Abstract
Background
Asthma, a chronic respiratory disease, is effectively managed with medications, yet many patients struggle due to irregular treatment and poor adherence. Pharmacists play a crucial role in improving asthma care through pharmaceutical care (PC) services. This study aims to assess pharmacists’ knowledge, attitudes, and behaviors regarding asthma PC in Türkiye.
Methods
This cross-sectional study in Türkiye evaluated community (CP) and hospital pharmacists’ (HP) knowledge level, attitudes, and behaviors regarding asthma care. A validated Asthma Pharmaceutical Care Knowledge (APCL) and Asthma Attitudes and Behaviors (AAB) questionnaires were used to assess their knowledge levels and attitudes toward asthma pharmaceutical care.
Results
Out of 400 pharmacists participated the questionnaire, the majority were CP (297, 74.25 %). Both CP and HP demonstrated adequate knowledge scores, 79.39 ± 12.32 and 80.66 ± 12.25, respectively. APCL mean scores of CP and HP were 4.22 ± 0.523 and 4.29 ± 0.383. No statistically significant difference in asthma knowledge levels was observed between CP and HP. Both groups reported positive attitudes and behaviors toward asthma care, with CP scoring 4.71 ± 0.446 and HP scoring 4.74 ± 0.330 on the AAB questionnaire.
Conclusions
This study revealed that both CP and HP have sufficient knowledge about asthma and they have positive attitudes towards providing asthma PC. Pharmacists have crucial role in asthma care with leveraging their expertise, patient interactions, and ability to referral capabilities.
Keywords: Asthma, Attitudes, Knowledge, Pharmaceutical care, Pharmacists, Patient care
1. Introduction
Asthma is a chronic respiratory non-communicable disease caused by complex interactions between genetic, environmental, and behavioral variables. It usually appears in childhood, lasts throughout life, disappears for a few years, recurs, and worsens at any age (Romero-Tapia et al., 2023, Trivedi et al., 2019).
One of the most significant features of asthma is that it cannot be cured, although it can be clinically managed with suitable medications. Asthma control is the most significant challenge of disease management (Levy et al., 2023). Asthma symptom control is measured by daytime and overnight symptoms, hospitalizations, reliever therapy use, occupational effect, exacerbations, and disease activity (Braido, 2013). Despite the numerous options available for managing asthma patients and the dissemination of evidence-based guidelines in recent years, asthma control remains far from optimal as indicated by the fact that disease-related morbidity and mortality have not changed (Zeitouni et al., 2022, Turktas et al., 2010). In the majority of cases, asthma is effectively treated with medications, but a considerable proportion of the asthmatic population is unable to control their condition due to a lack of regular therapy, poor adherence, and irregular medical follow-up. (Cazzoletti et al., 2007). Uncontrolled asthma constitutes for one-third of all asthma patients in Europe, with significant geographic variation ranging from 20 % to 67 % depending on the nation (Cazzoletti et al., 2007, Becker et al, 2017) Uncontrolled asthma contributes significantly to healthcare expenses related to treatment non-adherence or hospitalization, as well as a significant decrease in quality of life and an increased risk of anxiety or depressive episodes (Doz et al., 2013, Van Ganse et al., 2002).
Many patients have suboptimal asthma control, which can have an impact on their health, healthcare expenditures, and quality of life. Poor asthma control can be caused by behavioral and clinical variables, chronic exposure to asthma triggers, poor treatment adherence, and inadequate treatment implementation (Akagündüz, 2022, Turktas et al., 2010, George and Bender, 2019, Zhang et al., 2023). On the other hand, asthma treatment is largely dependent on the correct usage of inhalers since effective inhalation is essential for achieving the best therapeutic impact. Several studies have found that incorrect or misuse of an inhaler device is widespread in clinical settings. Improper technique might contribute to poor asthma control. The most recent asthma guidelines underlines the need for methods that help increase patient skills and knowledge in managing their disease (Akagündüz, 2022, Gibson et al., 2013).
On the other hand, drug-related problems (DRPs) are any event or condition involving drug therapy that actually or potentially interferes with desired health outcomes, which is known to be an important issue related to treatment outcomes (Pharmaceutical Care Network Europe Association, 2020, Khdour et al., 2020). One prominent way to reduce DRPs, enhance medication adherence, asthma knowledge, and proper inhaler technique is integrating pharmacists into the healthcare system by providing pharmaceutical care (PC) services and optimizing drug use, resulting in better asthma management (Khodur et al., 2020). Pharmaceutical care services offered by pharmacists can increase the quality of care in a variety of disease conditions, including hypertension, asthma, hyperlipidemia, diabetes, and cancer. Previous research revealed that PC services provided by pharmacist were favorable on patient health outcomes and plays a significant role in identifying, preventing and resolving DRPs and promote rational drug use (McLean et al., 2003, Mohiuddin et al., 2020, Al-Taie et a., 2024, Jia et al., 2020, Garcia-Cardenas et al., 2016; Kovačević et al., 2018).
