RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

Annexure – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. / NAME AND ADDRESS OF THE CANDIDATE / MR. MANJUNATHA RAO.S
I YEAR M.Sc.NURSING
INDIRA NURSING COLLEGE
FALNIR,
MANGALORE -575002
2. / NAME OF THE INSTITUTION / INDIRA NURSING COLLEGE
FALNIR,
MANGALORE -575002
3. / COURSE OF THE STUDY,
SUBJECT / I YEAR M.Sc NURSING
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / 15-07-2011
5. / Title of the Topic
“A study to assess the knowledge and attitude regarding the use of inhalers among bronchial asthma patient, attending outpatients department’s of selected hospitals of Mangalore Taluk with a view to prepare informational booklet”
6.
7 / B BRIEF RESUME OF THE INTENDED WORK:
6.1 INTRODUCTION

“The more deeper and more efficient that our breathing is, the pure is the blood, and this in itself must result in better health”. - RON WILLEY

Breathing is a basic need. It is a physiological function that is almost synonymous with being alive. There are several disorders that affect the movement of air in and out of the lungs such as bronchitis, emphysema and asthma is often occurred one. Asthma complex disorder involves biochemical, immunological, endocrine, infectious, autoimmune, psychological factors. The word asthma is derived from Greek word meaning ‘breathing or panting’ which is characterized by wide spread narrowing of airway.1,
The prevalence of asthma has increased significantly since the 1970s as of 2009; 300 million people were affected worldwide. In India, asthma affects 2.38% of the population and in Karnataka 3.47% of the population is affected by asthma.3
Inhaler usage is the best choice for the treatment of bronchial asthma than the oral medication. Inhalers are different types. The use of inhaler involves co-ordination with inspiration process. Due to the lack of knowledge regarding the usage of inhalers the treatment and relief from bronchial asthma is not adequate. Many members do not know at least the name of inhalers.
The value of inhalation as a route of drug administration has been recognized for thousands of years by the ancient civilization in India the middle east and as well as by a Hippocrates and Galen. The ayurvedic system of medicine advocates the use dhatura smoked in a pipe for a variety of ailments and atropa belladona was given by smoking as standard remedy for Asthma.
Bronchodilator aerosols have been used since 1935. In the adrenaline bronchodilator have been given by hand hold squeeze bulb nebulizers.This was cumbersome and modern pressurized aerosols were introduced in 1956 and constituted a breakthrough in inhalation treatment. In recent times inhalation therapy have higher level of sophistication although they are simple to use
Inhaled medications are administered directly to the airways, providing a higher local concentration and a lower risk of systemic side effects. For years, jet nebulizers were the only inhalation devices available; however, the development of other devices (metered-dose inhalers, with and without spacers, and dry powder inhalers) made it possible to improve the delivery of drugs to the lungs, as well as to decrease local and systemic side effects.4
6.2 NEED FOR THE STUDY
Inhaler devices are an important part of the armamentarium of clinicians who treat both these obstructive pulmonary diseases. The effectiveness of inhaled drugs depends on the patients’ ability to use the inhaler device correctly and adherence to the treatment regimens is likely to be influenced by their opinions and feelings about the use of inhalers as a mode of therapy. The successful management of COPD and asthma requires attention not only to the observable behavior of the patients, but also to the underlying knowledge and attitudes which drive that behavior. It is a well accepted fact that the patients’ views should be taken into account during the medical decision-making and the choice of therapy.4
In India asthma prevalence has increased from 9 percent in 1979 to 29.5 percent in 1999.It is a major health burden in our country. It is estimated that the chronic asthma cases in India will increase in number from 274.4 lakhs to 350.2 lakhs from 2001 to 2016.According to NFHS-2 report the estimated prevalence of asthma in India is 2468 for 1 lakh population. The prevalence rate was 2309 among those in the age group of 15-59 years. While it was 10375 in those above 60years.Asthma has recorded to be high in Karnataka above national average. The prevalence of severe asthma in Bangalore has shown an increased and reached 6.5 percent during 1999.2
