5.2%, 7/134). Nearly two-thirds (59.7%, 80/134) used only one form of technology, 26.9% (36/134) used two forms of technology, and 3.0% (4/134) used three or more forms of technology. Examples of other specific technology or gadgets used were fitness trackers (11.9%, 16/134), tablet computers (11.9%, 16/134), music players (3.0%, 4/134), conventional mobile telephones (1.4%, 2/134), and electronic books (1.4%, 2/134). Only 8 participants (5.9%, 8/134) used no “other forms of technology or electronic gadgets”. Levels of technology use were similar in those with and without asthma.
Nearly two-thirds (61.9%, 83/134) of the total participants indicated that they would be willing to wear a device to monitor their breathing, 7.4% (10/134) would not, and the remaining 30.5% (41/134) stated that their willingness depended on specific factors, described later in this section. There were no significant differences in willingness to adopt a wearable device for monitoring breathing between the 40 participants who currently used health monitoring devices and the 94 who did not (
Regardless of whether or not they were willing to use a wearable, participants were asked to indicate one or more factors that would make them consider using a wearable. These are detailed in
Females were more likely to use the device to track breathing patterns during stress and meditation compared to men (16%, 15/92 vs 3%, 1/39;
The ability to track breathing patterns during stress and meditation was a more common rationale for device use in younger than older age groups: 18-39 (37%, 7/19), 30-39, (4%, 1/27), 40-49 (13%, 2/15), 50-59 (19%, 5/26), 60-69 (3%, 1/31), older than 70 (0%, 0/13);
A larger proportion of the 40 participants who already used a health monitoring device would wear one to monitor their breathing for their asthma or to track patterns during stress (48%, 19/40 for both), compared to those out of the 94 who did not currently use a device (29%, 27/94 for both;
Participants were asked to indicate whether any respiratory illnesses other than asthma were part of their motivation to wear a wearable. Only 8 reported that this was a motivating factor.
Participant demographic information for the wearable survey study, stratified by health status.
Characteristic | Total, n (%) (n=131)a | No asthma, n (%) (n=55)b | Asthma, n (%) (n=76)c | |
Gender: Male | 39 (29) | 22 (40) | 17 (22) | |
18-29 | 19 (15) | 14 (25) | 5 (7) | |
30-39 | 27 (20) | 13 (23) | 14 (18) | |
40-49 | 15 (11) | 8 (15) | 7 (9) | |
50-59 | 26 (20) | 6 (11) | 20 (26) | |
60-69 | 31 (24) | 6 (11) | 25 (33) | |
70+ | 13 (10) | 8 (15) | 5 (7) | |
ACT, mean (SD)d | — | — | 17.4 (5.2) | |
Secondary school | 21 (16) | 6 (11) | 15 (20) | |
Higher certificate or diploma | 30 (23) | 9 (16) | 21 (28) | |
Bachelor degree or higher | 79 (60) | 39 (71) | 40 (52) | |
Prefer not to say | 1 (1) | 1 (2) | 0 (0) | |
Socioeconomic status: Low SESf | 25 (19) | 9 (16) | 16 (32) | |
Employment, full or part time | 80 (63) | 36 (65) | 44 (61) | |
Employment, casual | 12 (10) | 7 (13) | 5 (7) | |
Currently unemployed | 34 (27) | 11 (20) | 23 (32) | |
˂$26,000 | 12 (9) | 4 (7) | 8 (11) | |
$26,000-$51,999 | 20 (15) | 8 (15) | 12 (16) | |
$52,000-$72,799 | 19 (14) | 9 (16) | 10 (13) | |
$72,800-$103,999 | 21 (16) | 6 (11) | 15 (20) | |
$104,000-$155,999 | 9 (7) | 3 (5) | 6 (8) | |
≥$156,000 | 23 (18) | 15 (27) | 8 (11) | |
Prefer not to say | 27 (21) | 10 (18) | 17 (21) | |
Language other than English spoken at home | 19 (15) | 11 (20) | 8 (11) |
a131/134 participants who completed a survey provided demographic data.
b55/57 participants who did not have doctor-diagnosed asthma provided demographic data.
