ORIGINAL RESEARCH

 

Inter-professional education unveiling significant association between asthma knowledge and inhaler technique

 

 

Iman A. Basheti¹, Salim A. Hamadi², Helen K. Reddel³

¹ PhD. Associate professor in Clinical Pharmacy. Department of Clinical Pharmacy & Therapeutics, Faculty of Pharmacy, Applied Science University, Amman (Jordan). dr_iman@asu.edu.jo
² PhD. Professor in Clinical Pharmacy. Department of Pharmacology & Biomedical Sciences, Faculty of Pharmacy and Medical Sciences, Petra University. Amman (Jordan). shamadi@uop.edu.jo
³ PhD. Respiratory Physician and Associate Professor. Woolcock Institute of Medical Research, University of Sydney. Sydney, NSW (Australia). helen.reddel@sydney.edu.au

The authors are grateful to the Applied Science Private University Amman, Jordan, for the full financial support granted to this research project (Grant Number DRGS-2013-2014-13).

 

 

---

ABSTRACT

Objectives: To explore whether an association exists between health care professionals’ (HCPs) asthma knowledge and inhaler technique demonstration skills.
Methods: HCPs’ asthma knowledge and inhaler technique demonstration skills were assessed at baseline at an inter-professional educational workshop focusing on asthma medication use. Asthma knowledge was assessed via a published questionnaire. Correct inhaler technique for the three inhalers, the Accuhaler, Turbuhaler and pressurized Metered Dose Inhaler (pMDI) was assessed using published checklists.
Results: Two hundred HCPs agreed to participate: 10 specialists (medical doctors specialized in respiratory diseases) (5%), 46 general practitioners (23%), 79 pharmacists (39%), 15 pharmacists’ assistants (8%), 40 nurses (20%) and 10 respiratory therapists (5%). Backwards stepwise multiple regression conducted to determine predictors of HCPs’ inhaler technique, showed that out of many independent variables (asthma knowledge score, profession, age, gender, place of work, years in practice and previous personal use of the study inhaler/s), asthma knowledge score was the only variable showing significant association with inhaler technique (R²=0.162, p<0.001).
Conclusion: This study revealed significant associations between asthma knowledge and inhaler technique scores for all HCPs. Providing inter-professional workshops for all HCPs involved integrating education on asthma knowledge and practice of inhaler technique skills are looked-for.

Key words: Nebulizers and Vaporizers; Asthma; Health Knowledge, Attitudes, Practice; Interprofessional Relations; Jordan.

---

 

Introduction

Asthma is a chronic condition that has no cure, and it continues to impact on the health of millions of people, both worldwide (prevalence 5-10%)¹ and in Jordan (prevalence 8.8%).² Several inhaler devices have been developed; pressurized Metered Dose Inhaler (pMDIs) and the commonly used dry powder inhalers (DPI): the Accuhaler (ACC) and the Turbuhaler (TH).

Despite well-established management guidelines and ability of preventative asthma inhaler therapy to control the disease in most cases if used correctly¹, asthma remains a poorly controlled condition among many people.³ One main reason is poor knowledge by patients of asthma treatment and inhaler technique.^4,5 Research in the primary health care setting indicates that educating patients in correct use of their inhalers results in mastery of good inhaler technique and improved asthma control.^6-8

In clinical practice, it is important to maximize the opportunities to deliver this education across the spectrum of the primary health care setting, therefore, every health care professional (HCP) involved in asthma management needs to take the opportunity to educate asthma patients and reinforce key messages about their disease and its treatment.^1,9 HCPs can play an important role in delivering inhaler technique education to asthmatic patients.^10-13

However, many HCPs do not have the needed skills to deliver correct education to their asthmatic patients.³ Incorrect inhaler technique has been reported among pharmacists^3,14, nurses¹⁵, respiratory specialists and general practitioners.¹⁶ Problems with inhaler technique were found with both pMDIs and DPIs.^16,17 A resolution to this problem, starting with the HCP, is necessary.¹⁶

Both knowledge and skills are important concepts that describe HCPs’ competence in the world of clinical practice.¹⁸ Knowledge refers to learning concepts, principles and information regarding a particular subject(s), while skill refers to the ability of using information and applying it in a specific context.¹⁸ Competence is achieved when HCPs posses the knowledge and skills required to provide direct care to patients.^19,20 We suspect that better knowledge predicts better skills, but in the world of asthma, does better asthma knowledge predict better inhaler technique demonstration skills?

