Incorrect use of inhalers is a problem associated with poor patient outcomes. Despite improvement in the technique after verbal educations, this deteriorates over-time requiring re-enforcement through different educative strategies. This study aimed to assess the impact of a novel video-based teach-to-goal (TTG) educational intervention on: mastery of inhaler technique, disease control, medication adherence and disease-related quality of life (QoL) over-time among asthma and COPD patients.
This prospective, open-label, randomized controlled trial was registered in ClinicalTrials.gov: Identifier NCT05664347. After baseline assessment participants received either a verbal (control group) or a video-based (intervention group) TTG strategy. After 3-month the intervention was assessed for impact on the intended outcomes. Inhaler technique was assessed using standardized checklists, disease control using the Asthma control test and COPD assessment test respectively for asthma and COPD patients while adherence using the Morisky Green Levine scale. For QoL, the mini asthma quality of life questionnaire and the St. George respiratory questionnaire were used for asthmatic and COPD patients, respectively. Differences in outcomes between intervention-control groups were analyzed using either Chi-Square (X2)/Fisher Exact or Mann Whitney test. The impact of intervention on outcomes over-time was examined using either McNemar or Wilcoxon test.
At baseline, intervention (n = 51) and control (n = 52) groups had comparable demographic/clinical characteristics. At follow-up, inhaler technique improved among intervention group compared to control group (93.4% vs 67%) and to baseline (93.4% to 49.5%), (P<0.05). Similarly, medication adherence ameliorated among the intervention group in comparison to control group (88.2% to 61.5%) and to baseline (88.2% to 66.7%), (P<0.05). In regards to disease control, results showed an amelioration among the intervention group compared to baseline (35.3% to 54.9%) (P<0.05). QoL scores improved significantly among asthma patients (intervention group) at follow-up vs baseline. Better scores were also observed for COPD patients compared to controls, (P<0.05).
Video-based (TTG) was effective in enhancing inhaler technique over time as well as improving disease control, medication adherence, and QoL.
Citation: Al-Kharouf MS, Abdeljalil MH, Obeidat NM, Oweidat KA, Awwad O (2023) Video-based teach-to-goal intervention on inhaler technique on adults with asthma and COPD: A randomized controlled trial. PLoS ONE 18(6): e0286870. https://doi.org/10.1371/journal.pone.0286870
Editor: Mohammad Jamil Rababa, Jordan University of Science and Technology, JORDAN
Received: January 2, 2023; Accepted: May 17, 2023; Published: June 9, 2023
Copyright: © 2023 Al-Kharouf et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: Oriana Awwad (OA) received a grant (Reference number 161/2020/19) from the Deanship of Scientific Research at the University of Jordan, Amman Jordan. https://research.ju.edu.jo/Home.aspx. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Asthma and COPD are two respiratory conditions affecting millions of people around the world leading to morbidity and mortality [1–8]. In Jordan, their prevalence is increasing with COPD still being largely underdiagnosed [9,10].
Inhaled medications are the cornerstone management for both asthma and COPD [1,2,11]. Despite mastery of inhaler technique is mandatory to control respiratory symptoms, up to 80% of asthmatic patients are unable to use their inhalers correctly and more than two-thirds of COPD patients make at least one error using their devices [1,2,12–14]. In Jordan, only around 40% of asthmatic adults demonstrated correct technique while no data is available for COPD patients . Inhaler misuse has been associated with therapy failure, poor symptom control, lower quality of life (QoL), poor medication adherence and increased emergency department visits, hospitalizations, and use of oral corticosteroids [6,12,13,16–18].
Patient education on the correct use of inhalers can be crucial for technique mastery and the effective management of asthma and COPD, ameliorating symptom control, disease-related QoL, and medication adherence [16,19–21]. The teach-To-Goal (TTG) education is a multi-session educational approach that can be implicated to teach patients self-care skills and the proper use of medications, including inhalers, until they reach the learning goals (“Teach to Goal”) [22,23].
Despite being an effective educative method, studies showed that the inhaler technique, initially improved after a TTG education, deteriorates over time [23,24]. On these bases, patient education needs to be reinforced. Patients necessitate an effective, portable education that remains easily accessible whenever they need it. Technology-based interventions were shown to be effective at improving self-management of chronic conditions, including respiratory conditions [25–32]. However, no previous reports investigated the long-term effect of technology-based TTG education on patients with asthma and COPD. In Jordan, only few studies investigated the impact of inhaler technique education on asthma patients, none of these targeted COPD patients or implicated technology-based interventions [13,15,24,33,34].
The present study thus aimed to provide asthma and COPD patients with a novel inhaler educational approach, through the development of video-based Teach-To-Goal education that can be easily accessible by the patient at any time after the clinic visit. The study investigated the impact of this novel approach on the mastery of inhaler technique as well as other clinical parameters, asthma/COPD control, medication adherence, and quality of life.