c76/77 participants who had doctor-diagnosed asthma provided demographic data.
dA score of ≤19 indicates suboptimal asthma control.
e1/131 participants who provided demographic data did not report their education status.
fSocially disadvantaged at patient’s home address: “Disadvantaged” Socio-Economic Indexes For Area (SEIFA) quintile <3, “Advantaged” SEIFA quintile: 4-5 [
g2/131 participants who provided demographic data did not provide employment information; “Currently unemployed” includes unpaid or volunteer work, engagement in home duties, or not being in the labor force.
h27/131 participants who provided demographic data did not provide household income information.
User motivation for those willing to use a wearable device, stratified by self-reported, doctor-diagnosed asthma status.
When we restricted our analyses to the subgroup of those willing to use a wearable device only (61.9%, 83/134), the most common motivating factor to wear a device for those without asthma was “curiosity” (59%, 17/29;
In this subgroup (6.7%, 9/134), those without asthma stated they would not wear a device because they did not understand why monitoring breathing was important (eg, “I can’t see a reason why I would want to monitor my breathing”).
The reasons for not using the device in the four participants with asthma were that they felt their asthma was under control (eg, “Asthma is under control,” “I don’t get bad asthma attacks, just slight, not worth the bother”), or due to travel or cost (“I am overseas at this time,” “Such devices are too expensive”).
In this subgroup (31.3%, 42/134), 19 had asthma and 23 did not. The most common motivating factor for wearing a device in people with asthma was “I have asthma” (83%, 14/19;
The factors affecting wearability mentioned across all participants included design issues and user perception issues. In terms of design, the physical size, location, weight, and bulk of the device were common concerns. Related to these were user perception issues, such as comfort and inhibition of movement, discreetness, and how the device would be fitted to the body. Example of factors provided were “how comfortable and discrete the device is,” “how it’s worn,” “size ‒ would it inhibit normal movements and is it 24/7?”
All participants were asked to select which factors would cause them to consider a wearable device unappealing (
Unappealing factors for wearing a device, stratified by self-reported, doctor-diagnosed asthma.
The device-specific features were themed into five different categories: wearability, cost, power features, display, and data synchronization. All 134 survey participants completed this section. In general, there were no differences between those who were current users of health monitoring devices and those who were not, in preference for form factor, length of usage, cost, display or data storage time preferences, unless otherwise indicated below.
A majority (94.0%, 126/134) of respondents (with or without asthma) would use a wearable device during the day, night, or both day and night. Most users preferred to wear the device 5 nights/days a week or more (
Furthermore, those with asthma said they would wear the device more often than those without asthma during both the night and day: 82% (63/77) with asthma versus 46% (26/57) without asthma would wear the device 5 days or more a week;
Frequency of daytime and nighttime use was higher in older people. For example, older participants predicted they were more likely to wear the device 5 days a week or more during the night: 18-39 (37%, 7/19), 30-39, (59%, 16/27), 40-49 (53%, 8/15), 50-59 (81%, 21/26), 60-69 (74%, 23/31), older than 70 (77%, 10/13);
There was a clear preference for a wrist band over other formats such as earbuds, and preferences were similar for day versus nighttime use (
Total participant preference for how often the device is to be worn, separated by day and night use.
Total participant preference for the form of the device to be worn, separated by day and night use.
Over half (53.7%, 72/134) of the total participants would be happy to pay up to Aus $100 for a wearable respiratory monitor, 20.8% (28/134) would pay over Aus $100, and the remaining 25.3% (34/134) would use it only “if it were free.” No statistically significant differences were observed in responses by health status, different household income, age, or gender.
The most popular waiting time for the device to charge was overnight (45/134, 33.6%) as opposed to within 2 hours (22.3%, 30/134), 1 hour (23.1%, 31/134), 30 minutes (11.1%, 15/134), or other (10.4%, 14/134). Charging time did not appear to be a critical factor in user preferences, with other responses provided as: “As long as it takes. Good if the recharging was no more than 2 hours” or “However long it took to charge.” No differences were observed between those with or without asthma.
