Inhaler technique in Turkish people with poor English: a case of ...

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108 Pharm World Sci (2006) 28:107–114 Introduction Good information on how to take or use medicines is important if people are to get the most benefit from them. In the European Union, comprehensive leaflets for patients are now mandatory [1], and all medicine packs should contain a leaflet as a package insert, produced by the manufacturer. In the United Kingdom, these leaflets are written in English. Translation support for patients is available in hospitals and primary care, but provision is patchy and services over-stretched. People whose first language is not English (non- EFL) may therefore, have difficulty in accessing information about their medicines. This puts them at a significant disadvantage, yet there has been relatively little research [2, 3] in this area. Asthma is one example of a condition where the inability to understand and use printed information (functional illiteracy) could compromise effective management. The metered dose inhaler (MDI) is the first choice device for most people with asthma but these devices are not easy to use well [4–7] and many patients have problems. If the inhaler is pressed before the person starts to breathe in, then a good portion of the released dose will be lost. It is also important that the user breathes in deeply, and then holds their breath, to maximise drug delivery to the lungs. Good instruction can help to overcome these difficulties, [8, 9] particularly in relation to a poor hand/lung co-ordination. However, regular review takes staff time [10] and is not universally available. For many users in the UK, the first and only information they get on how to use their inhaler is the patient information leaflet (PIL) inside the pack. People with poor English reading skills may not be able to understand this information, and could use their inhaler incorrectly, resulting in sub-optimal dosing and sub-optimal response. The first aim of this study was to test this hypothesis by comparing inhaler technique in MDI users with poor English (EP) and people whose first language was English (FE). For the EP group, we chose to study people of Turkish origin, as previous work [11] in Haringey, London had suggested the language barrier was a significant factor in medicines compliance. 123 The second aim was to evaluate two interventions: a translated PIL plus verbal support from a translator, and a multimedia touch screen system (MTS) which provides the same information using video clips of an actual demonstration with own-language voice-over instruction. It was hypothesised that the MTS system might reduce the need for translator support. Method This was a single blind randomised controlled trial with two groups: MTS and a translated leaflet plus support from a translator fluent in Turkish and English (PIL + verbal). Patient allocation was done using random number tables. Patients did not know in advance which information method they would receive. The MTS system covered the material shown in Table 1 with additional information on posture. The subject could interact with the program by selecting to replay a step, or move on to the next one. The leaflet was produced by one of the authors (ZD) and was an exact translation of the current version of Allen and Hanbury’s PIL for the Ventolin MDI. Patient recruitment All recruits gave their informed consent to the study, which was approved by the relevant local ethics committees. Fluent English-speaking MDI users of non- Turkish origin who had been using an inhaler for more than 3 months were recruited through GP practices in Haringey and Camden, and assessed in the surgery. Reading ability was not formally assessed, but the recruitment method provided strong evidence that every volunteer had at least average literacy. Participants were recruited by letter and had to reply in writing, providing some initial information. Their responses could be validated against their handwriting on the consent form which was completed in the surgery before inhaler technique was assessed. Initially, Turkish-speakers (Turkish first language; not fluent in English) were recruited through GP surgeries in Camden but this was not
Pharm World Sci (2006) 28:107–114 109 Table 1 Information points h Take cover off and check the mouthpiece is clean h Shake the inhaler well h Hold the inhaler upright with thumb on the base, below the mouthpiece h Breathe out normally h Close lips firmly around the mouthpiece h Start to breathe in, then press down on top of the inhaler. Keep on breathing in steadily and deeply h Take inhaler from mouth h Hold breath for as long as is comfortable successful; of 100 invited to attend only 10 accepted. A ‘‘snowball’’ convenience sampling method was therefore used, using contacts in social clubs and informal networks in Tower Hamlets and Camden. Subjects were assessed mainly in their own homes. Written and spoken skills in English and Turkish were assessed using a language proficiency test devised by the Language Department at King’s College London. This included being asked to read and explain an English phrase and to answer the question: ‘‘what medicines do you have now?’’ Table 2 shows population data on literacy and birthplace for the three study areas. Study procedure Sessions for the EP group were run by a Turkish pharmacist (ZD) who acted as both researcher and translator. The procedure for the English group has been reported elsewhere [12]. Demographic and treatment-related information (see Table 3) was collected before each patient was Table 2 Area demography Area Total population % born outside UK/Eire Haringey 216,507 34.4% 5.3 Tower Hamlets 196,106 33.4% 10.6 Camden 198,020 33.6% 5.1 London 7,172,091 24.9% 4.9 England 49,138,831 8.3% 4.0 % very low literacy* *Data from Census 2001 and Basic Skills Agency Very low literacy: difficulties in coping with everyday reading and numbers; need intensive help to reach minimum standard. Includes people with learning difficulties assessed. As the time per patient was limited, only basic information was collected. Participants were not asked about their educational history, or for details of their current job. Access to GP records was only possible for the EP group. Asthma severity in the two groups could therefore not be compared. Recruits gave written consent for a videotape to be made. They then demonstrated to the camera the use of the MDI, without a spacer device, using a placebo canister placed into their own holder. Technique was demonstrated twice; before and after viewing information. Patients were allowed to use the program, or study the leaflet for as long as they wished before repeating the demonstration. The researcher/ translator identified areas where technique could be improved, then spent up to 15 min discussing this with the user. A final video recording was then made. This allowed the effect of the information alone to be separated from the combined effect of PIL + translator support. Assessment of inhaler technique Videotaped demonstrations were digitised, compressed to MPEG format and transferred to CD-ROM. They were subsequently assessed by two pharmacists with experience in respiratory medicine. These assessors did not attend experimental sessions and had no contact with patient volunteers. They were therefore, blind as to the information format, but not as to the patient’s probable ethnic origin. First, the assessors were asked to play the clip through without stopping and to rate global technique as poor, adequate or good. This would probably approximate to a ‘‘quick check’’ of technique performed in the clinic. Poor technique was defined as any of the following: – pressing the canister before inspiration – visible ‘‘mist’’ escaping from the mouth – no significant inhalation observed – not releasing a dose at all Assessors then assessed technique in detail using a checklist. The individual steps shown in Table 1 were scored as correct or incorrect. 123
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