Settings and participants
A prospective, open label, randomized controlled trial was conducted at the respiratory clinics of Jordan University Hospital (JUH) and Islamic Hospital (IH) during the period between June/2020 and February/2021. All eligible participants were invited to take part in the study. Inclusion criteria included: 1) adult patients, 2) with established asthma or COPD diagnosis, 3) treated chronically with an inhaler (pressurized metered-dose inhaler (pMDI), Accuhaler, Respimat soft mist inhaler, Turbohaler, Handihaler, and/or Easyhaler), 4) since at least one month. Patients were excluded from the study if they were: 1) at high risk of infection (immunocompromised patients), 2) presenting with a very severe clinical presentation (severe dyspnoea, confusion due to hypoxemia, in need to continuous oxygen therapy).
Ethical approval was obtained from the institutional review boards of JUH (2020/15074) and IH (378/2021/1). A verbal consent was obtained from each participant before participation. The IRB committee approved the verbal consent procedure to avoid spread of COVID-19 virus from sharing papers and pens needed during the written consent procedure. The patients’ names, their phone numbers and the date of data collection were recorded on the data collection forms. All the data was appropriately coded and analyzed anonymously. Only eligible patients who approved to take part in the research and gave an informed consent were enrolled in the study.
The patients, initially recruited by a clinical pharmacist in the clinic’s waiting room were asked to be interviewed in a separate place to assure privacy. To avoid spread of Corona virus, the clinical pharmacist was wearing a mask, gloves and a face shield during the whole interview. The trial was registered in the international trial register retrospectively [ClinicalTrials.gov: Identifier NCT05664347; 23rd December 2022]. The delay in the trial registration was due to investigators being unfamiliar to the administrative procedure of trials registration especially in the initial lack of a central institutional PRS administrator. The authors confirm that all ongoing and related trials for this intervention are registered. Fig 1 shows the Consort flow diagram.
Randomization and the study outcomes
The study implicated meeting each patient at the time of recruitment (time zero) and after 3 months for follow-up. The enrolled participants were randomized using simple randomization into two groups; odd numbers for the control group and even numbers for the intervention group. The control group received a verbal teach-to-goal (TTG) inhaler technique education while the intervention group received a video-based TTG education.
The main outcome of the study was inhaler technique mastery at follow-up (after 3 months). Secondary outcomes included amelioration of disease control, disease-related quality of life, and medication adherence at follow-up. Fig 2 shows a schematic representation of the study design.
A data collection form was used to collect information from the participants. A clinical pharmacist (research assistant) performed all the data collection. The data collection form comprised five parts; the first included patient demographics and clinical characteristics (e.g., age, gender, prescribed inhaled medications and comorbidities). The second part included checklists for the assessment of the inhaler technique. The inhaler checklists were obtained from the official websites of the inhaler-producing companies and were standardized to include 9 main steps for pMDI, Accuhaler, Turbohaler devices and 10 steps for Respimat, Breezhaler devices. All checklists are available in the (S1 File). Correct inhaler technique was defined as performing correctly 75% or more of the steps .
The third part of the data collection form assessed the patients’ disease control using the validated Arabic versions of the Asthma control test (ACT) and the COPD assessment test (CAT) for asthma and COPD patients respectively [1,2,35–37]. The ACT is a 5- items assessment tool with a score ranging between 5 and 25 where “higher scores indicate better control” [2,35]. The CAT is an 8-items assessment tool with a score ranging between 0 and 40 where “higher score indicates more burden and less disease control” [1,37].
The fourth part included the Arabic version of the 4-item Morisky Green Levine scale (MGLS) to assess medication adherence among the study participants . MGLS has been used to assess medication adherence in various chronic diseases [39–42]. The scores were interpreted as follows: low adherence to the treatment plan (score 0–1) and moderate-high adherence (score 2–4).
Patients were considered to adherent to their medication if they were taking correctly all the prescribed controller inhalers. The fifth part assessed the disease-related QoL using the validated Arabic version of the mini asthma quality of life questionnaire (mini AQLQ) for asthmatic patients and the validated Arabic version of the St. George respiratory questionnaire (SGRQ) for COPD patients. Both tools, their domains and scoring systems were provided by email upon request by the developers [43,44].
The mini AQLQ is a 15-item questionnaire developed and validated by Juniper et al. (1999). It covers 4 domains (‘symptoms’, ‘activity limitations’, ‘emotional functions’, and ‘environmental stimuli’) with a score that ranges between 1 and 7 for each item. The 7-point scale is calculated by diving the total score (15 questions) by 7 to get a score that ranges from 1 to 7. Increase in the 7-point scale score indicates less impairment in the patient’s quality of life as described by .
The St George respiratory questionnaire (SGRQ) is a 50-item validated tool that covers three major domains: ‘symptom’, ‘activity’, and ‘impact’ . Each question had a specific weight assigned by the developer and the SGRQ scores are calculated using an automated application also designed and afforded by the questionnaire developer .
The automated application can produce four scores; a total score, a ‘symptom’ score, an ‘activity limitation’ score and an ‘impact’ score. Each of these scores can range from 0 to 100, where a higher number indicates more impairment in the patient’s QoL . The total QoL score, can be also categorized into quartiles; patients with a total SGRQ score of less than 32 were assigned to the 1st quartile, while those with a score of 32–46, 46–60 and 60 or more were assigned to the 2nd quartile, 3rd quartile and fourth quartile, respectively .