In light of this, the primary aim of this study was to explore the association between asthma knowledge and inhaler technique demonstration skills during an inter-professional educational program. The secondary aim included assessing how HCP characteristic (age, gender, years in practice, professional group, place of work (reflecting socio-economic status) and personal use of asthma devices) impact inhaler skills. Results of the impact of the workshop on HCP inhaler technique skills are reported elsewhere.²¹

 

Methods

HCPs from Amman, Jordan, were approached for participation in this cross sectional study during an eight month period (March-November 2009). Medical respiratory specialists (physicians specializing in management of airways disease), general physicians (GP), pharmacists, pharmacists’ assistants, nurses and respiratory therapists were invited into the study. The study was approved by the Ethics Committee at the Jordan University Hospital. The HCPs were recruited from hospitals (public and private) and community pharmacies in the capital, Amman. HCPs involved in asthma management or education (medical respiratory specialists, general physicians (GP), pharmacists, pharmacists' assistants, nurses and respiratory therapists) were selected randomly to be approached about the study, using a complete HCP lists provided by the relevant professional societies and random number generator. HCPs who agreed to participate signed informed consent. They were invited to attend an educational workshop, designed in accordance with a model previously developed and validated by one of the authors (IB).¹⁰ The workshop was delivered by a certified asthma educator (IB) who has delivered this workshop previously on several occasions to HCPs in Australia, University of Sydney.¹⁰ Inclusion criteria included current practice at a community pharmacy or hospital located within the Amman area, and not being involved in any other clinical study. Questionnaires regarding HCPs’ demographic characteristics (age, gender, years of experience, receiving previous education on inhaler technique demonstration skills, time since last education on inhaler demonstration skills (years, mean, SD), profession (specialist, GP, Pharmacist, Pharmacist assistant, nurse, respiratory technician) were then completed by the participants.

Participants were also asked to self - complete a HCP asthma knowledge questionnaire (HQ) and a consumer asthma knowledge questionnaire (CQ). The HQ comprised 18 true/false questions about asthma and its treatment, as published by Kritikos et al.²² Question 12 was omitted as it involves an incentivized GP program specific to Australia; the HQ score is therefore presented as mean score (SD) out of 17. The CQ comprised 12 true/false questions about asthma and its treatment directed for consumers, with the score presented as mean score (SD) out of 12. Hence, the attributed score included one point for a true response with maximal (highest) score of respectively 17 and 12, respectively.

All questionnaires were administered in English since English is the official language of education for all HCPs in Jordan.

Inhaler technique assessment was completed using previously published methods (Table 1).¹⁰ Three inhalers were included in this study: Accuhaler (ACC, also known as Diskus), Turbuhaler (TH) and pMDI. Each of the checklists comprised 9 steps. The participant’s inhaler technique was assessed using placebo inhalers. Participants were given a score out of 9, corresponding to the number of steps correctly completed. During the workshop, participants took it in turns to act as the HCP and as the patient, so they could practice teaching patients correct inhaler technique.

 

 

All HCPs were then invited to attend an educational workshop on asthma management. The workshop was repeated over two evenings at the Ibn Al-haitham hospital in Amman. The workshop environment satisfied the requirements for a good learning environment.²³ The workshop costs were sponsored by AstraZeneca Jordan. GlaxoSmithKline provided placebo inhalers and peak flow meters. A summary of the learning techniques, time and content of each segment of the workshop is provided in the online supplement - Table 1.

Data analysis

Data were analyzed using the Statistical Package for Social Science (SPSS) version 20. For continuous variables: inhaler technique mean scores (out of 9), and asthma knowledge mean scores; comparisons between groups were performed by Independent Sample T test or Mann-Whitney U test, depending on the normality of distribution. Comparisons between groups were performed by One-way ANOVA. Preliminary checks to insure that there was no violation of the assumptions (normality, linearity, homogeneity of variance, homogeneity of regression slopes and reliable measurement of the covariate were performed. Proportional data were analyzed using Pearson's Chi-Square test (or Fisher's exact test).

Associations between inhaler technique demonstration skills and asthma knowledge scores (HQ and CQ scores) were investigated using Pearson Correlations.