A study was conducted investigate ‘the attitudes, Beliefs and Perceptions Regarding the use of Inhalers among 1276 COPD and asthma Patients and 1832 General Population in Punjab. A questionnaire which could identify the patients’ potential attitudes, beliefs and perceptions about inhalers was designed. The Results showed that only 15.1% patients and 17.2% subjects from the general population considered the use of Inhalers was a social stigma and preferred oral medication they expressed their inhibitions for inhaler use in public, wanted to keep the inhaler use as a secret, expressed preference for a smaller inhaler device and a single dose inhaler and thought that inhalers are were used in for serious diseases which once started on, inhalers had to be taken lifelong. Study concludes there are misplaced beliefs, attitudes and perceptions about inhalers among a majority of subjects will definitely inhibit the proper utilization of inhaler therapy. More importantly, the results have necessitated the urgent need for an individual and a collective national effort in the form of national educative programmes to dispel the misconception and inadequate knowledge, beliefs, attitudes and the perceptions of the patients and the common people towards inhalers.4
An observational study, To evaluate knowledge of and techniques for using prescribed inhalation devices among 120 volunteers: 60 with asthma and 60 with COPD patients at Brazil the result showed that all of the asthma patients and 98.3% of the COPD patients claimed to know how to use inhaled medications. 113 patients (94.2%) committed at least one error when using the inhalation device. Patients committed more errors when using metered-dose inhalers than when using the dry-powder inhalers Aerolizer (p < 0.001) or Pulvinal® (p < 0.001), as well as committing more errors when using the Aerolizer® inhaler than when using the Pulvinal® inhaler (p < 0.05). Using the metered-dose, Pulvinal® and Aerolizer® inhalers, the COPD group patients committed more errors than did the asthma group patients (p = 0.0023, p = 0.0065 and p = 0.012, respectively). The study conclude that although the majority of the patients claimed to know how to use inhalation devices, the fact that 94.2% committed at least one error shows that their technique was inappropriate and reveals a discrepancy between understanding and practice.5
Patients knowledge, attitude and practices play a important role in understanding, defining, and responding to illness and so, this study was aimed to exploring knowledge and attitudes and perception of the patients with regards to inhalers as a treatment modality. People have different knowledge about the use of inhalers in Asthma. Incorrect underlying knowledge belief and attitude about inhaler use may constitute a major obstacle to the adherence to disease management and other self management behavior, and such attitude thereby, may continue to poor treatment outcomes.
With this study, it will enhance the use of inhalers and improve the patient’s knowledge with regard to inhaler technique. It helps to improve the health status of the Asthmatic patient.
6.3 REVIEW OF LITERATURE
A cross sectional descriptive study was conducted to assess the level of knowledge regarding inhaler use among 298 chronic asthma patients attending three Institutes of Dhaka. Convenient sampling was adopted. Data were collected using one semi-structured questionnaire through face-to-face interview. Out of the total 298 respondents 103(35.8%) possessed "excellent knowledge" on inhalers. Ninety one (31.6%) had "adequate knowledge", sixty nine (24.0%) had "poor knowledge" and 35 (8.7%) respondents were found having "no knowledge" about inhalers. Males were seen having better knowledge than the females. The respondents receiving treatment from the indoor possessed better knowledge than those from the outdoors (p<0.001). Level of Knowledge was also found to be associated with the educational status of the respondents. Respondents with higher education possessed more than the respondents with lower education (p<0.001). the result conclude that physicians now prescribe inhalers, but many of them do not explain the proper use of inhaler. This may be corrected through training and motivation of physicians at Medical Colleges and Hospitals and during various medical conferences and other programs. To reduce the extent of suffering and economic burden of asthma patients and their families, active education program for the patients and training program for the health care providers, regarding "inhaler use technique" demands early consideration.6
A experimental study to ‘assess the impact of an asthma education programmed(AEP) on knowledge of asthma and medication, compliance to treatment’ in urban hospital Singapore states that Patients hospitalized for asthma exacerbation were administered a questionnaire to test their baseline knowledge and beliefs on asthma, its medications and their compliance to treatment. Their inhaler technique was assessed. They then underwent an AEP consisting of two individualized education sessions. Re-testing was performed after three months. Per protocol approach and McNamara’s test was used to analyze the statistical significance of the change in the pre- and post-AEP test scores. Hospital administrative data were used to determine the number of ED visits and hospital admissions pre- and post-AEP. Results: Among the 67 patients who completed the two-phase AEP, there was significant improvement in some knowledge aspects.7
