Predictors of Retention and Sustained Engagement With a 12-Month Asthma Self-Management App in Underserved Adults

Long-term retention and engagement with digital asthma self-management tools remain challenging in underserved adults. We examined predictors of study dropout and sustained engagement with ASTHMAXcel PRO, an asthma self-management mobile health app, over 12 months in an underserved adult population.

In this randomized controlled trial, adults with asthma who were on daily controller medications were recruited from 3 Bronx primary care clinics and randomized 1:1 to intervention (ASTHMAXcel PRO plus standard care) or control (standard care alone). Baseline questionnaires collected demographic, clinical (eg, asthma control, exacerbation history, and comorbidity), and health literacy data. Attrition was analyzed using Cox proportional hazards models. Engagement metrics in the intervention arm (logins, chapters read, and subject-reported outcomes) were evaluated with negative binomial mixed models, adjusting sequentially for sociodemographic and clinical covariates.

Among 99 participants (77% female; 97% non-White), 39 (39%) dropped out before the fourth study visit. Study dropout was associated with some college or technical education versus high school or less (hazard ratio [HR] 2.11, 95% CI 1.01-4.42, P = .048), assignment to the intervention versus control group (HR 2.11, 95% CI 1.05-4.24, P = .036), and the presence of at least 1 comorbidity (HR 2.14, 95% CI 1.12-4.09, P = .02). Engagement declined over time but was strongly predicted by higher early app use (logins incidence rate ratio [IRR] 40.95; chapters read IRR 7.23; subject-reported outcomes IRR 15.35; all P < .001). Higher educational attainment was also associated with greater sustained engagement across multiple metrics.

In this urban underserved cohort, comorbidities and some college/technical education predicted dropout, whereas greater early app use and higher education predicted sustained engagement. These findings highlight the importance of early identification of participants at risk of dropout to enable targeted retention strategies that support sustained self-management behaviors critical to asthma outcomes.