Knowledge of inhaler use among medical officers in the management of asthma in children in Dar es Salaam, Tanzania

INTRODUCTION

Asthma is the most common chronic disease in children, causing significant morbidity and mortality.^[1,2] About 339 million people suffer from asthma worldwide, with a global lifetime prevalence estimated between 1 and 18% of the general population.^[1,3]

In Tanzania, prevalence rates were reported to be 6.6% and 17% in rural and urban settings, respectively, in a study done in Northern Tanzania.^[4] In a more recent cross-sectional study done among adults in Tanzania, the prevalence of asthma was reported to be 10%.^[5]

Although asthma cannot be cured, adequate treatment as proposed by standard guidelines can enhance the quality of life in children by reducing frequent exacerbations and early deterioration of lung function.^[1]

Guidelines recommend the use of inhaled medication as the preferred first line in the pharmacological management of asthma.^[2] Inhalers, when used with spacer devices, improve the delivery of pressurized metered dose inhaler (pMDI)-generated aerosols to the distal airways and are as effective as the delivery of medication by nebulizers in reversing acute bronchospasm in infants and children.^[2]

Knowledge of correct inhaler use, especially by Healthcare workers, influences the success of asthma management.^[4] Incorrect inhaler technique can lead to inadequate asthma management, resulting in poor asthma control and clinical outcomes.^[5] In rural Tanzania, more than a third of patients with asthma were underweight and had lower body fat.^[6]

It has been demonstrated in several studies done to assess the knowledge and practice of inhaler use in treating asthma that there is generally low to average knowledge on the use of inhalers.^[7] Factors such as lack of education and training during and after medical school, unavailability, and cost of these devices account for the reduced usage and low knowledge levels of inhaler use.^[8]

In areas where these studies have been done, interventions have been instituted to improve their use with the overall improvement of outcomes in asthma management.

In Tanzania, clinicians’ knowledge of the correct use of inhalers and inhaler devices after the introduction of international guidelines into the Tanzania Standard Treatment Guidelines is not known, and neither is the factor affecting inhaler use.

This study was conducted to identify clinicians’ knowledge of the use of inhalers and inhaler devices in treating asthma in children in Tanzania.

MATERIAL AND METHODS

This was a cross-sectional descriptive study carried out at the regional and district hospital level, private and government hospitals in Dar es Salaam, Tanzania. Three of the five districts, Ilala, Kinondoni, and Temeke, were selected for the study. These are the major districts that make up the largest city in Tanzania, located on the coast of the Indian Ocean. There are socioeconomic differences and disparities in health resource distribution between the three districts, and this might affect health care delivery.^[9]

RESULTS

A total of 175 responses were analyzed. There were 96 males and 79 females, giving a male-to-female ratio of 1.2:1. The ages of the respondents ranged from 23 to 55 years, with a mean age of 31.98 (standard deviation 6.17). Up to 72.6% of respondents had <5 years’ work experience post-internship, and a majority (51.4%) worked in private hospitals. There was an almost equal number of participants who had a personal history or close relative with asthma compared to those who did not have one.

In assessing individual responses to the questions on inhaler technique knowledge, 79% of respondents acknowledged the need to shake the inhaler before each use, and 52% had incorrect choices with the right positioning of the inhaler during use [Table 1]. A majority of respondents, 57% versus 42.9%, had wrong choices on using the inhaler and spacer with infants, and 71% had wrong decisions on the time lapse between two puffs [Table 2].

There was a small number, 21 (12%) of respondents who had their knowledge from only one source, of which 14 were from medical school, 1 from reading books about the subject, 5 from clinical experience, and 1 from standard treatment guidelines. The majority have their knowledge from multiple sources [Tables 3 and 4].

The preferred route of asthma medication administration among the respondents was the inhaled route, with a prevalence of preference of 82.3%. Eighty-four percent (84%) of doctors mentioned that they assessed patients’ inhaler technique at clinic visits.

Adequate knowledge was given by a score of 4 and above.

Inadequate knowledge, scores <4

The knowledge score computed from the knowledge-based questions was adequate in 44 (25.1%) of respondents, with a larger proportion – 131 (74.9%) – having inadequate knowledge of inhaler use, as illustrated in Table 5.

Table 6 illustrates that on Chi-square analysis, knowledge score had significant correlations with the institution of practice, frequency of attending to children with asthma, and having a personal or family history of asthma (P < 0.05). However, in the multivariate analysis shown in Table 7, having a personal history or close relation with asthma was associated with adequate knowledge, with a P = 0.006 and odds of 2.7 (95% CI 1.29–5.8).

DISCUSSION

Knowledge of inhaler technique use by healthcare providers eventually leads to effective education and follow-up of asthma patients prescribed inhalers. Effective education, resulting in appropriate use, enhances effective drug delivery into the lungs and thereby achieves good control of asthma symptoms, which will eventually reduce the number of exacerbations, hospital visits, and admissions, and in the long term, reduce the rate of development of complications.

