Patient education and learning is well established as a core component of care for people with chronic respiratory disease ^[1][3]. Learning is considered to be the acquisition of new knowledge, practical skills, and attitudes, and in the context of healthcare, this is usually to support or educate a person to become more independent with the management of their health condition. Learning underpins the end goal of a person with a health condition changing their everyday activities and behaviours for successful health outcomes. This is often termed patient self-management. Specifically, patient education is the activity of supporting a person with chronic respiratory disease to learn information and psychomotor skills and shift their attitudes toward living a healthier life such as regular exercise, monitoring of symptoms, and adherence with medication routines. Patient education can be in the form of a formal structured activity or informal patient encounter, which leads to a conversation or coaching around a specific aspect of the patient’s condition and/or management. In using technology for patient education, there are two main approaches: synchronous and asynchronous. Synchronous “learning and teaching” occurs when the patient is online at the same time as the healthcare provider and/or their peers and interactive discussions around a topic takes place, for example live sessions online with healthcare providers using video conferencing. Asynchronous “learning and teaching” occurs when the patient accesses learning materials available to them online at a time convenient to them. This is the most common method of learning online for patients through websites and mobile apps on smart devices such as smart phones and tablets. Static material is usually presented in the form of written information and/or videos, with accompanying interactive tasks such as uploading self-monitoring data or completing quizzes or health questionnaires to understand impact of condition on health status [2]. Asynchronous learning can also be in the form of written communications for discussion and application of knowledge that the patient accesses at a convenient time to them.

2. Impact of Technology-Enabled Patient Education

2.1. User Satisfaction with Technology-Enabled Patient Education

For all studies that measured patient satisfaction, technology-enabled patient education was a positive experience by the majority of participants. The majority of participants would recommend the technology-enabled patient education to peers, finding the web-based and application-based education kept them motivated, was easy to use, and was relevant and perceived their knowledge and skills to have improved ^{[3][4][5][6][7][8][9][10][11]}[5,6,9,12,14,15,16,21,23]. Participants also found that the technology solution meant the information was always readily available and not able to be misplaced, and this was very helpful ^[4][6]. Programme content was well received for all approaches, with participants providing feedback that the symptom management, exercise/physical activity, inhaler, and healthy diet learning was most useful across studies ^[7][14]. Where technology was used to synchronously connect with healthcare professionals, most participants found this to save time and a welcomed approach ^[6][12]. Discussion forums with peers were met with varied enthusiasm, with some studies reporting patients contacted peers readily ^[12][7] and other authors stating 75% of participants were not interested ^[13][11]. Although, when there was a comparison educational experience not using technology, the satisfaction score was not greater in the technology-enabled model ^[7][14].

2.2. Gain of Skills and Knowledge

A significant increase in measuring learning outcomes has occurred in the last decade with 6 of the 13 studies evaluating gain of skills, knowledge, and attitudes. In adults, technology-enabled patient education showed an increased disease specific knowledge ^[6][10][12,21] and inhaler technique improved ^[14][13]. The perception of coping with the condition also increased ^[6][12]. Although not all studies found increases, Robinson et al. (2021) reported no change in COPD knowledge ^[13][11]. The review by Drummond et al. (2016) showed mixed results in the acquisition of asthma knowledge when comparing the use of computer games for children with other educational modes, but all studies examined found an improvement pre-post ^[8][15].

2.3. Behavioural Change

Self-care, medication adherence, and physical activity levels were the three key behaviour changes that were found to improve significantly following technology-enabled patient education for people with chronic respiratory conditions ^[13][7][8][11,14,15]. Because only three studies examined behaviour change following technology-enabled patient education for people with chronic respiratory conditions, confidence in effect is limited. This is an area that requires further investigation to understand how learning translates to changed behaviour and then in turn improved health outcomes. Further, no studies examined the maintenance of behaviour longer term. All measures were pre-post intervention, with limited understanding of whether people continued to access the technology-enabled education to remind themselves and maintain their health behaviours in the longer term.

2.4. Improved Health Outcomes

As has been observed in studies of face-to-face patient education for chronic respiratory diseases ^[15][16][24,25], the impact of technology-enabled patient education on health outcomes is variable. Pulmonary function, quality of life, exercise capacity, anxiety and depression, and healthcare use were examined across the studies. Many studies found significantly improved health-related quality of life, suggesting that technology-enabled patient education for people with chronic respiratory disease has an impact ^{[4][12][17][18][9]}[6,7,8,10,16] Healthcare use, measured as prescribed medication use, unplanned physician/nurse visits, emergency hospital presentations, and hospital admissions, was also found to be significantly lower following the participants involvement in technology-enabled patient education in two studies ^[18][14][10,13] but not in the other two studies that measured hospitalisations ^[8][11][15,23]. A proportion of studies found a significant difference in lung function, exercise capacity, or symptoms ^{[13][14][7][8]}[11,13,14,15]. These findings align with aforementioned systematic reviews of face-to-face disease specific chronic respiratory education ^[15][16][24,25], although, a meta-analysis of technology-enabled patient education studies with a rigorous systematic review is needed to confirm this finding. Technology-enabled patient educational programs with greater interactive activities, where the participant uploaded information, appeared to have significant positive impacts on health outcomes—more so than those focussed on information delivery.

2.5. Links between Levels of Impact

The study by Robinson et al. ^[11][23] demonstrated that the positive patient experience did not specifically lead to increased knowledge in COPD when compared to usual care (knowledge increased in both groups). The intervention group did change their behaviours, with greater daily step counts, but this did not lead to significant differences in the health outcomes including exercise capacity (six-minute walk distance), quality of life (St. George respiratory questionnaire), dyspnea (medical research council dyspnea scale), and healthcare use (COPD hospital admissions). This study does not demonstrate that by having a good educative experience using a web-based platform, there is greater learning than what occurs for patients in usual care. Comparable improvements in COPD knowledge were observed, yet the technology-enabled patient education group (who were using pedometers to track daily steps) were more active. However, behaviour change in physical activity levels did change health outcomes compared to usual care. These results suggest impacts are not linked, and other factors may be working to change behaviour beyond knowledge acquisition. However, as this is only one study, further research examining all four levels of anticipated impact (positive experience, learning attainment, behaviour change, and improved health outcomes) needs to be undertaken.