Meanwhile, an essential strategy of the pharmacist in asthma therapy is patient education and follow-up, particularly to enhance awareness of asthma, various asthma pathologies, and the causes that trigger exacerbation (Pande et al., 2013, Sakthong et al., 2015). Patients should also know about the proper use of asthma medications, the distinctions between which medications are considered therapeutic, and which medications are considered preventive and should be administered even if they have no symptoms. Pharmacists anticipated to gaining insights into how to use measuring tools in PC practices and can take role on many different responsibilities in the management of asthma. To the best of our knowledge, there are few studies investigating the pharmacists' provision of PC practices for asthma treatment in Türkiye. This study aimed to assess and predict the parameters that affect pharmacists' knowledge levels, attitudes, and perceptions regarding the provision of PC practices for asthma treatment and control in two different settings, community, and hospital pharmacy settings in Türkiye, thereby better demonstrating differences and giving a better picture for knowledge about asthma in these settings.
2. Materials and methods
2.1. Study design and setting
A descriptive, cross-sectional study conducted among pharmacists between September 2021 and February 2022 in Turkey. The study was designed in two groups. The first group was pharmacists working in community pharmacies, and they were categorized as CP, while the second group was hospital pharmacists, and they were categorized as HP. Ethical approval for the study was obtained from the Bezmialem Vakif University local Ethics Committee, with the decision number 2021/310.
2.2. Participants and sample size
The Raosoft sample size calculator software was used for the purpose of ascertaining the requisite sample size for this study. The target demographic encompassed Turkish pharmacists, with an estimated response rate anticipated to approximate 50 %. The exponential non-discriminative snowball sampling technique was employed for the purposive selection of participants. The study adheres to the CROSS (A Consensus-Based Checklist for Reporting of Survey Studies) standards for reporting (Sharma et al., 2021).
Under these parameters, and with a consideration for a 95 % confidence interval and a 5 % margin of error, the computed minimum sample size required to maintain a Type 1 error (α) of 5 % and a Type II error (β) of 95 % amounted to 345 participants. An error allowance of 15 % to accommodate potential instances of missing data, non-consent, and incomplete questionnaire responses. Subsequently, the required sample size was recalibrated to 398 participants.
2.3. Questionnaire setting, development, and distribution
An online questionnaire was self-developed by researchers and created following significant and in-depth literature research tailored to the current study's objectives. The questionnaire was distributed utilizing Google Forms as a web-based platform. The survey deployment encompassed diverse channels, including email, direct messaging, and various social media platforms, accompanied by comprehensive information regarding the study. To promote participation, individuals were incentivized to share the survey link within their social networks.
Each participant electronically endorsed a written consent form. Cross-verification procedures were implemented to confirm the uniqueness of each response. A hyperlink of the consent form was embedded within the online questionnaire for participants' personal use. The questionnaire form was configured to allow for a single completion, and participant identities were authenticated by cross-referencing against consent forms.
To enhance the linguistic precision of the questionnaire instrument, a panel of four experts was engaged to provide feedback, leading to subsequent revisions in accordance with their recommendations. Furthermore, a pre-test phase involving two individuals (MYB and SAAJ) possessing expertise in behavior change education was conducted. This pre-testing comprised retrospective cognitive interviews focusing on the evaluation of questionnaire content, format, and language. Subsequent to this, a pilot study was executed with a cohort of fifteen participants distinct from the initial evaluation group. The feedbacks gathered from pilot phase was used for refining the questionnaire's clarity and comprehensibility.
A separate group of twenty five participants, not part of the original study sample, was invited to complete the questionnaire within a two-week timeframe. The questionnaire, with an estimated completion time of 15–20 min, underwent further refinement based on the insights obtained during this phase. To gauge the test–retest reliability, statistical measures including the Spearman correlation coefficient, Wilcoxon test, and intraclass correlation coefficient (ICC) were applied to a sample of 25 participants. The results revealed a statistically insignificant correlation of 0.619 (p > 0.05) and an ICC of 0.761 (95 % CI: 0.463–0.894, F: 4.55, p < 0.001), indicating satisfactory reliability. The internal consistency of the questionnaire was assessed by Cronbach's alpha test and was found to be 0.828.
