Knowledge and pharmaceutical care practice regarding inhaled therapy among registered and unregistered pharmacists: an urgent need for a patient-oriented health care educational program in Iraq

Figures & data

Table 1 The demographic data of registered and unregistered community pharmacists in Iraq

Variables	Registered pharmacist (N=170)	Unregistered pharmacist (N=170)	Total KAT score (N=340)
Age (years)	31.62±8.661	24.75±2.554	8.92±3.188
Average number of patients with COPD seen weekly	7.98±3.566	–
Work experience (years)	7.61±7.585	–
Gender
Malea	52.4%	35.3%	9.40±3.029
Female	47.6%	64.7%	8.54±3.265
University type
Government	81.2%	31.8%	9.11±3.08
Private	18.8%	68.2%	8.67±3.316
Education level
Bachelor’s degree	89.4%	100%	8.82±3.168
Diploma	8.8%	–	10.40±2.898
Master’s degree	1.8%	–	12.00±4.583
Family/personal history of respiratory disease
Yes	28.2%	15.9%	9.56±3.477
No	71.8%	84.1%	8.74±3.084
Employment status
Private	24.7%	–	9.31±2.892
Government	21.2%	–	9.17±3.094
Both	54.1%	–	10.28±3.128
Pharmacy or hospital location
Rural	17.6%	–	9.50±2.910
Urban	82.4%	–	9.87±3.134
Information obtained on aerosol use
Undergraduate study	52.4%	72.4%	8.91±3.123
Postgraduate studyb	8.8%	0	10.38±2.68
Attending meeting, course, workshop	4.1%	7.1%	9.89±3.195
Reading article or specialized bookb	6.5%	20.6%	7.74±3.448
Reading leaflet accompanying inhaler device	22.4%	0	9.55±3.073
Directly from personal clinical experience and common sense	5.9%	0	7.90±2.961
Who trains the patient on inhaler device use?
Pharmacistb	26.5%	44.7%	9.08±2.960
Doctor	13.5%	4.7%	9.32±2.833
Either the doctor or pharmacist, it dependsa	54.1%	2.4%	9.50±3.129
Nobody, but we provide written information	2.4%	47.6%	7.73±3.339
Nobody, and we do not give written information	3.5%	0.6%	10.86±4.059
Primary obstacle in pharmaceutical care services
Time constraints	39.4%	–	10.15±3.006
Lack of training	52.4%	–	9.83±3.076
Lack of reimbursement	8.2%	–	8.00±3.187

Notes: Data presented as mean ± standard deviation or percentage. Significant difference between groups,

a P<0.001;

b P<0.05.

Abbreviation: KAT, Knowledge of Aerosol Tool.

Table 2 Psychometric properties of the KAT by item analysis (N=340)

Question number	Mean ± SD	Difficulty index	Point biserial correlation*	Cronbach’s alpha if item deleted
Question 1	2.53±1.085	0.460	0.144	0.634
Question 2	2.40±1.004	0.284	0.235	0.624
Question 3	2.30± 1.033	0.189	0.162	0.632
Question 4	2.29±1.161	0.278	0.156	0.633
Question 5	2.40±1.147	0.284	0.124	0.636
Question 6	1.82±1.058	0.573	0.235	0.624
Question 7	2.29±1.238	0.248	0.168	0.632
Question 8	2.17±1.248	0.514	0.115	0.639
Question 9	1.91±1.061	0.532	0.278	0.619
Question 10	2.51±1.169	0.278	0.226	0.625
Question 11	2.35±1.286	0.455	0.313	0.613
Question 12	2.37±1.228	0.413	0.361	0.608
Question 13	2.18±0.727	0.644	0.136	0.633
Question 14	2.26±0.881	0.455	0.260	0.623
Question 15	1.99±1.137	0.207	0.236	0.624
Question 16	1.79±0.801	0.508	0.164	0.631
Question 17	1.86±0.931	0.449	0.136	0.634
Question 18	2.31±1.141	0.390	0.120	0.637
Question 19	2.29±1.060	0.384	0.153	0.633
Question 20	1.80±1.139	0.667	0.249	0.622
Question 21	2.22±1.040	0.502	0.332	0.614
Question 22	2.19±1.125	0.130	0.298	0.617
Question 23	2.68±0.799	0.638	0.133	0.634
Question 24	2.40±1.044	0.319	0.231	0.624

Note:

* Corrected item-total correlation.

Abbreviation: KAT, Knowledge of Aerosol Tool.

