The Impact of Health Literacy Level on Inhaler Technique in Patients With Chronic Obstructive Pulmonary Disease

Impact of Pharmacist-Led Intervention on Adherence to Inhalers, Inhalation Technique, and Disease Control Among Asthma/COPD Patients in a Resource Limited Center: An Interventional Study

Background

Asthma and Chronic obstructive pulmonary disease (COPD) are chronic respiratory conditions characterized by airflow obstruction and respiratory symptoms. Adherence to prescribed inhaler therapy and correct inhalation technique are essential for effective disease management and optimal disease control. However, non-adherence and incorrect inhalation technique are common challenges faced by patients with asthma and COPD, leading to suboptimal treatment outcomes and increased healthcare burden.

Purpose

To study the impact of a pharmacist-led intervention on inhaler adherence, inhalation technique, and disease control among patients with asthma and COPD.

Patients and Methods

A pre-post interventional design assessed the effects of pharmacist-led intervention on inhaler adherence, inhalation techniques, and disease control in asthma and COPD patients at Dhulikhel Hospital in Nepal. Inclusion criteria: adult patient clinically diagnosed with asthma or COPD patients of all genders. The intervention comprised counseling patients with aids like videos, and informational leaflets. Impact was measured using checklist method for inhalation technique, the Test of Adherence to Inhaler (TAI) questionnaire for adherence to inhaler, and "Asthma Control Test (ACT)" or "COPD Assessment Test (CAT)" for disease control.

Results

The pharmacist-led intervention significantly increased adherence to inhalers, evidenced by a notable rise in the proportion of patients with good adherence (P<0.001). Sporadic, deliberate, and unwitting noncompliance pattern also improved significantly after the intervention (P<0.001, P<0.001 and P=0.001). Inhalation technique exhibited substantial improvement after intervention (P<0.001). The analysis indicated significant moderate negative correlations between "TIA" and "CAT" [ρ=-0.31; P=0.01], and between "inhalation technique score" and "CAT score" [ρ=-0.31; P=0.01] suggesting that as adherence to inhaler usage and inhalation technique improve, CAT scores tend to decrease, indicating reduced disease impact on the patient.

Conclusion

This study shows the potential efficacy of pharmacist-led intervention in enhancing adherence to inhaler, inhalation technique, and disease control in respiratory conditions such as asthma and COPD.

A systematic review of methods of scoring inhaler technique

Many inhaler devices are currently used in clinical practice to deliver medication, with each inhaler device offering different benefits to overcome technique issues. Inhaler technique remains poor, contributing to reduced airway drug deposition and consequently poor disease control. Scoring inhaler technique has been used within research as an outcome measure of inhaler technique assessment, and this systematic review collates and evaluates these scoring methods. The review protocol was prospectively registered in PROSPERO (CRD42020218869). A total of 172 articles were screened with 77 included, and the results presented using narrative synthesis due to the heterogeneity of the study design and data. The most frequently used scoring method awarded one point per step in the inhaler technique checklist and was included in 59/77 (77%) of articles; however limited and varied guidance was provided for score interpretation. Other inhaler technique scoring methods included grading the final inhaler technique score, expressing the total score as a percentage/ratio, deducting points from the final score when errors were made, and weighting steps within the checklist depending on how crucial the step was. Vast heterogeneity in the number of steps and content in the inhaler technique checklists was observed across all device types (range 5-19 steps). Only 4/77 (5%) of the inhaler technique measures had undertaken fundamental steps required in the scale development process for use in real world practice. This review demonstrates the demand for a tool that measures inhaler technique and highlights the current unmet need for one that has undergone validation.

Recognizing and Tackling Inhaler Technique Decay in Asthma and Chronic Obstructive Pulmonary Disesase (COPD) Clinical Practice

A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights.

How to co-design a health literacy-informed intervention based on a needs assessment study in chronic obstructive pulmonary disease

OBJECTIVE

To develop a co-designed health literacy (HL)-informed intervention for people with chronic obstructive pulmonary disease (COPD) that enables them to find, understand, remember, use and communicate the health information needed to promote and maintain good health.

DESIGN

This study used a co-design approach informed by the programme logic of the Ophelia (Optimising Health Literacy and Access) process. The co-design included workshops where possible solutions for an HL-informed intervention were discussed based on an HL needs assessment study.

SETTINGS

Five workshops were performed in a local community setting in the specialist and municipality healthcare services in Oslo, Norway.

PARTICIPANTS

People with COPD, multidisciplinary healthcare professionals (HCPs) from the municipality and specialist healthcare services, and researchers (n=19) participated in the workshops. The co-designed HL-informed intervention was based on seven focus groups with people with COPD (n=14) and HCPs (n=21), and a cross-sectional study of people with COPD using the Health Literacy Questionnaire (n=69).

