International Journal of Clinical Pharmacy

https://doi.org/10.1007/s11096-019-00882-8

RESEARCH ARTICLE

Counseling of inhalation medicine perceived by patients and their

healthcare providers: insights from North Cyprus
Onur Gültekin1 · Abdikarim Mohamed Abdi1 · Haider Al‑Baghdadi2 · Mustafa Akansoy3 · Finn Rasmussen4 ·
Bilgen Başgut1

Received: 19 July 2018 / Accepted: 10 July 2019

© Springer Nature Switzerland AG 2019

Abstract
Background In order to achieve patient adherence, individuals require different levels of information. Basic and adequate
information must be provided by different health care providers to patients. Objective To assess the information level of
patients with asthma and chronic obstructive pulmonary disease (COPD) and to determine the source of their information
regarding the medicine they use in addition to their satisfaction, inhalation usage techniques and perception of the informa-
tion providing role of health care professionals. Setting Respiratory disease clinics in Nicosia and Famagusta state hospitals
and community pharmacies in North Cyprus. Method A cross-sectional multicentered observational study was carried out
in respiratory disease clinics and community pharmacies. Patients’ knowledge and healthcare providers’ perceptions of their
roles were evaluated using “The satisfaction with information about medicines scale”. Evaluation of patient’s inhalation
techniques was performed using a validated checklist. Main outcome measure (a) Patients’ knowledge of their medication
and satisfaction with the information provided by health care professionals, (b) the prevalence of critical inhalation mistakes,
(c) health care professionals’ perceptions of their patient counseling practice. Results A total of 110 patients were evaluated,
and 6 physicians and 76 pharmacists were recruited for the interview. The health care professionals reported that they talk
about the action and the use of medicines with the patients. The standardized average patients’ satisfaction score for action
and use was 0.35 (± 0.21), whereas for potential side effects, it was 0.26 (± 0.15). Even though 92% of patients believed
that they use their inhaler properly, 75% of the patients made at least one critical mistake while using the inhalation demo,
which would likely affect the delivery of the medicine to the lungs. Conclusion In spite of health care professionals feel-
ing comfortable with their counseling practices, the majority of patients reported dissatisfaction with the information they
provided about medicine, and three out of four patients were making critical mistakes in the use of inhalers. More effort is
warranted by health care professionals on patient education to limit critical mistakes.

Keywords Asthma · COPD · Cyprus · Health education · Inhalation · Inhalation administration

Impacts on practice

• Gaps in patient education affect the quality of patient

* Abdikarim Mohamed Abdi
daud87@hotmail.com care provided resulting in patient’s dissatisfaction and
critical medication use errors that may negatively impact
1
Faculty of Pharmacy, Near East University, Near proposed outcomes.
East Boulevard, P.O. Box: 922022, Nicosia, • Optimizing patient education role of pharmacists in hos-
North Cyprus, Mersin 10, Turkey
pitals and community settings is necessary to enhance
2
Faculty of Pharmacy, Anadolu University, Eskisehir, Turkey patient satisfaction, minimize errors and achieve partner-
3
Dr. Burhan Nalbantoğlu Hospital, P.O. Box: 922022, Nicosia, ship in the use of medicine between patients and HCPs.
North Cyprus, Mersin 10, Turkey • A need exist for agreement between health professionals
4
Head of Respiratory Disease and Allergy Department, Near on the role and responsibility of each profession in terms
East University Hospital, Near East Boulevard, P.O. Box: of providing education to patients.
922022, Nicosia, North Cyprus, Mersin 10, Turkey

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 International Journal of Clinical Pharmacy

