The Extent of Patient’s Satisfaction Regarding Inhaler Counselling in the Kingdom of Saudi Arabia – A Cross-sectional Study

Introduction

Asthma is a common condition of chronic inflammation of the lower respiratory tract.¹ It is a significant public health issue that poses a substantial economic burden.² Asthma is diagnosed based on respiratory symptoms of wheezing, cough, chest tightness, and/or dyspnea together with physiologic evidence of variable expiratory airflow limitation.³ Nonadherence to inhalation therapy and incorrect inhalation technique is a significant challenge for optimal disease management.

The general population showed unsatisfactory asthma control in Italy.⁴ A study was conducted among asthma and COPD patients to educate them regarding proper adherence to inhaler techniques. It was found that before conducting the training program, the majority of patients (67.5%) were not adjusting well to the use of their inhalers. Personalized inhaler technique training was given for 24 weeks, after which the previous number dropped to 55% which was a considerable development.⁵ Among hospitalized asthmatic patients in Jordan, better inhaler technique had been reported after training by a pharmacist.⁶ As well as in Turkey, patient who waits in the outpatient clinic watching a presentation on the use of an inhaler device; provides significant benefits in device usage.⁷ The same results have been reported in different countries including Japan, the United States of America, and India, as Inhaler usage skills significantly improved after inhalation education.^8–10

In Saudi Arabia, educational pharmaceutical pictograms have been reported to be a practical and affordable strategy that can help asthmatic patients utilize inhalers correctly.¹¹ Al Ammari et al. showed that the inhaler techniques in hospitalized Saudi patients with asthma and chronic obstructive pulmonary disease were inadequate.¹² Patients frequently make critical errors while using their inhalers resulting in difficulty and disease progression. These mistakes can easily be corrected through training and educational sessions.¹³

Another study showed that inappropriate inhaler device use is linked to poor asthma control and more frequent visits to emergency rooms.¹⁴ Furthermore, two studies reported that community pharmacists failed to demonstrate proper inhalation techniques in Al Qassim and Al-Ahsa region.^15,16 In addition, some studies reported inadequate levels of knowledge about pharmacotherapy of asthma and adherence to guidelines among pharmacists.^17,18 In the United Kingdom, pharmacists serve a crucial function at community pharmacies. Not only are they responsible for providing prescribed medications to patients, but they also aid them through improving their knowledge regarding the medications in addition to providing insightful guidance.^19–21 These community pharmacies contribute to a progressively coordinated approach towards asthma control and care for patients by referring and reviewing medication. This signifies the importance of the role of pharmacists in patient care and improving aspects of asthma care, the pharmacists of the US and UK are notable examples.²² The significance of the role pharmacists play within their communities has been highlighted in this study, where disease control and inhaler use among the participants were tested before and after receiving thorough educational instructions from the pharmacists. This resulted in a clear improvement in inhaler usage among patients, however, most still made the common mistake of not exhaling before inhaling.²³ In a study conducted by Alhumam et al., 63.3% of physicians stated having demonstrated the correct usage of an inhaler device to caregivers at each visit. Additionally, the patient’s skill to properly use their inhaler was assessed by 46.7% of pharmacists. 42.2% of pharmacists recommended patients wash their spacer with warm water and detergent after each consecutive use. The disease to be treated with the prescribed inhaler was considered as the most important factor by 32.2% of the physicians.²⁴

To the best of our knowledge, there is very limited data available through studies previously conducted in Saudi Arabia to evaluate inhaler counseling by pharmacists. Thus, we aim to study the extent of patient satisfaction regarding inhaler counseling in the Kingdom of Saudi Arabia with a larger sample size than previously reported.

Methods

Results

Discussion

Asthma is a common condition due to chronic inflammation of the lower respiratory tract.¹ Chronic lower airway inflammation is known to be more common in individuals who also have inflammatory disorders of the upper airway, so this research was conducted to evaluate the knowledge and inhaler counseling of patients with asthma disease.² The findings in the present study are consistent with the findings of another investigator Alfadl et al.²⁵ suggesting that a low percentage of the patients were asked about the indication of the medication, drug interactions, precautions while using the drug, and common side effects that patients may experience.