A study on ‘Predictors of incorrect inhalation technique in patients with asthma or COPD’ at Netherland. A validated scoring method was used that consisted of triple viewing of video-recorded inhalations, using device-specific checklists. The following patient characteristics were investigated: gender, age, education level, diagnosis, treatment by a pulmonary physician, previously received inhalation instruction, exacerbation frequency, knowledge, self-management competence, pulmonary function, and use of multiple inhaler devices. Chi-square statistics were used for univariate associations between potential determinants and correctness of inhalation technique. Result showed that Overall, 40% of the patients made at least one essential mistake in their inhalation technique. Patients who never received inhalation instruction and patients who used more than one inhaler device made significantly more errors (odds ratio both 2.2). The study conclude that Incorrect inhalation technique is common among asthma and COPD patients in a pulmonary outpatient clinic. Our study suggests that the use of prefilled dry powder inhalers as well as inhalation instruction increases correct inhalation technique.8
A cross sectional study was conducted ‘to determine the prevalence of an incorrect inhalation technique and to examine its determinant among primary care patients of 558 asthma and COPD at Netherland. Inhalation technique was assessed using a standardized inhaler-specific checklist. Pulmonary function assessment and questionnaires were used to collect data about inhaler, patient and disease characteristics. The results showed that overall, 24.2% of the patients made at least one essential mistake in their inhalation technique. The type of inhaler appeared to be the strongest independent determinant of an incorrect inhalation technique. The study concluded that An incorrect inhalation technique is common among pulmonary disease patients in primary care. Our study suggests that especially patients with emotional problems and patients in a group practice are at increased risk for an incorrect inhalation technique.9
An observational study on ‘Assessment of Handling of Inhaler devices in real life’ among 3811 patient was performed in primary care at France,. 76% of patients made at least one error with pMDI compared to 49-55% with breath-actuated inhalers. Errors compromising treatment efficacy were made by 11-12% of patients treated with Aerolizer®, Autohaler, or Diskus®compared to 28% and 32% of patients treated with pMDI and Turbuhaler, respectively. Overestimation of good inhalation by general practitioners was maximal for Turbuhaler(24%), and lowest for Autohaler®and pMDI (6%). 90% of general practitioners felt that participation in the study would improve error detection. These results suggest that there are differences in the handling of inhaler devices in real life in primary care that are not taken into account in controlled studies. There is a need for continued education of prescribers and users in the proper use of these devices to improve treatment efficacy.10
A cross sectional study on ‘Relationships between repeated instruction on inhalation therapy, medication adherence, and health status on chronic obstructive pulmonary disease’ among 88 patient at Japan. A self-reported adherence questionnaire with responses on a 5-point Likert scale is used. Result showed that Of the 88 patients who were potential participants, 55 (63%) responded with usable information. Of the 55 respondents, 22 (40.0%) were given repeated verbal instruction and/or demonstrations of inhalation technique by a respiratory physician. Significant correlations were found between the overall mean adherence score and the health-related quality of life score. Furthermore, patients with repeated instruction showed better quality of life scores than those who did not receive instruction. The study conclude that repeated instruction for inhalation techniques may contribute to adherence to therapeutic regimens, which relates to better health status in COPD.11
6.3 Problem Statement: -
“A study to assess the knowledge and attitude regarding the use of inhalers among bronchial asthma patient attending outpatients department’s of selected hospitals at Mangalore Taluk with a view to prepare informational booklet”
6.4 Objectives of the study: -
The objectives of the study are to :
Ø  assess, the knowledge of bronchial asthma patient about the use of inhalers
Ø  assess, the attitude of the bronchial asthma patient towards use of inhalers
Ø  find out the association between knowledge of bronchial asthma patients regarding the use of inhalers and selected demographic variables
Ø  find out the association between attitude of the bronchial asthma patient towards the use of inhalers and selected demographic variables
Ø  develop and validate an informational booklet.
6.5  Operational definitions: -
Knowledge : Refers to the level of awareness among selected subjects about use of inhalers of bronchial asthma patients with structured questionnaire