2.4. Study variable and outcomes
The questionnaire was structured into four sections: the first section consisted of five items about the demographic characteristics of the pharmacists, the second section consisted of nine items to evaluate the asthma knowledge level among the participants. The third section had eighteen items to evaluate the level of Asthma Pharmaceutical Care Knowledge (APCL) among the participants. Each item was rated on a five-point Likert scale (Strongly disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly agree = 5). The last section evaluated the Asthma Attitudes and Behaviors (AAB) and comprising twelve items which were also rated on a five-point Likert scale.
2.5. Data analysis
Continuous variables were analysed with descriptive statistics, encompassing measures such as mean, median, standard deviation, and interquartile range (IQR), while categorical variables were explained with frequencies and percentages. The normality of continuous variables determined with the Kolmogorov-Smirnov and Shapiro-Wilk tests, Q-Q plots, histogram, and density analysis, as well as an assessment of skewness and kurtosis values. Comparative analyses of continuous variables were conducted utilizing either the t-test or Mann-Whitney U test, and categorical data analysed with Chi-Square test or Fischer Exact test, depending on the distribution characteristics of the data.
The internal consistency of the knowledge level, attitude, and behavior measurement questionnaire pertaining to asthma PC was assessed through the calculation of Cronbach's α coefficient. Values falling below 0.40 were deemed insignificant, warranting exclusion from questionnaire analyses. Reliability analyses were further conducted using Spearman's correlation coefficient, the Wilcoxon test, and the intraclass correlation coefficient (ICC). The asthma knowledge level measurement questionnaire, comprising nine questions, deemed participants with correct responses to 70 % of the questions as possessing an adequate knowledge level. Missing data were excluded from the analysis, and Statistical Package for Social Science (SPSS) version 26® and Jamovi version 1.6 software were employed for statistical analyses. Significance levels were defined at p < 0.05.
3. Results
3.1. Socio-demographic characteristics of the study participants
A total of 400 pharmacists participated in the questionnaire, with the majority identified as community pharmacists (297, 74.25 %) (Fig. 1). The mean age of the participants was 32.4 ± 8.86 years. Interestingly, a noticeable discrepancy in mean age was observed between the Community Pharmacists (CP) and Hospital Pharmacists (HP) groups, with mean ages of 32.87 ± 9.04 and 31.02 ± 8.22, respectively. This difference was statistically significant (p = 0.021), indicating a notable distinction in age distribution between the two groups, as shown in Table 1. The mean professional experience among pharmacists was 7.72 ± 8.05 years. Meanwhile, there was a significant difference in professional experience between CP and HP groups, with mean professional experiences of 8.41 ± 8.47 and 5.75 ± 6.36, respectively (p = 0.003). This suggests variations in the career trajectories of community and hospital pharmacists. A substantial portion of pharmacists (55.5 %) reported having a close relative with asthma (p < 0.005), highlighting a potential personal connection to the subject matter. Regarding pervious knowledge level of asthma disease, nearly half of the participants (53.3 %) did not consider themselves to possess an adequate level of information. Additionally, a significant difference in self-evaluation between CP and HP groups was identified (p < 0.05), underscoring variations in perceived knowledge levels. Detailed characteristics of the participants are summarized in Table 1, providing a comprehensive overview of the demographic and professional profile of the pharmacists.
Fig. 1.
Flowchart of the Study Participants. Data presented as percentage.
Table 1.
Sociodemographic characteristics of the participants.
