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Table of Contents
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 4-8

Assessment of community pharmacist's knowledge and skills about appropriate inhaler technique demonstration in Khartoum locality: A cross-sectional study

1 Department of Clinical Pharmacy, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
2 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan

Date of Submission16-Apr-2020
Date of Acceptance07-May-2020
Date of Web Publication12-Jun-2020

Correspondence Address:
Dr. Bashir Alsiddig Yousef
Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, Khartoum 11111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MTSP.MTSP_1_20

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Background: Inhalation represents the best choice of administration for the delivery of drugs to treat respiratory disorders such as asthma. Thus, the correct inhaler technique is required to ensure optimal clinical outcomes and improve the quality of life. Community pharmacists are responsible for counseling patients and their knowledge and skills of inhalers. This study aimed to assess the knowledge and skills of community pharmacists in demonstrating different inhalation device techniques in Khartoum locality. Methods: This was a cross-sectional observational study concerning Khartoum locality pharmacies using a mystery patient method. The data were collected using a checklist for each device, which was filled by the investigator after visiting the pharmacy, and then the data were analyzed descriptively using Statistical Package for the Social Sciences. Results: The study covered 232 pharmacies. Most of the pharmacists get the score of an adequate level of knowledge and skills; the percentage levels for each device were as 58.2%, 65.7%, and 58.8% for pressurized metered-dose inhaler (Ventolin®), dry powder inhaler (Turbuhaler™, Symbicort®), and dry powder inhaler (Diskus™, Seretide®), respectively. However, some of the pharmacists get the score of “don't know.” Although most pharmacists achieve an adequate score, they were varying in percentage when demonstrating critical steps for each device. Conclusion: The community pharmacists who are expected to educate asthmatic patients on how to deal with their inhaler's devices scored an adequate level of knowledge and skill on demonstrating different inhaler's device, so an extra effort should be made to level them up in that area through regular training programs.

Keywords: Asthma, community pharmacist, dry powder inhaler, knowledge, metered-dose inhaler

How to cite this article:
Omer AH, Yousef BA. Assessment of community pharmacist's knowledge and skills about appropriate inhaler technique demonstration in Khartoum locality: A cross-sectional study. Matrix Sci Pharma 2020;4:4-8

How to cite this URL:
Omer AH, Yousef BA. Assessment of community pharmacist's knowledge and skills about appropriate inhaler technique demonstration in Khartoum locality: A cross-sectional study. Matrix Sci Pharma [serial online] 2020 [cited 2023 Feb 4];4:4-8. Available from: https://www.matrixscipharma.org/text.asp?2020/4/1/4/286566

  Introduction Top

Inhalers are devices that used to deliver medicine into a spray form like that in aerosol. Inhalers differ in their delivering ability of drugs to the lower respiratory tract based on the kind of the device and the formulation of the medication.[1] The inhalation therapy provides local treatment that allows the use of smaller doses and reduces systemic side effects. Pulmonary inhalation devices provide a good route for administrating of systemic medicine due to their fast absorption by the massive surface area of the alveolar region. The delivered drug acts with maximum pulmonary specificity combined with a rapid onset and duration of action and the avoidance of the first-pass metabolism.[2] There are four main types of inhaler devices, manually metered-dose inhalers (MDIs), dry powder inhalers, nebulizer, and soft mist inhalers.[3]

Currently, inhalation therapy is an effective way of treating lung diseases such as asthma, cystic fibrosis, and chronic obstructive pulmonary disease. In comparison with oral or parenteral formulations, minute but therapeutic drug doses are delivered topically into the airways leading to local efficacy within the lung.[4] In order to achieve and maintain a proper asthma control, four major components are required including assessment and monitoring, education of patients for a partnership in care, control of environmental factors, and comorbid conditions that affect asthma and pharmacotherapy.[5]

Improper use of inhaler device can lead to poor asthma control and increase in the visits to the emergency department.[6],[7],[8] Hence, pharmacists play an important role in counseling patients with asthma; they play important roles in treatment and prevention from asthma attacks.[9] The counseling points provided by the pharmacists include demonstrating and teaching the correct inhaler technique, optimum selection for the medications, and avoidance of dispensing of other concomitant medications that may lead to exacerbate the asthma.[9],[10],[11]

The health care professionals including the community pharmacists are responsible for improvement of inhaler techniques by counseling and training the patients to the correct use of inhaler devices.[12],[13],[14] Thus, they should have basic knowledge and demonstration skills required to educate the patients correctly. Hence, the aim of this study to assess demonstrating knowledge and skills of the community pharmacists in Khartoum locality in using different available bronchial asthma inhaler delivery devices.