In this study, it was found that general inhaler knowledge was inadequate in 74.9% of respondents, even though the prevalence of preference for its use was high.^[14,15] This finding is similar to studies done in Nigeria, Egypt, Spain, and South Africa in which adequate inhaler knowledge accounted for 14.5%, 21.3%,14.2% and 16% of physicians by Ndukwu et al., Fattah et al., Plaza et al., and Maepa et al., respectively.^[9,10,16,17] These studies were similar to the current study in that they utilized similar questionnaire-based assessments of knowledge, where the knowledge score was based on responses to certain knowledge-based questions, and were carried out in 2016, 2015–2016, and 2010, respectively.^[7,8,14,15] There are other studies that have utilized both practical demonstration of the basic steps in the MDI technique and written knowledge, and both have shown inadequate knowledge of inhaler use.^[16]

This finding suggests a generally low level of inhaler use knowledge among medical doctors, the reason for which could be due to infrequent refresher courses on its use, unavailability, and cost of these devices, which make its use not preferred.^[17] This has resulted in an increased preference for other routes of management instead of the inhaled route, and hence the lack of desire to acquire knowledge on its appropriate use.

Knowledge levels could not be attributed to the source of knowledge on inhaler use. In this study, there was no specific source of knowledge of MDIs among medical doctors. Most doctors derived their knowledge from more than two sources, and this had no significant association with the level of knowledge. Ndukwu et al., in their study, also demonstrated this finding.^[8] Education on inhalers and their use is not well-trained among medical students, as the majority of medical officers in a study done in Tanzania had no training on inhaler use, and most doctors obtain their knowledge during residency programs or by attending workshops and seminars on the subject.^[17]

This was also shown by Maepa et al. After demonstrating low levels of knowledge, it was demonstrated that a third of the participants were never taught about inhaler use, and there were no identifiable educational programs in place for this. This prompted a structured intervention compared with no intervention, and after 8 months, healthcare workers exposed to the intervention exhibited a significant improvement in knowledge of inhaler use.^[14]

In Spain, before the study quoted, several studies had been done in the early 1990’s which had shown inadequate knowledge of inhaler use, and a list of educational strategies, such as meetings and workshops to educate physicians, had been carried out to improve this. More than a decade after these interventions, research still revealed inadequate knowledge of inhaler use in Spain.^[15] This suggests the need for frequent training to be carried out to improve inhaler knowledge. As suggested by studies and the GINA guidelines, it takes an average of 10 sessions of training for the acquisition of proper knowledge of inhaler use for patients, and this same principle ought to be utilized in training physicians on adequate inhaler use technique.^[2]

Adequate knowledge of inhaler use was strongly associated with a physician’s personal history of asthma (P = 0.001). A physician with a history of asthma or family history is 3 times more likely to have adequate knowledge than those without (P < 0.02, 95% CI 1.29–5.8). This association has not been demonstrated in other studies, and the finding in this study suggests that practical use or demonstration of inhaler use accounts for adequate knowledge, which has also been recommended by the GINA guidelines.

It presupposes that retraining physicians, especially with hands-on demonstration, is likely to yield positive results in the knowledge of inhaler use.

A study involving 1^st-year interns looked at the level of improvement of inhaler use based on the type of education provided. There was a marked improvement in knowledge levels as training progressed from simple demonstrations to active participation and, ultimately, to more intensive one-on-one sessions. The study concluded that traditional lectures are relatively ineffective for teaching interns proper inhaler technique compared with individualized, hands-on instruction.^[18] This finding would be useful in the planning of interventions to improve inhaler use among healthcare workers.

Those who worked in private institutions had higher knowledge levels in inhaler use than those in government institutions, but this finding was not statistically significant. This is in contrast to another study that compared government and private institutions, demonstrating that physicians in both institutions demonstrated no difference or association with the level of knowledge.^[19] The reason for the findings in our study is not known, but could be attributed to the availability of the inhaler devices, their cost, which will prevent frequent utilization, and when available, the inability of doctors to actively participate in the demonstration of their use to patients due to large patient numbers and time challenges. Doctors do not take up this role in most institutions and are usually supported by nursing staff, asthma educators, respiratory physiotherapists, and pharmacists in demonstrating the correct inhaler use technique.^[15]

Data from a Ugandan study showed that there is limited availability of these devices across the country, and this could reflect a similar situation in Tanzania. More studies should be done to demonstrate this in Tanzania.^[20] Neither sex nor age was significantly associated with general inhaler knowledge, and this has been demonstrated in previous studies.^[16]

CONCLUSION

There is generally inadequate knowledge of inhaler use among Medical doctors in our setting. Our study has shown that personal use and, hence, hands-on educational activities, at periodic intervals, would be useful in improving knowledge levels of inhaler use.