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

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112 Pharm World Sci (2006) 28:107–114 Table 5 Comparison of key steps in technique in fluent English-speakers and Turkish-speakers with poor English Shakes inhaler (% correct) suggests that GP perception of clinical need was similar in the two groups. The majority of participants in both FE and EP groups said they remembered a demonstration of how to use their inhaler when it was first prescribed. In addition, they would all have received the manufacturer’s PIL, which is included in every inhaler pack. These mandatory leaflets, defined by EU regulations, act as a reference source for the patient and family and carers and are intended to complement and reinforce any verbal advice from health professionals. PILs for asthma inhalers provide illustrations of the key steps in correct use, but these need to be viewed in conjunction with the text to be fully understood. It is therefore, reasonable to propose that the inability to read and understand the written information on how to use their inhaler may have made it more difficult for the EP group to develop good inhaler technique. Cultural differences in the use of primary care preventive services would have perpetuated this information deficit. Our EP sample was hard to recruit through surgeries, and also much less likely than the FE group to use non-acute services such as nurse-run asthma clinics. There were therefore, fewer opportunities for nurses and GPs to pick up and correct misunderstandings about technique. Table 6 Global technique change after intervention in poor English-speakers n shakes (sd) Checks mouthpiece (% correct) Co-ordination (% correct) Breathing-in time(secs) Fluent English 59(59%) 4.7 (5.9) 4 (4%) 28 (29.5%) 7.8 (4.4) n = 100 n =99 n = 100 n =95 n =52 Poor English 38 (55%) 7.0 (4.1) 10 (14.5%) 8 (11.6%) 4.8 (6.3) n =69 n =40 n =69 n =69 n =52 Difference ns P < 0.05 P < 0.01 P < 0.02 ns MTS PIL + translator After PIL After PIL + verbal Worse than baseline 5 (15%) 5 (16%) 4 (11%) No change 12 (35%) 18 (56%) 16 (48%) Better than baseline 17 (50%) 9 (28%) 15 (45%) 123 Poor reading skills are not just a problem for people whose first language is not English. Nationally 4 in 10 adults have been estimated[13] to have difficulties in coping with everyday literacy and numeracy requirements. A recent survey [14] found that 15% of 127 consecutive patients (125 Caucasian) attending a rheumatoid arthritis clinic were functionally illiterate. These patients did not have more severe disease than patients who could read information about their condition, but were more anxious and visited hospital more often. Motivation to read and the perceived authority of the information source are also factors. All of our volunteers with FE were able to read, yet a proportion also had poor technique. FE asthmatics[15] do not always look at PILs, or see them as important. They place a higher value on face-to-face individualised advice. Properly blinded studies of interventions to improve inhaler technique have rarely been attempted. The present study has attempted to overcome the problem of bias by filming patients using their inhalers and then digitising the films for ‘‘blind’’ assessment. Deciding if chest movement had occurred was sometimes very difficult, and this may explain the relatively low level of agreement between assessors. Bearing this weakness in mind, brief exposure to own-language information presented via multimedia and a translated leaflet with translator support appeared to be equally effective in changing what some inhaler users did, at least in the short term. Approximately, half the subjects had improved their technique after information given by either method. The effect of written translated information alone was smaller; only one quarter of subjects improved after a leaflet.
Pharm World Sci (2006) 28:107–114 113 Both information methods resulted in small but statistically significant improvements in some individual technique steps, although co-ordination, the most important aspect of technique, was only improved in a small number of people. Conclusions There were demographic differences between our two language groups, and this is an acknowledged weakness in this study. However, we do not believe that these differences alone explain why inhaler technique in the people with poor English was so much worse than in the FE users of the same inhaler (Ventolin). Discrimination in terms of access to the written information supplied inside every inhaler pack also needs to be considered. The interventions we tested suggested that a translated PIL, used alone, is of less benefit than the same leaflet used together with own-language verbal advice. This supports others [3, 16] who have concluded that it is simplistic to propose that written translation alone is the answer to the language barrier when providing medicines information. The Turkish inhaler-users in our study were mostly literate in their mother tongue but the assumption that if you can speak a language then you can read it is not necessarily true[13], either for native English speakers or for foreigners. A broad portfolio of methods, including pictograms, audiotapes and computer and web-based multimedia (available through terminals in surgeries, pharmacies and other public information points) needs to be developed if all patients are to Table 7 Categorical technique variables (paired data; sign test) Technique measure Checks mouthpiece (n correct) Shakes inhaler (n correct) Co-ordination (n correct) Multimedia group Leaflet + translator group N cases Before info After MTS P value have equal access to good medicines information. Lack of computer experience need not be a barrier. The majority of Turkish-speaking subjects and elderly English subjects had little or no experience but found the method both easy and enjoyable. The ability to offer patients a choice of language makes multimedia systems useful educational tools but they are not a panacea to the problem of poor inhaler technique. Our volunteers were long-term inhaler users, with deeply ingrained habits. The impact of information on their inhaler technique was modest at best, and co-ordination did not improve in the majority of patients tested. Greater benefits could be expected in people using inhalers for the first time, and a multimedia touch-screen computer could offer a convenient alternative to the use of a translator for the brief explanations normally given in surgery or pharmacy. However, the findings demonstrate that information alone is rarely enough to change behaviour. To improve poor co-ordination, the inhaler user first needs to see and understand what he is doing wrong, and then to practise until the correct method becomes automatic. This learning process needs practical one-to-one teaching from someone who can demonstrate correct MDI technique. In our study, the video camera was a very useful teaching and learning tool. This study suggests that a significant proportion of inhaler users with poor English may never attend GP asthma check clinics, and only visit the surgery when they become ill. However, all inhaler users must present their prescriptions to a pharmacist. The acceptability and feasibility of N cases Before info After PIL P value After PIL + verbal advice P value 34 8 (23%) 16 (47%) 0.05 35 2 (6%) 1 (3%) ns 11 (31%) 0.004 34 16 (47%) 24 (72%) 0.04 35 22 (62%) 16 (46%) ns 35 (100%) 0.001 34 4 (12%) 11 (35%) ns 35 4 (11%) 6 (18%) ns 10 (28%) ns 123
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