Participants selected between the three different displays shown in
Participants indicated that they would like to receive alerts when their breathing was problematic. Alerts were more popular in those with asthma than those without asthma: 79% (61/77) versus 63% (36/57);
The majority of participants (79.8%, 107/134) reported wanting to sync the device to their phone/tablet. The proportion was higher among those who already use a monitoring device (93%, 37/40). Less than half (45.5%, 61/134) wanted to sync the device with their computer. Those who selected “other” responded with “remote analysis and syncing with my GPs office,” “sync with sleep study,” or “cloud service.” Younger participants were more likely to report wanting to sync their breathing data (number of breaths per minute) with a phone or tablet than older participants: 18-39 (100%, 19/19), 30-39 (100%, 27/27), 40-49 (87%, 13/15), 50-59 (77%, 20/26), 60-69 (68%, 21/31), older than 70 (54%, 7/13);
The majority of participants reported wanting to save their data for at least 1 week (58.9%, 79/134).
A display of breathing data by numerical information (left), bar graph (middle), and line graph (right).
In this survey, we identified a number of reasons to adopt new technologies to monitor breathing in participants with or without asthma. In participants without asthma, the main factor that influenced motivation for using a wearable was curiosity. The ability to track breathing patterns during stress or meditation and fitness tracking were motivational factors for younger participants. In asthma, the main motivations for use were “having asthma” and the ability to track breathing patterns during periods of breathlessness. We found that most users were willing to wear the device continuously both day and night and that the most preferred device format was a wrist band, regardless of health status. Other desired features were alerts when breathing is problematic (for both asthma and non-asthma groups), the ability to synchronize data with a phone or tablet, a recharging period of every 24 hours, and cost of≤Aus $100.
Previous studies have found that perceived value has a significant influence on both potential and actual customers, with perceived value as an important factor influencing the consumer’s decision to adopt new products or services [
As might be anticipated, motivation for using a wearable device in asthma was different to those without asthma. In people with asthma, there appeared to be a desire to use breathing monitoring to gain greater control over the management of their asthma, particularly during episodes of breathlessness. An episode of extreme breathlessness during a respiratory exacerbation is often extremely frightening to both patients and their family members [
Patients are known to employ a number of strategies to cope with breathlessness episodes, including breathing techniques and reduction of physical exertion [
The observed difference in the rationales for using a breathing monitoring device between participants with and without asthma indicates the need to collect separate data on the motivation for use and the utility and feasibility of wearables (for breathing or other purposes), in people with and without (different) health conditions. Conversely, the rationale for choosing not to adopt a wearable device for breathing monitoring was similar between those with and without asthma. The main reason given was a lack of perceived purpose or need for such a device, for example, because asthma was already “under control.” Indeed, there is a lack of direct evidence showing that the ambulatory monitoring of breathing patterns over time is useful for asthma. This is despite the disease being characterized by shortness of breath. However, indirect support comes from measurements made using breathing-based lung function tests [
To the best of our knowledge, this is the first time user preferences for a wearable device aimed at respiratory health monitoring have been investigated. This is important as desired design features often come at a technical cost. The results of this study inform us which features are of high value and which features could be compromised in exchange for technical tradeoffs. Furthermore, acceptance of a new technology may be affected by the perceived risk or inconvenience posed by the device. Previous research suggests that factors such as wearability design, physical size, location, weight, and bulk may negatively impact perceived device value. Costly and complicated recording devices may result in low compliance [
There are little data available to suggest what constitutes acceptable levels for these features and for human factors in a breathing monitor wearable. In this study, we found significant user perception issues around comfort and inhibition of movement, discreetness, and where the device fits on the body. Our study also revealed that more than 90% of participants would wear the device both day and night, and more than 90% preferred a wrist-worn device. Comfort and frequency of use are likely to interact, with more comfortable devices used for longer.
Most users preferred a wrist band over other formats for site of monitoring; however, this may have been influenced by the type of devices most commonly available on the market at the time. We note that chest bands and ear buds were also identified as next preferred formats for monitoring and may have been selected by participants with existing exposure. Device design choice needs to be made in terms of both user acceptability as well as signal quality. Further study is required to determine the relative feasibility and accuracy in obtaining the breathing signal from these various sites. We did not find significant differences between health groups and their device form preferences.