Educational tools and interventions
For each of the five types of inhalers, an educational video showing the correct inhaler technique was developed and recorded by the research team except for Breezhaler, for which the original company-producing video was used . The videos were created to be clear, easy to understand, and in Arabic language. The educational videos showed all the steps necessary to master the inhaler technique as per the standardized checklists used to assess the inhaler technique. A link for each video is available in the (S1 File).
During the patients’ interview, the correct use of inhalers was assessed for each device using the respective checklist in order to obtain a baseline assessment of the patient’s inhaler technique (S1 File). Based on their randomization into control or intervention group, participants then received either a standard verbal TTG education or a video-based TTG educational intervention, respectively. The verbal TTG strategy (control) consisted of cycles of verbal demonstration and assessment, using the appropriate inhaler device, of the correct use of inhalers as per respective standardized checklist. On the other hand, the video-based TTG strategy (intervention) comprised cycles of demonstration and assessment of the correct inhaler techniques but using educational videos, that were displayed to patients through a smartphone. The videos showed step-by-step the correct inhaler technique as per standardized checklists. For each wrong step performed by the patient, the video was displayed again until technique mastering. At the end of the interview the intervention group received a copy of the video/s via WhatsApp® and was invited to watch the video/s whenever needed.
After three months (follow-up interview), inhaler technique, disease control, medication adherence and disease-related quality of life were all assessed again.
For ethical considerations, at the end of the second interview, participants were encouraged to take their medications regularly as prescribed. In addition, they received a peak flow meter as compensation for taking part in the study.
Data analysis and sample size
The targeted sample size was calculated using ClinCalc® automated sample size calculator . Based on published data, the prevalence of inhaler mastery among Jordanian adults with asthma is around 40% [15,33,34]. No data is available for COPD patients. Assuming an increase in the technique mastery from 40% to 80%, a statistical power of 90% and an alpha value of 0.05, the estimated sample size was 48 patients per study arm based on chi-square test of proportions.
All data were coded and analyzed using the statistical package SPSS (version 23). Sociodemographic and clinical characteristics were presented as frequency (percentage) for categorical variables and median (IQR) for continuous variables (variables were not normally distributed). Differences in the outcomes between the intervention and control groups (two independent groups) were assessed using Chi-Square (X2) Test or Fisher Exact Test for categorical/ordinal variables and Mann Whitney U test for continuous variables (variables were not normally distributed). The impact of the education on the inhaler technique, disease control, adherence and quality of life within each group over time (matched pairs) were examined using McNemar Test for categorical variables and Wilcoxon test for continuous/ordinal variables. P-value <0.05 indicated statistical significance.
A total of 926 patients were screened for participation in the study; 546 did not meet the inclusion criteria. Of those eligible to take part in the study, 228 refused to participate while the rest (152 patients) were enrolled in the study and randomized equally into control and intervention groups. No significant differences were initially observed between the two groups in their sociodemographic/clinical characteristics. After three months 103 patients (67%) returned for follow-up and their data included in the final analysis; 52 (50.5%) were in the control group (verbal TTG), 51 (49.5%) in the intervention group (video-based TTG). Fig 1 shows the Consort flow diagram.
No significant differences were observed in the sociodemographic/clinical characteristics between the patients included in the final analysis (patients followed up, N = 103) and those that dropped out from the study (N = 49).
Patient demographic and clinical characteristics
Table 1 displays the baseline demographic and clinical characteristics of the participants (N = 103). Most of the study participants (N = 87, 84.5%) were asthmatic patients, the remaining (N = 16, 15.5%) had COPD.
The median (IQR) age of all the participants was 55 [45–62) years. Most of the them were females (N = 70, 68%), married (N = 79, 76.7%), and had a scholarly degree (N = 67, 65%). The most were unemployed/retired (69%) and were receiving a salary of less than 600USD per month (N = 71, 68%). Of all the patients 17.5% (N = 18) were active smokers, 41.7% (N = 43) were passive smokers, and 40.8% (N = 42) nonsmokers.
More than half of the participants (N = 65, 63.1%) were prescribed two or more inhaler devices at the time of the recruitment with Turbohaler being the inhaler device mostly used among the study population (N = 58, 56.3%). Details regarding the number of participants using each type of inhaler are illustrated in the (S1 File).
Among all the patients, 38.8% (N = 40) had at least one acute exacerbation leading to hospitalization during the last year and 26.2% (N = 27) received oral corticosteroids during the previous month. When asked about vaccination, only 13.5% of the patients (N = 14) stated receiving annual influenza vaccine, just one reported being vaccinated against pneumococcus species.
When looking at the asthma and COPD comorbidities, allergic rhinitis (N = 61, 59.2%), and GERD (N = 45, 43.6%) were the two most prevalent conditions. More details are presented in the (S1 File).
No significant differences were observed in terms of demographic and clinical characteristics between the control and intervention groups at baseline.
Inhaler techniques were assessed for each inhaler device used by each patient at baseline and at follow-up (after 3 months) using the checklists in the (S1 File). This resulted in a total of 182 assessments at baseline and similarly 182 at follow-up (91 per study arm).
