Abstract

Background : The main goal of asthma treatment is to control symptoms and reduce emergency department (ED) visits due to acute exacerbations. Drug delivery through inhalation is an important component of asthma management. Patients with asthma should have a good knowledge of their disease to recognize signs of worsening that can be prevented by early detection. Asthma control can be evaluated using the Asthma Control Test (ACT).

Objective: To determine the effect of providing education on the use of inhalers on the degree of asthma based on the ACT in patients at Tanjungpura Regional General Hospital.

Method: This quasi-experimental study conducted from March 2024 to May 2024, used a one-group pre-test and post-test design to evaluate the effect of education via smartphone applications on asthma control (ACT). Obtained 54 patients who were diagnosed asthma at Tanjungpura Regional General Hospital. The sample consisted of asthma patients using inhalers, selected consecutively based on inclusion and exclusion criteria.

Results: Most patients were female (64.8%) with ages 18-60 years (83.3%). The majority were housewives (46.2%). Post-test showed that 75.9% of patients had partial asthma control. All patients (100%) used inhalers correctly after education. There was a significant difference in ACT results before and after education (P-value 0.001) and an increase in ACT scores after the first and second education (P-value 0.002 and 0.001, respectively).

Conclusion: Providing education on the use of inhalers has a positive effect on ACT scores in asthma patients, with an increase in the mean ACT score from 15.67 before education to 17.11 after the first education, and 20.96 after the second education.

Keywords: Asthma, asthma control test, asthma degrees, education, inhalers

INTRODUCTION

A Asthma is a heterogeneous disease usually characterized by chronic airway inflammation. The disease is diagnosed based on a history of respiratory symptoms, such as wheezing, shortness of breath, chest tightness, and coughing that vary in intensity over time along with variable expiratory airflow limitation."[1]

Asthma sufferers as people who have the potential to experience asthma attacks must have a good knowledge of their disease, so that they can recognize signs that indicate the worsening of the disease which can actually be prevented if known early.[6] Therefore, understanding the level of asthma control and the ability of asthma sufferers to detect their level of asthma control at any time is a major problem in achieving a level of asthma that is fully controlled. If patients know clearly what triggers their disease, then they can avoid these triggers and the possibility of asthma attacks can be avoided. If they cannot avoid the triggers then they know what preventive measures to take."[7] The asthma control test (ACT) is a tool that can be used to evaluate asthma control in patients and its use is recommended. This tool is very simple and easy because it contains 5 questions that must be filled in by the patient, then given a score on each question answer with a score value of 1 to 5. The maximum score is 25 with the following division: score 19 or less (uncontrolled asthma); score 20 - 24 (partially controlled asthma) and score 25 (totally controlled asthma)[8].

The primary goals of asthma treatment are to control symptoms and to reduce emergency department (ED) visits for treatment of acute asthma exacerbations.[9] One study reported only 5% asthma control among patients hospitalized with tertiary care.[10] Poor asthma control remains a frequent cause of ED visits and hospitalizations.[11] In addition, it should be kept in mind that the cost of uncontrolled asthma care is considerable. For example, ER visits for asthma management account for nearly one-third of all asthma costs in the United States."[12] Today, inhaled drug delivery is an integral component in the treatment and management of patients with airway obstruction disease. Unlike systemic treatment, inhaled medications are rapidly directed into the airways allowing for rapid onset.[13] Inhaled administration of corticosteroids is considered the optimal route for proper drug delivery for the treatment of bronchial asthma and can reduce asthma hospitalizations by as much as 80%.[14] Drug classes used in the management of this disease include β-receptor agonists, anticholinergic agents, and corticosteroids.[These drugs are often administered in the form of a pressurized metered-dose inhaler (pMDI), dry powder inhaler (DPI), or with a nebulizer. pMDI and DPI are the preferred inhalation methods as patients can use them on their own with minimal assistance if taught well.[16] The most important advantage of inhalation therapy is the direct and localized delivery of high concentrations of drugs to the airway with minimal systematic side effects.[17]

This study aims to evaluate the effect of providing inhaler use education on asthma grade based on asthma control test (ACT) among asthma patients in developing countries such as Indonesia and to identify the determinants of poor inhaler technique by offering solutions on how to improve inhaler use among the growing number of asthma patients.