Backwards stepwise multiple regression was conducted in order to determine predictors of HCPs’ inhaler technique (average score over the three inhalers) as the dependent variable and the following independent variables: asthma knowledge average score (a score out of one for each participant, as total score over the two questionnaires (HQ (score=17) and CQ (score=12)) was divided by 29), profession, age, gender, place of work (hospital or community), years in practice and previous personal use of the study inhaler/s.

For all statistical analyses, p-values of 0.05 or less were considered significant. No multiplicity adjustment was made.

 

Results

A total of 496 HCPs were invited to participate in this study. Two hundred HCPs (40%) agreed to participate: 10 respiratory specialists (referred to as specialists later on) (5%), 46 GPs (23%), 79 pharmacists (39%), 15 pharmacists’ assistants (8%), 40 nurses (20%) and 10 respiratory therapists (5%). Participants were from different hospitals and community pharmacies in Amman/Jordan, located equally in higher socio-economic and lower socio-economic areas. Participants were also distributed equally between education, public and private hospitals.

The majority of specialists, GP and respiratory therapists were males (specialists 100%; GPs 72%; respiratory therapists 80%), while the majority of pharmacists, pharmacist assistants and nurses were females (pharmacist 63%; Pharmacist assistant 60%; nurse 77%).

Nurses were the youngest amongst the group (mean age 28.7; SD=5.7) followed by the GPs (30.7; SD=5.6), then the pharmacists (33.6; SD=8.4) and pharmacist assistants (33.7; SD=9.5). Respiratory technicians (40.7; SD=11.0) and specialists (44.7; SD=7.5) were the oldest amongst the group.

Majority of specialists and respiratory therapists received previous education on inhaler technique demonstration skills (specialist =96.67%, respiratory therapists=100%). As for the other HCPs, many never received such education (nurses=32.67%, GPs=48.33%, pharmacists=52.67%, Pharmacist assistants=58.0%). As for the time since last education on inhaler use (years, mean; SD), nurses had the most recent education (2.13; SD=0.33), followed by the GPs (2.93; SD=0.53), pharmacist assistants (5.13; SD=1.77), pharmacists (5.43; SD=0.87), respiratory therapists (7.17; SD=2.03) and specialists (10.67; SD=1.62). No significant correlation between years since last inhaler technique education, and inhaler technique scores was found for the pMDI (r=0.246, p=0.11), the TH (r=0.058, p=0.59) or the ACC (r=0.139, p=0.21).

Many of the HCPs were themselves using or had used inhalers for treating themselves or their close family members (specialists (6; 60%); nurses (5; 13%); GPs (12, 26%); pharmacists (17; 22%); pharmacist assistants (4; 27%); respiratory therapist (4; 40%). No significant difference in inhaler score (average score for the TH, ACC and pMDI) was found between HCPs who reported previous personal use of the inhaler/s (mean 5.88; SD=0.97) and those who did not (5.84; SD=0.60); p=0.528, Mann Whitney U-Test). As for asthma knowledge (average score out of 1), previous personal use showed a significant difference in asthma knowledge average score between HCPs who reported previous personal use (mean 0.72; SD=0.12), and those who did not (0.65; SD=0.126), p=0.001, Mann Whitney U Test.

For asthma knowledge (HQ score out of 17)²², significant variation between HCPs was found (p<0.001, One way ANOVA), with specialists scoring the highest (12.20; SD=2.70), and nurses scoring the lowest (7.95; SD=2.29) (Table 2).

 

 

For the CQ knowledge (score out of 12), there was also a significant difference between HCPs (p<0.001, One way ANOVA), with physicians scoring the highest followed by the respiratory therapists, while nurses scored the lowest here (Table 2).

Significant association between place of work and HQ (p<0.001) scores and CQ scores (p<0.001) was found. HCPs recruited from the ‘private/medium socio-economic status’ and ‘educational/public/medium socio-economic status’ hospitals performed significantly better than HCPs recruited from ‘private/high socio-economic’ or ‘public/low socio-economic’ status hospitals. Inhaler technique scores were also significantly different across the hospitals (p<0.001), showing similar results to asthma knowledge (online supplement - Table 2).

