European Journal of Cardiovascular Medicine

Chronic respiratory diseases, including asthma and chronic obstructive pulmonary disease (COPD), constitute a significant and escalating global public health issue. Asthma is estimated to impact over 300 million individuals globally and is responsible for approximately 15 million disability-adjusted life years each year.1 The prevalence of adult asthma in India is estimated to be between 2.4% and 4.8%, varying by region and methodology used.2 Chronic obstructive pulmonary disease (COPD) significantly impacts morbidity and mortality, ranking as one of the leading causes of death worldwide.

Inhalational therapy is acknowledged as fundamental in the management of asthma and COPD, as it administers medication directly to the airways, thus improving efficacy and minimizing systemic side effects.3 The effectiveness of inhaler therapy is contingent not only upon the prescription of the appropriate pharmacologic agent or device but also on patients' understanding of their condition and inhaler devices, their attitudes towards inhaler use (including beliefs, myths, and stigma), and their practices, which encompass proper inhaler technique, adherence to treatment protocols, regular follow-up, and device maintenance. Adequate knowledge, attitudes, and practices are essential; otherwise, device misuse, non-adherence, and resulting sub-optimal disease control are common occurrences.

Research indicates that errors in the use of inhaler devices are prevalent. A recent meta-analysis indicated that 14% to 92% of patients with asthma or COPD committed at least one critical inhaler-use error.3 Non-adherence to inhaled medication is prevalent in various contexts; a study conducted in India indicated non-adherence rates of approximately 65% among patients with asthma and COPD, attributing this issue to socioeconomic factors, device technique, and knowledge.4

In the Indian context, while there are KAP studies on asthma among general populations and parents/caregivers, there is a relative scarcity of research specifically addressing inhaler device-related knowledge, attitudes, and practices in adult asthma and COPD patients within tertiary care settings. A recent study conducted in Chennai revealed that asthmatic patients and their caregivers possess moderate knowledge and a positive attitude. However, it also highlighted significant gaps, including misconceptions regarding inhaler usage, the necessity of lifelong therapy, and embarrassment associated with public use.5 A study conducted in central India revealed that approximately two-thirds of asthmatic outpatients possessed adequate knowledge, while adherence levels were found to be low.3

The present study was conducted at a tertiary-care teaching hospital in North Maharashtra, emphasizing the significance of region-specific data for the development of patient education, device training, and quality improvement interventions. The study aimed to: (1) evaluate the knowledge of inhalational devices among adult patients with asthma and COPD; (2) examine patient attitudes regarding inhaler usage; (3) assess practices related to inhaler technique, adherence, and follow-up; and (4) investigate the relationships between knowledge, attitudes, and practices (KAP) scores and various socio-demographic and clinical factors. Findings are expected to guide the development of targeted educational strategies and device-use training specific to the local patient population.