Methods

The research was performed in an experimental study using the method of one-group pre-test and post-test design from from March 2024 to May 2024 in Tanjungpura General Hospital. The research had ethical clearance agreement number 149/KEPK/USU/2024 and applied strict health protocols. The research was conducted in several stages, including demographic data collection, asthma control test (ACT) before and after inhaler use education, and evaluation of inhaler use. Education was provided in two sessions, and ACT test results were compared to assess the effect of education.

RESULTS

Patient Demographics

A total of 54 asthma patients participated in this study. The majority of patients were female (35 people, 64.8%) and were in the age range of 40-60 years (32 people, 59.3%). Most patients worked as housewives (25 people, 46.2%).

Table 1. Demographic Characteristics of Asthma Patients

ACT Test Results

Before education, 48 patients (88.9%) had uncontrolled asthma control, and only 6 patients (11.1%) had partial asthma control. After the first education, the number of patients with uncontrolled asthma control decreased to 46 (85.1%), while patients with partial asthma control increased to 8 (14.9%). After the second education, the number of patients with uncontrolled asthma control reduced further to 10 (18.5%), patients with partial asthma control increased to 41 (75.9%), and 3 patients (5.6%) achieved full asthma control.

Table 2. ACT Test Result

Inhaler Usage

Before education, 32 patients (59.3%) used the inhaler correctly, and 22 patients (40.7%) used the inhaler in the wrong way. After education, there was an increase in the correct use of inhalers among patients.

Table 3. Inhaler Usage

DISCUSSION

Based on the results of the study, it is known that women are the most asthma patients, namely 35 people (64.8%). Studies have shown that asthma is more common in boys than in young girls; however, gender differences reverse after puberty, with females experiencing higher rates of asthma exacerbations and hospital admissions in adulthood [18,19]. Furthermore, women with asthma are more likely to report poor asthma control, increased exacerbations, and obesity despite having higher percent FEV1 estimates, lower FeNO, and Total IgE compared to their male counterparts [20]. This suggests that women with asthma face unique challenges in managing their condition, which may be exacerbated by factors such as depression and salicylate sensitivity, which have been found to have a higher prevalence among women with early onset difficult asthma [21]. The most common occupation was housewife as many as 25 people (46.2%), then traders as many as 17 people (31.4%), and farmers as many as 4 people (7.4%). The prevalence of asthma among housewives is strongly influenced by exposure to allergens and irritants found in the home environment. For example, peeling raw potatoes has been identified as a trigger for asthma attacks and rhinoconjunctivitis in housewives, highlighting the role of specific food allergens in exacerbating asthma symptoms[22,23]. In addition, the use of cleaning products, especially those containing bleach and ammonia, have been strongly associated with an increased risk of asthma and chronic bronchitis symptoms among women involved in household cleaning[24,25,26]. In conclusion, most female asthmatics are those who are post-pubertal, obese, and may have a genetic predisposition, with hormonal changes playing an important role in the exacerbation of the condition [27,28,29].

The highest age was 18-60 years, namely 45 people (83.3%). This study is in line with Sofie's research (2015), that the highest incidence of asthma is at the age of 18-60 years, and reinforced by Brunello (2013) who said the prevalence of asthma was higher at the age of <60 years [30,31].

Based on the results of the study, it was also found that the asthma control test scores of patients after being given education on the use of inhalers increased. Studies have shown that proper inhaler technique, essential for effective asthma control, is often lacking among patients, with most using their inhalers incorrectly, leading to poor disease control [32,33]. Educational interventions, especially those led by pharmacists, have been shown to markedly improve inhaler technique [34,35,36]. For example, asthma education interventions

have resulted in significant improvements in asthma control test scores, indicating better asthma control[37,38]. In addition, educational programs targeting patients and patient caregivers have been associated with improved asthma control, including a reduction in daytime and nighttime symptoms, as well as decreased emergency department visits and hospitalizations[39]. These programs also lead to better inhalation techniques and lung function, further contributing to improved quality of life for asthma patients[40].

