A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE

AND PRACTICE OF INHALER THERAPY AMONG

BRONCHIAL ASTHMA PATIENTS WITH A VIEW TO
DEVELOP GUIDELINES AT SELECTED HOSPITALS,
JALANDHAR, PUNJAB, 2015.

A synopsis
submitted for the partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING

Medical Surgical Nursing
of
Baba Farid University of Health Sciences,
Faridkot, Punjab

2014

Navneer Kaur

MHR DAV Institute of Nursing, Jalandhar

A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE
AND PRACTICE OF INHALER THERAPY AMONG
BRONCHIAL ASTHMA PATIENTS WITH A VIEW TO
DEVELOP GUIDELINES AT SELECTED HOSPITALS,
JALANDHAR, PUNJAB, 2015.

A synopsis
submitted for the partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING

Medical Surgical Nursing

of
Baba Farid University of Health Sciences,
Faridkot, Punjab

2014

Navneer Kaur

Name & Signature of Supervisor Name & Signature of Co-Supervisor

Mrs . Veena Williams Ms . Salin.S

Prof. cum Principal Lecturer ,
Medical Surgical Nursing Medical Surgical Nursing
M.H.R DAV Institute of Nursing M.H.R DAV Institute of Nursing .
Jalandhar Jalandhar

MHR DAV Institute of Nursing, Jalandhar

 SYNOPSIS OF THE STUDY

STATEMENT OF THE “A descriptive study to assess the knowledge and

PROBLEM practice of inhaler therapy among bronchial asthma
patients with a view to develop guidelines at
selected hospitals, Jalandhar, Punjab 2015”

SUPERVISOR Mrs Veena Williams

Prof. cum Principal, M.Sc(Nursing)Medical
Surgical Nursing, Pursuing Ph.D.
M.H.R DAV Institute of Nursing, Jalandhar.

CO-SUPERVISOR Ms. Salin. S

Lecture, Medical Surgical Nursing
M.H.R DAV Institute of Nursing, Jalandhar
SUBMITTED BY Navneer Kaur
M.Sc. Nursing 1st Year
Medical Surgical Nursing
M.H.R DAV Institute of Nursing, Jalandhar.

ABSTRACT OF PLAN OF THESIS

TITLE “A descriptive study to assess the knowledge and
practice of inhaler therapy among bronchial asthma
patients with a view to develop guidelines at selected
hospitals Jalandhar, Punjab, 2015.
FOR THE DEGREE OF M.Sc. Nursing
Medical Surgical Nursing
NAME OF THE Navneer kaur
CANDIDATE
SUPERVISOR Mrs. Veena Williams
Prof. cum Principal,M.Sc (Nursing), Medical Surgical
Nursing, Pursuing Ph.D.
M.H.R DAV Institute of Nursing, Jalandhar.
CO-SUPERVISOR Ms. Salin. S
Lecturer, Medical Surgical Nursing
M.H.R DAV Institute of Nursing
INSTITUTION M.H.R DAV Institute of Nursing, Jalandhar.
UNIVERSITY Baba Farid University of Health Science, Faridkot,
Punjab- 151203
ABSTRACT
Bronchial asthma is usually a chronic lifelong disease affecting millions of people in
the daily lives. Bronchial asthma is a condition in which the airway of the lungs are
narrowed making normal breathing difficult. This study will be undertaken to assess the
knowledge and practice of inhaler therapy among bronchial asthma patients. A non
experiment research approach and descriptive research design will be used. The sample
size will be 100 from selected hospitals from Jalandhar. Before conducting the study the
researcher will get prior permission from the hospital authorities and informed consent
would be taken from the patients who would be included in the study. A self structured
questionnaire regarding knowledge of inhaler therapy and a checklist to assess the
practice of inhaler therapy will be used to collect data. The collected data will be
analyzed and interpreted by using descriptive and inferential statistics.
S. NO. CONTENT PAGE NO.
 1. Chapter I: Background of the Study
1.1 Introduction 1-3
1.2 Need of Study 3-5
1.3 Research Problem 5
1.4 Aim of The Study 5
1.5 Objectives 5-6
1.6 Operational Definitions 6
1.7 Assumptions 6
1.8 Delimitations 6
2. Chapter II: Review of Literature 7-18
3. Chapter III: Methodology
3.1 Research Approach 19
3.2 Research Design 19
3.3 Research Setting 19
3.4 Target Population 19
3.5 Sample & Sampling Technique 19
3.6 Inclusion Criteria & Exclusion Criteria 19-20
3.7 Selection & Development of Tool 20
3.8 Description of Tool 20
3.9 Validity of Tool 20
3.10 Reliability of Tool 20
3.11 Pilot Study 21
3.12 Data Collection Procedure 21
3.13 Ethical Consideration 21
3.14 Plan of Data Analysis 21
3.15 Methodology Flowchart 22
4. References 23-25
5. Annexures
Annexure I - Permission Letter of Civil Hospital,
Jalandhar