Study design and setting: This was a hospital-based, cross-sectional study conducted in the Department of Pulmonary Medicine of a tertiary-care teaching hospital in North Maharashtra, India, during the period from March 2025 to July 2025. Participants: Adult patients (≥ 18 years) diagnosed with asthma or COPD as per standard criteria (GINA for asthma; GOLD for COPD) who had been on one or more inhalational devices (metered dose inhaler [MDI], dry powder inhaler [DPI], MDI + spacer, nebuliser) for at least 3 months, and attending the outpatient department or admitted in the pulmonary unit, were eligible. Exclusion criteria included patients with interstitial lung disease, recent major cardiac event, cognitive inability to answer questionnaire, or unwillingness to consent. Sample size and sampling: Based on prior literature indicating inhaler-device awareness and correct practice rates of ~40 – 60 % in similar settings, and taking a margin of error of 10 % at 95 % confidence, the sample size was calculated as approximately N = 200. A consecutive sampling method was used till the target sample was reached. Ethical considerations: The study was approved by the institutional ethics committee. Written informed consent was obtained from all participants. Confidentiality and anonymity were maintained. Data collection instrument: A structured, pre-tested questionnaire in the local language (Marathi/English) was used. It consisted of four parts: (i) socio-demographic data (age, sex, education, occupation, rural/urban residence, socioeconomic status); (ii) clinical details (diagnosis asthma or COPD, disease duration, inhaler type(s), number of hospitalisations/exacerbations in past year); (iii) knowledge domain: 10-15 items covering disease awareness, inhaler purpose (controller vs reliever), device type, need for inhaler technique, side-effect awareness; (iv) attitude domain: ~8–10 items covering beliefs about inhaler therapy (addiction, cost, side-effects), stigma/public use, preference for oral medication, willingness for long-term use; (v) practice domain: ~8–10 items assessing device-handling (self-report of technique steps, demonstration if feasible), adherence (self-report of missed doses), regular follow-up, cleaning/maintenance of device. Each domain was scored (knowledge maximum score e.g., 15; attitude maximum e.g., 30; practice maximum e.g., 15) with higher scores indicating better KAP. Data collection procedure: After obtaining consent, the questionnaire was administered face-to-face by a trained research assistant. For the practice domain, participants were asked to demonstrate their inhaler device (when feasible) and technique was observed using a standard checklist of steps. Adherence was assessed by self-report (missed doses in last month) and follow-up regularity by history. Data analysis: Data were entered into Microsoft Excel and analysed using SPSS version 20. Descriptive statistics (mean, standard deviation, frequencies, proportions) were calculated for KAP domains and socio-demographic/clinical variables. Associations between KAP scores (categorized as adequate vs inadequate based on median or predetermined cut-offs) and independent variables (age group, sex, education, disease type, duration, prior inhaler demonstration) were tested using chi-square test or independent t-test as appropriate. A p-value < 0.05 was considered statistically significant.

On analysing overall mean KAP scores mean knowledge score was 8.4 ± 2.1 with adequate response seen in 62.3% patients. Mean attitude score was 17.2 ± 3.5 with an adequate response seen in 58% of the patients. Mean Practice score was 7.9 ± 2.0, with an adequate response rate of 60.7% (table 1).

Table 1: Overall Mean KAP Scores

The responses of knowledge parameter in participants of present study are shown in table 2. Majority of the correct responses were received for knowledge question of smoking worsens disease even with inhaler (80%).

Table 2: Knowledge responses.

Majority of agreements in attitude questionnaire was marked for question of device demonstration/training accounting for 85% agreement responses. Majority of disagreement responses were obtained for questions on inhalers are addictive and oral tablets are preferable. The responses of attitude parameter in participants of present study are shown in table 3.

Table 3: Attitude responses

Majority of agreements in practice questionnaire was marked for question of misuse worsens disease accounting for 78% agreement responses. Majority of disagreement responses were obtained for question on missed ≥1 inhaler dose last month. The responses of practice parameter in participants of present study are shown in table 4.

Table 4: Practice responses

This cross-sectional study conducted in a tertiary-care teaching hospital in North Maharashtra evaluated the knowledge, attitudes, and practices regarding inhalational devices among a diverse group of adult patients with asthma and COPD.  The findings indicate significant deficiencies across all three domains, corroborating and expanding upon observations from various Indian and international studies.

 A minority of individuals attained the 'adequate' level of understanding within the knowledge domain.  Significant deficiencies were identified, including a lack of understanding regarding the distinction between reliever and controller inhalers, the misconception that inhalers are exclusively for older individuals or those with more severe conditions, and insufficient recognition of the importance of proper inhaler technique and consistent usage during asymptomatic periods.  The findings align with a study conducted in Chennai, where approximately 50% of asthmatic patients and caregivers demonstrated acceptable knowledge. Many held misconceptions, including the belief that inhalers are addictive or only necessary during exacerbations. Five  In a comparable study, Rao et al. observed that approximately 70% of patients in an Indian tertiary-care setting were unaware of home monitoring devices, while around 45% lacked knowledge regarding reliever medications.6  A community-based survey conducted in rural South India revealed a low level of awareness regarding asthma triggers and treatment options.7

 Our observations indicated that fewer individuals than expected had received prior demonstrations of inhaler technique; furthermore, among those who did, many continued to make errors or missed doses.  This is consistent with existing literature; a recent review article indicated that up to 45.6% of pMDI users and 28.4% of DPI users commit at least one critical inhaler technique error.3  A study conducted in India revealed that 64.7% of patients with asthma or COPD exhibited non-adherence to inhaler therapy, with socioeconomic status, insufficient knowledge, and improper technique identified as contributing factors.4  Our finding of a positive correlation between knowledge and practice supports the notion that knowledge facilitates appropriate behavior.