Examination of various studies reveals a consistent pattern indicating that educational interventions significantly improve knowledge and techniques related to inhaler use, which can be inferred to impact asthma control test (ACT) scores indirectly through improved asthma management. Jayachandran and Dr. Suvarnaletha Devi's (2020) study showed a significant increase in knowledge about inhaler use among asthma patients following a structured education program, suggesting that better understanding may lead to improved asthma control [41]. Similarly, Nevhiz Gundogdu and Necla Benlier (2020) found that higher education levels were associated with greater dexterity and perceived therapeutic benefit in the use of inhaler devices, although they did not directly link this to asthma control test scores [42]. Jaishree Ganjiwale et al.'s (2019) study on nurses showed that individualized training significantly improved proficiency of inhaler use, which is critical for patient education and potentially improving patient asthma management outcomes [43]. G K Nalini et al. (2019) highlighted that educational interventions, especially interactive demonstrations, are effective in teaching correct inhaler technique to healthcare professionals, which can indirectly influence patient education and asthma control [44]. S A Mahfouz et al (2016). and R.P. Thomas et al. (2017) both emphasized the importance of correct inhaler use and continuing education in improving COPD and asthma management, showing a potential positive impact on asthma control test scores through better disease control [45,46]. Sevda Efil et al (2015). and Olufemi Olumuyiwa Desalu et al (2020). both reported improvements in medication management and knowledge of asthma and inhaler techniques following educational interventions, which may lead to better asthma control as measured by asthma control test scores [47, 48]. Jasmin Shijo's (2020) study of an educational intervention among mothers of children with respiratory infections showed a significant improvement in knowledge and practice regarding the use of metered dose inhalers, which is important for effective asthma management in children, potentially affecting their asthma control test scores [49]. Lastly, Tiago Maricoto et al. (2013) directly linked an educational intervention to improve inhaler technique with significant improvements in clinical and functional control of asthma, which would likely be reflected in improved asthma control test scores [50]. The results of research by Sunarti (2015) showed that based on the Mann Whitney test there were changes in the level of asthma control in the control and counseling groups with a p value of p=0.000 (α<0.05). This study concluded that education can affect the level of asthma control in the education group compared to the control group [51]

CONCLUSION

Inhaler use education in patients with asthma was found to be effective in improving asthma control and adherence to inhaler use. Continuous and ongoing education is needed to achieve optimal asthma control in patients.

Acknowledgments

We would like to thanks to the Tanjungpura Regional General Hospital Faculty of Medicine, Universitas Sumatera Utara and everyone who take part for this research.

Conflict of Interest

“All the authors declare that there are no conflicts of interest.”

Funding

“This study received no external funding.”

Authors’ Contribution

“Derived data supporting the findings of this study are available from the corresponding author on request.”

References

1. Global Initiative for Asthma. GINA Report: Global Strategy for Asthma Management and Prevention. . Global Initiative for Asthma; 2023

2. Yii AC, Soh AZ, Chee CBE, Wang YT, Yuan J-M, Koh W-P. Asthma, Sinonasal Disease, and the Risk of Active Tuberculosis. J Allergy Clin Immunol Pract. 2019 Feb;7(2):641-648.e1.

3. D'Amato M, Molino A, Calabrese G, Cecchi L, Annesi-Maesano I, D'Amato G. The impact of cold on the respiratory trasthma control test and its consequences to respiratory health. Clin Transl Allergy. 2018;8:20.

4. Burrows B, Barbee RA, Cline MG, Knudson RJ, Lebowitz MD. Characteristics of asthma among elderly adults in a sample of the general population. Chest. 1991 Oct;100(4):935-42.

5. Martin AJ, Landau LI, Phelan PD. Lung function in young adults who had asthma in childhood. Am Rev Respir Dis. 1980 Oct;122(4):609-16.

6. Pedersen S. From asthma severity to control: a shift in clinical practice. Primary Care Respiratory Journal. 2009 Oct 16;19(1):3-9.