  Methods Top

Study design

Three kinds of inhaler devices (pressurized MDI [Ventolin ®], dry powder inhaler [Turbuhaler™, Symbicort ®], and dry powder inhaler [Diskus™, Seretide ®]) were used in this study. A cross-sectional observational study from June to August 2019 was carried out at Khartoum locality to assess the clinical communication and counseling skills of the community pharmacist about the three types of inhaler device using the mystery patient method. In addition, it assesses the prescription pattern of over-the-counter medications and the impact of continuing professional training program.[15]


The researcher and investigator posed as a “mystery patient”, they entered the pharmacy carrying pre-selected two inhaler devices, and talked to the community pharmacist and said, “I has just prescribed this device form my doctor. However, the doctor did explain to me how to use it. So can you kindly please teach me how I can use it?” then the pharmacist start to demonstrate it, and the researcher observed him carefully, and directly filled the checklist after leaving the pharmacy. The checklist contains all steps required for the proper technique, including the critical steps, which are highlighted (*) in the [Table 1], [Table 3] and [Table 4].
Table 1: Demonstration steps for using pressurizes metered-dose inhaler (Ventolin®) by a total community pharmacists (n=232)

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Table 2: Overall score of knowledge and skill in demonstrating of different inhaler' s devices among community pharmacists

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Table 3: Demonstration steps for using Turbuhaler™ (Symbicort®) by a community pharmacists (n=137)

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Table 4: Demonstration steps for using Diskus™(Seretide®) by a community pharmacists (n=97)

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Inclusion and exclusion criteria

The study included all community pharmacists who are working in pharmacies that are registered in the Ministry of Health of Sudan and located at Khartoum locality.

Sample size and sampling technique

There are 552 community pharmacies located in the Khartoum locality, Khartoum state, Sudan. Using Slovin's equation,[16] the sample size (n = 232) was calculated from the known population as follows: n = N/1 + N(e)2

Where, N = total target population attending the center. n = sample size e= margin of error (0.05) at 95% confidence level. The sampling method approach for this study was a systemic randomization sampling technique, followed a simple random selection of the first pharmacy from the list. For the inhalation device, Ventolin® was used in all pharmacies, but Symbicort® and Seretide® alternate between pharmacies.

Data collection and scoring methods

A pilot study was done in the same area for testing the validity of the checklist, and all checklists that were used in the pilot study were excluded. The data were collected using a valid checklist for each device which is completed and filled by the investigator after the pharmacy visit. The critical steps for each device were previously specified.[15]

Depending on the inhalation device type, the performance of community pharmacists was assessed and manually scored according to the steps that are identified in the checklist, which consists of general and critical steps. The critical errors are those missing steps that have a significant effect on aerosol drug delivery; missing these critical steps can lead to either little or no drug delivery to the target point.[17],[18] Based on these steps (general and critical), for each inhaler device, the following four evaluation categories were formulated: optimal technique, a label that is awarded to pharmacists completing all steps except 2 steps and critical step except 1 step successfully; adequate technique, a label that is awarded to those who completed all steps except 4 steps and critical step except 2 steps; poor technique, a label that is awarded to pharmacists who failed to complete <4 steps and <2 for critical step; and does not know, a label that is awarded for pharmacists who either did not explain any steps or said “I don't know.”

Data analysis

The data were entered and analyzed using International Business Machines (IBM); Statistical Package for the Social Sciences (SPSS) for Windows, Version 21.0 software (Armonk, NY, USA: IBM Corp). The data were demonstrated as tables that contain numbers and frequencies for pharmacists with the correct demonstration for each step.

Ethical consideration

The study was approved by the Ethical Committee of Faculty of Pharmacy, University of Khartoum (FPEC-05-2019). Additional approval was obtained from the ministry of health. All collected checklists were coded with ensuring confidentiality throughout the study.

  Results Top

The knowledge and skills of 232 licensed community pharmacists about appropriate inhaler devices techniques were evaluated. All of them were evaluated for the pressurized metered-dose inhaler (MDI) (Ventolin®), while 137 and 97 community pharmacists were approached using two types of dry powder inhaler (Symbicort® and Seretide®), respectively.

For the pressurized MDI, as shown in [Table 1], most of the steps were correctly demonstrated by most of the pharmacists. Moreover, among the critical steps, only steps 2, 6, and 7 were well-explained by more than half of the pharmacists, particularly for step number 6, which appropriately demonstrated by 93.5% of the participants. However, only 46.1% of them clearly explained step number 4, while a few numbers of pharmacists (27.2%) properly demonstrated the step of holding the breath for 10 s. Following the measurement of the overall score, more than half (58.2%) of pharmacists have an adequate level of knowledge and skill for demonstration of Ventolin ® [Table 2].

Regarding the dry powder inhaler (Turbuhaler™) device, as described in [Table 3], most of the demonstration steps were clearly explained by many pharmacists. Nevertheless, step 12, which involved rinsing and gargling the mouth with water after administrating the dose, was only mentioned by 8% of the participants. Regarding the critical steps, steps 1, 2, and 7 were satisfactorily demonstrated by the pharmacists. On the other hand, a high percentage of participating pharmacists failed to explain steps 4 and 8 correctly. Collectively, the overall demonstration knowledge of Symbicort® was varied, but most of the practicing pharmacists (65.7%) showed to have an adequate level of knowledge [Table 2].