Table 3 provides a detailed description about the proportion of HCPs that answered each of the questions in the HQ and CQ questionnaires correctly.

A strong association was found between HCPs’ scores for the HQ and CQ asthma knowledge questionnaires (r=0.345, p<0.001 Pearson correlation).

Results of backwards multiple regression showed that the final model (R²=0.162, p<0.001) for the dependent variable Inhaler technique score (average for ACC, TH and pMDI) with its associated predictors, size and direction of the association (n=200) showed significant association only with asthma knowledge average score (Table 4).

 

 

 

Discussion

This is the first study to investigate associations between asthma knowledge and inhaler technique demonstration skills comparing all HCPs engaged in asthma patient education. The study reveals a strong association between inhaler technique demonstration skills and asthma knowledge, indicting perhaps the importance of optimizing knowledge in order for good inhaler technique skills to be maintained. We previously communicated the positive impact of this inter-professional education focused on inhaler technique use, involving the specialists, pharmacists, pharmacist assistants, respiratory therapists and nurses. The education not only optimized the HCP’s inhaler technique skills, but also maintained it over long term.²¹

To the best of our knowledge, this is the first study that provides a detailed comparison between the different HCPs with regards to their answers to the individual questions in the HQ and CQ questionnaires. It highlights the pitfalls in asthma knowledge practiced by the different health professionals. These identified pitfalls are important in designing future educational workshops on asthma management.

The HCP asthma knowledge questionnaire (HQ) and consumer asthma knowledge questionnaire (CQ) used in this study contain questions about asthma and its treatment for HCPs and consumers respectively.²² They were considered to be more suitable for this study population than other, more recent, questionnaires, which were directed at specific groups such as teachers of elementary schools²⁴, healthcare workers with occupational asthma²⁵, or adult asthma patients and parents/guardians of children with asthma in non-English speaking countries.^26,27 Strong correlations were found between both HQ and CQ scores. Generally HCPs were able to score higher on the CQ, which is probably due to its content being more consumer based and hence simpler. Both the HQ and CQ are internationally validated asthma knowledge questionnaires used for the assessment of the HCPs involved in this study.²² It is an updated questionnaire with current concepts of asthma and its management based on international asthma management guidelines. Specialists scored highest in answering these questionnaires, which is similar to previous findings.^16,22 As for the CQ, results were consistent with previous findings as well, where respiratory therapist and specialists scored the most in answering the questionnaire.²² This is most likely due to the higher rate of contact between the specialists and respiratory therapists with asthmatic patients. Specialists in Jordan have a system to identify patients with poor inhaler technique and are engaged in inhaler technique education.²¹ Also, patients reported that they obtain education on inhaler technique most commonly from their specialist (69%) followed by the hospital clinic (respiratory therapist) (49%).²⁸ This is different to the case in many countries, where specialists do not have time to provide inhaler technique education to patients. This could also be due to variations in the health system and the professional curricula between the countries.

Nurses have a critical role in educating patients on correct inhaler technique and in assessing potential barriers to successful learning of technique by the patients.²⁹ Although they are a key component of patient education in the hospital, this study showed that they lack adequate knowledge of asthma medications.¹⁷ In Jordanian hospitals, nurses are the only HCPs that can have stretched interactions with the inpatients. Similar to previous studies^15,17, nurses performed poorly in this study signifying poor asthma knowledge and inhaler technique demonstration skills. This is alarming considering their vital role in this area. Considering that only about a third of the nurses in this study ever received education on inhaler technique, which was more than 2 years before this study, these results are not surprising and call on the policy makers to introduce continuous educational programs in hospitals regarding asthma management.

Pharmacists in this study also scored fairly low on both the HQ and CQ questions, especially questions pertaining to medication use. Studies have shown that solutions at the University level are needed to address these weaknesses in pharmacists/pharmacy students.³⁰ Recent results have shown that the current standard educational training on correct use of inhalers in a representative Jordanian Faculty of Pharmacy is missing the practice element. The majority of pharmacy students (78%) reported that lack of practice with inhaler devices and insufficient training with real asthma patients is a primary barrier to demonstrating correct inhaler technique. Follow-up studies showed that engaging pharmacy students with real asthma patients in a simulated scenario involving correct device technique education resulted in better device technique demonstration skills among students.³¹ Hence, hands-on-training with the inhaler devices, for pharmacists/pharmacy students and nurses/nursing students are needed for better demonstration skills of inhaler technique.^3,21

Knowledge refers to theory and skill refers to successfully applying knowledge in practice. Unveiling the significant association between asthma knowledge and inhaler technique skills opens new perspectives in the world of HCP’s inhaler technique demonstration skills. Asthma knowledge (average score across both the HQ and CQ questionnaire scores) was the only variable that showed association with HCP’ inhaler technique score (average score across the three inhaler devices). Hence, based on this significant association identified in this study, optimizing both asthma knowledge and inhaler technique skills is vital.

