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 Table of Contents  
Year : 2018  |  Volume : 15  |  Issue : 4  |  Page : 207-212

The competence of community pharmacists in Lagos, Nigeria, on correct inhaler techniques

1 Department of Medicine, College of Medicine, University of Lagos; Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Medicine, Obafemi Awolowo University, Ile-Ife, Nigeria

Date of Web Publication3-Dec-2018

Correspondence Address:
Dr. Obianuju B Ozoh
Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcls.jcls_42_18

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Background and Objectives: Community pharmacists are in an excellent position to train asthma patients on inhaler techniques. Their competence in the use of these devices contributes to the effectiveness of their training. We aimed to evaluate the knowledge and competence in the use of various inhaler devices among community pharmacists in Lagos, Nigeria. Subjects and Methods: This was a cross-sectional study using standard checklists and dummy devices to evaluate the competence of pharmacists on the use of the metered-dose inhaler (MDI), Diskus, Turbuhaler, and the MDI with spacer. Results: There were 42 participants, 66.7% male and median age of 40.5 (interquartile range: 34.6–50.0) years. All were familiar with the MDI, 60%, 7%, and 5% were familiar with the Diskus, Turbuhaler, and the spacer, respectively. The mean checklist scores on the MDI and Diskus were 5.3 ± 3.0 and 2.3 ± 3.3 (maximum 11), respectively. One participant performed all the steps correctly on either device. Only one participant scored a point on the Turbuhaler, and the mean score for the spacer was 0.8 ± 2.9 (maximum 13). No participant performed all the steps correctly on either the Turbuhaler or the spacer. Previous training on inhaler technique was the only independent determinant of better performance on the MDI (odds ratio 0.44; 95% confidence interval 0.97–4.74). Conclusion: The competence of community pharmacists in Lagos, Nigeria, on inhaler techniques is poor. Their awareness of the Diskus, Turbuhaler, and spacer devices is also very low. Educational interventions are needed to improve competence in correct use of inhalers among pharmacists to enable them effectively play their role in asthma care.

Keywords: Asthma, inhaler technique, Nigeria, pharmacist

How to cite this article:
Ozoh OB, Omogie H, Obaseki DO, Dosu AO. The competence of community pharmacists in Lagos, Nigeria, on correct inhaler techniques. J Clin Sci 2018;15:207-12

How to cite this URL:
Ozoh OB, Omogie H, Obaseki DO, Dosu AO. The competence of community pharmacists in Lagos, Nigeria, on correct inhaler techniques. J Clin Sci [serial online] 2018 [cited 2022 Aug 18];15:207-12. Available from: https://www.jcsjournal.org/text.asp?2018/15/4/207/246766

  Introduction Top

There is a high burden of asthma in Nigeria with about one in every ten adolescent or adult estimated to have asthma.[1],[2],[3],[4],[5] This burden is made worse by a high rate of poorly controlled asthma which ranges from 52% to 83% compared to 45% in developed countries.[5],[6],[7],[8],[9]

Inhaled medications are the cornerstone of asthma management due to their fast onset of pharmacological action, lower systemic bioavailability, and decreased potential for adverse effects. Poor inhaler technique is associated with the delivery of subtherapeutic doses of medications and leads to poor asthma control.[9],[10],[11]

Poor inhaler technique has been reported frequently among asthma patients in Nigeria and was related to a lack of or inadequate patient training on inhaler technique by health-care providers.[12],[13] Randomized control trials have demonstrated that patients' inhaler technique can be improved by training from health-care professionals (HCPs).[14] However, for patients to gain maximum benefit from training, they need to be trained by HCPs whose own competence meets accepted standards.

It has been reported that many doctors often do not train patients on correct inhaler techniques.[8] Reasons include poor knowledge on correct inhaler technique among the doctors and time constraint.[12],[15],[16] Pharmacists are in an excellent position to educate patients on inhaler technique by virtue of their accessibility and frequent contact with patients during prescription refilling. In developing countries such as Nigeria, pharmacists are also sought by patients to provide primary care. Studies have demonstrated that competent community pharmacists can provide effective training on inhaler technique.[17],[18] Furthermore, the International Asthma Guidelines recommend that pharmacists should form part of the asthma management team, especially with regard to training on correct inhaler technique.[19] Limited data from Africa suggest that the knowledge and competence of pharmacists about various inhaler devices and correct inhaler techniques are inadequate.[20],[21],[22] The current curriculum in pharmacy schools in Nigeria does not emphasize training on inhaler techniques, and continuing medical education (CME) programs on asthma also do not prioritize training on inhaler techniques.

We conducted this pilot survey as part of an asthma education initiative for health-care workers to evaluate the knowledge and competence of community pharmacists regarding correct inhaler techniques for the commonly available inhaler devices used in asthma management in Nigeria.

  Subjects and Methods Top

This was a cross-sectional study conducted among community pharmacists attending CME programs on respiratory infections and marketing strategy at two locations in Lagos. We obtained prior ethical approval for the study from the Health Research Ethics Committee of the Lagos University Teaching Hospital and all participants provided informed consent.