Introduction The aim of the study

Asthma and chronic obstructive pulmonary disease (COPD) The aim of this study is to assess (1) asthma and COPD
are chronic respiratory diseases that have an impact on patients’ knowledge of their medicine and inhalation tech-
patients’ quality of life and result in an economic burden niques, (2) patients’ satisfaction with the information pro-
on the healthcare system. It has been reported that there are vided by HCPs, and (3) HCPs’ perceptions of their infor-
235 million people with asthma and 64 million people with mation providing role in North Cyprus.
moderate COPD globally [1, 2]. In spite of the presence
of effective therapies, the morbidity and mortality rates of
asthma and COPD remain high [1, 2].
Ethics approval
Inhalation medicine has been the main drug delivery
method of bronchodilators and steroids in the care of asthma
Confidentiality was assured during the study for patient’s
and COPD patients for decades [3, 4]. The goal is to mini-
privacy. Ethical approval for this study (YTK1.01-629-
mize the impact of a current exacerbation and to prevent the
18-E.724) was obtained from the Dr. Burhan Nalbantoglu
development of subsequent exacerbations that are associated
State Hospital Ethical Committee. Written informed con-
with emergency visits, hospital admissions and the reported
sent was obtained from all participants. Only initials were
mortality [3–6]. Previous studies have shown that errors in
used during the study, while the patient’s addresses and
inhaler handling are frequent in all types of devices [e.g.,
other nonclinical, personal information was not recorded.
metered-dose inhalers (MDIs), dry-powder inhalers (DPIs)]
The research was conducted in accordance with the Dec-
[7, 8]. In addition to adherence, poor inhalation technique is
laration of Helsinki.
among the major factors that contribute to the poor control
of diseases, since the medication is not effective unless it
reaches the targeted airways [9–15]. Identifying inhaler tech-
nique errors of patients and correcting the errors is a crucial Method
aspect of disease management [16–19]. Patients’ compe-
tency on inhaler device use should be assured by healthcare A cross-sectional multicentered observational study was
providers (HCPs) [16–19]. However, many HCPs claim that carried out in respiratory disease clinics in Nicosia and
they are unable to educate or counsel patients about inhaler Famagusta state hospitals and community pharmacies
device use due to various reasons (e.g., busy clinic hours, in North Cyprus between 01 March and 30 April 2018.
inadequate number of HCPs, etc.) [20–23]. In the first part of the study, asthma or COPD patients
As patient engagement in disease management is impor- using inhalers regularly were invited to an in-person struc-
tant in treating asthma and COPD, patients on discharge are tured interview using a published and validated checklist
eager to acquire information about their treatment in terms to assess their inhaler use technique [30] and a validated
of side effects, risks, duration of therapy, appropriateness questionnaire “The Satisfaction with Information About
of current treatment and other treatment options [24–26]. Medicines Scale” (SIMS) [27] to evaluate the patient’s
An important indicator of the quality of the information knowledge of their medicine and satisfaction with infor-
provided to the patients regarding their therapy is that their mation about medicine obtained from different HCPs and
individual needs are met and patients are satisfied with the other sources. In the second part, a trained pharmacist
given information [27]. Evaluating the level of satisfaction administered the SIMS questionnaire to investigate res-
of patients with medication information is an important piratory specialized physicians’ and community pharma-
component of predicting the quality of patient care provided cists’ perceptions of their information providing role in
and a prerequisite for partnership in the use of medicine their setting.
to achieve proposed outcomes [27]. HCPs have a mutual
responsibility to provide coordinated information about the Patient selection and recruitment
medications [28, 29].
No studies have been carried out in North Cyprus to Upon the patients arrival at their appointment for examina-
evaluate patients’ inhalation techniques and their satis- tion at one of the hospitals, patients who were eligible for
faction with information provided by different healthcare the study were referred by doctors to a clinical research
professionals. pharmacist for the purpose of conducting the interviews.
Adult patients aged over 18 years who had previously been
diagnosed with either asthma or COPD and who were
using inhalers were considered eligible. Patients who were