RESULTS

The workshop co-design process identified 45 action points and 51 description points for possible intervention solutions to meet the HL needs of people with COPD. The final recommendation for an HL-informed intervention focused on tailored follow-up after hospitalisation, which uses motivational interviewing techniques, is based on the individual's HL, self-management and quality of life needs and is implemented in cooperation with HCPs in both the specialist and municipality healthcare services.

CONCLUSION

During the codesign process, the workshop group generated several ideas for how to help patients find, understand, remember, use and communicate health information in order to promote and maintain good health. People with COPD need tailored follow-up based on their individual HL needs by HCPs that have knowledge of COPD and are able to motivate them for self-management tasks and help them to improve their quality of life (QOL) and decrease hospitalisation.

Health literacy in asthma and chronic obstructive pulmonary disease (COPD) care: a narrative review and future directions

Respiratory self-care places considerable demands on patients with chronic airways disease (AD), as they must obtain, understand and apply information required to follow their complex treatment plans. If clinical and lifestyle information overwhelms patients' HL capacities, it reduces their ability to self-manage. This review outlines important societal, individual, and healthcare system factors that influence disease management and outcomes among patients with asthma and chronic obstructive pulmonary disease (COPD)-the two most common ADs. For this review, we undertook a comprehensive literature search, conducted reference list searches from prior HL-related publications, and added insights from international researchers and scientists with an interest in HL. We identified methodological limitations in currently available HL measurement tools in respiratory care. We also summarized the issues contributing to low HL and system-level cultural incompetency that continue to be under-recognized in AD management and contribute to suboptimal patient outcomes. Given that impaired HL is not commonly recognized as an important factor in AD care, we propose a three-level patient-centered model (strategies) designed to integrate HL considerations, with the goal of enabling health systems to enhance service delivery to meet the needs of all AD patients.

Assessment of Poor Inhaler Technique in Older Patients with Asthma or COPD: A Predictive Tool for Clinical Risk and Inhaler Performance

BACKGROUND/OBJECTIVES

Older patients with asthma or chronic obstructive pulmonary disease (COPD) are particularly susceptible to inhaler technique errors and poor clinical outcomes. Several factors may influence their risk, but most studies are inconsistent and contradictory. We developed a tool for the major predictors of individual risk in these patients.

DESIGN, SETTING AND PARTICIPANTS

In this multicentre, cross-sectional study, several demographic, socioeconomic and clinical characteristics were collected as potential predictors. Clinical features and inhaler technique performance were the main outcomes. Linear and logistic regression models were set up to identify significant variables. Subgroup analysis was performed according to age, cognitive performance and different types of inhalers.

RESULTS

We included 130 participants, mean age of 74.4 (± 6.4) years. Mean years of device use were 5.8 (± 7.3). Inhaler errors affected 71.6% (95% CI 64-78.5) and critical mistakes 31.1% (95% CI 24-38.8). There were respiratory comorbidities in 82.3% of participants, and 56.2% had moderate to severe disease. A predictive score of misuse probability was developed for clinical practice, including points attributable to cognitive score, adherence and having received previous education on a placebo device. Other significant variables of individual risk were having respiratory allergies or comorbidities, smoking status, depression and educational level. Worse performance was detected in cognitively impaired patients older than 75 years who were using dry powder inhalers (DPI). Lung function was associated with smoking load, incorrect dose activation and absent end pause after inhalation.

CONCLUSIONS

Individual risk assessment in older individuals should focus on inhaler technique performance (mainly on dose activation and end pause) and adherence, smoking, respiratory comorbidities and cognitive impairment. Placebo device training provided by doctors seems to best suit these patients.

Do Chronic Obstructive Pulmonary Diseases (COPD) Self-Management Interventions Consider Health Literacy and Patient Activation? A Systematic Review

Self-management (SM) includes activities that patients initiate and perform in the interest of controlling their disease and maintaining good health and well-being. This review examines the health literacy and patient activation elements of self-management interventions for Chronic Obstructive Pulmonary Diseases (COPD) patients. We investigated the effects of the intervention on health-related quality of life, self-efficacy, depression, and anxiety among people with COPD. We conducted a systematic review of studies evaluating the efficacy of self-management interventions among COPD patients that also included health literacy or patient activation as keywords. Four electronic databases Medline, EMBASE, PsycINFO, and Google Scholar, were searched to identify eligible studies. These studies were screened against predetermined inclusion criteria. Data were extracted according to the review questions. Twenty-seven studies met the criteria for inclusion. All of the included studies incorporated health literacy components and focused on COPD and self-management skills. Three studies measured health literacy; two showed improvements in disease knowledge, and one reported a significant change in health-related behaviors. Seventeen studies aimed to build and measured self-efficacy, but none measured patient activation. Eleven studies with multicomponent interventions showed an improvement in quality of life. Six studies that focused on specific behavioral changes with frequent counseling and monitoring demonstrated improvement in self-efficacy. Two interventions that used psychosocial counseling and patient empowerment methods showed improvement in anxiety and depression. Most self-management interventions did not measure health literacy or patient activation as an outcome. Successful interventions were multicomponent and comprehensive in addressing self-management. There is a need to evaluate the impact of comprehensive self-management interventions that address and measure both health literacy and patient activation on health outcomes for COPD patients.

