The effectiveness of telegram‐based virtual education versus in‐person education on the quality of life in adolescents with moderate‐to‐severe asthma: A pilot randomized controlled trial

Abstract Aim In recent years, mobile applications have been developed for health education purposes. The aim of this study was to determine whether Telegram‐based virtual education versus in‐person education can be effective for improving the quality of life in adolescents with moderate‐to‐severe asthma. Design A single‐blind randomized trial. Methods Participants were 64 adolescents aged 12–19 years and were equally assigned randomly to group A (Telegram‐based education) and group B (in‐person education) during 22 June 2017–19 February 2018. The educational contents were similar for both groups. The Mini Pediatric Asthma Quality of Life Questionnaire was used prior to intervention and 5 weeks postintervention for both groups of adolescents. Results A statistically significant increase was observed in the quality of life in both groups (p < .001). After controlling the quality‐of‐life scores, there was no statistically significant difference between the groups in terms of the mean score for the quality of life and its domains (p < .05).

tion technology can reduce the burden of chronic diseases such as asthma for patients and healthcare systems. Mobile health apps in particular could enable low-cost, clinically efficacious interventions for asthma, asthma self-management, improving a patient's quality of life through dissemination of educational materials and symptom monitoring tools (Tinschert, Jakob, Barata, Kramer, & Kowatsch, 2017).

Today, social networks such as Telegram, Viber, Instagram and
WhatsApp are offering countless opportunities to inform and educate patients (Ebrahimpour et al., 2016).
Mobile-based learning is a viable alternative for patient education in nursing (Kim & Park, 2019). In recent years, mobile applications have been developed for health education purposes, especially for asthmatic patients (Stukus et al., 2018). Telegram is a messaging mobile application similar to WhatsApp with the ability to create groups and supergroups as members or users to share large files such as documents, photographs and videos (Alabdulkareem, 2015).
Educational intervention through Telegram app could be more appealing to adolescents with a higher success rate compared with other teaching methods of interventions.
According to the Lundy & Janes (2009), nurses are the largest group of healthcare providers. The nurses' role in teaching through alternative methods was studied, and findings revealed the acceptance of chat apps by adolescents (Suter et al., 2015). But very few studies contributed data to quality of life (QoL) as outcome.
Furthermore, no study has explored the use of Telegram-based education (TBE) among the asthmatic adolescents to evaluate improvement in their quality of life. The purpose of this study was to determine whether Telegram-based virtual education versus in-person education can be effective for improving the quality of life in adolescents with moderate-to-severe asthma.

| Design of the study
This single-blind randomized trial, pre-and post-test equivalent control group design, was conducted to examine the effectiveness of a TBE versus in-person education on the quality of life of adolescents with moderate-to-severe asthma. The registration code for this study on the clinical trial website is IRCT201704224613N23.
We obtained institutional research ethics committee approval for this study to collect and analyse data from the Committee of Ethics

| Participants
Adolescents diagnosed with moderate-to-severe asthma were recruited from a paediatric outpatient clinic specializing in respiratory diseases that serve as a referral centre affiliated with a public university in Tabriz, Iran, during 22 June 2017-2019 February 2018. The inclusion criteria consisted of being between 12-19 years, asthma diagnosis for over a month, willingness to be in the study and having a cell phone or computer, familiarity with the use of Telegram app on the mobile or computer, access to Internet and no prior participation in an educational programme.
Exclusion criteria included chronic diseases in addition to asthma and missing more than one training session.
Adolescents and their legal guardians signed an informed consent for voluntary participation with assurance for privacy and data confidentiality. The written informed consents were followed by a demographic survey questionnaire asking the individual's phone numbers to provide educational materials through Telegram app and help install the programme if absent for the training session.
Sixty-four adolescents were equally assigned to group A (Telegram-based education) and group B (control group) to receive in-person education by a researcher who generated the random allocation sequence according to Rand-List software and a 1:1 allocation ratio. Furthermore, for allocation concealment, the intervention content was written on paper and placed in sequentially numbered concealed envelopes.

| Description of intervention
The educational contents such as subjects and structure were developed based on the outpatient requirements for asthmatic patients similar to previously published research (Zarei et al., 2014) and the National Asthma Education and Prevention Program guidelines (Rai et al., 2018;Williams, Schmidt, Redd, & Storms, 2003) for both groups. It consists of vignettes covering the basic pathophysiology of asthma, asthma symptoms, causes, environmental triggers, allergy agents, strategies to control and manage asthma, use of inhalers, how to use sprays, how to use a peak flow meter, sport, a travel guide to control asthma, nutrition and foods and medicines to asthma control (Castro & Kraft, 2008;Hockenberry et al., 2015).
All the introduced topics were language-and age-appropriate to adolescents.
After an expert review of the programme content, in-person ed- A cell phone and phone number were taken from all participants.
In group A, adolescents signed up for Telegram-based education, the cell phone of participants or their companions regarding the existence of Telegram application was checked, and if needed, it was installed. They were taught how to use the Telegram application.
High-speed Internet was provided by the research team and used to avoid time lapses for downloading contents. They were received multimedia asthma educational contents by Telegram app to receive in form of video, photograph, voice recording and text messages.
The intervention group was actively guided by experienced nurses.
The 50-min educational content on Telegram was divided into several parts, and after each episode, video, photograph, text and voice messages were sent to the participants to ensure that all participants had access to the educational contents to review and find answers to their questions. All follow-up sessions in both groups began by reviewing and discussing questions on the previous contents.
In group B (in-person education), educational sessions were held at the conference hall of the Nursing and Midwifery School for 32 participants in the control. Adolescents participated in five sessions once every three days for 50 min each, held by a researcher using PowerPoint ® and whiteboard within 2 weeks after entering the trial, followed by comments and discussions for another 15 min. At the beginning of each session, adolescents had an opportunity to ask questions and share additional content with the group on previous and new topics. The time interval was every 3 days to study the contents of the previous session and to satisfy the participants and as their requested.
The educational content was similar for both groups. Families and adolescents could call by telephone or Telegram chat with the case manager whenever they felt it necessary. For any communication delay or absence in either group, researchers used identifying date and education sessions to contact and follow-up with the participants. As the delay or non-attendance of the participants was expected at the appointed time, this issue was followed up and controlled by determining and emphasizing the date of the visit and contact by the researcher. In case of absence of more than one session, the person was excluded from the study.

| Description of instrumentation
In a two-part questionnaire, data were collected, where the first part completed during orientation session consisted of demographic information such as age, gender, asthma onset, family history of asthma, socio-economic status and the place of residence.

The second part included the Mini Pediatric Asthma Quality of Life
Questionnaire (Mini PAQLQ) by Juniper et al. designed for paediatric patients between the ages of 11-18 years to determine the primary outcomes (Juniper, Guyatt, Cox, Ferrie, & King, 1999;Juniper et al., 1996). Data were collected in eight months starting from 22

| D ISCUSS I ON
This is the first study where Telegram-based education has been used to improve the quality of life in adolescents with asthma.
Health education is an important part of paediatric asthma management (Rai et al., 2018;Williams et al., 2003), and TBE can equally be an effective approach compared with in-person education for improving the quality of life for adolescents diagnosed with moderateto-severe asthma.  Regarding self-directed Internet-based education, researchers found the same effectiveness in a small group of students learning about the inhaler use techniques compared with the traditional patient education (Toumas, Basheti, & Bosnic-Anticevich, 2009 **independent-sample t test.

TA B L E 2 Mean and standard deviation of quality-of-life scores before and after the intervention in the groups
***Covariance test.