Impact of health literacy on education on proper inhaler use in COPD, asthma

A recent study found that education-to-goal methods were more effective than brief interventions in metered-dose inhaler education for patients with chronic obstructive pulmonary disease (COPD) and asthma, but results may vary by health literacy levels.

When trained to use a metered-dose inhaler (MDI) with goal-directed training methods, patients diagnosed with asthma and chronic obstructive pulmonary disease (COPD) had a lower rate of MDI misuse after training than those trained through brief interventions, according to a recent research study published in Respiratory medicine.

However, patients with low health literacy, a problem more common in older patients (aged 65 and older), had a higher rate of MDI misuse after training than patients with adequate health literacy.

The researchers aimed to examine risk factors for MDI misuse among older hospitalized patients with asthma and/or COPD, and to compare how different educational interventions affect post-training levels of inhaler technique in older and younger patients.

Improper technique when using MDI is an important issue for older patients with asthma or COPD. Therefore, it is important to investigate possible risk factors that affect this group of patients, the authors write.

The present study is a secondary analysis of data derived from 5 previous prospective interventional studies. These studies included 394 patients with a mean age of 51.9 years; 67% of patients were female, 90.6% were black, and 20% were age 65 or older. Patients were diagnosed with asthma or COPD and were hospitalized in 2 urban academic hospitals. The time frame for enrollment in these studies was from 2007 to 2017.

The researchers assessed the patients’ vision and health literacy. Patients were screened for health literacy using the Short Test of Functional Health Literacy in Adults (STOFHLA) if their vision was sufficient. The STOFHLA measures reading comprehension by asking patients to correctly select the missing words to complete given sentences. A score of 23/36 or higher on the STOFHLA indicates adequate health literacy, and a score lower than 23/36 indicates low health literacy.

A 12-step checklist assesses patients’ MDI technique before and after inhaler training. Less than or equal to 9 out of 12 correct steps on the checklist identifies MDI abuse.

All 5 studies assigned patients to 1 of 3 MDI educational interventions:

  • Teach-to-Goal (TTG) which follows a reverse teaching method where a demonstration is given followed by the patient teaching the information back in a 3 round cycle
  • Virtual Teach-to-Goal (V-TGG), which is the virtual version of TGG
  • A brief intervention (BI) that consists of one-time simple verbal instructions

Most of the patients (189, or 47.9%) were assigned to TTG, followed by 142 (36.0%) to V-TTG and 63 (15.9%) to BI.

At baseline, 88.8% of patients misused their MDIs as assessed by the 12-step checklist. Scores averaged 6.49 out of 12. There was no significant difference in baseline abuse between older and younger patients, patients with poor and sufficient vision, or patients with high and low levels of literacy.

After receiving training on how to use these inhalers, MDI scores improved across all 3 educational interventions, with the mean score increasing to 10.3 out of 12. Among patients assigned to the BI group, significantly more (74.6%) continued to misuse the inhaler compared to those assigned to the TGG or V-TTG interventions. In the BI group, no patients older than 65 years improved their MDI technique.

Almost one fifth (19.3%) of patients have low health literacy. Compared with those patients over 65 years of age, a higher proportion of those under 65 years of age had adequate health literacy.

More (46.7%) patients with low health literacy continued to misuse MDI after training compared with fewer (23.9%) patients with adequate literacy. This pattern is also present in the TGG and V-TGG groups. In the BI group, no significant effect of health literacy on MDI misuse rates was found after training.

Binary logistic analysis showed that a higher baseline MDI technique score, high health literacy, and TTG and V-TTG were factors that reduced patients’ odds of MDI misuse after training.

Factors that did not significantly influence MDI abuse after training were age and visual acuity. Although age was not a significant factor influencing MDI misuse, age was associated with low health literacy. Because health literacy is an important factor in the increase in MDI abuse, older people may be at higher risk for incorrect inhaler techniques.

Limitations of this study include a relatively small sample size in the BI group compared to the size of the TGG and V-TTG groups, the authors wrote. They also note that most patients analyzed were urban, female and black, so the results may not be applicable to other groups. Because this study was a secondary analysis of previous data, the researchers had limited data on age-specific questions. Another limitation was the study’s use of the STOHFLA, which required adequate vision and therefore did not allow the researchers to assess the health literacy of patients with poor vision.

The effectiveness of the training-to-target methods lies in the continuously tested scientific material, improving memory and allowing training to be individually tailored to the patient, the authors said. TTG and V-TTG are less effective for those with low health literacy, which disproportionately affects older patients. Therefore, it is important to develop individually tailored, patient-centered educational interventions about MDI for this population, the researchers concluded.


Trela ​​KC, Zajac P, Zhu M, Press VG. Health literacy and type of educational intervention predicting incorrect use of metered dose inhalers after training. Respir Med. Published online July 12, 2022. doi:10.1016/j.rmed.2022.106930

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