Upon comparing inhaler technique at baseline (all the 182 assessments), 49.5% (N = 45) and 54.9% (N = 50) of the techniques resulted correct among the intervention and control group, respectively (P = 0.458) (Table 2). However, at follow up significant increase in the number of correct techniques was observed among the intervention group compared to control group (N = 85, 93.4% vs N = 61, 67%, P = 0.001) (Table 3).
Technique mastery was also analyzed for each type of inhaler. No significant differences were detected in the number of patients mastering pMDI (P = 0.382), Accuhaler (P = 0.184), Respimat (P = 0.215), Turbohaler (P = 0.539) and Breezhaler (P = 1) between the control and intervention groups at baseline (P>0.05) (Table 2). At follow-up a significant difference was observed in the mastery of Respimat (P = 0.002) and Turbohaler (P = 0.021) in favor of the intervention group (Table 3).
When looking at the technique mastery over time within each group (Table 4), significant improvement was observed in all the assessments among the intervention group (from N = 45, 49.5% at baseline to N = 85, 93.4% at follow-up; P<0.001). Significant improvements were also observed in the numbers of patients mastering the technique of pMDI (from N = 12, 52.2% to N = 22, 95.7%; P = 0.002), Accuhaler (from N = 6, 35.3% to N = 15, 88.2%; P = 0.012) and Turbohaler (from N = 20, 57.1% to N = 35, 100%; P< 0.01). No significant differences were observed in the control group (P>0.05) (Table 4).
At baseline, of the 103 participants 43.7% (N = 45) had a well-controlled, less symptomatic condition (Table 2). No significant differences were detected between the intervention and control group in terms of disease control neither at baseline (Table 2) nor at follow-up (Table 3).
Over time, however, more participants in the intervention group had a well-controlled, less symptomatic condition compared to baseline (N = 28, 54.9% at follow-up vs N = 18, 35.3% at baseline; P = 0.013). When looking at the ACT and CAT scores, significant ameliorations were also observed in the median (IQR) of both scores over time within the intervention group (P<0.05) compared to baseline (Table 4).
Among all the 103 participants, 65% (N = 67) of them had a moderate-high level of adherence at baseline, with no significant difference observed between the control and intervention groups at baseline (P = 0.733) (Table 2). Interestingly, at follow-up, a significant difference was observed between the two groups (N = 45, 88.2% of the intervention group were adherent vs N = 32, 61.5% of the controls; P-value = 0.002). (Table 3).
Significant amelioration in the medication adherence was also detected within the intervention group over time, with 88.2% (N = 45) showing moderate-to-high adherence at follow-up compared to 66.7% (N = 34) at baseline (p = 0.003) (Table 4).
Disease-related quality of life
When looking at the disease-related QoL, the total AQoL and the activity limitation AQoL scores were initially significantly different between the two groups at baseline, with the control group showing higher scores (i.e., better quality of life) (P = 0.039) (Table 2). Three months later, these differences were not anymore detected and the intervention group showed a non-significant amelioration in both scores (Table 3).
Significant ameliorations were also observed overtime in the total (P <0.001), symptom (P = 0.001), activity limitation (P = 0.004) and emotional function (P = 0.018) AQoL scores within the intervention group in comparison to baseline. This group also showed less impaired QoL over time as per the 7-point scale AQoL (P = 0.001) (Table 4).
In regards to COPD patients, no differences were detected in the QoL between the control and intervention groups at baseline (Table 2), however, at follow-up a significant p-value was observed in the total QoL score as well as the activity and impact QoL scores (intervention vs control) (Table 3). Over time, significant ameliorations in the symptom (P = 0.046) and activity scores (P = 0.046) were detected within the intervention group at follow-up in comparison to baseline (Table 4).
This is the first RCT investigating the effect of a video-based teach-to-goal educational intervention on inhaler technique mastery, in addition to its effect on disease control, disease-related quality of life, and medication adherence among adults with asthma and COPD over a period of three months.
The underdiagnosis of COPD among Jordanians might have contributed to the discrepancy in the number of asthma and COPD patients enrolled in the study [10,49,50]. In addition, most of the encountered COPD patients didn’t meet the inclusion criteria (for instance, they were critically ill). Assessment of the participants’ demographic characteristics showed consistency with the literature with predominance of male and female gender among COPD and asthma patients respectively [1,2].
Upon assessment of all the inhaler techniques used by the study population, almost half of the techniques were incorrect at baseline. This result cannot be compared to previously published data due to the presence of several checklists and scoring systems used to evaluate the correct use of inhalers . However, worldwide studies, including Jordan reported that 29–94% of the patients use their inhalers incorrectly [11,13,23,24,32–34,52–57].
Turbohaler was the inhaler most frequently prescribed among the study participants which goes in line with the GINA recommendations to prescribe formoterol/budesonide combination (Turbohaler-Symbicort®) as the maintenance and reliever therapy for the treatment of asthma. The widespread and longtime use of Turbohaler might have contributed to the device being the most correctly used among the study participants.
The educational intervention adopted in this study demonstrated superiority over the verbal TTG education and it was able to retain good technique over time. The uniqueness of this intervention is that it blends the initial face-to-face education with a technology-based education. This pinpoints the advantage of interaction with the clinical pharmacists in addition to that offered by a video . Video-based educations have the ability to simulate physical demonstration that if added to verbal and/or written instructions can result in device technique improvement . In addition, when supported by social media, videos have the advantage to be easily accessible, well-reached, and free of charge allowing patients to reinforce their knowledge after the initial education .