INDEX
 Chapter-I : Background of the study

1.1 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

Murthy KJR(2007)1 Bronchial asthma is usually a chronic lifelong disease affecting

millions of people in the daily lives. It can only be prevented or controlled as it is very
difficult to cure completely patients are found to be ignorant about prevention, treatment
and medication of asthma. So an ample knowledge about these aspects is required to
decrease the cases of asthma and its severe symptoms. Asthma affects school attendance,
occupational choices, physical activity and other quality of life issues. The main causes
of asthma are allergen inhalation like: animal danders, house dust mite, cockroaches,
pollens, molds, air pollutants like perfumes, cigarette smoke, Stress, drugs like aspirin,
non-steroidal anti-inflammatory drugs, occupational exposure like metal salts, wood and
vegetable dusts, industrial chemicals and plastics, food additives like beer, wine, dried
fruits and hormones/menses.

Horwitz RJ(2006)2 Bronchial Asthma is a serious global health problem. People of all
ages in countries throughout the world are affected by this chronic airway disorder that
can be severe and sometimes fatal. The prevalence of bronchial asthma is increasing
everywhere, especially among children. Bronchial Asthma is a significant burden, not
only in terms of health care costs but also of lost productivity and reduced participation in
family life. During the past two decades, we have witnessed many scientific advances
that have improved our understanding of bronchial asthma and our ability to manage it
effectively. However, the diversity of national health care service systems and variations
in the availability of bronchial asthma therapies require that recommendations for
bronchial asthma care be adapted to local conditions throughout the global community.

1
A.N. Aggarwal (2004)3 Data on prevalence of asthma is now available from several
countries. Prevalence varies from region to region depending upon the definition used for
diagnosis of asthma. Current bronchial asthma is reported in 1.2 to 6.3% adults in most
countries. On the other hand, diagnosed Bronchial asthma in adults is generally reported
as 2.7 to 4.0% in most European countries, 12.0% in England and 7.1% in the US, In
Australia, the prevalence is rather high (9.5 to 17.9%). The overall burden of bronchial
asthma in India is estimated at more than 15 million patients. However, India is a vast
country with immense geographical, economical, racial, religious and socio-political
diversity. There are obvious differences in prevalence of disease and approach to
management of health problems.

Han P(2004)4 Asthma can be classified as mild intermittent, mild persistent, moderate
persistent or severe persistent. 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 or 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.

Dhand and Guntur(2003) Metered Dose Inhalers are used to administer medication to
patients with reversible diffuse airways obstruction. Their main advantage is that drugs
can be delivered directly to the airways avoiding the side effects associated with oral
therapy. However, these are expensive and need skill for proper use. Use of inhalers is
relatively more expen-sive if they are not use properly. An effective asthma control can
only be achieved when the patient is comfortable to use a particular de-vice correctly.
Poor inhaler technique reduces the drug delivery to the airways, and hence, decrease the
effectiveness of the inhaled drugs.

Bonner and Carr(2002) Earlier studies demonstrated that the scope of non-compliance
with prescribed medication is rampant in majority of patients that result in drug related
emergencies. Of the many attributes associated with patient non-compliance and thus
drug misuse, misunderstanding of direction by patients has been implicated as a frequent
problem.

2
Kemp T (1996)5 Bronchial asthma is a condition in which the airways of the lungs are
narrowed making normal breathing difficult. It is a chronic inflammatory disorder of the
airways. The chronic inflammation causes an increase in airway hyper responsiveness
that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough
particularly at night or in the early morning. These episodes are associated with
widespread but variable airflow obstruction that is usually reversible either spontaneously
or with treatment. The clinical course of asthma is unpredictable, ranging from periods of
adequate control to exacerabations of dyspnea, wheezing and chest tightness.

Choudhury MAJ(1992)6 A study in Bangladesh shows that only 17 percent asthma

patients could demonstrate the technique of Inhaler use properly. Another study shows
that 69.6% of bronchial asthma patients are lacking the knowledge of correct use of
Inhalers. The aim of this study was to evaluate patients ‘knowledge about Inhaler
therapy’ and to evaluate patients improper handling of Inhaler devices, investigate
different factors that might contribute to scope of inducting awareness on proper use by
education.

1.2 Need of Study

Vitull k. Gupta(2011)7 Inhaler devices are important part of the armamentarium of

clinicians who treat both these obstructive pulmonary disease. The effectiveness of
inhaled drugs depends on the patient’s ability to use the inhaler devices 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
chronic obstructive pulmonary disease and asthma requires attention not only to the
observable behaviour of the patients, but also to the underlying knowledge and attitudes
which drive that behaviour. It is well accepted fact that the patient’s views should be
taken into account during the medical decision making and the choice of therapy.

