The search term was applied to six bibliographic databases (Ovid MEDLINE, PubMed, BioMed Central, ProQuest Computing, Web of Knowledge, and ACM Digital Library) including only English articles published between 2004 and October 2014. The search was conducted in the following steps.

We limited the search to English-language articles published between 2004 and October 2014. The search term was:

The primary reviewer evaluated the abstracts, titles, and index terms of all matching articles in the bibliographic databases where the search term was applied. Based on this preliminary review, all relevant articles were listed for potential inclusion.

In this step, the primary reviewer evaluated relevant articles in the preliminary list for final inclusion or exclusion based on their abstract, study type, and intervention focus with respect to the full set of priori inclusion and exclusion criteria.

Internal and cross-database duplicates were identified and removed from all included articles from Step II. Duplicates within each database were first identified and removed. Cross-database duplicates were then identified and removed through a manual consolidation process.

The complete published papers of all included articles were then reviewed, analyzed, and assessed thoroughly by two reviewers independently. The primary and secondary reviewers independently reviewed the complete content of the included articles to identify the applied theoretical frameworks, clinical guidelines, and assessment tools with the objective to answer the priori research questions. Findings and disagreements between the primary and secondary reviewers were resolved by in-depth discussions and through a consolidation process for each of the included articles.

The motive behind conducting this review was to answer the primary research question with respect to whether existing Internet-based interventions for asthma were founded on any behavioral-change theories. And if so, to what extent did these theoretical frameworks inform the design and evaluation of these interventions?

This review identified 17 out of 85 interventions (20%) where at least one model, framework, and/or construct of a behavioral change theory was applied. This implies that the majority of our reviewed interventions did not apply any documented behavioral change theory to inform the design of their interventions. This finding is consistent with what is reported in the literature. Theory-driven strategies for aiding individuals in changing or managing health behaviors are lacking [9].

As such, this review found that there are only a limited number of well-established behavioral change theories and models that were referenced and applied across multiple studies. In total, the reviewers were able to identify 10 behavioral change theories and models that were applied across multiple interventions versus 13 other theories and models that were only applied once within the context of a single study and/or intervention.

Table 1 provides a list of all applied theoretical frameworks and models that were identified across the 85 reviewed interventions.

In the following sections, the theoretical frameworks that were applied in more than three studies will be further analyzed and discussed.

In the past, computer and video games were perceived to be a waste of time and harmful in many aspects to those who play such games excessively, especially for the child and adolescent age groups [26,27]. Nevertheless, the advancement in audio-visual and telecommunication technologies has ignited a new era for today’s games. While the term “gamification” is still evolving, it could be defined as “the use of video game elements in non-gaming systems to improve user experience (UX) and user engagement” [28].

There is a growing body of evidence emphasizing the potential benefits of the social, health, and educational science behind computer games [29]. The potential application of computer games in the health domain was well addressed by the Games for Health projects. The project has defined a taxonomy to depict five main types of games used in health care: Preventative, Therapeutic, Assessment, Educational, and Informatics [27].

This review has shown that principles, concepts, and strategies of gamification were only applied in four studies. However, these four studies only targeted children up to 12 years old [13-16]. The reviewers could not cite any Internet-based asthma interventions employing gamification concepts for the adolescent or adults’ population groups.

In one study conducted in 2013, an online peer support group for asthmatic children used an existing commercial networking website, Club Penguin, to help asthmatic children deal with difficult situations in an engaging manner [14].

Another two studies reported the success of an award-winning program called “Okay With Asthma”, where an interactive digital story was developed and delivered online to support children with their asthma and psychosocial management strategies. This was done through leveraging and employing a novel behavioral model, the Biobehavioral Family Model [15,16].

The “Okay With Asthma” program successfully used the five factors (simulation interactivity, construct interactivity, immediacy, feedback, and goals) identified by the Norma Engaging Multimedia Design model to design its usability and feasibility testing approach [16,30].

As well, the Watch-Discover-Think-Act (WDTA) study [13] provided an applied example of how behavioral and motivation theories could be translated within the context of gamification. The WDTA program developed a game that walks through 18 real-life and four fantasy scenarios. The players, who are children with asthma, have to complete a set of tasks related to asthma self-management in order to progress across scenarios. Feedback is provided as a reinforcement of information for the children and their parents.

As depicted in Table 2, the reviewers were able to validate the translation steps of the behavioral change theoretical methods in the “Watch-Discover-Think-Act” [13] study against a number of other studies, such as the five factors of the Norma Engaging Multimedia Design model that were applied within the context of “Okay With Asthma” [16]. The correlation between the findings of those two different studies validates the impact and influence gamification theories and methods could have to increase patients’ motivation, self-efficacy, and engagement level within the context of Internet-based asthma interventions.

The Health Belief Model dates back to the 1950s, initially developed by Hochbaum (1958) and Rosenstock (1960), and then extended by Kirscht and Becker in 1974 [32]. The Health Belief Model is a theoretical framework that attempts to study and predict the individual’s health preferences and actions based on observed attitudes and personal beliefs. The model explains the individual’s motivation to take a health care-related action based on the following factors:

The Health Belief Model was applied in the context of providing individualized messages and communication with patients to promote self-efficacy and better patient engagement [10-12,17].