Interestingly, when Press et al. (2017) studied the effectiveness of a virtual TTG education without providing direct contact with healthcare providers, patients showed good theoretical knowledge but incorrect inhaler techniques at the time of education . Previous literature also revealed insufficiency of one TTG session provided directly by health care providers on the long-term retention of technique mastery [23,29,33,58,59]. During the clinic visit, patients might be tired and frustrated, which if added to limited time and knowledge of healthcare providers may let to provision of unsatisfactory education [11,33,60,61]. On this basis, patients need multiple sessions of education to fully understand (master) the inhaler technique [62,63]. These suggest that hybridization of face-to-face education to virtual one is needed to retain the correct technique over time. In this line, Bosnic-Anticevich et. al (2010) showed the addition of physical demonstration to written and verbal instructions to be associated with improvement in pMDI technique . Similarly, van der Palen et al. found patients receiving group education on inhaler technique, and those receiving video-based instructions in addition to a home-taken videotape, having better ability to retain inhaler mastery over up to 9 months compared to those receiving classical in-person education .
When looking at disease control, the non-significant amelioration between the intervention and control groups at follow-up can result from the initial baseline difference observed in the ACT and CAT levels in favor to the control group. Significant amelioration was however clearly observed after three months within the intervention group in comparison to baseline, which might be a result of inhaler technique improvement among these participants. Mastery of inhaler technique has, in fact, been directly correlated to better control of disease-related symptoms such as shortness of breath and cough, as well as fewer exacerbations. [1,2,12,17,64–66]. For instance, a literature review by Usmani et al. (2018) reported higher number of inhaler errors associated with poorer disease outcomes and similarly, positive correlation between inhaler technique education, technique mastery, and disease control among asthma and COPD patients . These results go in line with the recommendations from GINA and GOLD guidelines, stressing on the importance of inhaler technique mastery to improve disease control and reduce exacerbation risk [1,2].
Improvement in the symptoms and activity domains of the disease-related QoL might also be attributed to the amelioration of inhaler technique and its subsequent benefit on disease control among the intervention group [67,68]. As showed by different studies better disease control is positively correlated to better quality of life among asthmatic and COPD patients [68–72].
Medication adherence was also improved significantly over time among participants receiving the video-based TTG education. Better understanding the device technique should have contributed to patients feeling more comfortable in using their inhalers improving adherence [20,21,65,73,74]. On these bases, Ovchinicova et al. (2011) observed positive relationships between disease control, retaining good inhaler technique and medication adherence. Patients feeling improvement with treatment, were more motivated to use their inhalers correctly in terms of dosage regimen and technique . Similar effect was also detected by Takemura et al. demonstrating significant impact of medication adherence on disease-related quality of life among patients with asthma and COPD [20,21].
Study limitations include the loss of some patients at follow-up. Due to the COVID-19 pandemic some participants preferred not to visit the study site. Moreover, despite the intention to address both asthma and COPD, the study didn’t achieve a balance in the number of participants with a dominance of asthmatic patients.
In conclusion, this study demonstrates that the video-based TTG education could significantly improve the inhaler technique mastery, disease control, disease-related patients’ quality of life and the medication adherence among patients with chronic respiratory conditions. The long-term effect on the study secondary outcomes is suggested to be directly related to the improvement in the inhaler technique mastery and to the reinforcing nature of the videos, easily accessible by the patients at any time.
S1 Checklist. Consort checklist CONSORT 2010 checklist of information to include when reporting a randomised trial*.
S1 Protocol. Study protocol.
- 1. (GOLD) GIfCOLD. Global Strategy for the Diagnosis, Managment, and Prevention of Chronic Obstructive Pulmonary Disease 2020 [Available from: https://goldcopd.org/gold-reports/.
- 2. (GINA) GIfA. Global Strategy for Ashtma Managment and Prevention 2021 [Available from: https://ginasthma.org/gina-reports/.
- 3. WHO WHO. Chronic Obstructive Pulmonary Disease (COPD) 2017 [Available from: https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd).
- 4. WHO WHO. Asthma 2020 [updated May, 15 2020. Available from: https://www.who.int/news-room/q-a-detail/asthma.
- 5. European Respiratory Society. The Global Impact of Respiratory Disease. Sheffield; 2017.
- 6. The global asthma report (GAR). The Burden of Asthma 2018 [Available from: http://www.globalasthmareport.org/burden/mortality.php.
- 7. Løkke A, Lange P, Lykkegaard J, Ibsen R, Andersson M, de Fine Licht S, et al. Economic Burden of COPD by Disease Severity—A Nationwide Cohort Study in Denmark. International journal of chronic obstructive pulmonary disease. 2021;16:603–13. pmid:33731990
- 8. CDC CfDCaP. Chronic obstructive pulmonary disease (COPD) 2021 [Available from: https://www.cdc.gov/copd/infographics/copd-costs.html.