Furthermore, the community pharmacists get an adequate level of knowledge and skill in using the dry powder inhaler (Diskus™) device [Table 2] as most of the steps including general and critical steps were adequately demonstrated by most of the pharmacists, particularly for the steps 1, 2, 3, 5, 6, and 9. However, the step of washing the mouth following using of the drug was also failed to be demonstrated by the community pharmacists. Moreover, the critical step for breathing out away from the mouthpiece of the device was only exhibited by 35.1% of the participants [Table 4].

  Discussion Top

Proper use of inhalation devices will secure proper dosing of the medication and better management of the disease, which, in turn, results in enhanced quality of life and prevents complications.[8],[19] Thus, the goal of this study was the assessment of knowledge and skills of community pharmacists in the techniques of using inhalation devices as the pharmacist plays a crucial role in providing accurate direction of use for the patients due to his/her responsibility of drug dispensing and counseling including demonstration of correct device use.[20] Regarding the use of Ventolin®, 31% of pharmacists matched the criteria of the optimal score, 58% were fall in the adequate category, while 6% and 4.8% were fall in the group of poor and don't know, respectively. Previous research done in Sudan showed different findings in the score as no pharmacist awarded the optimal score.[15] It is possible that the awareness of the community pharmacists in using the MDI has been improved over the past 10 years. This may arise due to the incorporation of a practical course about using inhalation devices in the updated pharmacy undergraduate curricula in Sudanese universities.

The importance of the critical steps about MDI usage is justified as they are key in ensuring an adequate amount of the drug has reached the intended site.[17] In the current research, the assessment of the MDI knowledge and skill consisted of 5 critical questions. 56.9% stated the step of shake well several times, which is very important in order to have a uniform heterogeneous suspension to get the same amount of the drug at each dose.[21] Whereas, the step of exhaling until you can breathe out no more, is gotten right by only by 46.1%, and it is critical since it helps to have a better inhalation. Holding the breath for 10 s will give the time for the drug particles to sediment and interact with receptors resulting in better efficacy.[21] Unfortunately, only 27.2% got this right that may contribute to an inadequate dose and consequently poor management of the disease. Most previous studies were concluded the same result in which most pharmacists failure to complete all critical steps.[5],[22] Interestingly, Sudanese community pharmacists had improved in their knowledge and skills regarding the use of MDI compared to pharmacists in neighboring countries.[5],[23] However, extra efforts in the education process for the professional community pharmacist at the pharmacy level and pharmaceutical companies will have a significant impact on the knowledge.

The assessment of knowledge and skill in using Turbuhaler , 65.7% were fall in the adequate category, which is better than the previous research done in Sudanese pharmacists that showed only 4.9% have adequate level of knowledge. 23.4% of the study group scored the optimum level of knowledge. These findings are also positively different from the previous one, as a poor level of knowledge was high.[15] This as well further shows a good sign of improvement in the education of the community pharmacists. An in-depth analysis of the result showed that only 8% of the participants directed the mystery patient to rinse their mouth out and gargle with water after use, which may affect the overall score.

Similar results to Turbuhaler™ in the aspect of scoring the knowledge were observed in the use of Diskus™, as the majority of the pharmacists (58.8%) achieved the adequate score, followed by (31%) optimal score. Giving the fact that the two previous devices are well known as they have been in the market for a quite long time.[24],[25] This is a critical area of improvement, and future investigations should report that the majority of the community pharmacists joined the group of optimal skill and knowledge. A limited number of studies had looked at the ability of the pharmacists to demonstrate the adequate technique of the Diskus™ inhaler. Assessing the most problematic steps by a published study revealed that almost all the pharmacists were able to demonstrate the critical steps correctly.[10]

The critical steps that are involved in the assessment of the dry powder inhalers' knowledge and skills are as important as those of the MDI. The steps of unscrewing and lifting off the cover for Turbuhaler and place a thumb on groove were correctly demonstrated in 90.5 % and 89.7%, respectively.[18] Turbuhaler™ and Duskus™ commonly share similar critical steps for both optimal drug deliveries that can be achieved by “exhaling to residual volume.” Only 33.6% and 35.1% are correctly demonstrated, respectively. Of course, this will affect the treatment outcome. Failure to “inhale forcefully” from the beginning leads to partial delivery of the drug to the lungs and deposition in the mouth and pharynx. 75.9% and 81.4% of the pharmacists succeeded in conveying this to the mystery patient, but 100% is an excellent picture. It is well known that both Turbuhaler™ and Diskus™ contain corticosteroids and failure to remove them immediately might pose some problems such as the risk of oropharyngeal side effects.[18]

The current study has some limitations. First, the study design is cross-sectional that may not allow generalizing the findings to all Sudanese pharmacists in Sudan. Second, the study is based on the single-investigator observation, which may become a source of subjective bias. Finally, as the mystery patient will not buy the inhaler, this may lead to a loss of pharmacist's interest to make the proper demonstration.

  Conclusion Top

The study concludes that community pharmacists were able to achieve an adequate level of knowledge and skill in demonstrating different inhaler devices, but on the other hand, for critical step for each device, they scored different degrees of percentage. These are going to have a negative impact on patient education and need to push more in this area through training courses for students before and after graduation. Furthermore, pharmaceutical companies must do enlightenment and training lectures, all these to reduce the burden on the patient due to improper use of inhaler.

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]


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