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unable to read or write as well as those who were severely you satisfied with the information you received about …
sick were excluded. ?”. Patients were asked to rate the amount of information
they were provided using a response scale with the follow-
Patient questionnaires and data collection ing options: “too much”, “about right”, “too little”, “none
received”, “none needed”.
Patients were interviewed using The Satisfaction with Infor- Patients who reported that the information was ‘‘about
mation About Medicines Scale (SIMS) questionnaire. The right’’ or ‘‘none needed’’ were classified as satisfied and
questionnaire contains 17 items. Items 1–9 of this question- scored 1. Patients who reported that the information was
naire assess perceived knowledge and satisfaction of patients ‘‘too much’’, ‘‘too little’’ or ‘‘none received’’ were clas-
regarding the effects and usage of medicines. Items 10–17 sified as dissatisfied and scored 0 [27]. Patients’ responses
assess information regarding possible side effects of the for each item were examined to determine specific types of
medicine [27]. information perceived to be inadequately addressed.
Knowledge was measured using SIMS questions, and In the 8th question of the SIMS, patients were further
patients were asked to “please rate the extent to which you requested to demonstrate how they use their inhalers using
know the following.”. Response categories ranged between placebo devices. The patient’s inhaler use techniques for
“knows” as 3, “partially knows” as 2 and “does not know” each device were assessed through observation using a pre-
as 1. In addition, patients were asked about their source of examined checklist (Fig. 1). This checklist was derived from
information regarding the knowledge as follows: “What is the manufacturers’ recommendations and a previously pub-
the source of information on …?”. Response categories lished inhalation technique evaluation checklist [30]. The
were as follows: physician, pharmacist, both physician Kuder–Richardson (KR-21) Formula was utilized to measure
and pharmacist or other. Finally, patients were asked, “Are the reliability of the checklist tool. The result showed that

Fig. 1  Inhaler checklist [30]. MDI Metered dose inhaler. Bold indicates steps that are critical, for which incorrect performance would lead to lit-
tle or no medication reaching the lungs

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KR21 = 0.89, indicating a homogeneous test. Mistakes in among diagnosis, education and satisfaction scores. The
specific steps in the checklist were considered to be critical Mann–Whitney U test was used to determine the relation
(shown with bold in Fig. 1). Incorrect application of any between gender, duration of treatment and satisfaction
of these steps could cause little or no medication to reach scores. Also, Mann–Whitney U test and Chi squared test
the lungs [31] and thus was considered a critical mistake. were used where relevant to determine differences between
Minor mistakes were defined as those that affect the medica- demographic groups and occurrence of a critical mistake
tion reaching the lungs (e.g., for MDI usage, not breathing during inhaler use demonstration. In addition, the Chi
out before inhaling the medication was considered a minor squared test was used to determine whether using more than
mistake). one type of inhaler results in more critical mistakes than
Translation of both tools from English to Turkish was using only one type of inhaler.
performed according to the guidelines published by Tsang
et al. [32]. To estimate the internal consistency of the tools,
Cronbach’s alpha was calculated. A pilot study with 30 Results
patients was conducted, and the results were analyzed. The
resulting Cronbach’s alpha score was 0.765. The pilot study Study sample
subjects were not included in the study.
Interviews were conducted with 110 patients out of 140
Healthcare provider’s perspective patients approached (79% response rate). Six respiratory
physicians of the 8 currently working in North Cyprus (75%
The perception of the informative role of and practices of response rate) and 76 out of 114 pharmacists (67% response
HCPs was also assessed based on SIMS. All physicians rate) were also interviewed. Patient characteristics are sum-
who specialized in respiratory diseases (a total of 8 special- marized in Table 1.
ists) and were registered with the Cyprus Turkish Medical
Association were invited to participate along with 114 reg- Patient knowledge
istered community pharmacies in the two cities. HCPs were
questioned regarding how often they discussed each of the According to the interviews, the majority of patients per-
SIMS information topics with their patients and what they ceive that they know “how to use your medicines” (92%),
perceived their responsibility to be in discussing these top- “how to get additional supplies” (89%) and “what is their
ics with patients. A 5-point Likert scale (“always”, “often”, medicine called” (59%). Patients also perceive that they
“when asked”, “rarely” or “ never”) was used to collect the are less knowledgeable about potential side effects (74%
HCPs’ answer. The Cronbach’s alpha score for the HCP
SIMS version was 0.839.