A study was conducted investigate “the attitudes, beliefs and perceptions regarding the
use of inhalers among 1276 chronic obstructive pulmonary disease 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 result was

3
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 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.

Souza ML(2009)8An observational study, to evaluate knowledge of and techniques for

using prescribed inhalation devices among 120 volunteers. Patients committed more
errors when using metered dose inhalers than when using the dry powder inhalers.
Aerolizer or Pulvinal, as well as committing more errors when using the Aerolizer
inhaler than when using the Pulvinal inhaler. Using the metered dose, Pulvinal and
Aerolizer inhalers, the chronic obstructive pulmonary disease group patients committed
more errors than did the asthma group patients. 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.

A.N. Aggarwal(2006) Bronchial Asthma was diagnosed in 2.28%, 1.69%, 2.05% and
3.47% respondents respectively at Chandigarh, Delhi, Kanpur and Bangalore, with
overall prevalence of 2.38%. Female sex, advancing age, usual residence in urban area,
lower socio-economic status, history suggestive of atopy, history of asthma in a first
degree relative, and all forms of tobacco smoking were associated with significantly
higher odds of having asthma. Prevalence estimates of asthma in adults in this study,
although lower than several previously reported figures, point to a high overall national

4
burden of disease. Improper asthma management leads to increased mor-bidity as well as
economic burden to individuals and societies.

This study is done to 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. Bronchial asthma is one of the chronic disease where the patient suffers from
childhood to old age. During stress or any exercise, there may be sudden exacerbations of
asthma for patients at home. Advance in medicine has proved that using correct technique
in Inhaler therapy can provide comfort for the patient to maintain a patent airway until
they can seek for medical assistance. Many patients are prescribed with inhaler therapy
but as they are not following skills in using the inhalers, they are not able to meet their
immediate oxygen needs. As nursing profession is concerned with disease prevention,
health promotion and restoration of health, there is a felt need to identify the knowledge
and practice of bronchial asthma patients on Inhaler therapy and to provide a guidelines
on the correct technique of inhaler therapy.

1.3 Research Problem

A descriptive study to assess the knowledge and practice of Inhaler therapy among
bronchial asthma patients with a view to develop guidelines at selected hospitals,
Jalandhar, Punjab, 2015.

1.4 Aim of Study

The study is aimed to assess the knowledge and practice of Inhaler therapy among
bronchial asthma patients with a view to develop guidelines on the proper technique of
using inhalers as it can prevent acute exacerbation of bronchial asthma.

1.5 Objectives

 To assess the knowledge of Inhaler therapy among Bronchial Asthma patients.

 To assess the practice of Inhaler therapy among Bronchial Asthma patients .
 To determine the correlation between knowledge and practice regarding Inhaler
therapy among Bronchial Asthma patients .
5
 To analyze the relationship of knowledge and practice of Inhaler therapy among
Bronchial Asthma patient with selected socio - demographic variables .
 To prepare and distribute the guidelines on Inhaler therapy among Bronchial Asthma
patients.

1.6 Operational definitions

Assess - It is continuous process to examine outcome achievement among use of

inhaler therapy among bronchial asthma patient.

Knowledge – It refers to the correct response of bronchial asthma patients to the

questionnaire regarding knowledge and practice of inhaler therapy .
Practice - It refers to the way of using correct technique of inhaler for the treatment
of bronchial asthma.
Inhaler therapy - It refers to a device containing aerosol medication which is inhaled
through oral route used in treatment of bronchial asthma.
Bronchial Asthma - Bronchial asthma is a chronic, inflammatory disease of the
respiratory tract, which is characterized by bronchial hyper-activity and respiratory
obstruction.

1.7 Assumptions
 Bronchial asthma patients may have inadequate knowledge and practice regarding
use of inhalers.
 Improper technique in using inhaler may not be helpful in treating exacerbation of
asthma.

1.8 Delimitations
The study will be limited to :
 Bronchial asthma patients who are on Inhaler therapy.
 100 Bronchial asthma patients.
 Bronchial asthma patients in selected hospitals at jalandhar.

6
 Chapter- II : Review of literature

The review of literature is defined as a broad comprehensive, in depth systematic and

critical review of scholarly publications, unpublished scholarly print materials, audio
visual material and personal communication.

Review of literature is an important step in the development a research project. It

involves the systemic identification, factors and summary of written materials that
contain information on research.