We regarded competence in the use of a device as knowledge of the device and ability to perform all the steps correctly in the use of the device.

First, we used a self-administered questionnaire that obtained sociodemographic information including the highest educational qualification and number of years in practice as a pharmacist. They also provided information on how frequently they dispensed inhalers and if they provided instruction to patients on correct inhaler technique. The questionnaire also obtained information of prior training on correct inhaler techniques and the types of inhaler devices they were aware of and familiar with. We pretested the questionnaire among a group of pharmacists in the hospital before use.

Second, we used a guideline-recommended checklist to assess their competence on correct inhaler technique using dummy devices to assess their performance in the use of each device.[23] We assessed their performance on the metered-dose inhaler (MDI), the Accuhaler/Diskus dry powder inhaler (DPI), the Turbuhaler DPI, and the MDI with a spacer. They demonstrated the use of each of the devices while providing a running commentary on the instruction they would give to the patient for each step. We noted the critical steps for each device, for which incorrect performance would lead to little or no medication reaching the lungs.[24] Each omitted or wrongly demonstrated step received a score of 0, while each correctly performed step received a score of 1.

After all the participants had completed the study, we demonstrated the correct steps on all the devices.

Data analysis

We summed up all the correct scores on each device to obtain total score for that device. Total scores were also expressed as means and standard deviations (SDs) and percentages based on the maximum obtainable score. Higher scores indicate better performance and competence in the use of each device. The maximum score obtainable for the correct performance of all the steps in the use of the MDI and Accuhaler/Diskus was 11, respectively, 9 for the Turbuhaler and 13 for the MDI with spacer. We used univariate and multivariate regression to explore the association between the total scores and sociodemographic variables. P < 0.05 was considered as statistically significant for all associations.

  Results Top

A total of 42 community pharmacists participated in the study and 28 (66.7%) were male. Their age ranged from 26 to 76 years and the median age was 40.5, interquartile range (IQR) 34.6–50.0. All participants had basic pharmacy degree and 6 (14.3%) had additional nonpharmacy qualifications (business or public health). The number of years since qualification as a pharmacist ranged from 1 to 37 years and the median (IQR) was 12.0 (5.8–21.5).

There were 69% participants who dispensed inhalers to patients on a regular basis, at least once weekly. A high proportion (78%) offered some form of training on inhaler use to patients while dispensing the medication. However, 45% only did so when asked by the patient. Only 28.6% of participants had received any prior training on inhaler technique.

All participants were aware of and familiar with the MDI; 60%, 7%, and 5% were aware of the Diskus, Turbuhaler, and the spacer device, respectively.

Use of the metered-dose inhaler

The proportion of participants who demonstrated the steps correctly on the use of the MDI is shown in [Table 1]. None of the steps was performed correctly by all participants. Of the five critical steps on the use of the MDI, the steps on coordination between the start of slow inspiration and activation of the canister (Step 4) and continuing to take a deep breath (Step 5) were the least correctly performed steps. Over 80% removed the cap (Step 1) and about 66% shook the inhaler properly before use (Step 2). The maximum total score obtainable on the MDI was 11 and their scores ranged from 0 to 11. The mean score ± SD was 5.3 ± 3.0 and this corresponds to about 48.2% correct performance on the MDI. Three participants (7.1%) scored 0 and only one participant (2.4%) had a score of 11 (able to demonstrate all steps correctly). About 67.6% of all participants scored ≥6 corresponding to about 55% performance.
Table 1: Proportion of participants with correct techniques on the steps in the use of the metered-dose inhaler

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We assessed the determinants of the total score on the use of the MDI both in univariate and multivariate regression models [Table 2]. Previous training on inhaler techniques (odds ratio [OR] 0.4 [95% confidence interval (CI]) 1.01–4.79], P = 0.004) was the only significant determinant of higher scores on univariate analysis. In multivariate analysis, we adjusted for age, sex, and number of years in practice. Previous training on inhaler technique had a weak association with higher scores on the use of the MDI (OR 0.44, 95% CI 0.97–4.74).
Table 2: Multivariate linear regression analysis for the independent determinants of the total performance score on the metered-dose inhaler

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Use of the Diskus

Correct performance on the steps for the Diskus is shown in [Table 3]. None of the steps was performed correctly by all participants. Only one participant (2.4%) performed all the steps correctly with the maximum score of 11 and 24 (57.1%) performed all the steps wrongly and had a score of 0. The mean total score was 2.3 ± 3.3 (median 0, IQR 0–5) corresponding to 20.9% correct performance on the Diskus and 19% had a score ≥6 corresponding to about 55% performance. Of the three critical steps in the use of the Diskus, only about a third could open the device properly and actually get the medication loaded and ready to use (Steps 2 and 3) and about a quarter took an adequate deep and steady breath to get the medication into the lung (Step 6). None of the sociodemographic factors were independently associated with the total performance score on the Diskus.
Table 3: Proportion of participants with correct techniques on the steps in the use of the Diskus