| Parameter |
Community Pharmacist (CP) n (%) |
Hospital Pharmacist (HP) n (%) |
Total N, % |
p-value |
|---|---|---|---|---|
| 297 (74.25) | 103 (25.75) | 400 (100) | NA | |
| Age (Means ± SD), (year) | 32.87 ± 9.04 | 31.02 ± 8.22 | 32.4 ± 8.86 |
=0.021# U: 13,242 |
| Age groups (years) |
=0.068 χ2 = 8,730 |
|||
| 20–30 | 147 (36.8) | 67 (16.8) | 214, (53.5) | |
| 31–40 | 98 (24.5) | 40 (5.0) | 118 (29.5) | |
| 41–50 | 36 (9.0) | 11 (2.8) | 47 (11.8) | |
| 51–65 | 15 (3.8) | 5 (1.3) | 20 (5.0) | |
| >65 | 1 (0.3) | 0 (0) | 1 (0.3) | |
| Gender |
>0.05* χ2 = 1,190 |
|||
| Males | 116 (29.0) | 34 (8.5) | 150 (37.5) | |
| Females | 181 (45.3) | 69 (17.3) | 250 (62.5) | |
|
Professional experience (Means ± SD), (year) |
8.41 ± 8.47 | 5.75 ± 6.36 | 7.72 ± 8.05 |
=0,003# U: 12,497 |
| Professional experience (years) |
<0.004* χ2 = 13,330 |
|||
| 0–5 | 146 (36.5) | 72 (18.0) | 218 (54.5) | |
| 5–10 | 66 (16.5) | 14 (3.5) | 80 (20.0) | |
| 10–2 | 57 (14.2) | 12 (3.0) | 69 (17.3) | |
| >20 | 28 (7.0) | 5 (1.3) | 33 (8.3) | |
| Having a close relative with asthma |
<0.005* χ2 = 7,834 |
|||
| Yes | 177 (44.3) | 45 (11.3) | 222, (55.5) | |
| No | 120 (30.0) | 58 (14.5) | 178 (44.5) | |
| Pervious knowledge level of asthma disease |
<0,05* χ2 = 2,690 |
|||
| Yes | 146, 36.5 % | 41, 10.3 % | 187, 46.8 % | |
| No | 151, 37.8 % | 62, 15.5 % | 213, 53.3 % |
* Chi-Square test, # Mann Whitney U Test. Data presented as number and percentages; NA: not applicaple; significance set at p < 0.05.
3.2. Asthma knowledge level between the community pharmacists and hospital pharmacists
According to the responses from pharmacists to the asthma knowledge level questionnaire, the mean scores were recorded at 79.70 ± 12.3. When examining these scores by professional groups, CP and HP exhibited scores of 79.39 ± 12.32 and 80.66 ± 12.25, respectively. Notably, no statistically significant difference was observed between the asthma knowledge level questionnaire scores of the CP and HP groups, suggesting a comparable level of knowledge in the domain of asthma PC. Further analysis revealed that a significant proportion of both CP and HP scored above the proficiency threshold, with 234 individuals (58.5 %) in the CP group and 82 individuals (20.5 %) in the HP group achieving scores exceeding 70 % on the asthma knowledge level questionnaire. The responses of community and hospital pharmacists to the individual questions within the asthma knowledge level questionnaire, along with the corresponding comparisons, are visually presented in Fig. 2. The Fig. 2 serves as a comprehensive illustration of the distribution of knowledge across various facets of asthma PC, providing valuable insights into potential areas of strength or improvement within each professional group.
Fig. 2.
Comparison of asthma knowledge level between the community pharmacists and hospital pharmacists.
3.3. Level of asthma pharmaceutical care knowledge (APCL) between community pharmacists and hospital pharmacists
Responses to the APCL questionnaire by CP and HP, mean, standard deviation, median and interquartile range are presented in Table 2. Cronbach’s alpha was 0.775 for APCL and the mean ± SD score of the pharmacist was 4.03 ± 0.373. The KMO measure of sampling adequacy was 0.759 and Barlett test was significant (p < 0.001). Although there was no significant difference reported for the majority of items of the APCL questionnaire, the CP and HP reported a good level of asthma pharmaceutical care knowledge. This was observed by the APCL mean score reported by CP and HP as 4.22 ± 0.523 and 4.29 ± 0.383, respectively (Table 2). Meanwhile, the mean of the item “The effect of asthma on mood is insignificant” for CP and HP groups were 2.36 ± 1.82 and 1.76 ± 1.48 respectively and shows a significant difference (p = 0.030).
Table 2.
Comparison of the level of asthma pharmaceutical care knowledge (APCL) between community pharmacists and hospital pharmacists.