The researcher will review the literature under the following headings:

2.1 Review of literature related to prevalence and incidence of bronchial asthma

2.2 Review of literature related to knowledge of bronchial asthma

2.3 Review of literature related to Prevention of bronchial asthma

2.4 Review of literature related to Knowledge regarding Inhaler therapy

2.1 Review of literature related to prevalence and incidence of bronchial asthma

Guddattu V (2010)9A study was conducted in Manipal to find out the household and
environment factors associated with asthma among Indian women. A multilevel
approach. This study aims to find prevalence and risk factors for asthma among Indian
women aged 15 to 49 based on Indian national family health survey-3. This overall
prevalence of asthma was 17 / 1000 women. Overweight, obesity, exposure to alcohol,
smoking, use of biomass for cooking, and low education are proven to be risk factor for
asthma. The study result shows that exposure to biomass fuels were observed to have
high population – attributable risk percentage (19%, 18.6%). Control of these variables
may reduce major burden on asthma.

Aggarwal AN (2006)10 A field study was conducted in Chandigarh, Kanpur and

Bangalore about prevalence and risk factor for bronchial asthma in Indian adults,

7
through a two stage stratified sampling and uniform methodology using a previously
validated questionnaires. Besides demographic data, information on smoking habits,
domestic cooking fuel use, atopic system and family history of asthma was collected.
Data from 73.605 respondents were analysed. One or more respiratory symptoms present
in 4.3 to 10.5 %. Asthma was diagnosed in 2.28% , 1.69 %, 2.05 % and 3.47%
respondents at Chandigarh, Delhi, Kanpur and Bangalore with overall prevalence of
2.38%. This study pointed out a high overall national burden of disease.

Chhabra SK, (2006)11 A study was conducted in Haryana to find out the Incidence of
Asthma among Children in a Rural Block of Haryana. This study aims to find out the
Incidence and prevalence of asthma among pediatric population in the age group of 0-5
years. A total of 2,250 children between 0-5 years were screened for bronchial asthma.
1150/2250 (633 males and 517 females) had diagnosed of respiratory cases, giving a
prevalence rate of 51.1%. The study found the maximum patients 45.2% were of
bronchial asthma followed by cough 315 cases (27.3%). The study also depicted that
Indoor pollution i.e Smoke produced from cowdung, kerosene, wood, kitchen smoke
etc. were in 374 (72.0%) cases, 312 (60%) cases had overcrowded families while 39%
cases gave the history of smoking in families. Air pollution contributes to increase in the
number of bronchial asthma cases and asthma aggravation in the world. The study
concluded that reduction in the indoor smoke can decrease the incidence of bronchial
asthma in children.

Lissner L, (2000)12 A study was conducted in a Swedish community to find out the
prevalence and incidence of asthma related to waist circumference and Body Mass Index
in a Swedish community sample. In all, both asthma and obesity have become more
common in affluent societies during the recent decades and several studies have shown a
correlation between the presence of asthma and obesity. In order to further study this
association we have investigated a population from a community in southern Sweden,
where almost all inhabitants had their body indices measured as part of a study on
diabetes at a primary care centre. An asthma unit working with a structured care
programme for asthma was available. This organization enabled us to study whether body
mass index and waist circumference was associated with having or developing asthma.

8
There was a significant association between both overweight, increased waist
circumference and asthma, P<0.01. The risk for developing asthma was associated with
increased body weight and abdominal circumference, P<0.05. The increase in asthma
morbidity in the overweight subjects was found almost exclusively in the non-atopic
asthma patients .This study confirms earlier findings of an increased prevalence of
asthma in obese and overweight patients. Increased obesity and especially abdominal
obesity is thus a risk factor for asthma, which probably contributes to the high prevalence
of asthma in affluent societies.

Vignola AM (1998)13 revealed on asthma and rhinitis are often co morbid conditions, and
the overall characteristics of the diseases and the treatment options for the disorders are
similar. Several recent epidemiologic studies in the general population have provided
evidence to strongly associate the development of asthma with a previous history of
either allergic or perennial rhinitis. Additional links between asthma and rhinitis include a
description of increased aspirin intolerance in both disorders and the observation that
most subjects with occupational asthma experience rhinitis. Further, the likelihood of the
development of asthma is much higher in individuals with both perennial and seasonal
rhinitis than for individuals with either condition alone. Asthma and rhinitis were found
to be co morbidities regardless of atopic state, and perennial rhinitis has been associated
with an increase in nonspecific bronchial hyper responsiveness. Several studies have
identified rhinitis as a risk factor for asthma, with the prevalence of allergic rhinitis in
asthmatic patients being 80% to 90%. These studies and others demonstrate that the
coexistence of asthma and allergic rhinitis is frequent, that allergic rhinitis usually
precedes asthma, and that allergic rhinitis is a risk factor for asthma. Finally, studies that
have examined the age of onset of atopy as a confounding factor for the development of
asthma and allergic rhinitis have suggested that early age atopy may be an important
predictive factor for respiratory symptoms that continue into late childhood. In
conclusion, rhinitis and asthma are strongly associated, and rhinitis has been identified as
a risk factor for asthma.

