Usability, educational engagement, and patient-reported outcomes in a mobile asthma intervention

Mobile health tools offer scalable strategies for asthma self-management, but relationships between usability, engagement, and clinical outcomes remain unclear. We evaluated whether usability of ASTHMAXcel PRO, a mobile asthma education and self-management application, promotes educational engagement and whether early engagement predicts asthma outcomes. Adults with asthma on daily controller therapy from three Bronx clinics participated in a 12-month study using ASTHMAXcel PRO in addition to usual care. Usability was assessed using the Questionnaire for User Interface Satisfaction (QUIS). Early engagement was measured during the first two months, with high educational engagement defined as the top quartile of chapters completed. Outcomes included asthma control (Asthma Control Test [ACT]), asthma-related quality of life (mini-Asthma Quality of Life Questionnaire [mini-AQLQ]), and composite asthma-related healthcare utilization. Associations were examined using mixed-effects, interaction, logistic, and mediation analyses adjusted for age, gender, and baseline outcome status. Among 44 participants (mean age 43.75 ± 14.07 years; 84.1% female; 95.5% non-White), higher usability was associated with greater early engagement (OR 2.39 per 1-SD increase, 95% CI 1.28–5.19, p = 0.01). ACT and mini-AQLQ improved over time. However, early engagement was not associated with differential improvements in either outcome. Baseline outcome status was the strongest predictor of longitudinal outcomes, and no mediation effects were observed. In this urban, high-burden cohort, usability predicted early engagement but not clinical benefit. Baseline outcome status remained the strongest predictor of longitudinal outcomes. These findings suggest that digital asthma interventions may require targeted, content-specific engagement strategies beyond usability alone to improve outcomes.