| Knowledge Level about Asthma Pharmaceutical Care |
Agree n (%) |
Neither agree nor disagree n (%) |
Disagree n (%) |
Means ± SD, Median [IQR] |
p-value | ||||
|---|---|---|---|---|---|---|---|---|---|
|
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
||
| The pharmacist plays an important role in the asthma care team. | 273 (68.25) | 90 (22.5) | 18 (4.5) | 13 (3.25) | 6 (1.5) | 0 (0) | 4.8 ± 0.73, 5[5–5] |
4.75 ± 0.67, 5[5–5] |
0.589 |
| Asthma pharmaceutical care provided by community pharmacists results in improved clinical and economic outcomes. | 278 (69.5) | 97 (24.25) | 15 (3.75) | 5 (1.25) | 4 (1) | 1 (0.25) | 4.85 ± 0.63, 5[5–5] |
4.86 ± 0.58, 5[5–5] |
0.185 |
| Because asthma treatment is highly variable, it should be monitored periodically. | 274 (68.5) | 96 (24) | 19 (4.75) | 7 (1.75) | 4 (1) | 0 (0) | 4.82 ± 0.66, 5[5–5] |
4.86 ± 0.51, 5[5–5] |
0.704 |
| Asthma control is affected by many physiological, environmental, and behavioral factors. | 280, (70) | 100 (25) | 15 (3.75) | 3 (0.75) | 2 (0.5) | 0 (0) | 4.87 ± 0.54, 5[5–5] |
4.94 ± 0.34, 5[5–5] |
0.309 |
| Monitoring therapeutic outcomes by community pharmacists is an effective strategy to improve the quality of medication therapy for asthma patients in primary care. | 266 (66.5) | 94 (23.5) | 22 (5.5) | 6 (1.5) | 9 (2.25) | 3 (0.75) | 4.73 ± 0.84, 5[5–5] |
4.77 ± 0.81, 5[5–5] |
0.338 |
| The proper use of inhalers and inhalation techniques is one of the most important counseling aspects provided by pharmacists to patients. | 273 (68.25) | 93 (23.25) | 15 (3.75) | 4 (1) | 9 (2.25) | 6 (1.5) | 4.78 ± 0.80, 5[5–5] |
4.69 ± 1.00, 5[5–5] |
0.291 |
| The provision of pharmaceutical care positively affects cost savings. | 264 (66) | 96 (24) | 24 (6) | 7 (1.75) | 9 (2.25) | 0 (0) | 4.72 ± 0.85, 5[5–5] |
4.86 ± 0.51, 5[5–5] |
0.394 |
| Studies investigating facilitators and barriers to asthma management are needed. | 275 (68.75) | 92 (23) | 18 (4.5) | 10 (2.5) | 4 (1) | 1 (0.25) | 4.82 ± 0.65, 5[5–5] |
4.77 ± 0.70, 5[5–5] |
0.061 |
| The most important member of the asthma care team is the patient. | 258 (64.5) | 96 (24) | 28 (7) | 4 (1) | 11 (2.75) | 3 (0.75) | 4.66 ± 0.93, 5[5–5] |
4.81 ± 0.77, 5[5–5] |
0.333 |
| It is important to evaluate the patient's compliance with the medication, inhaler technique, and environmental control measures before prescribing a new medication in the treatment of asthma. | 141 (35.25) | 56 (14) | 17 (4.25) | 2 (0.5) | 139 (34.75) | 45 (11.25) | 3.01 ± 1.94, 3[1–5] |
3.21 ± 1.98, 5[1–5] |
0.207 |
| A significant portion of patients have difficulty using metered dose inhaler delivery systems. | 238 (59.5) | 91 (22.75) | 50 (12.5) | 8 (2) | 9 (2.25) | 4 (1) | 4.54 ± 0.98, 5[5–5] |
4.69 ± 0.92, 5[5–5] |
0.620 |
| Using the wrong inhaler device causes more frequent emergency room and hospital admissions. | 250 (62.5) | 86 (21.5) | 31(7.75) | 12 (3) | 16 (4) | 5 (1.25) | 4.58 ± 1.05, 5[5–5] |
4.57 ± 1.04, 5[5–5] |
0.499 |
| Asthma causes individuals to lose their school and workdays. | 237 (59.25) | 85 (21.25) | 43 (10.75) | 14 (3.5) | 17 (4.25) | 4 (1) | 4.48 ± 1.11, 5[5–5] |
4.57 ± 0.99, 5[5–5] |
0.359 |
| The effect of asthma on mood is insignificant. | 90 (22.5) | 16 (4) | 22 (5.5) | 7 (1.75) | 185 (46.25) | 80 (20) | 2.36 ± 1.82, 1[1–5] |
1.76 ± 1.48, 1[1–1] |
0.030 |
| There is a significant relationship between asthma control level and gender. | 110 (27.5) | 28 (7) | 95 (23.75) | 47 (11.75) | 92 (23) | 28 (7) | 3.12 ± 1.65, 3[1–5] |
3 ± 1.48, 3[1–5] |
0.855 |
| Younger patients under 20 years of age have better asthma control than older patients. | 172 (43) | 53 (13.25) | 76 (19) | 38 (9.5) | 49 (12.25) | 12 (3) | 3.83 ± 1.52, 5[3–5] |
3.8 ± 1.38, 5[3–5] |
0.548 |
| Asthma patients do not benefit from disease monitoring with a peak flow meter. | 120 (30) | 45 (11.25) | 77 (19.25) | 24 (6) | 100 (25) | 34 (8.5) | 3.13 ± 1.72, 3[1–5] |
3.21 ± 1.75, 3[1–5] |
0.646 |
| Control of respiratory function in asthma care is very complex. | 141 (35.25) | 49 (12.25) | 81 (20.25) | 29 (7.25) | 75 (18.75) | 25 (6.25) | 3.44 ± 1.65, 3[1–5] |
3.47 ± 1.64, 3[3–5] |
0.828 |
| Cronbach's alpha: 0.775, Mean ± SD: 4.03 ± 0.373 | |||||||||
According to intragroup comparisons of APCL questionnaire with sociodemographic a statistically significance has been reported in age groups (p = 0.008), professional experience (p < 0.001) regarding the HP group, and self-evaluation of asthma knowledge level (p = 0.026) regarding the CP group, as shown in Table 5. In the CP group, a statistically significant correlation was observed between the APCL questionnaire and the participants' knowledge level (Spearman’s rho: 0.147, p < 0.001). Conversely, within the HP group, a statistically significant negative correlation was established between the APCL questionnaire and both age (Spearman’s rho: −0.313, p < 0.05) and knowledge level (Spearman’s rho: −0.248, p < 0.05).