2.2 Review of literature related to knowledge of Bronchial Asthma

9
Forck I (2007)14 A study conducted on knowledge on bronchial asthma of primary
physical education teachers in Schleswig-Holstein. There is a high prevalence
of bronchial asthma among school children in primary schools (age 6-10 years).
Although physical exertion may induce acute episodes of asthma in the majority of
children, exercise may also be an important part of the therapy for asthma and motor
development of children with asthma. In the present study, the knowledge
concerning asthma and exercise among teachers in primary schools was investigated 120
teachers of physical education in Schleswig-Holstein were interviewed concerning their
baseline data (age, gender, education) and their knowledge about asthma and physical
exercise.44% do not plan their lessons with regard to possible stimuli for asthma attacks.
Only 32 teachers prefer correct interval training and only a small minority check
the asthma emergency medication before the exercise lessons. There were no differences
with regard to gender, age or education of the teachers. Our data demonstrate an
insufficient knowledge about bronchial asthma among the teachers we studied. Both the
medical knowledge (reaction in case of acute episodes of asthma) and the principles of
exercise in children with asthma were not satisfactory.

Prasad R (2003)15A study conducted in Lucknow to assess the perception of patients

about bronchial asthma. In all, 135 consecutive patients of bronchial asthma attending in
and outpatient services of department of T.B. and chest disease were interviewed using a
questionnaire. The ratio of urban to rural population was 2.6. Majority of patients that is
81(60%) belonged to middle class, 42 (31.1%) patients to lower class and 12(8.9%)
patients to upper class. One hundred and seven patients (79.3%) showed ignorance about
the aetiology of asthma. Only 6 (4.4% ) patients were aware about the various medication
prescribed for asthma. As many as 52 were aware about the various medication
prescribed for asthma. As many as 52 (38.5%) patients were aware of allergy test and 39
(28.9%) about immunotherapy. None of the patient knew about peak flow meter, lung
function tests as tools for monitoring of their disease. Most of the patients i.e. 98 (72.6%)
were from urban population, yet were ignorant about their disease. A large no. of
(95.6%) patients were not having any knowledge about the types of treatment for asthma.

10
This study revealed that an average asthmatic patient is generally ignorant about his
ailment and his misconceptions.

Rovithis E(2001)16 A study was conducted to assess the level of knowledge for bronchial
asthma of the primary healthcare physicians serving a rural population on the island of
Crete, both before and immediately after a one-day educational course. Twenty-one
primary health care physicians, randomly selected from a list of 14 Health Care Centres
on the island of Crete were invited to participate in the study and attended an educational
course. Nine of the 21 physicians were fully qualified general practitioners, while the
remainder were non-specialized (NSs) physicians who had recently graduated from the
University of Crete, Medical School. A questionnaire of 20 items based on
current bronchial asthma clinical guidelines was used. Three scores, the mean total,
knowledge subscore and attitudes subscore, were calculated for each group of physicians,
both before and after the course. At baseline mean total score and knowledge and
attitudes subscores were higher for non-specialized physicians than for the general
practitioners, but the differences were not statistically significant (p > 0.05). The
knowledge subscore was improved in both groups, however the difference was
statistically significant only for the non-specialized physicians (t = 2.628, d.f. = 11, p <
0.05). The mean total score after the course was significantly higher for the non-
specialized physicians in comparison to that of the general practitioners (t=-2.688, d.f. =
19, p < 0.05) .This study adds to the information about the success of continuing medical
education, and also demonstrates that the recent graduates in the studied population,
could be educated with more positive results than the fully qualified practitioner.

Stohlhofer B (1998)17 This study revealed on the current knowledge of Vienna primary
school teachers about bronchial asthma in children. This study was performed to examine
the causes, triggers and therapy of bronchial asthma in a statistically relevant group of
teachers at primary schools in Vienna. Furthermore, it was intended to investigate the
correlation between their knowledge and their approach in respect of the management of
asthmatic pupils.1054 (80.4%) of 1311 questionnaires were returned and evaluated. Five
items were investigated: "general knowledge", "symptoms and triggers"; "exercise",
"treatment" and "individual experience". Statistical analysis was performed by using

11
counting statistics. For the correlation of items, Spearman correlation coefficients and
Wilcoxon's test were used. The teachers in primary schools showed a good basic
knowledge of asthma and its symptoms. Poor understanding was found with regard to the
medical treatment and trigger factors of asthma; only 34% of the teachers knew that
playing games in cold wind may provoke an exacerbation of asthma; less than half of the
teachers (45%) were aware of the fact that an asthma attack can be prevented by
prophylactic treatment. A significantly positive correlation was found between previous
instruction on asthma and its management, the degree of individual experience, and the
correct belief that asthmatic children should be encouraged to fully participate in school
sports and activities (p = 0.001). Most of the teachers (94%) felt the lack of sufficient
information. Only 2% had received proper instruction on asthma and revealed a
significantly better knowledge of all items (p = 0.0001). The study suggested that
teachers at primary school receive further instruction on asthma, especially regarding its
practical aspects.