 A significant proportion of patients expressed concerns regarding inhaler side effects, costs, potential for addiction, and the public stigma associated with device use.  This aligns with previous studies; for instance, Chokani et al. reported that approximately 64% of physicians observed patients omitting medications when asymptomatic, while around 74% noted patient embarrassment regarding inhaler usage.8  Beliefs and stigma can negatively impact adherence and proper practice, despite adequate knowledge.

 The findings are significant from a regional perspective, as North Maharashtra includes both urban and rural populations. Our data highlight the necessity for structured inhaler-device education that is adapted to the local sociocultural context.  Namely: (i) device demonstration (preferably face-to-face with a trained nurse/respiratory therapist); (ii) repeated reinforcement during follow-up; (iii) addressing myths and attitudes (e.g., "inhaler = addictive", "only for old age", "ashamed to use in public"); (iv) monitoring and documenting inhaler technique periodically; (v) considering socioeconomic barriers (cost, travel, device availability) in educational planning.

 A comparison of our results with previously published studies from India is presented.  The 2016 study conducted by Shamkuwar et al. in Pune/Nagpur reported mean knowledge and attitude scores that were somewhat higher than those observed in our study (mean knowledge ~10.7/16, attitude ~17.1/24); however, adherence remained low.2  In comparison to the 2024 study by Jayadev et al., which reported that 46.2% of participants possessed prior knowledge and 37.7% employed incorrect techniques, our study reveals comparable or marginally worse proportions, highlighting an ongoing challenge.9

 International data indicate that inhaler misuse and non-adherence continue to pose significant challenges to achieving optimal outcomes in asthma and COPD management. 10  Our study contributes to the evidence that device-related KAP deficits are widespread, though their magnitude may differ based on regional, educational, and healthcare resource contexts.

 The limitations of this study encompass its single-centre design, cross-sectional nature, which prevents causal inference, and partial reliance on self-report for adherence and practice responses, potentially leading to an overestimation of actual correct behaviour.  Furthermore, we did not assess objective inhaler usage through electronic monitors or correlate knowledge, attitudes, and practices (KAP) scores with clinical outcomes such as exacerbation frequency and lung function, which could enhance the validity of our findings.  The observational data offer valuable insights for the local context.

In this cross-sectional study of adult asthma and COPD patients in a tertiary-care teaching hospital in North Maharashtra, substantial gaps were observed in knowledge regarding inhalational devices, unfavourable attitudes toward inhaler use (including myths and stigma) and sub-optimal practice (incorrect technique, missed doses). An elevated level of education and previous demonstration of inhaler technique correlated with improved performance. These findings indicate the need for structured inhaler-device education programmes, regular technique reinforcement, and measures to address attitudinal barriers and socioeconomic constraints. Incorporating routine inhaler-technique assessment into respiratory clinics and embedding patient education in follow-up pathways may improve inhaler use efficacy and thereby support better disease control in asthma and COPD. Conflict of interest: None.

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8.       Chokhani R, Razak A, Waked M, et al. Knowledge, practice pattern and attitude toward asthma management amongst physicians from Nepal, Malaysia, Lebanon, Myanmar and Morocco. J Asthma. 2021;58(7):979-989.

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10.  Plaza V, Fernández-Rodríguez C, Melero C, et al. Validation of the 'Test of the Adherence to Inhalers' (TAI) for Asthma and COPD Patients. J Aerosol Med Pulm Drug Deliv. 2016;29(2):142-152.