Table 3 Descriptive and correct answer percentages for KAT and its subscales

Characteristics	KAT			Knowledge of aerosol administration techniques subscale			Knowledge of aerosol medicine use subscale
	Total sample (N=340)	Registered pharmacists (N=170)	Unregistered pharmacists (N=170)	Total sample (N=340)	Registered pharmacists (N=170)	Unregistered pharmacists (N=170)	Total sample (N=340)	Registered pharmacists (N=170)	Unregistered pharmacists (N=170)
Mean ± SD	9.21±3.175	10.13±3.152	8.29±2.930	4.18±1.885	4.41±1.954	3.95±1.788	5.03±2.248	5.72±2.085	4.35±2.201
Potential range	0–24	0–24	0–24	0–12	0–12	0–12	0–12	0–12	0–12
Correct answer	38.38%	42.21	34.54%	34.83%	36.75	32.91%	41.92%	47.67	36.25%

Abbreviation: KAT, Knowledge of Aerosol Tool.

Table 4 KAT answer frequencies (N=340)

KAT	Registered pharmacist (N=170)	Unregistered pharmacist (N=170)
1. The most important advice the pharmacist can give the patient for correct pressurized metered dose inhaler (pMDI) use is
a. Shake the device before inhalation.	34.7%	20.6%
b. Exhale deeply before inhalation.	10%	11.2%
c. Firing the device after beginning inspiration.	40%	46.5%
d. Inhale deeply and forcefully.	15.3%	21.8%
2. When using the pMDI, a rapid inspiration is recommended
a. True.	30%	18.8%
b. False.	27.1%	22.9%
c. Depend on the patient status.	32.9%	40.6%
d. I do not know.	10%	17.6%
3. How long do you tell patients to wait before taking a second puff?*
a. At least 5 seconds.	23.5%	27.6%
b. At least 10 seconds.	38.8%	32.4%
c. At least 20 seconds.	29.4%	14.1%
d. I do not know.	8.2%	25.9%
4. How long do you tell patients to hold their breath for after taking a puff?
a. At least 4 seconds.	35.9%	35.9%
b. At least 6 seconds.	24.1%	15.3%
c. At least 8 seconds.	26.5%	20.6%
d. I do not know.	13.5%	28.2%
5. Which of these sentences about spacers for metered dose inhalers is correct?
a. They can be used regardless of the patient’s age.	29.4%	27.6%
b. If the patient is cooperative, it is better to administer the drug directly in the mouth.	25.3%	30.0%
c. They have to be washed once a day.	22.9%	14.7%
d. I do not know.	22.4%	27.6%
6. How often do you tell patients to clean their spacer?
a. After each use.	51.2%	54.7%
b. Every day.	25.3%	24.7%
c. Every week.	9.4%	8.2%
d. I do not know.	14.1%	12.4%
7. The most important step for correct dry powder inhaler (DPI) inhalation is:**
a. Shake the device before inhalation.	42.9%	38.2%
b. Exhale deeply before inhalation.	18.2%	13.5%
c. Firing the device after beginning inspiration.	4.1%	31.8%
d. Inhale deeply and forcefully.	34.7%	16.5%
8. How often do you tell patients to clean their DPI mouth piece?
a. After each use.	49.4%	42.4%
b. Every day.	23.5%	8.2%
c. Every 2 to 3 weeks.	13.5%	13.5%
d. I do not know.	13.5%	35.9%
9. It is OK if the patient does not feel the DPI powder go down.
a. True.	43.5%	52.4%
b. False.	24.7%	27.1%
c. Depends on the DPI apparatus.	22.4%	4.1%
d. I do not know.	9.4%	16.5%
10. How much time can pass between solution placed in the nebulizer and its administration?
a. Ten minutes.	29.4%	25.9%
b. No more than 1 h.	12.9%	30.0%
c. It is irrelevant.	24.1%	21.8%
d. I do not know.	33.5%	22.4%
11. How often should the nebulizer bulb be washed?*
a. After each use.	47.6%	31.8%
b. Once a day.	21.2%	13.5%
c. Once a week.	12.4%	10.6%
d. I do not know.	18.8%	44.1%
12. Spacer use results in a significant reduction in the amount of aerosol that is deposited in the mouth and throat.
a. True.	32.9%	39.4%
b. False.	17.6%	18.2%
c. Depends on the inhaler type.	25.9%	11.2%
d. I do not know.	23.5%	31.2%
13. When is the use of inhalational corticosteroids recommended?
a. In the majority of cases with viral or allergic wheezing.	15.3%	8.2%
b. Only in cases with allergic wheezing or asthma.	62.9%	69.4%
c. In bronchiolitis.	15.9%	13.5%
d. I do not know.	5.9%	8.8%
14. The purpose of using a corticosteroid inhaler is:**
a. To stop an asthma attack when it occurs.	17.6%	22.9%
b. To prevent asthma attacks.	55.3%	29.4%
c. For immediate relief only when required.	20%	37.1%
d. None of the above.	7.1%	10.6%
15. Inhaled steroid effectiveness is improved by taking a β-agonist first.
a. True.	51.2%	47.6%
b. False.	15.3%	18.8%
c. Depends on the dose of β-agonist.	20.6%	15.9%
d. I do not know.	12.9%	17.6%
16. Corticosteroid inhalers should be taken:**
a. When the patient feels an asthma attack coming on.	27.1%	50.0%
b. At regular intervals.	62.4%	36.5%
c. At least once weekly.	6.5%	5.9%
d. I do not know.	4.1%	7.6%
17. Improvement of patient’s condition with the use of the corticosteroid inhalers:***
a. Is obtained immediately.	41.2%	42.4%
b. May take 1 to 4 weeks.	45.9%	35.3%
c. Is not noticeable.	5.3%	10.6%
d. None of the above.	7.6%	11.8%
18. When starting corticosteroid, the patient should be concerned about which of the following regarding other medicine:
a. Stopping other steroid medicine which can result in mental depression, weight loss, and/or muscle and joint pain.	33.5%	30.6%
b. Changing the times other medicine is taken.	22.9%	30%
c. Patient does not have to worry if he/she stops taking oral steroid since corticosteroid inhaler is also a steroid.	20.6%	18.2%
d. None of the above.	22.9%	21.2%
19. The major advantage of using the corticosteroid inhalers is:***
a. There are not as many side effects as with oral steroids.	43.5%	30.6%
b. It is easier to remember to take inhaler medicine.	2.4%	7.6%
c. It works faster.	47.1%	51.8%
d. None of the above.	7.1%	10.0%
20. It is important to advise the patient to rinse his/her mouth out or gargle after inhaled corticosteroid use:**
a. True.	72.9%	51.8%
b. False.	7.6%	10.6%
c. Gargle but not every time.	11.2%	17.6%
d. I do not know.	8.2%	20.0%
21. When is ipratropium bromide recommended?**
a. Instead of salbutamol.	21.8%	27.1%
b. Together with salbutamol in cases of severe wheezing.	66.5%	32.9%
c. Never.	2.4%	7.6%
d. I do not know.	9.4%	32.4%
22. When is aerosol therapy with mucolytics recommended?
a. In various cases of upper and lower respiratory tract infections.	42.9%	26.5%
b. Only in the case of acute bronchitis or pneumonia.	38.8%	24.7%
c. Almost never.	9.4%	16.5%
d. I do not know.	8.8%	32.4%
23. What is the first-choice treatment for respiratory distress?*
a. Mucolytic aerosol.	8.2%	14.1%
b. Inhaled corticosteroid aerosol.	18.8%	20.6%
c. Salbutamol aerosol.	67.6%	51.2%
d. I do not know.	5.3%	14.1%
24. Which of the following is true when salbutamol aerosol is used for bronchiolitis?
a. It should be used until obtaining a clinical cure.	18.8%	26.5%
b. It should only be continued in the case of a positive response.	36.5%	31.8%
c. It should be used together with corticosteroid inhaler.	28.8%	18.2%
d. I do not know.	15.9%	23.5%