Acquiring of knowledge and skills in asthma management and proper inhaler technique is expected to be extrapolated to direct patient care, as previous studies have shown that improved inhaler technique demonstration skills by pharmacists and nurses following training can result in an increase in inpatients having their inhaler technique assessed and corrected³², and improved asthma outcomes.^6,8 Other studies have shown that acquiring knowledge and skills on correct inhaler technique improves confidence and willingness to perform patient inhaler technique education.¹⁰

Inhaler specific checklists (Table 1) were used in inhaler technique assessment for the three devices, TH, ACC and pMDI. Each of the checklists was comprised of 9 steps, giving each participant a score out of 9 corresponding to the number of steps correctly completed. Not all of the steps in these checklists are as likely to have the same clinical impact³³; for example, step 4 in the TH checklist (exhale to residual volume) is not as critical as step 2 (hold inhaler upright (during priming)). However, in this study, all of the steps were given equal weight because HCPs need to demonstrate all steps associated with inhaler administration correctly and in the correct order, in order to educate patients properly on correct inhaler technique.¹⁰

This research poses a number of challenges. Most significant is the small proportion of some of the HCPs who agreed to participate in the study and eventually attend the workshop. A more balanced proportion of participants from the various disciplines would have made the comparisons between the various groups of HCPs more expressive. However, this is challenging due to the original differences in the number of HCPs in the various settings in Jordan. As the data of the questionnaires was dependent on self-reporting by participants, inaccuracies maybe inherent due to social desirability bias and the potential for misinterpreting questions. However, this was minimized by establishing face and content validity, piloting the questionnaire prior to distribution and making it anonymous. The study focuses on the Jordanian population, however, due to the focus of the study (educational technique with related factors influencing aerosol therapy in asthma control) being a reality in other countries as well, results can be extrapolated to other populations. Most asthma guidelines recommend the use of a spacer with the pMDI, but HCPs also need to be able to train patients in use of a pMDI alone (e.g. for use of short-acting bronchodilators); in this study, pMDI technique was only assessed without a spacer. It would be useful to also check HCP technique with pMDI and spacer. Finally, although inhaler technique assessment was based on previously published methods^10,11, no universal accordance on the steps (and critical steps) of good inhaler technique, specifically for pMDIs, is yet found.³³

 

Conclusions

Significant association between asthma knowledge and inhaler technique demonstration skills was unveiled through the inter-professional educational program conducted in this study. Poor asthma knowledge among HCPs could be a potential cause to loosing inhaler technique demonstration skills quicker over time. Optimizing asthma knowledge with inhaler technique demonstration skills periodically may both be needed for inhaler technique demonstration skills to be maintained. This paper presents novel important findings that can propose desired strategies to optimizing inhaler technique demonstration skills within the inter-professional domain.

 

Acknowledgements

We would like to acknowledge Dr Eyad Qunaibi and Pharmacist Noor Al-Saraj for their role in conducting this research. This study was funded by the Deanship of Academic Research, Applied Sciences University, Amman, Jordan. The authors wish to thank the health care professionals who participated in this study.

 

Conflict of interest

HKR has been a member of the Advisory Boards for AstraZeneca, GlaxoSmithKline, Novartis and Boehringer Ingelheim; Chair of the data safety monitoring board for AstraZeneca, GlaxoSmithKline Merck and Novartis; provided consulting for AstraZeneca and GlaxoSmithKline; prepared and delivered independent medical presentations for AstraZeneca, GlaxoSmithKline, Mundipharma, Novartis and Teva; and has received unrestricted research grants from AstraZeneca and GlaxoSmithKline for investigator-sponsored research. As for the other authors, no financial or other potential conflicts of interest exist.