Statistical analysis Table 1  Patients characteristics

Characteristics Frequency (%)
The sample size (SS) was calculated using the following
Gender, Male 62 (56)
equation: SS = Z2 × p × (1 − p)/c2, where Z represents the
Mean age (years) ± SD 44.0 ± 19.2
level of confidence (e.g., 1.96 for a 95% confidence level),
Education level
p is the estimated percentage of picking a choice (assigned
Primary school 22 (20)
50%), and c is the desired level of precision, which is 0.05
Middle school 10 (9)
[33, 34]. According to the Health Ministry of North Cyprus,
High school 38 (34.5)
5% of the adult population suffers from asthma and COPD.
University 40 (36.5)
Hence, we estimated that we would be drawing from a popu-
Diagnosis
lation of 11,500 eligible patients and thus it would be nec-
Asthma 91 (83)
essary to include at least 96 patients in the analysis. SPSS
COPD 8 (7)
(Statistical Package for Social Sciences, version 17.0) was
Both 11 (10)
used to conduct statistical analyses. Patient satisfaction
Duration of treatment (month)
scores were standardized so that comparisons could be
1–60 54 (49)
made between the 9-item Action and Usage scale and the
61–120 24 (22)
8-item Potential Problems scale. The Wilcoxon signed-rank
121–240 23 (21)
test was used to compare satisfaction scores of “action and
> 240 9 (8)
usage” with those of “potential problems and side effects”.
Smoker (currently smoking) 42 (38)
The Kruskal–Wallis test was used to determine the relation

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Table 2  Patient-perceived knowledge towards their therapy, source of information and the percentage of satisfied patients for related items
Questions Patients’ perceived knowledge n (%) Patients’ source of information n (%) Satisfied
patient
Knows Partially knows Doesn’t know Doctor Pharmacist Doctor and None Other* (%)
pharmacist

What is your medicine called? 65 (59) 21 (19) 24 (22) 73 (66) 8 (7) 6 (6) 23 (21) – 66
What is each medicine for? 55 (50) 47 (43) 8 (7) 72 (65) – 17 (16) 12 (11) 9 (8) 45
What your medicine does? 36 (33) 45 (41) 29 (26) 29 (26) 2 (2) 7 (6) 45 (41) 27 (25) 16
How does your medicine Works? 15 (14) 30 (27) 65 (59) 34 (30) 4 (4) 6 (6) 63 (57) 3 (3) 17
How long will your medicine take 45 (41) 42 (38) 23 (21) 28 (25) 5 (5) 1 (1) 55 (50) 21 (19) 11
to act?
How can you tell if it is working? 36 (33) 60 (55) 14 (12) 25 (23) 13 (12) 7 (6) 43 (39) 22 (20) 22
How long will you use your 53 (48) 24 (22) 33 (30) 45 (41) 1 (1) – 64 (58) – 31
medications?
Do you know how to use your 101 (92) 8 (7) 1 (1) 49 (44) 23 (21) 21 (19) 1 (1) 16 (15) 45
medicine?
How to get a further supply? 98 (89) 11 (10) 1 (1) 80 (73) 7 (6) 13 (12) 10 (9) – 71
Whether the medicine has any 27 (25) 42 (38) 41 (37) 21 (19) 5 (5) – 59 (53) 25 (23) 12
unwanted effects?
What are the risks of you getting 10 (9) 19 (17) 81 (74) 7 (6) – 2 (2) 100(91) 1 (1) 6
side effects?
What should you do if you experi- 47 (43) 17 (15) 46 (42) 32 (29) 2 (2) 8 (7) 57 (52) 11 (10) 26
ence an unwanted effects?
Whether you can drink alcohol 12 (11) 7 (6) 91 (83) 11 (10) – – 93 (84) 6 (6) 81
with your medicine?
Whether the medicines interfere 9 (8) 6 (6) 95 (86) 9 (8) 2 (2) – 99 (90) – 4
with other medicines
Medications make you feel 40 (36) 14 (13) 56 (51) 6 (6) 8 (7) 3 (3) 67 (61) 26 (23) 10
drowsy?
Whether the medication will 8 (7) 3 (3) 99 (90) 2 (2) – – 99 (90) 9 (8) 57
affect your sex life?
What should you do if you forget 25 (23) 25 (23) 60 (54) 20 (18) 4 (4) 2 (2) 69 (63) 15 (13) 5
to take a dose?