- 9. Abu-Ekteish F, Otoom S, Shehabi I. Prevalence of asthma in Jordan: comparison between Bedouins and urban schoolchildren using the International Study of Asthma and Allergies in Childhood phase III protocol. Allergy and asthma proceedings. 2009;30(2):181–5. pmid:19463207
- 10. Khassawneh BY, Samrah SM, Jarrah MI, Ibdah RK, Ibnian AM, Almistarehi AW, et al. Prevalence of undiagnosed COPD in male patients with coronary artery disease: a cross-sectional study in Jordan. International journal of chronic obstructive pulmonary disease. 2018;13:2759–66. pmid:30233166
- 11. Lavorini F, Fontana GA, Usmani OS. New inhaler devices—the good, the bad and the ugly. Respiration; international review of thoracic diseases. 2014;88(1):3–15. pmid:24902629
- 12. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory medicine. 2011;105(6):930–8. pmid:21367593
- 13. Basheti IA, Obeidat NM, Ammari WG, Reddel HK. Associations between inhaler technique and asthma control among asthma patients using pressurised MDIs and DPIs. The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease. 2016;20(5):689–95. pmid:27084826
- 14. Duarte-de-Araujo A, Teixeira P, Hespanhol V, Correia-de-Sousa J. COPD: misuse of inhaler devices in clinical practice. International journal of chronic obstructive pulmonary disease. 2019;14:1209–17. pmid:31213798
- 15. Basheti IA, Obeidat NM, Reddel HK. Inhaler technique education and asthma control among patients hospitalized for asthma in Jordan. Saudi pharmaceutical journal: SPJ: the official publication of the Saudi Pharmaceutical Society. 2018;26(8):1127–36. pmid:30532633
- 16. Hashmi A SJ, Memon A, Soomro T. Incorrect Inhaler Technique Compromising Quality of Life of Asthmatic Patients. Journal of Medicine. 2012;13(1).
- 17. Usmani OS, Lavorini F, Marshall J, Dunlop WCN, Heron L, Farrington E, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respiratory research. 2018;19(1):10. pmid:29338792
- 18. Sriram KB, Percival M. Suboptimal inhaler medication adherence and incorrect technique are common among chronic obstructive pulmonary disease patients. Chronic respiratory disease. 2016;13(1):13–22. pmid:26396159
- 19. Khurana AK, Dubey K, Goyal A, Pawar KS, Phulwaria C, Pakhare A. Correcting inhaler technique decreases severity of obstruction and improves quality of life among patients with obstructive airway disease. Journal of family medicine and primary care. 2019;8(1):246–50. pmid:30911514
- 20. Takemura M, Mitsui K, Itotani R, Ishitoko M, Suzuki S, Matsumoto M, et al. Relationships between repeated instruction on inhalation therapy, medication adherence, and health status in chronic obstructive pulmonary disease. International journal of chronic obstructive pulmonary disease. 2011;6:97–104. pmid:21407822
- 21. Takemura M, Kobayashi M, Kimura K, Mitsui K, Masui H, Koyama M, et al. Repeated instruction on inhalation technique improves adherence to the therapeutic regimen in asthma. The Journal of asthma: official journal of the Association for the Care of Asthma. 2010;47(2):202–8. pmid:20170330
- 22. Baker DW, DeWalt DA, Schillinger D, Hawk V, Ruo B, Bibbins-Domingo K, et al. "Teach to goal": theory and design principles of an intervention to improve heart failure self-management skills of patients with low health literacy. Journal of health communication. 2011;16 Suppl 3:73–88. pmid:21951244
- 23. Press VG, Arora VM, Trela KC, Adhikari R, Zadravecz FJ, Liao C, et al. Effectiveness of Interventions to Teach Metered-Dose and Diskus Inhaler Techniques. A Randomized Trial. Annals of the American Thoracic Society. 2016;13(6):816–24. pmid:26998961
- 24. Basheti IA, Salhi YB, Basheti MM, Hamadi SA, Al-Qerem W. Role of the pharmacist in improving inhaler technique and asthma management in rural areas in Jordan. Clinical pharmacology: advances and applications. 2019;11:103–16. pmid:31413644
- 25. Farwana R, Sheriff A, Manzar H, Farwana M, Yusuf A, Sheriff I. Watch this space: a systematic review of the use of video-based media as a patient education tool in ophthalmology. Eye (London, England). 2020;34(9):1563–9. pmid:32152516
- 26. Correnti CM, Chen SC, Stoff BK. Video-based education about systemic corticosteroids enhances patient knowledge more than verbal education: A randomized controlled trial. Dermatology online journal. 2017;23(9). pmid:29469713
- 27. Denny MC, Vahidy F, Vu KY, Sharrief AZ, Savitz SI. Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction. PloS one. 2017;12(3):e0171952. pmid:28333925
- 28. Lirsac B, Braunstein G. [Randomized evaluation of two teaching methods using aerosol dosers]. Revue des maladies respiratoires. 1991;8(6):559–65.