7. Global Initiative for Asthma. GINA Report: Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma; 2023 .

8. Fuhlbrigge AL, Adams RJ, Guilbert TW, Grant E, Lozano P, Janson SL, et al. The Burden of Asthma in the United States. Am J Respir Crit Care Med. 2002 Oct 15;166(8):1044-9.

9. National Heart Lung and Blood Institute. Expert panel report 3 (EPR3): guidelines for the diagnosis and management of asthma. 2007.

10.Al-Jahdali HH, Al-Hajjaj MS, Alanezi MO, Zeitoni MO, Al-Tasan TH. Asthma control assessment using asthma control test among patients attending 5 tertiary care hospitals in Saudi Arabia. Saudi Med J. 2008 May;29(5):714-7.

11.Adams RJ. Factors associated with hospital admissions and repeat emergency department visits for adults with asthma. Thorax. 2000 Jul 1;55(7):566-73.

12.Weiss KB, Gergen PJ, Hodgson TA. An Economic Evaluation of Asthma in the United States. New England Journal of Medicine. 1992 Mar 26;326(13):862-6.

13.Usmani OS. <p>Choosing the right inhaler for your asthma or COPD patient</p>. Ther Clin Risk Manag. 2019 Mar;Volume 15:461-72.

14.Blais L, Suissa S, Boivin J-F, Ernst P. First treatment with inhaled corticosteroids and the prevention of admissions to hospital for asthma. Thorax. 1998 Dec 1;53(12):1025-9.

15.Steinberg M, Pervanas H. Assessment of Proper Medication Inhaler Technique in Adult Patients. Journal of Pharmacy Technology. 2014 Dec 13;30(6):195-200.

16.Rubin BK, Fink JB. Optimizing aerosol delivery by pressurized metered-dose inhalers. Respir Care. 2005 Sep;50(9):1191-200.

17.Broeders ME, Sanchis J, Levy ML, Crompton GK, Dekhuijzen PR. The ADMIT series - Issues in Inhalation Therapy. 2) Improving technique and clinical effectiveness. Primary Care Respiratory Journal. 2009 May 27;18(2):76-82.

18. Mona, Reda, Dina, Ruby. Female Sexual Dysfunction Among a Sample of Egyptian Patients with Asthma. The Open Respiratory Medicine Journal, (2020). doi: 10.2174/1874306402014010038

19. Myers, Rachel A., et al. "Genome-wide interaction studies reveal sex-specific asthma risk alleles." Human molecular genetics 23.19 (2014): 5251-5259. doi: 10.1093/HMG/DDU222

20. Hayley, A., Scott, Hayley, A., Scott, Hayley, A., Scott, Peter, G., Gibson, Peter, G., Gibson, Manohar, L., Garg, John, W., Upham, Lisa, Wood, Lisa, Wood. Sex hormones and systemic inflammation are modulators of the obese-asthma phenotype. Allergy, (2016). doi: 10.1111/ALL.12891

21. H., L'youssfi, Hasna, Jabri, H., Moubachir, Wiam, Elkhattabi, H., Afif. Profil de l'asthmatique ménopausée: à propos de 120 cases. Revue Des Maladies Respiratoires, (2016). doi: 10.1016/J.RMR.2015.10.096

22. Heena Mistry, Adnan Azim, Yvette Thirlwall, Frances Mitchell, Clair Barber, Hans Michael Haitchi, Colin Newell, Paddy Dennison, Yueqing Cheng, Ramesh Kurukulaaratchy. Does early-onset difficult asthma in adulthood differ by sex? Findings from WATCH. European Respiratory Journal, (2018). doi: 10.1183/13993003.CONGRESS-2018.PA1088

23. Lola, Loewenthal, Jim, Busby, R, Mcdowell, Tom, Brown, Hassan, Burhan, Rekha, Chaudhuri, Patrick, Dennison, J, Dodd, S, Doe, Shoaib, Faruqi, R, P, Gore, Elfatih, Idris, David, A, Jackson, Mitesh, Patel, Thomas, Pantin, I, D, Pavord, P, Pfeffer, DP, Price, Shamin, Naseem, Siddiqui, L, Heaney, Andrew, Menzies-Gow. Characterizing the impact of sex on severe asthma (SA) in the UK Severe Asthma Registry (UKSAR). (2022). doi: 10.1183/13993003.congress-2022.308