*Other: Source of information is either the internet or patient information leaflets or both

don’t know) and drug interactions (86% don’t know). Patient’s satisfaction
Additional results are provided in Table 2.
Patients were significantly more satisfied with the infor-
mation related to the action and usage of medicine than
Patients’ source of information with information on potential problems of the medicine
(p < 0.001). The standardized average satisfaction score
Patients reported that physicians were more likely than for action and use was 0.35 (± 0.21), whereas for poten-
pharmacists to provide information such as what is the tial side effects, it was 0.26 (± 0.15). Patients reported
medication used for, 81% of the patients said that physi- the highest satisfaction with “how to obtain additional
cians provided this information and 16% said that phar- supplies” and “what is your medicine called” (71% and
macist provided this information (Table 2). Patients also 66%, respectively). The lowest satisfaction scores were
reported that they did not receive any information about reported with “medicines interfere with other medicines”
drug-alcohol interactions from the pharmacists. and “what should you do if you forget to take a dose” (4%
On the other hand, patients reported that they also and 5%, respectively) (Table 2). The study also found that
obtained information about what the medicine does there was no relation between satisfaction score and gen-
(25%), whether the medication caused drowsiness (23%), der, duration of treatment, diagnosis, and education level
and the side effects of the medications (23%) from other of the patients (p = 0.249, p = 0.961, p = 0.258, p = 0.906
resources, such as the internet or patient information leaf- respectively).
lets (Table 2).

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Table 3  Frequency table of types of inhalers that patients use HCPs’ perception
Type of inhaler Frequency Percent (%)
Physician’s perceptions about responsibility in counseling
MDI (alone) 43 39 patients
Diskus (alone) 11 10
Turbuhaler (alone) 4 4 According to the information obtained from the interviews,
Handihaler (alone) 17 15 physicians stated that they talked with patients more fre-
MDI with Diskus 31 28 quently about the effect and use of medicines than about
MDI with Turbuhaler 4 4 potential side effects (p < 0.001). Physicians stated that they
informed patients about the names of medicines used for
treatment, what each medicine does, how to use the medi-
Inhalation techniques cines and how to obtain additional supplies on every visit.
Regarding potential side effects, they expressed that they
Patients participating in the study used four different types occasionally talked to patients about them (Table 4).
of inhalers (Table 3). A total of 68% of patients used a single Most physicians (4 out of 6) thought that they are respon-
inhaler, and 32% used two different inhalers. The most com- sible for informing patients about the action and usage of the
mon inhaler type used was a metered-dose inhaler (n = 78, medications. Only half of them thought that both physicians
71%), and the least common was a turbuhaler (n = 8, 7%). and pharmacists have a mutual responsibility in informing
Even though 92% of patients perceived that they know how patients on potential side effects and warnings.
to use their medications, our assessment showed that only 10
patients (9%) were using inhalers correctly, while 75% of the Pharmacist’s perception about responsibility in counseling
patients made at least one critical mistake during the inhaler patients
use demonstration. The frequencies of the observed mistakes
are shown in Fig. 2. Demographic factors have no significant The majority of pharmacists considered themselves to be
effect on the occurrence of critical mistakes during inhaler responsible for counseling patients in each topic of action-
use (p < 0.05). Regarding making critical mistakes, there was usage and potential problems. In contrast to these percep-
a significant difference between users with only one type tions, pharmacists expressed that in their actual practice,
of inhaler and those with two type inhalers (71% and 97% they counseled patients only when patients asked a ques-
respectively, p < 0.0001). tion about the effects and use of medicines and potential

Fig. 2  Percentage of patients demonstrating inhalation errors for each step of the checklist. *Critical mistakes (shown in Fig. 1)

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Table 4  Frequency table of HCPs role perception and how often they discuss topics with patients
Whose responsibility is it to discuss these topics? Fre- How often do you dis-
quency (%) cuss these topics with
your patients?
Dr Pharm Median (IQR)
Doctor Pharmacist Both Doctor Pharmacist Both Doctors Pharmacists