The Puff City program that was evaluated in six Detroit high schools and reported in four different studies [10-12,17] identified and evaluated three core behaviors: namely, controller medication adherence, rescue inhaler availability, and smoking cessation/reduction. In the event of a negative change in any of the three core behaviors, theory-based health messages and information on asthma control were sent to the patients to sustain their self-efficacy and asthma self-regulation [12].

In the literature, “tailoring” is defined as “…assessment and provision of feedback based on information that is known or hypothesized to be most relevant for each individual participant of a program” [11,34,35], and “…any combination of information or change strategies intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and have been derived from an individual assessment” [10,35].

A number of studies and interventions have pointed out the significance of identifying the resistant groups at earlier stages of the intervention. These groups are less motivated to change their behavior and take ownership in managing their asthma. The objective is to use “tailoring” as a means to apply behavioral change theories, such as the Transtheoretical Model and the Health Belief Model, to motivate those subgroups and achieve positive changes in their behaviors with respect to their self-efficacy and asthma management [10-13]. The reviewed studies have utilized “tailoring” to customize the communication and education strategies with the targeted resistant subgroup based on their beliefs, attitude, and personalized information.

The Transtheoretical Model promotes individuals to change their behaviors for a healthier lifestyle.

The review identified three different studies where the concepts of the Transtheoretical Model were applied in the methods’ design and patients’ assessment through the stages of the change [9,10,12,17].

The Asthma Management Demonstration Project was developed to manage the following four asthma-related behaviors for asthma patients among employees and students of Western Michigan University: monitoring peak flow measurements, accessing asthma services, using prescription asthma medications properly, and managing environmental triggers [9]. Based on concepts of Transtheoretical Model, the project developed transactional questioning to stage their asthma patients according to their readiness to change their asthma-related behavior [9].

The Web-based Puff City program has also applied concepts of Transtheoretical Model to motivate their patients to change three core asthma-related behaviors: controller medication adherence, rescue inhaler availability, and smoking cessation/reduction [10,12,17].

In response to our secondary research question, we found that the application and employment of clinical guidelines and assessment tools were more abundant than theoretical frameworks across the reviewed interventions. The review identified 30 out of 85 interventions (35%) where at least one documented clinical guideline was applied. In total, there were six clinical guidelines applied across the 30 identified interventions as listed in Table 3.

As such, the review identified 32 out of 85 interventions (38%) where at least one documented assessment tool was applied. In total, there were 21 assessment tools applied across the 32 identified interventions as listed in Table 4.

This review found that many guidelines and assessment tools were broadly adopted by a relatively large number of interventions, for example, the National Asthma Education and Prevention Program referenced across 15 (of the 85) interventions [10-12,16-18,20-22,37-42], the Global Initiative for Asthma (GINA) guidelines referenced across 13 interventions [43-55], and the Asthma Control Questionnaire referenced across 11 interventions [19,20,44,49,56-62].

With the aim to employ an evidence base to reduce asthma prevalence, morbidity, and mortality, the Global Initiative for Asthma (GINA) was launched in 1993 as a collaboration between the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the World Health Organization [72]. The GINA guidelines were referenced in 13 of the 85 reviewed interventions [43-55].

Another example of internationally applied asthma guidelines is the International Survey of Asthma and Allergies in Childhood (ISAAC) questionnaire. Established in 1991, the ISAAC guidelines aimed to investigate asthma in the pediatric population as a measure to control the increasing conditions on the global scale [73]. Items from the ISAAC guidelines were included in the Lung Health Survey in four of the reviewed interventions [11,12,55,68].

In response to the increasing asthma challenges in the United States, the National Asthma Education and Prevention Program (NAEPP) was initiated in March 1989 by the National Heart, Lung, and Blood Institute (NHLBI) [74]. This review has shown that the NAEPP guidelines were the most referenced asthma guidelines across all reviewed interventions as they were implemented in the design of 15 out of the 85 reviewed interventions [10-12,16-18,20-22,37-42].

This review identified a number of national clinical guidelines that were adopted and applied in a smaller number of interventions conducted at the national level, such as the British Guideline on the Management of Asthma [54], the Canadian Asthma Consensus Guidelines (CACG) [63], and the Air Quality Health Index (AQHI) in Canada, as well as the standardized checklist of the Dutch Asthma Foundation [57,59].

In addition to the national and international guidelines, the review also identified a number of children-specific guidelines such as the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) [43,50,52,53,57,61,67,68], International Survey of Asthma and Allergies in Childhood (ISAAC) questionnaire [11,12,55,68], the Eyberg Child Behavior Inventory (ECBI) [25], the Children’s Health Survey for Asthma (CHSA) by the American Academy of Pediatrics [70], and the Child Asthma Control Test (C-ACT) [52,53,68].