There are similarities regarding counseling points are found to be below acceptable standards between the present study and those described by Alfadl et al.²⁵ Contrary to expectations, research described by Dhand et al. finds that most patients do not clean the inhaler device, while in our study, most patients cleaned their inhaler device.²⁶ Another study mentions that patients often find it inconvenient to regularly clean their inhalers, they prefer Dry Powder Inhalers (DPI) over metered-dose inhalers (pMDIs) because DPIs require much less cleaning.²⁷

In a study conducted by Basheti et al.,⁶ they reported the majority of patients were provided proper information on the correct usage of their inhalers, whereas in this study the opposite was observed. The results of the study described by Basheti et al.⁶ show that most patients believed that it was the respiratory specialist’s role to educate them on asthma and inhaler techniques, and only a few believed it was the pharmacist’s role. These findings are consistent with our data that most patients rely on their doctor’s explanations, and few ask the pharmacist for counseling.⁶ Considering previous studies, it was not surprising that Basheti et al. discovered that patients’ primary source of inhaler technique instruction before this point was their specialist, with the pharmacist having a minimal impact.⁶ The current study found a statistically significant relationship between selected socio-demographic variables and Counselling points that correspond to Basheti et al.⁶ and Ammari et al.¹²

The present study aligns with earlier research, which commonly suggests the need for further investigations into the evaluation of patient knowledge and the provision of inhalation counseling for individuals with asthma. The study highlighted the crucial role of pharmacists in providing comprehensive education on inhalation therapy, including the causes, proper usage techniques, and potential side effects. This aligns with the findings of Alghadeer et al.,²⁸ who emphasized the importance of regular pharmacist consultations to ensure patient reassurance and stressed that pharmacists should take full responsibility for offering guidance and advice. Similarly, in studies by Spencer et al.²⁹ and Caminati et al.⁴ reported comparable outcomes, reinforcing the pharmacist’s role in patient education and support.

Khan et al.¹⁶ highlighted the critical need for patients to be adequately informed about proper inhaler use. The findings also revealed that some pharmacists lack the necessary knowledge to effectively explain inhaler techniques and their potential effects to patients. This knowledge gap can result in patients losing trust in their pharmacists as health personnel. Another study reviewing past research revealed how only 15.5% of healthcare professionals knew how to properly use inhalers and, therefore cannot be responsible for correctly demonstrating their use to patients.^30,31 Findings of these studies contradict the results of our current study, which found that there is good knowledge by pharmacists of inhalers, and they are providing sufficient care and information to the patients. Majority of patients. 107 (37.4%) were satisfied with the counseling provided by their pharmacists. The study of Adnan et al. showed there is a gradual improvement in providing information by pharmacists about the handling of MDI as compared to earlier studies in the region.¹⁵

The study’s results were presented in two key sections. In the first, the relationship between two socio-demographic factors—age and education level—and patients’ preferences for counseling methods was examined. A significant association was found between age and the preference for receiving counseling through educational videos (p = 0.036), as well as between age and relying solely on the doctor’s explanation (p = 0.00). Regarding education level, a strong correlation was noted between higher education and obtaining counseling from leaflets (p = 0.00), along with patients with higher education levels also relying on doctor-provided counseling (p = 0.00).

The second part of the study explored the connection between proper inhaler use and two socio-demographic factors: age and education level. A significant relationship was found between age and correct inhaler usage (p = 0.010), as well as between age and actions like holding one’s breath while taking the medication (p = 0.018) and cleaning the inhaler (p = 0.007). Similarly, education level showed a significant correlation with correct inhaler use (p = 0.000) and holding breath while using the inhaler (p = 0.003). However, no statistically significant link was observed between education level and cleaning the inhaler device. In contrast, there was a significant relationship between certain aspects of patient opinions on counseling and inhaler use based on the age of the patients. Additionally, there was a connection between various counseling points and patient opinions on counseling, as well as correct inhaler usage in relation to the patient’s level of education.

This study was conducted to evaluate the impact of pharmacist counseling on the incorrect use of inhalers. The findings suggest that pharmacists should dedicate more time to patient counseling to improve medication adherence. This study had several strengths. Notably, the sample size was substantial, and data collection was conducted face-to-face, enhancing the reliability of responses. Additionally, this study is unique in including the assessment of inhaler cleaning practices, an often-overlooked aspect of inhaler use. However, the study has some limitations. Patients were not asked to demonstrate their inhaler technique, and the findings were based solely on self-reported data. Furthermore, the study was limited to Heraa General Hospital in Mecca. Expanding the research to a national level would yield more comprehensive insights into pharmacists’ counseling practices across different regions.

Conclusion

This study aimed to assess the impact of pharmacist counseling on the proper use of inhalers among asthma patients, with a focus on evaluating knowledge and counseling practices. The findings reveal that while pharmacists in the study demonstrated good knowledge of inhaler use, there is a need for more consistent and comprehensive patient counseling to enhance medication adherence and correct inhaler techniques. This study also showed that the majority of patients were satisfied by pharmacists’ counseling regarding inhalers; however, the inhaler technique among these patients was inadequate.

Ethical approval

Approval was obtained from Umm Al-Qura University medical college committee with the IRB Approval number (HAPO-02-K-012-2023-01-1421). Written informed Consent was obtained from all participants who answered the survey questions. Moreover, consents were obtained from parent/guardian of minors under 18 years old in addition to minor assent Al with voluntary participation and data privacy, the study was adhered to the principles stated in the ‘Declaration of Helsinki’.