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Use of the Turbuhaler

The performance of the participants on the use of the Turbuhaler is shown is [Table 4]. The maximum score obtainable was 9 and nearly all the participants could not perform any of the steps on the use of this device. The only participant that scored a point could just unscrew the cover to open the device but could not perform any other step.
Table 4: Proportion of participants with correct techniques on the steps in the use of the Turbuhaler

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Use of the metered-dose inhaler with a spacer

Performance of the steps in the use of the MDI with a spacer is shown in [Table 5]. None of the participants got all the steps correctly (13 points). Only four participants scored any points on these devices, one scored 11, another 12, another 8, and another scored 1 (just able to assemble the spacer). About 90.5% scored 0, as they could not assemble the spacer for use. The mean total score was 0.8 ± 2.9.
Table 5: Proportion of participants with correct techniques on the steps in the use of the metered-dose inhaler and spacer

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  Discussion Top

Our findings in this study demonstrate that a wide gap exists in the knowledge and competence of pharmacists about correct inhaler techniques. While most participants were familiar with the MDI, competence in its use was very poor. Familiarity and competence in the use of the Diskus, Turbuhaler, and MDI with spacer were also very poor and many pharmacists had never seen them.

Our findings are similar to the previous reports of low competency regarding correct inhaler technique among pharmacists in different countries and this brings to the fore a gap that exists in asthma care delivery in Nigeria.[20],[21],[22],[25],[26],[27] In a previous study in Nigeria, among hospital pharmacists on the use of the MDI, the baseline mean score (38%) was lower than in our study (48%) despite the possession of additional pharmacy degrees by over 50% of their participants and previous training on inhaler technique in about 40%.[20] We found that previous training on inhaler technique was a major determinant of level of competence, but this suggests that regular training and retraining through the CME programs are more likely to lead to sustained competence. Another study among community pharmacists in Sudan used a mystery patient to evaluate technique for the various inhaler devices (MDI, Diskus, and Turbuhaler) and also found that participants had better awareness and competence with the MDI compared to the other devices and very poor competence with the use of the spacer with the MDI.[22] Unawareness of different inhaler devices for asthma management among pharmacists is likely to contribute to the high rate of poorly controlled asthma in most developing countries because pharmacists are unable to play their role effectively as part of the asthma management team. Previous studies have reported that pharmacists with poor knowledge of correct inhaler techniques often refer patients back to the physician for training.[22],[28] This is very cumbersome for the patients and the doctors and many patients may remain untrained.

The low awareness regarding the Diskus and Turbuhaler in our study is a major concern because most controller medications for asthma management that are readily available in Nigeria are delivered in either of these devices. This may provide some explanation to the reported overuse of rescue medications among asthma patients even when controller medications have been prescribed.[29] Many patients in our experience report that pharmacists dispense reliever medications to them in place of controller medications. The Diskus and Turbuhaler are excellent delivery systems that patients can learn to use easily with training.[27] Drug delivery with the MDI is highly dependent on the accurate performance of the critical steps of actuation with slow and deep inhalation. Most children and some adults find this coordination challenging limiting drug delivery and therapeutic effects of the medication. Use of the MDI with a spacer mitigates this challenge by allowing the person breath normally with enhanced distal delivery of medications.[30] Use of spacers also reduces oropharyngeal deposition of drug which lowers side effects such as oral candidiasis and vocal cord dysfunction which can occur with inhaled steroids.[30] Lack of familiarity with the spacer devices by pharmacists implies that many patients who are unable to use the MDI correctly are not likely to be offered this device.

We recognize that our findings are limited by the relatively small sample size. Therefore, our results may not be generalizable to all pharmacists in Nigeria. However, our findings are similar to reports from other developing countries and bring to the fore the wide gap that exists in the knowledge and competence of pharmacists regarding asthma management. This highlights the need for a strong initiative to provide a potentially effective training to this group of health-care workers.[20],[30],[31] This training can be conducted by incorporating it into the undergraduate pharmacy curriculum skill acquisition workshops or as part of CME programs. The modality for effective training on inhaler techniques has been shown to be by face-to-face demonstration, observation and feedback since reading instructional leaflets is inadequate in developing competence.[32] An important strength in this study is that we assessed competence in all the inhaler devices commonly available in Nigeria and also highlighted the critical steps that ensure adequate drug delivery so as to minimize the bias that may occur by considering total scores alone which can be erroneously high despite missing the critical steps.

  Conclusion Top

The competence of community pharmacists in Lagos, Nigeria, regarding inhaler techniques for asthma management is poor. Awareness of the Diskus, Turbuhaler, and the spacer devices is also very low. The strategic role pharmacists play in the health-care delivery systems should be harnessed in asthma care. This can be achieved by developing educational interventions to improve their competence in correct use of inhalers to enable them effectively play their role in asthma care delivery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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