 

References

1. Global Initiative for Asthma (GINA) - Global strategy for asthma management and prevention 2014. Available at: http://www.ginasthma.org (accessed 1 September 2014).         [ Links ]

2. 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 Asthma Proc. 2009;30(2):181-185. doi: 10.2500/aap.2009.30.3208.         [ Links ]

3. Basheti IA, Qunaibi E, Bosnic-Anticevich SZ, Armour CL, Khater S, Omar M, Reddel HK. User error with Diskus and Turbuhaler by asthma patients and pharmacists in Jordan and Australia. Respir Care. 2011;56(12):1916-1923. doi: 10.4187/respcare.01205.         [ Links ]

4. British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax 2014; 69(Suppl 1):1-192.         [ Links ]

5. National Heart Lung and Blood institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/02_sec1_intro.pdf (accessed 1 May 2014).         [ Links ]

6. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007;119(6):1537-1538.         [ Links ]

7. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, Serra M, Scichilone N, Sestini P, Aliani M, Neri M; Gruppo Educazionale Associazione Italiana Pneumologi Ospedalieri. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930-938. doi: 10.1016/j.rmed.2011.01.005.         [ Links ]

8. 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 Educ Couns. 2008;72(1):26-33. doi: 10.1016/j.pec.2008.01.014.         [ Links ]

9. Bosnic-Anticevich SZ, Stuart M, Mackson J, Cvetkovski B, Sainsbury E, Armour C, Mavritsakis S, Mendrela G, Travers-Mason P, Williamson M. Development and evaluation of an innovative model of inter-professional education focused on asthma medication use. BMC Med Educ. 2014;14:72. doi: 10.1186/1472-6920-14-72.         [ Links ]

10. Basheti IA, Armour CL, Reddel HK, Bosnic-Anticevich SZ. Long-term maintenance of pharmacists' inhaler technique demonstration skills. Am J Pharm Educ. 2009;73(2):32.         [ Links ]

11. 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. J Asthma. 2010;47(3):251-256. doi: 10.3109/02770900903580843.         [ Links ]

12. McCarty K, Rogers J. Inpatient asthma education program. Pediatr Nurs. 2012;38(5):257-262.         [ Links ]

13. Lehr AR, McKinney ML, Gouin S, Blais JG, Pusic MV, Ducharme FM. Development and pretesting of an electronic learning module to train health care professionals on the use of the Pediatric Respiratory Assessment Measure to assess acute asthma severity. Can Respir J. 2013;20(6):435-441.         [ Links ]

14. Adnan M, Karim S, Khan S, Al-Wabel NA. Comparative evaluation of metered-dose inhaler technique demonstration among community pharmacists in Al Qassim and Al-Ahsa region, Saudi-Arabia. Saudi Pharm J. 2015;23(2):138-142. doi: 10.1016/j.jsps.2014.06.007.         [ Links ]

15. Giner J, Roura P, Hernández C, Torrejon M, Peiro M, Fernández MJ, Lopez de Santa María E, Gimeno MA, Macian V, Tarragona E, Plaza V. Knowledge and Attitudes of Nurses in Spain about Inhaled Therapy: Results of a National Survey. J Aerosol Med Pulm Drug Deliv 2015, (Epub ahead of print).         [ Links ]

16. Barthwal MS, Pethe MP. Study of asthma management practices among general practitioners and physicians in and around Pune city. J Indian Med Assoc. 2013;111(12):840-844.         [ Links ]

17. De Tratto K, Gomez C, Ryan CJ, Bracken N, Steffen A, Corbridge SJ. Nurses' knowledge of inhaler technique in the inpatient hospital setting. Clin Nurse Spec. 2014;28(3):156-160. doi: 10.1097/NUR.0000000000000047.         [ Links ]

18. Hodges B, Inch C, Silver I. Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950-2000: a review. Am J Psychiatry. 2001;158(10):1579-1586.         [ Links ]

19. American College of Clinical Pharmacy, Burke JM, Miller WA, Spencer AP, Crank CW, Adkins L, Bertch KE, Ragucci DP, Smith WE, Valley AW. Clinical pharmacist competencies. Pharmacotherapy. 2008;28(6):806-815. doi: 10.1592/phco.28.6.806.         [ Links ]