Factors associated with health literacy in rural areas of Central China: structural equation model

Background

Health literacy is a strong predictor of health status. This study develops and tests a structural equation model to explore the factors that are associated with the health literacy level of rural residents in Central China.

Methods

The participants were recruited from a county-level city in Central China (N = 1164). Face-to-face interviews were conducted to complete the self-designed questionnaire of each participant. The questionnaire included items for the (1) demographic information, (2) socioeconomic status, and (3) health literacy of the participants. Mplus analyses were performed to evaluate the proposed model.

Results

The final model showed good fit for the data, and both demographic characteristics (i.e., age, BMI, and residence) and socioeconomic status (i.e., monthly income, occupation, and education level) were significantly associated with health literacy level. The effects of these two variables were − 0.277 (P < 0.05) and 0.615 (P < 0.001), respectively, and the model explained 70.2% of the variance in health literacy.

Conclusions

Health literacy was significantly associated with age, BMI, distance between residence and nearest medical institution, monthly income, occupation, and education level, whereas socioeconomic status was a dominant predictor of health literacy level. Targeting these factors might be helpful in allocating health resources rationally when performing health promotion work.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4094-1) contains supplementary material, which is available to authorized users.

Chronic obstructive pulmonary disease in the long-term care setting: current practices, challenges, and unmet needs

: Chronic obstructive pulmonary disease (COPD) is a prevalent and disabling disorder in the United States, especially affecting older individuals, women, and those with a history of smoking. Studies show that COPD may be underrepresented, underdiagnosed, and undertreated in elderly patients residing in long-term care (LTC) facilities. The quality of care for LTC residents with COPD is heterogeneous in regard to both the facility and the patient. For LTC facilities, care should be driven by staff education, interstaff communication, and interfacility communication. From the perspective of the LTC patient, choice of medication and device should be based on appropriate diagnosis, comorbidities, ability to perform treatment, and patient preferences. Nebulization is currently underutilized in LTC settings, although it would benefit older patients with low peak inspiratory flow, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. Authors developed a COPD treatment algorithm that focuses on three primary patient aspects to consider when deciding on respiratory device in patients in LTC facilities: inspiratory flow, hand dexterity and coordination, and cognitive capacity.

Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal

Background

The majority of patients with asthma and chronic obstructive pulmonary disease (COPD) have been known to perform inhaler technique inadequately. We aimed to evaluate the benefit of hospital pharmacy intervention on the current status of dry powder inhaler (Rotahaler^®) technique in such patients and the factors associated with the correct use.

Methods

A pre–post interventional study was conducted at the outpatient pharmacy in a teaching hospital of the Central Development Region, Nepal, in patients with asthma and COPD currently using a Rotahaler device. Patients’ demographics and Rotahaler technique were assessed before intervention. Those who failed to demonstrate the correct technique were educated and trained by the pharmacist, and their technique was reassessed after 2 weeks of intervention. Descriptive statistics, including Wilcoxon signed rank test, Mann–Whitney U test, Spearman’s correlations and Kruskal–Wallis test, were performed for statistical analysis.

Results

Before intervention, only 5.7% (10 of 174) of the patients demonstrated the correct Rotahaler technique and the most common errors observed were failure to breathe out gently before inhalation (98.8%) and failure to hold breath for about 10 seconds after inhalation (84.8%). After the intervention (n=164), 67.1% of the patients showed their technique correctly (p≤0.001) and failure to breathe out gently before inhalation was the most common error (27.44%). Age (p=0.003), previous instruction (p=0.007), patient’s education level (p=0.013) and source of instruction (p<0.001) were associated with an appropriate technique before intervention, while age (p=0.024), duration of therapy (p=0.010) and gender (p=0.008) were the factors correlated with correct usage after intervention.

Conclusion

The current status of Rotahaler technique is inadequate in patients with asthma and COPD attending the Chitwan Medical College Teaching Hospital in the Central Development Region, Nepal. However, a single hospital pharmacy intervention can significantly improve the correct use of the technique, highlighting the role of hospital pharmacies in the improvement of inhaler technique.