Brook U (1993)18 A study was conducted to assess the Knowledge and attitude of
healthy high school students toward bronchial asthma and asthmatic pupils. One hundred
sixteen healthy high school pupils were interviewed and completed a questionnaire
concerning their knowledge about asthma and their attitude towards asthmatic peers.
They were compared with 35 asthmatic pupils studying at the same school. The level of
knowledge was quite satisfactory, with the knowledge of the asthmatic pupils being
somewhat higher than that of the healthy pupils, but without statistical significance.
There was a correlation with the age of the pupils in both groups (p < 0.0001). The source
of pupils' knowledge came principally from the media (television and newspapers), the
family (talking with parents), treating physicians, and school nurses. The healthy pupils
displayed less tolerance toward the asthmatic disease and its limitations on activity than
that displayed by the asthmatic pupils (p < 0.001). A correlation was found between the
level of knowledge and attitude, with an increased level of knowledge implying a more
tolerant attitude. A correlation was also found between tolerant attitudes and increasing
age, increasing parental education, and the pupils behavior marks. The recommendation
of the survey is to improve the instruction regarding bronchial asthmatic diseases with
12
classes taught by physicians or nurses. By increasing the knowledge of the healthy pupils
at school, their attitudes will be more tolerant and positive toward the asthmatic pupils.

2.3 Review of literature related to Prevention of bronchial asthma

Haughney J, (2008)19 revealed on achieving asthma control in practice: understanding the

reasons for poor control. Achieving asthma control remains an elusive goal for the
majority of patients worldwide. Concomitant rhinitis, a common co-pathology and
contributor to poor control, can often be identified by asking a simple question. Smoking
too has been identified as a cause of poor asthma control. Practical barriers such as poor
inhaler technique must be addressed. The study concluded that an appreciation of patients
views and concerns about maintenance asthma therapy can help guide discussion to
address perceptual barriers to taking maintenance therapy .

Behera D, (2008)20 explored on avoidance of allergens by the patients with bronchial

asthma. Association between environmental allergens and bronchial asthma is well
established. A great number of substances found in the environment can precipitate or
aggravate respiratory symptoms of asthmatics. Avoiding allergens is recognized as an
integral part of management. The total enrolled patients were 523 of which 260 were
included in the study group to whom self care manual was given and 263 in the control
group with no access to self care manual. Both the groups were comparable on majority
of the socio-demographic variables. The study concluded that the number of patients
whose symptoms were aggravated by particular triggering factor reduced significantly on
each successive visit in the study group.

Melani AS (2007)21 conducted a study ay polyclinic Le Scotte, Italy with an aim to study
regarding inhalation therapy as the preventive measure of asthma. The objective of the
study was to know how effective are the various inhaled drugs since patients with in this
it is shown that patient education factor play a role in use and misuse of delivery devices
and effectiveness of aerosol therapy. Finally the study concluded that all inhaling
therapies are equally effectiveness if used in rights technique.

13
A.N. Aggarwal, (2006)2 investigated on prevalence and risk factors for bronchial asthma
in Indian adults: a multicentre study. The objectives of the study were to estimate
prevalence of bronchial asthma in different regions of India and to define risk factors
influencing disease prevalence. Study was conducted at Chandigarh, Delhi, Kanpur and
Bangalore through a two stage stratified (urban/rural) sampling and uniform methodology
using a previously validated questionnaire. Data from 73605 respondents (37682 men,
35923 women) were analysed. One or more respiratory symptoms were present in 4.3-
10.5% subjects. The study shows that asthma was diagnosed in 2.28%, 1.69%, 2.05 and
3.47% respondents respectively at Chandigarh, Delhi, Kanpur and Bangalore, with
overall prevalence of 2.38%.

