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

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110 Pharm World Sci (2006) 28:107–114 Table 3 Subject details Inhaler-shaking (counts) and length of inspiration (seconds) were assessed directly from the videotape recordings. The variable ‘‘breathing-in’’ was defined as the time interval between starting to breathe in and exhaling. Rater reliability Intra-rater Demonstrations from a purposive sample of 12 patients, chosen to illustrate the range of good and poor technique, were rated twice. There was good agreement between the two data sets (Global technique: Chi-square df 4 P < 0.002; co-ordination: kappa 0.795 P < 0.0001). Inter-rater All kappa scores for individual observations were positive and comparison of all observations yielded a median kappa score of 0.5 (quartile range 0.32–0.75). Whilst this demonstrates only a modest level of agreement, assessing breathing patterns was often a problem. ‘‘Difficult to assess’’ subjects were equally distributed between groups. Statistical analysis Chi-square test (categorical variables) and independent t-tests (continuous normally distributed 123 variables) were used to compare baseline data in the English and Turkish groups. Global technique ratings before and after information were compared and subjects categorised as improved, no change, or worse. Chi-square test was used for differences in proportions. The sign test was used for checklist variables; the paired t-test for inhaler-shaking frequency and breathing-in time. Results Fluent English N = 105 Turkish-speaking N =69 Age (years) Mean +/) sd Age group 51 +/) 20.9 42 +/) 17.5
Pharm World Sci (2006) 28:107–114 111 Approximately, a quarter of both language groups said they had not received initial instruction from a health professional on how to use their inhalers. There was no difference in use of spacing devices: approximately a third of both groups used these for at least some of their doses. The EP group were significantly less likely to report seeing the practice nurse about their asthma than the FE group. Nearly half (45%) the EP group said they never saw the nurse, compared with 25% of the English-speaking group. (Chi square = 6.8, df 1, P < 0.01). Tables 4 and 5 compare inhaler technique. Turkish-speakers performed better than Englishspeakers in terms of shaking the inhaler and were more likely to check the mouthpiece. However, there was a marked difference in global scores for inhaler technique, in co-ordination, and in breathholding, all of which were significantly worse in the group with poor English. Impact of interventions in group with poor English Thirty-four Turkish patients with EP were randomised to the MTS group and thirty-five to the PIL/verbal group. Groups were well matched for age, gender and baseline (before information) inhaler technique ratings. Only 4 of the 35 people in the MTS group had used a computer. Despite this, they needed little instruction on use of the system. Changes in inhaler technique after information are presented in Tables 6–8. Half the MTS group were rated as improved compared to 28% of those given a translated leaflet. A further six people (17%) improved after subsequent verbal advice in their own language. Table 4 Global technique assessments in fluent Englishspeakers and Turkish-speakers with poor English Global technique rating Poor Adequate Good Total Fluent English 36 48 11 95 (37.9%) (50.5%) (11.6%) Poor English 57 12 0 69 (83%) (17%) – Chi-square = 30.36 df 2 P < 0.0001 Many subjects had shallow breathing which made accurate assessment difficult. In some cases, they failed to take any perceptible inhalation and five failed to release a dose. Own-language verbal instruction after reading the PIL produced small but statistically significant improvement in breath-holding. Inhaler-shaking and mouthpiece-checking improved significantly in both groups after information. The proportion of patients with correct co-ordination also increased in both groups but numbers were small and changes did not reach statistical significance. Multiple quick actuation of the inhaler was observed in 21% MTS and 20% PIL/verbal before instruction. This problem was resolved in most subjects by all modes of instruction. Discussion The inhaler users with FE and EP in this study came from three London boroughs with diverse mix of ethnic backgrounds and languages. Approximately, a third of the local population in each borough had been born outside the UK. All participants were volunteers who were interested in having an ‘‘inhaler technique check’’. The FE group could all read English; most of the EP group could not. The FE and EP groups were recruited by different methods, and assessed in different settings. We did not take an education history, but the broad occupational profile of the two groups was clearly different, with more retired people in the English group and more women looking after the home in the Turkish group. Inhaler technique in the FE group was in line with previous reports, [5–9] with around a third graded as poor and two-thirds having some co-ordination deficiencies. Global technique in the EP group was almost universally rated as poor, with some extreme co-ordination problems observed. It was not possible to compare asthma severity in the two groups, as the researchers only had access to GP records for patients recruited through surgeries. However, the reported prescribing of large volume spacer devices (roughly a third of both groups said they used a spacer) 123
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