We found that young participants were more likely to use the device for exercise, but we do not know the reasons why older people were less likely to use such technology for exercise. This could be due to overall lower exercise rates in older people or to less engagement or familiarity with exercise tracking.
Cost can be a barrier to the uptake of monitoring devices, but more than half of our participants would be happy to pay up to Aus $100 (approximately US $80) for a wearable that tracks breathing rate. At this price point, such a breathing wearable would be comparable to lower end activity trackers currently on the market and would require a simple design. While creation of a wearable is feasible at this price point, sacrifices in both reliability and comfort may arise. One area of cost reduction could be eliminating a display from the wearable. Any display could be viewed on an external screen such as a mobile phone, while alerts could be processed locally on the device.
Another consideration is device battery life, that is, power consumption must be carefully managed as a small form factor places constraints on battery life [
Given the user requirement for data synchronization and data storage, it is recommended that any wearable device should primarily capture and store data. Data transmission to a mobile phone or tablet can take place secondarily by participant demand or when local device storage is full. Any advanced data processing should also take place post transmission.
User security or privacy could potentially be compromised by continuous monitoring [
There are factors limiting the applicability of our findings. The first relates to whether the sample was representative of the population in general. There was a relatively high level of technology use over the population sampled, though only a third of participants were specifically current users of health monitoring devices. Also, 60% had a university education, a high percentage of respondents were female, and the ages of the study sample were not normally distributed. Although we measured educational level, we did not measure the health literacy of the participants, which may have impacted their responses to the survey. These demographics may not be representative of the general population, and there may have been a selection bias in those who chose to complete the survey (eg, 24% of those invited from the volunteers database agreed to participate). While we acknowledge there is a potentially high selection bias in those who chose to complete the survey towards those who were already motivated to adopt a wearable, the primary aims of the survey included determining specific user motivation and their preferences for usage and features they wish to have in such a wearable. The population captured was arguably the most appropriate to answer those questions.
Second, while we were able to show differences in the survey responses of those with and without asthma, people without asthma were younger than those with asthma, making it difficult to disentangle the effects of age and disease status. There is some suggestion that older users are more ready to adopt health-related technologies, but the reasons for this require further investigation [
Third, display preferences were examined in a rudimentary manner in this survey, to determine whether graphical displays were preferred over text. Furthermore, we did not assess in detail whether participants understood how the information was presented, for example, by asking whether they thought the display indicated that their breathing was stable. Once wearable technology is established to measure breathing over time, another study to determine a suitable display of information from the participant’s perspective should be explored.
Finally, we did not collect data on whether those who used other health monitoring devices were current or former users, or the reasons for discontinuation of use. Information on how long and why people stay engaged beyond curiosity would have provided major insight into user psychology as well as device development.
We have explored the motivations for, and the likelihood of, adopting wearable technology for the purpose of breathing monitoring and identified user preferences for key design features. We found participants were motivated to adopt a wearable breathing monitor regardless of health status, yet there were distinctly different rationales for use between those with and without asthma. There is a clear need to identify the benefits of monitoring breathing in health and asthma. Next steps will require the development and testing of reliable breathing metrics or indicators that can be safely used by people with asthma for monitoring breathing over time or that assist in the identification of symptom worsening and asthma exacerbations. These findings will help inform the design of a user-acceptable wearable device that will facilitate its eventual uptake in both healthy and asthma populations.
Online questionnaire.
Asthma Control Test
The authors acknowledge the role of the Google Impact Challenge Grant, which provided seed funding for the greater study. We also acknowledge the role of Michele Goldman of Asthma Australia in co-development of the proposal leading to the seed funding.
JBP was partially funded by an Australian Postgraduate Award and a philanthropic Google Grant, of which PMY and ET were primary investigators in collaboration with Asthma Australia. In the last 3 years, the Woolcock Institute of Medical Research has received independent research funding from AstraZeneca and GlaxoSmithKline for asthma research carried out by JMF.