Toelle BG (1993)22 revealed on Evaluation of a community-based asthma management

program in a population sample of school children. To assess the effect of a community-
based management program, incorporating both education and treatment directed at
children, parents, doctors, pharmacists, community nurses and school teachers. The effect
of this intervention in a population sample of 65 children with a wide range of morbidity
due to asthma was compared with a control group of 55 children living in a different area.
Both groups were re-evaluated concurrently after three and six months. Forced expiratory
volume in one second; bronchial responsiveness to histamine measured as the provoking
dose causing a 20% fall in forced expiratory volume in one second and as dose-response
ratio; Airflow meter variability; symptom frequency; and knowledge of asthma.
Morbidity was measured by parents using a self-administered questionnaire and included
days absent from school and unscheduled doctor or emergency room visits. At three
months, the intervention group had a significant improvement in knowledge of asthma
compared with both their baseline and the control group's change in knowledge. Also,
forced expiratory volume in one second improved in this group and symptoms which
limit activity decreased significantly. However, the largest improvements were recorded
at the six-month follow up. In the intervention group, bronchial responsiveness and night
cough were reduced significantly forced expiratory volume in one second was improved,
compared with both baseline measurements and the control group. Knowledge of asthma
also improved significantly from baseline, and unscheduled doctor or emergency room

14
visits were reduced. These improvements in this group of children, many of whom had
mild asthma, verify that community-based management programs can be effective in
treating childhood asthma.

2.4 Review of literature related to knowledge regarding Inhaler therapy

Parvin IA ,(2011)23A 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.

Plaza V(2011)24 This study revealed that physicians' knowledge of inhaler devices and
inhalation techniques remains poor in Spain. Studies in many countries in the 1990s
revealed deficiencies in physicians' knowledge about inhalation therapy. The objective of
the present study was to assess changes in attitudes and knowledge about inhalers and
inhalation techniques in a sizable sample of physicians. An 11-question multiple choice
test was developed and administered throughout Spain to practicing physicians from

15
specialties that frequently prescribe inhaler devices. The survey collected demographic
characteristics (four items), preferences (two items), and issues related to knowledge
(three items) and education (two items) about devices and inhalation techniques.
Completion of the questionnaire was voluntary, individual, and anonymous. A total of
1514 respondents completed the questionnaire. Dry powder inhalers were preferred by
61.2% physicians, but only 46.1% identified "inhale deeply and forcefully" as the most
significant step in the inhalation maneuver using these devices. Only 27.7% stated that
they always checked the patient's inhalation technique when prescribing a new inhaler. A
composite variable, general inhaled therapy knowledge, which pooled the correct answers
related to knowledge, revealed that only 14.2% physicians had an adequate knowledge of
inhaled therapy. Multivariate analysis showed that this knowledge was lowest among
internal medicine and primary care physicians. The study shows that prescribers'
knowledge of inhalers and inhalation techniques remains poor in Spain. The causes
should be identified in further research to allow effective educational strategies to be
developed. Specific educational policies should be addressed to general practitioners.

Petro W(2005)25 A study conducted on Inhalation therapy by dose-inhalers: analysis of

patients performance and possibilities for improvement. Inhalation therapy in chronic
obstructive airways disease requires an efficient inhalation technique. This study analyses
step by step the mistakes made in the usage of different metered dose inhalers, relates
these to patient information prior to the testing and examines several teaching procedures
for improvement of knowledge and performance of the inhalation technique. 125 patients
suffering from chronic obstructive pulmonary disease were assigned to six different
groups according to their background knowledge in the inhalation technique. The
performance was assessed in standardized single steps and as overall performance.
Furthermore the efficacy of an interactive pc-based-training program was evaluated. The
worst performance was seen in patients who only used the suppliers medication leaflet as
a guide. Patients trained in outpatient clinics as well as patients trained in small groups
during an inpatient stay showed a better performance. A high improvement rate was seen
in prior metered dose inhalers naive patients after they had undergone the interactive pc-
based training program. Most problems were detected in the application step "exhalation

16
before inhalation" and in the actuation-inhalation step. Besides the classical and the pc-
based training the use of metered dose inhalers phantoms showed very good results. The
practical conclusion of this study is that the ability of patients to use inhalation
pharmacotherapy efficiently needs improvement. Training programs of different intensity
lead to a different outcome in performance and knowledge depending on prior
knowledge. Inhalation pharmacotherapy without adequate training is insufficient.

Cunha AJ (2003)26 A study on the Knowledge of pediatricians in Rio de Janeiro, Brazil,

about inhalation therapy in asthmatic children. The purpose of this study was to describe
pediatrician's knowledge of spacers and of concepts of chilhood asthma, as well as their
prescribing habits concerning inhalation therapy, in the public health system of the city of
Rio de Janeiro. A descriptive cross-sectional study was performed in a sample of 72
pediatricians from the public health system of Rio de Janeiro. A questionnaire was used
to assess prescriptions for spacers, the reasons whay spacers were not used, the models
employed, classification of asthma according to clinical severity and symptom frequency,
recommendation for the correct spacer volume according to age group, and the concept
of asthma as an inflammatory disease. The results of this study suggested that
pediatrician's knowledge of inhalation therapy with dosed aerosol spacers and of asthma-
related concepts in the public health system in Rio de Janeiro is limited. This may restrict
the quality of care given to the asthmatic children in the city and suggests the need for
training programs for the management of asthmatic children.

