Exploring Patient’s Perspectives and Experiences After Start with Inhalation Maintenance Therapy: A Qualitative Theory-Based Study

Figures & data

Table 1 Patient Characteristics (n=23)

Characteristic	Value
Age (years), mean (range)	56.3 (20–84)
Female, n (%)	19 (82.6)
Inhalation maintenance medication, n (%)
Beclomethasone/formoterol	6 (26.1)
Budesonide	1 (4.3)
Budesonide/formoterol	1 (4.3)
Ciclesonide	8 (34.8)
Fluticasone	5 (21.7)
Salmeterol/fluticasone	1 (4.3)
Vilanterol/fluticasone furoate	1 (4.3)
Type of inhaler, n (%)
pMDI	19 (82.6)
DPI	4 (17.4)

Figure 1 Flowchart patient inclusion.

Abbreviation: ICS, inhaled corticosteroids.

Table 2 TDF Domains and Illustrative Quotes

Domain	Themes	Illustrative Quotes
Knowledge	Knowledge of the clinical indication, the duration of therapy, or doubts on the right indication Knowledge of potential medication side effects (and prevention)	“And then I thought: ‘well, do you have to persist for six weeks? Or can you stop if you do not feel it anymore?’ I actually did not know that.” [P20] “I did not read the leaflet; because I only read a leaflet when I experience things of which I think: ‘hey, I do not have that normally’.” [P14] “No, I do not rinse [my mouth after inhalation], but I always take it [the medication] before breakfast. So actually I think that [taking it] with the breakfast, this maybe might have the same result [in preventing side effects]?” [P7]
Skills	Inhaler technique Organizing life in general	“Well, sometimes I notice that I am inhaling too hard. So then he [the spacer] will beep. And then I think: ‘oh yes, wait a bit, a little bit slower’. And then it goes well.” [P16]
Social/professional role and identity	Patient autonomy (“medication use is my own responsibility”)	“I do not use that [spacer]. Well, I did not like this. No, I did not even try it at all.” [P6] “No, then I have to watch the clock, I do not like that.”[P1] “Yes, the last couple of days I only did it [taking medication] before the night, because I experienced that I had a cough in the evening, but not in the morning. Yes, I still benefit sufficiently from that.” [P11] “I do have not really a question, but just. I had to use it for a month. But I feel that. If it helped me, I actually want to stop and see what happens. And if it [symptoms] comes back, then yes, I will take it again.” [P14] “So I did not use it for 4 or 5 days and then I felt that it [shortness of breath] was coming back. So then I just started puffing again and now I use it every day again.” [P20]
Beliefs about capabilities	Physical or technical capability Organizing inhaler use in daily life	“I think that inhaling does not have to be that hard. But of course it is important that you receive proper instructions.” [P23]
Beliefs about consequences	Concerns about consequences of long term ICS use or possible side effects. Perception on the effects of medication Perceived necessity of medication	“Of course I have read over side effects in the leaflet, so I was a bit worried about that. I hoped that I would not … that it [sleeping problems/anxiety complaints] would not bother me again.” [P23] “If I do not see any results, when I just stay that tired and the coughing continues. Then I think: ‘well, how much sense does it make?” [P10] “Because I was always wheezy and now, I can just breathe again. I actually like it.” [P15] “I need it [the spacer], because I must say that otherwise it [the medication] does not help that much.” [P4]
Intentions	Intention to use medication, intrinsic motivation	“I think I have to use it properly, because otherwise it makes no sense.” [P13] “Well, probably because I have never had any medicine, I feel like: ‘yes, I have to do this properly’.” [P1]
Goals	Reducing number of prescribed medications Clinical goals	“[My goal is] that I have enough breath. That I can do everything intensively, like I always did: my work-out, riding a bike, playing at home with the children, climbing a staircase. Just that I have enough breath.”[P20]
Memory, attention and decision processes	Forgetting medications Paying attention to medication out of normal context	“Well, I forget it sometimes” [P12] “Eh yes, during the weekend I am having a lot of fun. When you went to bed late the night before, then in the morning you are not always that fresh, and sometimes I do not succeed [in taking medicines].” [P7] “Well, [I was] a little bit nervous, we were in a small house with children and so on. So I thought: ‘I have to sit down quietly and [learn] on my own way how to deal with it.” [P10]
Social influences	Social support or pressure from family Involvement or pressure from healthcare professionals	“I only take it; my wife put it ready for me.” [P2] “Of course I cannot return to the pulmonologist and say: ‘well, I tried it for 8 days, but then I was not in the mood anymore’.” [P10]
Emotions	Anxiety about the possibility of having an underlying disease	“To be honest, I must say that I get scared. Because you read and hear it regularly: people are tired, are coughing for a long time, and yes, then suddenly it turns out to be lung cancer. I experienced that one and a half year ago with my mother. She coughed too, and at one moment there was also blood. And then she had lung cancer. And yes, that stays in my mind.” [P19]
Behavioral regulation	Personalized routine Practical reminder strategies eHealth applications	“I also brush my teeth every night, so I just do it before the tooth brushing.”[P22] “I have to do is twice a day, so then it is one time in the morning and one time in the evening, not at fixed times.” [P14] “Well, look, I have downloaded an app, I believe it is called ‘my therapy’, where you can set that you have to take your medication. I programmed that and I get a very nice whistle at the times that I have to take it. And I also get. It also gives you. Let us say, if you are opening your telephone, then you can see that you still have to take it [the medication].” [P23]