Table 5.
Association between demographic data with level of asthma pharmaceutical care knowledge (APCL) between community pharmacists and hospital pharmacists.
| Variable |
Community Pharmacist (CP) |
p-value |
Hospital Pharmacist (HP) |
p-value |
|---|---|---|---|---|
| Gender | ||||
| Males | 4.17 ± 0.41 | 0.126 | 4.15 ± 0.35 | 0.126 |
| Females | 4.21 ± 0.36 | 4.22 ± 0.29 | ||
| Age groups (years) | ||||
| 20–30 | 4.19 ± 0.35 | 0.068 | 4.27 ± 0.30 | 0.008 |
| 31–40 | 4.20 ± 0.41 | 4.09 ± 0.36 | ||
| 41–50 | 4.18 ± 0.43 | 4.07 ± 0.24 | ||
| 51–65 | 4.22 ± 0.29 | 4.02 ± 0.12 | ||
| >65 | 4.78 ± 0.35 | − | ||
| Professional Experience (years) | ||||
| 0–5 | 4.19 ± 0.35 | 0.742 | 4.24 ± 0.30 | <0.001 |
| 5–10 | 4.19 ± 0.38 | 4.13 ± 0.41 | ||
| 10–2 | 4.23 ± 0.44 | 4.19 ± 0.18 | ||
| >20 | 4.15 ± 0.37 | 3.84 ± 0.13 | ||
| Pervious knowledge level of asthma disease | ||||
| Yes | 4.25 ± 0.28 | 0.026 | 4.23 ± 0.24 | 0.147 |
| No | 4.15 ± 0.45 | 4.15 ± 0.40 | ||
| Data presented as number and percentages; significance set as p < 0.05. | ||||
3.4. Asthma attitudes and behaviors (AAB) between the community pharmacists and hospital pharmacists
Responses to the AAB questionnaire by CP and HP, mean, standard deviation, median and interquartile range are presented in Table 3. The Cronbach’s alpha value was 0.757 for AAB and the mean ± SD score of the pharmacist was 4.26 ± 0.433. The KMO measure of sampling adequacy was 0.739 and Barlett test was significant (p < 0.001). Although there was no significant difference reported for the AAB questionnaire, the CP and HP reported a good level of asthma attitudes and behaviors. This was observed by the AAB mean score reported by CP and HP as 4.71 ± 0.446 and 4.74 ± 0.330 respectively (see Table 4).
Table 3.
Comparison of asthma attitudes and behaviors (AAB) between the community pharmacists and hospital pharmacists.