Notes: Correct answers appear in bold; significant association

* P<0.01,

** P<0.001,

*** P<0.05.

Abbreviation: KAT, Knowledge of Aerosol Tool.

Table 5 Appropriate pharmaceutical care practice regarding inhaled therapy among registered community pharmacists in Iraq (N=170)

Pharmaceutical care practice	Never	Rarely	Often	Always
1. Do you assess patient inhaler skill use?	5.3%	30%	24.1%	40.6%
2. Do you assess sick day management?	16.5%	35.9%	28.8%	18.8%
3. Do you assess pharmacotherapy?	14.1%	30.6%	35.9%	19.4%
4. Do you assess comorbid disease management?	14.1%	34.7%	31.2%	20.0%
5. Do you assess healthy living choices?	4.7%	11.2%	47.1%	37.1%

Table 6 Correlation matrix between pharmaceutical care practice and knowledge of aerosol tool (N=170)

Characteristics	Total KAT score	Knowledge of aerosol administration techniques subscale	Knowledge of aerosol medicine use subscale
Total KAT	–	0.680**	0.814**
Do you assess patient inhaler skill use?	0.133	0.033	0.141
Do you assess sick day management?	0.117	0.111	0.084
Do you assess pharmacotherapy?	0.188*	0.239**	0.063
Do you assess comorbid disease management?	0.208**	0.179*	0.154*
Do you assess healthy living choices?	0.092	0.029	0.150

Note:

* P<0.05,

** P<0.01.

Abbreviation: KAT, Knowledge of Aerosol Tool.