20. Casset A, Meunier-Spitz M, Rebotier P, Lefèvre H, Barth C, Heitz C, de Blay F. Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey. J Asthma. 2014;51(9):964-973. doi: 10.3109/02770903.2014.936446.         [ Links ]

21. Basheti IA, Qunaibi E A, Hamadi SA, Reddel HK. Inhaler technique training and health-care professionals: effective long-term solution for a current problem. Respir Care. 2014;59(11):1716-1725. doi: 10.4187/respcare.02671.         [ Links ]

22. Kritikos V, Krass I, Chan HS, Bosnic-Anticevich SZ. The validity and reliability of two asthma knowledge questionnaires. J Asthma. 2005;42(9):795-801.         [ Links ]

23. Caffarella RS. Planning programs for adult learners. A practical guide for educators, trainers and staff developers. 2nd ed. San Francisco, CA: Jossey-Bass; 2002.         [ Links ]

24. González Diaz SN, Cruz AA, González González AY, Félix Berumen JA, Weinmann AM. Validation of a knowledge-questionnaire about asthma applied to teachers of elementary school of Monterrey, Mexico. Rev Alerg Mex. 2010;57(2):44-49.         [ Links ]

25. Delclos GL, Arif AA, Aday L, Carson A, Lai D, Lusk C, Stock T, Symanski E, Whitehead LW, Benavides FG, Antó JM. Validation of an asthma questionnaire for use in healthcare workers. Occup Environ Med. 2006;63(3):173-179.         [ Links ]

26. Borges MC, Ferraz E, Pontes SM, Cetlin Ade C, Caldeira RD, Silva CS, Araújo AC, Vianna EO. Development and validation of an asthma knowledge questionnaire for use in Brazil. J Bras Pneumol. 2010;36(1):8-13.         [ Links ]

27. Rodríguez Martínez C, Sossa MP. Validation of an asthma knowledge questionnaire for use in parents or guardians of children with asthma. Arch Bronconeumol. 2005;41(8):419-424.         [ Links ]

28. Basheti IA, Obeidat NM, Ammari WG, Reddel HK. Associations between inhaler technique and asthma control among asthma patients using pressurised MDIs and DPIs. Int J Tuberc Lung Dis 2016; 20 (5): In Press.         [ Links ]

29. Lareau SC, Hodder R. Teaching inhaler use in chronic obstructive pulmonary disease patients. J Am Acad Nurse Pract. 2012;24(2):113-120. doi: 10.1111/j.1745-7599.2011.00681.x.         [ Links ]

30. Basheti IA, Natsheh AI, Ammari WG, Khater S, Qunaibi EA, Bosnic-Anticevich SZ. Education on Correct Inhaler Technique in Pharmacy Schools: Barriers and Needs. Trop J Pharm Sci. 2015;14(4):1319-1326.         [ Links ]

31. Basheti IA. The effect of using simulation for training pharmacy students on correct device technique. Am J Pharm Educ. 2014;78(10):177. doi: 10.5688/ajpe7810177.         [ Links ]

32. Nguyen YBN, Wainwright C, Basheti IA, Willis M, Bosnic-Anticevich SZ. Do Health Professionals on Respiratory Wards Know How to Use Inhalers? J Pharm Pract Res 2010;40(3):214-219. doi: 10.1002/j.2055-2335.2010.tb00541.x.         [ Links ]

33. Basheti IA, Bosnic-Anticevich SZ, Armour CL, Reddel HK. Checklists for powder inhaler technique: a review and recommendations. Respir Care. 2014;59(7):1140-1154. doi: 10.4187/respcare.02342.         [ Links ]

34. Melani AS, Zanchetta D, Barbato N, Sestini P, Cinti C, Canessa PA, Aiolfi S, Neri M; Associazione Italiana Pneumologi Ospedalieri Educational Group. Inhalation technique and variables associated with misuse of conventional metered-dose inhalers and newer dry powder inhalers in experienced adults. Ann Allergy Asthma Immunol. 2004;93(5):439-446.         [ Links ]

35. Caffarella RS. Planning programs for adult learners. A practical guide for educators, trainers and staff developers. San Francisco: Jossey-Bass; 2002. ISBN: 978-0470770375.         [ Links ]

 

 

Received (first version): 25.12.15
Accepted: 04.03.16