What is your medicine called? 4 (67) – 2 (33) 24 (32) 9 (12) 43 (56) 5 (0) 4 (1)
What is each medicine for? 4 (67) – 2 (33) 12 (16) 21 (28) 43 (56) 5 (0.5) 4 (2)
What your medicine does? 4 (67) – 2 (33) 6 (8) 30 (40) 40 (52) 5 (0) 4 (1)
How does your medicine Works? 4 (67) – 2 (33) 8 (10) 34 (45) 34 (45) 5 (0.25) 2 (2)
How long will your medicine take to act? 4 (67) – 2 (33) 14 (18) 32 (42) 30 (40) 5 (1.25) 3 (1)
How can you tell if it is working? 4 (67) – 2 (33) 6 (8) 39 (51) 31 (41) 5 (2) 3 (1)
How long will you use your medications? 4 (67) – 2 (33) 23 (30) 17 (22) 36 (48) 5 (0.25) 2 (1)
Do you know how to use your medicine? 3 (50) – 3 (50) 2 (3) 42 (55) 32 (42) 5 (0) 2 (0)
How to get a further supply? 4 (67) – 2 (33) 8 (10) 34 (45) 34 (45) 5 (0) 5 (2)
Whether the medicine has any unwanted effects? 4 (67) – 2 (33) 22 (29) 15 (20) 39 (51) 5 (0) 4 (3)
What are the risks of you getting side effects? 4 (67) – 2 (33) 5 (7) 27 (35) 44 (58) 5 (1.25) 4 (2)
What should you do if you experience an unwanted 4 (67) – 2 (33) 14 (18) 23 (30) 39 (51) 4.5 (2) 2 (2)
effects?
Whether you can drink alcohol with your medicine? 4 (67) – 2 (33) 27 (35) 15 (20) 34 (45) 5 (1) 2 (1)
Whether the medicines interfere with other medicines 3 (50) – 3 (50) 1 (1) 53 (70) 22 (29) 4 (1.25) 4 (2.75)
Medications make you feel drowsy? 4 (67) – 2 (33) 5 (7) 52 (68) 19 (25) 3.5 (2.25) 3 (2)
Whether the medication will affect your sex life? 4 (67) – 2 (33) 3 (4) 51 (67) 22 (29) 2.5 (4) 3 (1.75)
What should you do if you forget to take a dose? 4 (67) – 2 (33) 16 (21) 33 (44) 27 (35) 2 (2) 2 (0)

How often do you discuss with your patients? (1 never, 2 rare, 3 when asked, 4 often, 5 always)
IQR Interquartile range

problems, while some of them provided counseling only if they inform about action and usage of medications only.
the patient came to the pharmacy with a prescription and was However, pharmacists counsel their patients only when
going to use that prescribed drug for the first time (Table 4). patients ask a question regarding their medicine. A study
conducted by Auyeung et al. also reported that patients had
less knowledge about potential problems and side effects of
Discussion drugs and that healthcare professionals discussed this less
frequently with patients [35]. Informing patients about side
This is the first study in North Cyprus that examines effects has some risks. HCPs may avoid talking about the
patients’ inhaler handling techniques and measures their side effects of medications because this may lead to discon-
satisfaction and the perceived role of HCPs. In our study, tinuation of the therapy. The attitudes of HCPs toward edu-
we found that the majority of patients made critical errors cating on side effects were also similar in previous studies
during inhaler use (75%). Also, surveyed patients were not conducted elsewhere on different patient groups [29, 38–42].
satisfied with the information they received about potential This attitude of HCPs may cause dissatisfaction and make
problems and side effects. patients seek other resources. Many patients reported that
The results observed from our study in terms of the they seek information from the internet, patient informa-
knowledge and satisfaction of patients regarding the infor- tion leaflets or other experienced patients. As the quality
mation they received is similar to the findings of other and quantity of information obtained from these resources
studies carried out using the same instrument to measure are not equally standardized, the information received from
patients’ satisfaction [35–39]. Patients had less knowledge some of these resources can negatively affect the treatment
and were not satisfied with the information they received process. Healthcare professionals should provide the nec-
from the HCPs about potential problems and side effects. essary information to patients and direct them to accurate
Most of the patients stated that they largely do not receive resources (Patient information leaflets, official websites, offi-
enough relevant information. Although physicians reported cial drug information resources, etc.) in order to avoid poten-
that they always counsel their patients, yet most of the time tial negative outcomes of biased or inaccurate information.

