This is the first study to show that completion of the self-test RRT tool encourages patients to review their asthma treatment with their doctor. It demonstrates the positive impact of brief tailored messages on attitudes towards asthma treatment and how this can address SABA over-reliance. Given that reducing SABA use is a key element of asthma treatment guidelines6, the RRT could help to ensure patients receive optimal guideline driven treatment. Our results show that the tool is acceptable to patients (72–75% found it helpful and important) and that it encourages patients to think differently about their SABA. This may better prepare them for a consultation in which changes to their asthma treatment could be made.

Around two thirds of the patients in this study have poorly controlled asthma and report being very attached to their SABA, even in patients who are also prescribed ICS. Over half have been living with asthma for over ten years. This is a group of patients who may be thought of as resistant to change and may be particularly hard to convince11. However, we have shown that the RRT can motivate even these patients to seek help. The results show very high rates of intention to take action, with three quarters of patients indicating that they intend to make an appointment to discuss their treatment with a healthcare professional. It is likely that not all patients will follow through on this intention, and it was not possible to measure patient behaviour in this study. Nonetheless, these are very high rates of intention, especially compared with similar behaviour change interventions15,16.

Interestingly, even within those who are told they are at low risk of over-reliance, around half appear to have had their perceptions about asthma changed and 41% intend to discuss their treatment with their doctor. This may be due to the very brief messaging provided to low-risk patients, which informs them that SABA only treats the symptoms of asthma and not the underlying cause. This messaging, independent of information about their personal risk of SABA over-reliance, has prompted people to want to review their asthma treatment with their doctor. Future work should explore the impact on low-risk patients and ensure the test does not cause anxiety.

The SABA monotherapy cohort are interesting. It may seem entirely obvious that patients who report only being prescribed one treatment for asthma are likely to be overly reliant on this treatment. However, it is important to recognise that the SABA Reliance Questionnaire (SRQ) component of the RRT differentiates between people based on their perceived necessity for SABA, with very high necessity beliefs being indicative of over-reliance (e.g., SABA is the best way to control my asthma). The clinical relevance of this is that such patients may be reluctant to consider alternative approaches to managing their asthma, e.g. the addition of ICS maintenance treatment and/or an ICS-LABA as anti-inflammatory reliever therapy (AIR) or maintenance and reliver therapy (MART).

Changes made by the RRT to the patient’s mindset around asthma and its treatment pave the way HCPs to be able to discuss alternative treatment options with patients. As it currently stands, HCPs may be reluctant to discuss these issues with patients, due to time constraints or lack of confidence in identifying or addressing excessive SABA use themselves17. The RRT may therefore be useful in clinical practice as a tool to help to identify those at risk of over-reliance, and to prepare patients for conversations around the risks associated with over-using SABA and the importance of alternative treatments such as anti-inflammatory treatment. This increases patient receptiveness to messaging, reduces the burden on clinicians, and provides them with an opportunity to have a meaningful discussion about treatment options.

There are several limitations with this study. Firstly, there was a risk of selection bias, as participants had to agree to participate, and a relatively large percentage of patients dropped out before completing the survey. Participants who dropped out may have been at lower risk of SABA over-reliance. Patients also had to have a level of digital literacy in order to take part in the study. However, the included participants represent an important group of patients who are over-reliant on their SABA and have poorly controlled asthma, which is the target population group for the RRT. Secondly, the sample size was small. Future studies should test this effect in a larger trial. Third, some patients may be relying on their SABA due to issues around accessibility or cost, and the RRT does not explore these factors. Some patients were prescribed SABA monotherapy, and their lack of a preventer therapy will likely contribute towards their over-use or over-reliance on their SABA. From our sensitivity analysis we conclude that patients on SABA monotherapy are more reliant on SABA than those who are also on ICS treatments. However, the differences were not substantial and high rates of over-reliance were still seen in the ICS sample and so the results still highlight a need for the RRT. Fourth, we relied on self-reported diagnosis of asthma rather than clinical diagnosis. Finally, the study only assessed changes to perceptions and intentions. We do not know how many of these patients followed up on their intention and visited their doctor. Future research is needed to explore the impact of the RRT on behaviour change, to test in larger samples and explore the effectiveness of the RRT across multiple countries.

Nonetheless, although limited in scope, this pilot study suggests that the RRT holds promise as a low-cost intervention to change patients attitudes to SABA, educate them about asthma treatment and encourage patients to seek treatment reviews with HCPs. Results indicated the RRT was well accepted by the patients who completed it. It is likely that the tool could be easily rolled out and widely applied, as it can be completed very quickly and can be delivered through advertisements and social media, or given the tool directly by their HCP18. This could include the pharmacy team who are the last HCPs patients interact with before taking their treatment home. When delivered directly with a HCP, it is a brief, pragmatic way of identifying the beliefs that drive SABA over-reliance and provides HCPs with specific targets to discuss in consultations. If the patient completes the RRT outside of the consultation, it serves as a tool to alert the patient to the risks of over-using SABA and help them come to terms with the fact that there may be a better way of treating their asthma.

Future research should explore the most effective strategy to support HCPs, so they can continue on from the work of the RRT and appropriately counsel patients towards meaningful behaviour change. The results from this study show that even patients who score at low risk of over-reliance on the RRT intend to visit their doctor to discuss their asthma treatment, as they have been informed that there are better treatment options available. Therefore, the HCP and healthcare system needs to be ready to help these patients and to provide suitable support. Data should also be collected to assess whether campaigns increase demand in such a way that HCPs do not have the resources to deal with. Furthermore, special care will have to be taken to train HCPs in countries where alternatives to SABA are not readily available or too costly. The RRT has currently only been tested in a few countries. Further cross-cultural adaptation and validation is needed.

The RRT is effective at identifying and addressing SABA over-reliance and motivating people to seek help, in a sample of patients who are largely overly reliant on their SABA and have poor asthma control. This study supports its potential usefulness as a tool in clinical practice. Motivating patients to reduce their SABA usage should help more patients achieve optimal outcomes. The current study only measured intentions to seek help. More research is needed to explore the extent to which the RRT will change help-seeking behaviour and medication usage.