| Pharmacists' Attitude and Behavior towards Asthma PC Provision |
Agree n (%) |
Neither agree nor disagree n (%) |
Disagree n (%) |
Mean ± SD, Median [IQR] |
p-value | ||||
|---|---|---|---|---|---|---|---|---|---|
|
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
||
| Pharmacist intervention has a positive impact on asthma-related outcomes in patients. | 280 (70) | 100 (25) | 11 (2.75) | 3 (0.75) | 6 (1.5) | 0 (0) | 4.85 ± 0.67, 5[5–5] |
4.94 ± 0.34, 5[5–5] |
0.793 |
| Asthma education provided by pharmacists is more effective than usual care in improving clinical outcomes. | 252 (63) | 85 (21.25) | 31 (7.75) | 12 (3) | 14 (3.5) | 6 (1.5) | 4.6 ± 1.01, 5[5–5] |
4.53 ± 1.09, 5[5–5] |
0.221 |
| Community pharmacists are required to receive continuing professional training to update their knowledge and skills. | 263 (65.75) | 87 (21.75) | 16 (4) | 6 (1.5) | 18 (4.5) | 10 (2.5) | 4.65 ± 1.03, 5[5–5] |
4.5 ± 1.24, 5[5–5] |
0.058 |
| Asthma training offered to pharmacists should be on asthma self-management. | 260 (65) | 89 (22.25) | 30 (7.5) | 11 (2.75) | 7 (1.75) | 3 (0.75) | 4.7 ± 0.83, 5[5–5] |
4.67 ± 0.89, 5[5–5] |
0.300 |
| Pharmacist review of patients' asthma medication treatment results in a decrease in the average frequency of acute attacks. | 271 (67.75) | 91 (22.75) | 21 (5.25) | 10 (2.5) | 5 (1.25) | 2 (0.5) | 4.79 ± 0.71, 5[5–5] |
4.73 ± 0.79, 5[5–5] |
0.075 |
| The outcome of asthma treatment depends more on the patient's behavior than on the efforts of healthcare providers. | 196 (49) | 71 (17.75) | 65 (16.25) | 27 (6.75) | 36 (9) | 5 (1.25) | 4.08 ± 1.40, 5[3–5] |
4.28 ± 1.15, 5[3–5] |
0.594 |
| Successful management of asthma requires good communication between the patient and the healthcare team. | 282 (70.5) | 100 (25) | 11 (2.75) | 3 (0.75) | 4 (1) | 0 (0) |
4.87 ± 0.59, 5[5–5] |
4.94 ± 0.34, 5[5–5] |
0.549 |
| Communication between healthcare professionals and patients should be improved to prevent suboptimal medication use in asthma patients. | 280 (70) | 99 (24.75) | 12 (3) | 4 (1) | 5 (1.25) | 0 (0) |
4.85 ± 0.64, 5[5–5] |
4.92 ± 0.39, 5[5–5] |
0.593 |
| Lack of proper asthma education can be a big cause of incorrect device use. | 274 (68.5) | 96 (24) | 21 (5.25) | 6 (1.5) | 2 (0.5) | 1 (0.25) | 4.83 ± 0.60, 5[5–5] |
4.84 ± 0.61, 5[5–5] |
0.437 |
| Inhaler devices should be prescribed after providing the necessary training on the use of the device and ensuring that the patient can use this device. | 259 (64.75) | 87 (21.75) | 20 (5) | 10 (2.5) | 18 (4.5) | 6 (1.5) | 4.62 ± 1.05, 5[5–5] |
4.57 ± 1.07, 5[5–5] |
0.193 |
| The technique of using asthma medications such as Turbuhaler should be demonstrated to the patient by pharmacists. | 281 (70.25) | 100 (25) | 12 (3) | 3 (0.75) | 4 (1) | 0 (0) |
4.87 ± 0.60, 5[5–5] |
4.94 ± 0.34, 5[5–5] |
0.840 |
| There is a need for patient education about asthma in Turkey. | 281 (70.25) | 101 (25.25) | 12 (3) | 2 (0.5) | 4 (1) | 0 (0) |
4.87 ± 0.60, 5[5–5] |
4.96 ± 0.28, 5[5–5] |
0.703 |
| Cronbach's alpha: 0.757, Mean ± SD: 4.26 ± 0.433 | |||||||||
Table 4.
Comparison between the total mean of asthma pharmaceutical care knowledge, attitudes and behaviors between community pharmacists and hospital pharmacists.
| Questionnaire total mean |
Community Pharmacist (CP) |
Hospital Pharmacist (HP) |
p-value |
|---|---|---|---|
| Asthma pharmaceutical care knowledge (APCL) | 4.20 ± 0.37 | 4.20 ± 0.31 | 0. 511 |
| Asthma attitudes and behaviors (AAB) | 4.71 ± 0.4 | 4.74 ± 0.33 | 0.864 |
According to intragroup comparisons of AAB questionnaire with sociodemographic a statistically significance has been obtained in age groups of CP group (p = 0.002), self-evaluation of asthma knowledge level for CP and HP groups (p = 0.008, p = 0.01 respectively), and professional experience for HP group (p = 0.027), as shown in Table 6. Moreover, within the CP group, a low-level but statistically significant correlation was seen between the AAB questionnaire and the participants' knowledge level (Spearman’s rho: 0.184, p < 0.001). Similarly, in the HP group, a correlation was identified between the AAB questionnaire and knowledge level (Spearman’s rho: 0.267, p < 0.05).