Hanania N (1994)27 A study revealed on the medical personnel's knowledge of and ability
to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated
dry powder inhalers. To address this problem, patient education by medical personnel has
been recommended and a variety of alternate inhaler devices have been developed. The
surveyed medical personnel to assess their knowledge of and ability to use three widely
used inhaler devices; metered dose inhalers, metered dose inhalers with a spacing
chamber (Aerochamber, Trudell Medical, Canada), and a breath-actuated multidose dry
powder inhaler (Turbuhaler, Astra Pharmacy, Inc, Conada). Thirty respiratory therapists,
30 registered nurses, and 30 medical house staff physicians were asked to demonstrate
the use of each device using placebo inhalers and to answer 11 clinically relevant

17
questions related to the use and maintenance of the tested devices. More respiratory
therapists (77 percent) had received formal instruction on the use of devices at school
than either registered nurses (30 percent) or medical house staff physician (43 percent) (p
< 0.05). The study concluded that many medical personnel responsible for monitoring
and instructing patients in optimal inhaler use lack rudimentary skills with these devices,
nurses and physicians seldom receive formal training in the use of inhaling devices, and
newer inhaling devices designed to obviate problems of technique are at present less
likely to be used well by medical personnel soon after their introduction.

Chapter-III : Methodology

18
3.1 Research approach

A non-experimental research approach will be used for study.

3.2 Research Design

Descriptive Research design will be used to assess knowledge and practice of inhaler
therapy among patients with Bronchial Asthma. .

3.3 Research Setting

The study will be conducted at selected hospitals, Jalandhar.

3.4 Target Population

Bronchial Asthma patients at selected hospitals, Jalandhar.

3.5 Sample and Sampling technique

The sample size will consists of 100 bronchial asthma patients using inhaler therapy. The
purposive sampling technique will be used to collect the data.

3.6 Inclusion and Exclusion criteria

Inclusion criteria
 Bronchial asthma patients visiting OPD and admitted in medical wards of
selected hospital, Jalandhar.
 The bronchial asthma patients who can read and write Punjabi, Hindi and English.
Exclusion criteria

 The Bronchial asthma patients who are not willing to participate in the study.
 Bronchial asthma patients who are critically ill.

Variables

19
Independent Variables
The independent variable for the study will be knowledge and practice of inhaler
therapy.
Dependent Variable
The dependent variable for the study will be Bronchial asthma patients.

3.7 Selection and Development of tool

After extensive review of literature and expert guidance, a self-structured questionnaire
with multiple choice questions to assess knowledge and checklist containing yes or no
items will be used to observe the practice of inhaler therapy.

3.8 Description of tool

Self-structure questionnaire which consist of 3 parts
Part –A : Socio-demographic variables like age, sex, education, occupation, income,
type of family, no. of years on inhaler therapy, types of inhaler.

Part –B : Self- structured knowledge Questionnaire.

Part –C : Checklist

3.9 Validity of tool

Content of tool will be validated by obtaining the expert’s opinion regarding the
relevance of items from the field of medical and surgical nursing.

3.10 Reliability of Tool

The reliability of knowledge questionnaire will be established by split half method and
the practice checklist will be assessed using inter rater reliability method and the
reliability co efficient will be calculated using spearman’s brown prophecy formula.

3.11 Pilot Study

Pilot study will be conducted on 10% of sample to find out the reliability and feasibility
of the study.
3.12 Data Collection Procedure
20
The investigator would get the permission prior to data collection from concerned
authority. The investigator will introduce herself to the participants and obtain written
consent from bronchial asthma patients. After getting consent the self structured
knowledge questionnaire will be given to the samples with a request to fill the
questionnaire. The patient will be then asked to use their inhalers and a checklist with
“yes” or “no” will be used to marked to observe whether correct technique is followed in
inhaler therapy.

3.13 Ethical Consideration

 Ethical clearance will be obtained from the ethical committee of the MHR DAV
Institute of Nursing, Jalandhar.
 Written Consent will be taken from the clients who will be willing to participate
in the study.

3.14 Plan of Data Analysis

The data will be analysed in accordance to objectives by using descriptive and inferential
statistics .

Flow Chart of Brief Outlines of Research Methodology

21
Research Approach: Non experimental Research
Approach

Research Design: Descriptive Design

Target population: Bronchial asthma patients at selected

hospitals, Jalandhar

Sample: 100 Bronchial Asthma patients at selected

hospitals, Jalandhar

Sampling Technique: Purposive Sampling Technique

Selection and Development of Tool: Tool will be

formulated after extensive review of literature and
discussion with the experts and guide

Selection and Development of tool: The tool consists of 3

parts:

Part A: Socio- Demographic Variables

Part B: Self structured knowledge questionnaire

Part C: Checklist

Data analysis: Descriptive and inferential statistics

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