- 29. van der Palen J, Klein JJ, Kerkhoff AH, van Herwaarden CL, Seydel ER. Evaluation of the long-term effectiveness of three instruction modes for inhaling medicines. Patient education and counseling. 1997;32(1 Suppl):S87–95. pmid:9516764
- 30. Shah RF, Gupta RM. Video instruction is more effective than written instruction in improving inhaler technique. Pulmonary pharmacology & therapeutics. 2017;46:16–9. pmid:28797611
- 31. Windisch W, Schwarz SB, Magnet FS, Dreher M, Schmoor C, Storre JH, et al. Using web-based videos to improve inhalation technique in COPD patients requiring hospitalization: A randomized controlled trial. PloS one. 2018;13(10):e0201188. pmid:30325931
- 32. Press VG, Kelly CA, Kim JJ, White SR, Meltzer DO, Arora VM. Virtual Teach-To-Goal Adaptive Learning of Inhaler Technique for Inpatients with Asthma or COPD. The journal of allergy and clinical immunology In practice. 2017;5(4):1032–9.e1.
- 33. Basheti IA, Obeidat NM, Reddel HK. Effect of novel inhaler technique reminder labels on the retention of inhaler technique skills in asthma: a single-blind randomized controlled trial. NPJ primary care respiratory medicine. 2017;27(1):9. pmid:28184045
- 34. Almomani BA, Mokhemer E, Al-Sawalha NA, Momany SM. A novel approach of using educational pharmaceutical pictogram for improving inhaler techniques in patients with asthma. Respiratory medicine. 2018;143:103–8. pmid:30261980
- 35. Department of health UAE. Asthma control test for 12 years or older 2019 [updated 2019, March 10. Available from: https://www.doh.gov.ae/programs-initiatives/chronic-respiratory-diseases-awareness-program.
- 36. Lababidi H, Hijaoui A, Zarzour M. Validation of the Arabic version of the asthma control test. Annals of thoracic medicine. 2008;3(2):44–7. pmid:19561904
- 37. Al-Moamary MS, Al-Hajjaj MS, Tamim HM, Al-Ghobain MO, Al-Qahtani HA, Al-Kassimi FA. The reliability of an Arabic translation of the chronic obstructive pulmonary disease assessment test. Saudi medical journal. 2011;32(10):1028–33. pmid:22008922
- 38. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical care. 1986;24(1):67–74. pmid:3945130
- 39. Wang Y, Lee J, Toh MP, Tang WE, Ko Y. Validity and reliability of a self-reported measure of medication adherence in patients with Type 2 diabetes mellitus in Singapore. Diabetic medicine: a journal of the British Diabetic Association. 2012;29(9):e338–44. pmid:22672497
- 40. Oliveira-Filho AD, Morisky DE, Costa FA, Pacheco ST, Neves SF, Lyra DP Jr., Improving post-discharge medication adherence in patients with CVD: a pilot randomized trial. Arquivos brasileiros de cardiologia. 2014;103(6):503–12. pmid:25590930
- 41. Beyhaghi H, Reeve BB, Rodgers JE, Stearns SC. Psychometric Properties of the Four-Item Morisky Green Levine Medication Adherence Scale among Atherosclerosis Risk in Communities (ARIC) Study Participants. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2016;19(8):996–1001. pmid:27987650
- 42. Awwad O, AlMuhaissen S, Al-Nashwan A, AbuRuz S. Translation and validation of the Arabic version of the Morisky, Green and Levine (MGL) adherence scale. PloS one. 2022;17(10):e0275778. pmid:36206237
- 43. Juniper EF, Guyatt GH, Cox FM, Ferrie PJ, King DR. Development and validation of the Mini Asthma Quality of Life Questionnaire. The European respiratory journal. 1999;14(1):32–8. pmid:10489826
- 44. London SGuo. St George’s Respiratory Questionnaire (SGRQ) 2021 [Available from: https://www.sgul.ac.uk/about/our-institutes/infection-and-immunity/research-themes/research-centres/health-status.
- 45. Jones P, Lareau S, Mahler DA. Measuring the effects of COPD on the patient. Respiratory medicine. 2005;99 Suppl B:S11–8. pmid:16236492
- 46. Müllerová H, Gelhorn H, Wilson H, Benson V, Karlsson N, Menjoge S, et al. Health status predicts long-term outcomes in patients with chronic obstructive pulmonary disease (COPD): Pooled analysis of patient-level data from the COPD biomarker qualification consortium database. European Respiratory Journal. 2015;46(suppl 59):PA3017.
- 47. The Deutsche Atemwegsliga (German Airway League). Breezhaler (Mono) الاستنشاق بجهاز بريزهيلر. 2016.
- 48. ClinCalc. Sample size calculator [Available from: https://clincalc.com/stats/samplesize.aspx.
- 49. Al Omari M, Khassawneh BY, Khader Y, Dauod AS, Bergus G. Prevalence of chronic obstructive pulmonary disease among adult male cigarettes smokers: a community-based study in Jordan. International journal of chronic obstructive pulmonary disease. 2014;9:753–8. pmid:25092972
- 50. Mohamed Hoesein FA, Zanen P, Lammers JW. Lower limit of normal or FEV1/FVC < 0.70 in diagnosing COPD: an evidence-based review. Respiratory medicine. 2011;105(6):907–15.