24. James, Temprano., David, M., Mannino. The effect of sex on asthma control from the National Asthma Survey. The Journal of Allergy and Clinical Immunology, (2009). doi: 10.1016/J.JACI.2008.12.009

25. Hansen, Sofie, et al. "Gender differences in adult-onset asthma: results from the Swiss SAPALDIA cohort study." European Respiratory Journal 46.4 (2015): 1011-1020. doi: 10.1183/13993003.02278-2014

26. Brunello, Wüthrich, Peter, Schmid-Grendelmeier, Christian, Schindler, Medea, Imboden, Andreas, J., Bircher, Elisabeth, Zemp, Nicole, Probst-Hensch. Prevalence of atopy and respiratory allergic diseases in the elderly SAPALDIA population. International Archives of Allergy and Immunology, (2013). doi: 10.1159/000351416

27. Renymol, B. A Study on the Clinical Profile of Late Onset Asthma in Females in a Tertiary Care Center in South Kerala. journal of medical science and clinical research, (2017). doi: 10.18535/JMSCR/V5I11.149

28. Santiago, Quirce, M, L, Diez, Gómez, Miguel, Hinojosa, Manuela, Cuevas, V, Ureña, Montserrat, Fernandez, Rivas, J, Puyana, Javier, Cuesta, E, Losada. Housewives with raw potato-induced bronchial asthma. Allergy, (1989). doi: 10.1111/J.1398-9995.1989.TB04197.X

29. M, Medina-Ramón, Jan-Paul, Zock, Manolis, Kogevinas, Jordi, Sunyer, Josep, M, Antó. Asthma symptoms in women employed in domestic cleaning: a community based study. Thorax, (2003). doi: 10.1136/THORAX.58.11.950

30. Umran, Ozden, Sertcelik, Ebru, Damadoğlu, Gül, Karakaya, Ahmet, Ugur, Demir, Ali, Fuat, Kalyoncu. Impact of socioeconomic factors and house cleaning on asthma control in women... Allergy and Asthma Proceedings, (2022). doi: 10.2500/aap.2022.43.210003

31. Vasudeva, Guddattu, A, Swathi, N, Sreekumaran, Nair. Household and Environment Factors Associated With Asthma Among Indian Women: A Multilevel Approach. Journal of Asthma, (2010). doi: 10.3109/02770903.2010.481343

32. Abdulredha, M. H., Aljobouri, H. J., & Alareedh, M. D. Evaluation of Inhaler Technique in COPD and Asthma Patients. Kufa Medical Journal, (2023). 19(1), 59-75.

33. El, Atawy, Khaled, Im, Eldeen, Im, Eldeen, M, Yousif, Hamed, Fadlallah, Hamed. Impact of a Pharmacist-led Educational Intervention on Inhalation Technique among Sudanese Patients with Asthma. (2022). doi: 10.52981/ojps.v2i3.2869

34. Abbas, Khazaal, Okab, Aligholi, Hadi, Ied, Al-Sadoon, Mudher, Al-, Khairalla. Evaluating Community Pharmacist Provided Short Education Program to Improve Clinical Status of Selected Asthmatic Patients. Pakistan Journal of Medical and Health Sciences, (2022). doi: 10.53350/pjmhs22167469

35. Heba, Omara, M, Mansour, Raffay, M, Badr Asthma education and its impact on pediatric asthma severity: a prospective cohort study. Journal of Asthma, (2022). doi: 10.1080/02770903.2022.2082306

36. Grace, A., Shayo, Amina, Omary, Ferdinand, Mugusi. Inhaler Non-Adherence, Associated Factors and Asthma Control among Asthma Patients in a Tertiary Level Hospital in Tanzania. East African health research journal, (2022). doi: 10.24248/eahrj.v6i1.682

37. J., Cohen, Bernice, Oberman, Irit, Katz, Dekel, Shlomi. The impact of pharmacist-guided inhaler technique education on chronic obstructive pulmonary disease and asthma patients. Journal of Pharmaceutical Health Services Research, (2023). doi: 10.1093/jphsr/rmad032