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Selinger proved in his study that the information obtained integrated in the state hospitals of North Cyprus. In addition
from informal websites did not contribute any positive to receiving physicians’ advice, patients should be counseled
effects towards the treatment of patients, but in fact had a by a pharmacist before they are discharged from hospital.
negative impact [43]. Acquiring the right patient education Studies showed that when patients are educated by clinical
from the right information resource is of utmost importance pharmacist before being discharge from the hospital, this
for the effectiveness of treatments. It has been observed that has a significant effect on patient adherence and therapeutic
sufficient patient education was not achieved because most outcomes [56, 57].
pharmacists were not proactive in delivering patient educa- One of the major limitations of this study is that only six
tion, although some were aware of their responsibility to respiratory disease physicians working in government hospi-
educate patients. tals were surveyed, while 76 pharmacists were interviewed.
To achieve treatment goals in asthma and COPD patients, This difference in numbers limits statistical comparison
assuring patients’ competency in using inhalers is crucial between the two groups. Even though nurses are healthcare
(4, 5). Our study found that 75% of patients make critical professionals, they were excluded in this study because the
mistakes during inhaler use, which is significantly greater outpatients did not have contact with the nurses during their
than the incidence of inhalation errors reported in the litera- clinical visit. Another limitation is due to the prevalence
ture, which ranged between 19.8% and 59% [16, 30, 44–49]. of asthma and COPD. In the study setting less number of
In other studies, while factors such as age, gender, level of COPD patients were surveyed compared to asthma which
education have been found to affect the incidence of criti- may restrain the generalization of results to this population.
cal errors [47–51], in this study it has been observed that Future studies may qualitatively assess the barriers prevent-
these factors have no significant effect on the occurrence of ing effective counseling in pharmacies in North Cyprus.
critical errors during inhaler use. Coordination and inhala-
tion mistakes were found to be frequent and critical in our
study. Other studies had similar findings with MDI use and
proved that such mistakes can cause poor disease control Conclusion
and decrease medication outcomes [16, 44, 45]. Dry-powder
inhalers (Diskus, Turbuhaler, Handihaler) require a differ- In spite of patients’ positive perceptions of their knowl-
ent inhalation technique. Our findings show that the most edge of drug use and HCPs’ satisfaction with their coun-
frequent and critical error with this type of inhaler is the seling practice, three quarters of the patients made at least
method of inhalation. Patients generally inhale with these one critical mistake when using inhalation demonstration
inhalers as if they are breathing normally. This may cause kits. Patients reported that they obtain the least amount of
low deposition of the medication in the lungs. Other studies counseling information from pharmacists, though they are
have also shown the same trend with DPI use and proved generally dissatisfied with information they receive from
that this mistake is critical due to the associated poor dis- HCP. Similarly, pharmacists stated that they mostly provide
ease control and decreased medication outcomes [16, 44, counseling on patient request. Major differences between
45]. It is also important to highlight that the prevalence of the expectations of physicians and pharmacists in patient
making critical mistakes was greater in patients using two education were observed; respiratory physicians play a more
different types of inhalers. Different types of inhalers require prominent role in patient education on medicine, while phar-
different usage techniques. The majority of patients who use macists’ contribution was less visible. Patients also reported
different types of inhalers may not be aware of this, which that they are less satisfied with the information regarding
may explain the increased prevalence of critical mistakes potential side effects. More effort is warranted by HCPs
in this population. To overcome this, it is recommended (especially pharmacists) on patient education to limit critical
prescribing the same type of inhaler devices for relevant mistakes while using inhalers, as the integration of clinical
patients [52–55]. HCPs can also prevent such problems by pharmacy services into government hospitals may further
providing proper and adequate education and training. In improve the quality of patient education and care provided
the long term, HCPs should regularly control and verify to respiratory disease patients.
the patients’ competency on inhaler handling [16]. In the
Acknowledgements The investigators thank all the patients, physicians
state hospitals of North Cyprus, pharmacists working in the and pharmacists who participated in this study. Also, we acknowledge
hospital pharmacy are only responsible for supplying drugs Simon Thompson for the language editing of this manuscript.
to inpatients. They do not provide any other pharmacy ser-
vices. Counseling patients before discharge from the hos- Funding None.
pital by a pharmacist may improve therapeutic outcomes.
To overcome busy clinic hours and share the responsibil-
ity of patient education, clinical pharmacist services can be

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Conflicts of interest The authors declare that they have no conflicts 17. Hammerlein A, Muller U, Schulz M. Pharmacist-led interven-
of interest. tion study to improve inhalation technique in asthma and COPD
patients. J Eval Clin Pract. 2011;17:61–70.
18. Barthwal MS, Katoch CD, Marwah V. Impact of optimal
asthma education programme on asthma morbidity, inhalation
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