- 51. Normansell R, Kew KM, Mathioudakis AG. Interventions to improve inhaler technique for people with asthma. The Cochrane database of systematic reviews. 2017;3:Cd012286. pmid:28288272
- 52. Jahedi L, Downie SR, Saini B, Chan HK, Bosnic-Anticevich S. Inhaler Technique in Asthma: How Does It Relate to Patients’ Preferences and Attitudes Toward Their Inhalers? Journal of aerosol medicine and pulmonary drug delivery. 2017;30(1):42–52. pmid:27676193
- 53. van der Palen J, Klein JJ, van Herwaarden CL, Zielhuis GA, Seydel ER. Multiple inhalers confuse asthma patients. The European respiratory journal. 1999;14(5):1034–7. pmid:10596686
- 54. Press VG, Arora VM, Shah LM, Lewis SL, Ivy K, Charbeneau J, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. Journal of general internal medicine. 2011;26(6):635–42. pmid:21249463
- 55. Press VG, Arora VM, Shah LM, Lewis SL, Charbeneau J, Naureckas ET, et al. Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial. Journal of general internal medicine. 2012;27(10):1317–25. pmid:22592354
- 56. Bosnic-Anticevich SZ, Sinha H, So S, Reddel HK. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma: official journal of the Association for the Care of Asthma. 2010;47(3):251–6. pmid:20394511
- 57. Alzayer R, Chaar B, Basheti I, Saini B. Asthma management experiences of Australians who are native Arabic speakers. The Journal of asthma: official journal of the Association for the Care of Asthma. 2018;55(7):801–10. pmid:28800268
- 58. Ovchinikova L, Smith L, Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient’s perspective. The Journal of asthma: official journal of the Association for the Care of Asthma. 2011;48(6):616–24. pmid:21623690
- 59. Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, Chetsadaphan N, Choomuang W. Evaluating inhaler use technique in COPD patients. International journal of chronic obstructive pulmonary disease. 2015;10:1291–8. pmid:26185435
- 60. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respiratory care. 2005;50(10):1360–74; discussion 74–5. pmid:16185371
- 61. Karle E, Patel TP, Zweig J, Krvavac A. Understanding the Knowledge Gap and Assessing Comfort Level among Healthcare Professionals Who Provide Inhaler Education. Copd. 2020;17(2):197–204. pmid:32237908
- 62. Nimmo CJ, Chen DN, Martinusen SM, Ustad TL, Ostrow DN. Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices. The Annals of pharmacotherapy. 1993;27(7–8):922–7. pmid:8364279
- 63. Baker DW, Dewalt DA, Schillinger D, Hawk V, Ruo B, Bibbins-Domingo K, et al. The effect of progressive, reinforcing telephone education and counseling versus brief educational intervention on knowledge, self-care behaviors and heart failure symptoms. Journal of cardiac failure. 2011;17(10):789–96. pmid:21962415
- 64. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient education and counseling. 2008;72(1):26–33. pmid:18314294
- 65. Giraud V, Allaert FA, Roche N. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011;105(12):1815–22. pmid:21802271
- 66. Levy ML, Hardwell A, McKnight E, Holmes J. Asthma patients’ inability to use a pressurised metered-dose inhaler (pMDI) correctly correlates with poor asthma control as defined by the global initiative for asthma (GINA) strategy: a retrospective analysis. Primary care respiratory journal: journal of the General Practice Airways Group. 2013;22(4):406–11. pmid:24042172
- 67. George M, Bender B. New insights to improve treatment adherence in asthma and COPD. Patient preference and adherence. 2019;13:1325–34. pmid:31534319
- 68. Harnett CM, Hunt EB, Bowen BR, O’Connell OJ, Edgeworth DM, Mitchell P, et al. A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic. The Journal of asthma: official journal of the Association for the Care of Asthma. 2014;51(4):440–5. pmid:24393080
- 69. Souza DS, Noblat Lde A, Santos Pde M. Factors associated with quality of life in patients with severe asthma: the impact of pharmacotherapy. Jornal brasileiro de pneumologia: publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2015;41(6):496–501. pmid:26785957
- 70. Almomani BA, Al-Sawalha NA, Samrah SM, Gamble JM, Al Momani MA. Asthma insights from Jordan: cross-sectional observational study. The Journal of asthma: official journal of the Association for the Care of Asthma. 2016;53(4):349–55. pmid:26666170
- 71. Miravitlles M, Molina J, Naberan K, Cots JM, Ros F, Llor C. Factors determining the quality of life of patients with COPD in primary care. Therapeutic advances in respiratory disease. 2007;1(2):85–92. pmid:19124350
- 72. Schlecht NF, Schwartzman K, Bourbeau J. Dyspnea as clinical indicator in patients with chronic obstructive pulmonary disease. Chronic respiratory disease. 2005;2(4):183–91. pmid:16541601
- 73. Braido F, Chrystyn H, Baiardini I, Bosnic-Anticevich S, van der Molen T, Dandurand RJ, et al. "Trying, But Failing"—The Role of Inhaler Technique and Mode of Delivery in Respiratory Medication Adherence. The journal of allergy and clinical immunology In practice. 2016;4(5):823–32. pmid:27587316
- 74. Vrijens B, Dima AL, Van Ganse E, van Boven JF, Eakin MN, Foster JM, et al. What We Mean When We Talk About Adherence in Respiratory Medicine. The journal of allergy and clinical immunology In practice. 2016;4(5):802–12. pmid:27587314