38. Silvano, Dragonieri, Vitaliano, Nicola, Quaranta, Enrico, Scisci, Elena, Capozza, Federica, Barratta, M, L, de, Candia, Giovanna, Elisiana, Carpagnano. The role of education in the self-compilation of asthma control test score in patients with asthma. Acta Bio-medica: Atenei Parmensis, (2022). doi: 10.23750/abm.v93i3.12278

39. Shinyoung, Park, Suhyun, Choi, Yumi, Cha, Dongryun, Lee, Seungwon, Shin, Dokshin, Lim. Interaction Design of Asthma Inhaler Assistant Device. (2022). doi: 10.1007/978-981-16-1781-2_63

40. Hamad, Ghaleb, Dailah. Investigating the Outcomes of an Asthma Educational Program and Useful Influence in Public Policy. Frontiers in Public Health, (2021). doi: 10.3389/FPUBH.2021.736203

41. Jayachandran, T, Dr., Suvarnaletha, Devi. Knowledge regarding inhalers among patients with bronchial asthma. (2020). doi: 10.47211/IDCIJ.2020.V07I03.008

42. Nevhiz, Gundogdu, Necla, Benlier. Evaluation of Knowledge and Skills of Patients With Asthma and COPD in Using Inhaled Therapy. Clinical Pulmonary Medicine, (2020). doi: 10.1097/CPM.0000000000000363

43. Jaishree, Ganjiwale, Ravish, M, Kshatriya, Yoshaan, Joshi, Somashekhar, M, Nimbalkar. The effect of single educational intervention on improving nurses' proficiency in using different inhaler devices in a tertiary care setting. Indian Journal of Allergy, Asthma and Immunology, (2019). doi: 10.4103/IJAAI.IJAAI_22_19

44. Jaishree, Ganjiwale, Ravish, M, Kshatriya, Yoshaan, Joshi, Somashekhar, M, Nimbalkar. The effect of single educational intervention on improving nurses' proficiency in using different inhaler devices in a tertiary care setting. Indian Journal of Allergy, Asthma and Immunology, (2019). doi: 10.4103/IJAAI.IJAAI_22_19

45. G, K, Nalini, Jayashree, V, Nagaral, Sahana, K, Hebbar, G, N, Sahana, P, Deepak, S, Kavitha. Impact of educational intervention on pressurized metered dose inhaler technique among undergraduate medical students. International journal of basic and clinical pharmacology, (2016). doi: 10.18203/2319-2003.IJBCP20163237

46. S, A, Mahfouz, Zullies, Ikawati, Djoko, Wahyono. The Effectiveness of Video Education How to Use Diskus® DryPowder inhaler on Out-Patients of Copd In Mojokerto, Indonesia. Pharmaceutical and Clinical Research, (2017). doi: 10.25258/IJPCR.V9I3.8325

47. R., P., Thomas., N., V., Rani., G., Kannan., P., Thennarasu., Safreena, Mohammed. Impact of Pharmacist-Led Continuous Education on the Knowledge of Inhalation Technique in Asthma and COPD patients. International Journal of Medical and Health Sciences, (2015).

48. Sevda, Efil, Nuray, Enç, Turhan, Ece. Effect of training provided to patients with chronic obstructive pulmonary disease on drug management... Japan Journal of Nursing Science, (2020). doi: 10.1111/JJNS.12333

49. Sevda, Efil, Nuray, Enç, Turhan, Ece. Effect of training provided to patients with chronic obstructive pulmonary disease on drug management. Japan Journal of Nursing Science, (2020). doi: 10.1111/JJNS.12333

50. Desalu, Olufemi O., et al. "Impact of short-term Educational Interventions on Asthma Knowledge and metered-dose Inhaler Techniques among post basic nursing students in Ilorin, Nigeria-Result of a pilot study." Sudan journal of medical sciences 8.2 (2013): 77-84.

51. Sunarti, S., & Andayani, T. M. (2015). The Effect of Pharmacist Education on The Level of Asthma Control. Indonesian Journal of Pharmacy, 12(1), 85-93.