Table 6.
Association between demographic data with asthma attitudes and behaviors (AAB) between the community pharmacists and hospital pharmacists.
| Variable |
Community Pharmacist (CP) |
p-value |
Hospital Pharmacist (HP) |
p-value |
|---|---|---|---|---|
| Gender | ||||
| Males | 4.66 ± 0.45 | 0.002 | 4.70 ± 0.36 | 0.854 |
| Females | 4.75 ± 0.44 | 4.76 ± 0.31 | ||
| Age groups (years) | ||||
| 20–30 | 4.74 ± 0.34 | 0.119 | 4.78 ± 0.30 | 0.103 |
| 31–40 | 4.67 ± 0.58 | 4.67 ± 0.42 | ||
| 41–50 | 4.69 ± 0.74 | 4.61 ± 0.33 | ||
| 51–65 | 4.84 ± 0.20 | 4.77 ± 0.36 | ||
| >65 | 4.83 ± 0.28 | NA | ||
| Professional Experience (years) | ||||
| 0–5 | 4.74 ± 0.35 | 0.653 | 4.76 ± 0.30 | 0.027 |
| 5–10 | 4.67 ± 0.58 | 4.65 ± 0.47 | ||
| 10–2 | 4.70 ± 0.55 | 4.82 ± 0.26 | ||
| >20 | 4.73 ± 0.30 | 4.37 ± 0.25 | ||
| Pervious knowledge level of asthma disease | ||||
| Yes | 4.78 ± 0.25 | 0.008 | 4.80 ± 0.25 | 0.01 |
| No | 4.64 ± 0.57 | 4.63 ± 0.40 | ||
| Data presented as number and percentages; NA: not applicaple; significance set as p < 0.05. | ||||
4. Discussion
Community pharmacists' participation in asthma care has been associated with better asthma control and the quality of life for patients with asthma (Bridgeman and Wilken, 2021, Mahdavi and Esmaily, 2021). Although, the study showed that CP and HP reported no statistically significant difference regarding asthma knowledge level, the respondents reported a high rate of knowledge level regarding different aspects of the asthma knowledge level. This might suggest a comparable level of knowledge in the domain of asthma PC. Meanwhile, the study revealed that a significant proportion of both groups scored above the proficiency threshold, achieving scores exceeding 70 % on the asthma knowledge level questionnaire. This uniformity in scores above the proficiency threshold indicates a generally high level of asthma knowledge within both professional groups. The good pharmacists’ knowledge could be attributed to the current pharmacists’ role of not only dispensing medications without focus on providing patient-centered care in Türkiye (Bektay et al., 2023, Al-Taie et al., 2020 et al.). The findings of this study corroborate with the results of a study conducted by Chiang et al. (Chiang et al., 2010 et al.) which reported a positive total score of asthma knowledge level (p = 0.008), and by Emiru et al. (Emiru et al., 2020) which indicated the ability of community pharmacists to detect and manage the triggering factors of asthma for their patients. However, the findings of our study were higher than the results of the previously conducted studies in Jordan by Jarab et al. (Jarab et al., 2024) and in Egypt by Said et al. (Said et al., 2024) which reported that poor knowledge levels were achieved by 57.5 % and 30.54 % of the community pharmacists, respectively. Consistently, the findings of our study were in disagreement with a previous study conducted by Gemicioglu et al. (Gemicioglu et al., 2014) among Turkish pharmacists who reported having limited or incorrect asthma knowledge proposed using various teaching strategies to correct asthma misconceptions and enhance asthma control among patients.
Although there was no significant difference reported for most items of the APCL questionnaire, the CP and HP reported a good level of asthma PC knowledge. These findings indicated that the percentage of responses was high. This suggests that most pharmacists are competitive enough to intervene with asthma patients. This was also observed by the APCL mean score reported by CP and HP as 4.22 ± 0.523 and 4.29 ± 0.383 respectively. Patients would benefit more from optimum patient care collaboration between physicians and pharmacists, as well as adequate communication interactions between healthcare professionals and patients. In accordance to this, the respondents in the present study reported a high rate of knowledge regarding this concern (95 %) that collaboration between the healthcare professionals and patients would provide more health benefits to the patients.
Patient counselling is a cornerstone for pharmaceutical care and can improve a patient's quality of life and pharmacists are ideally positioned to provide optimal clinical outcomes in patients with asthma. In our study, the pharmacists were evaluated on their level of involvement in educating patients about asthma and its pathophysiology. This was observed by a high rate to determine the opinions of pharmacists regarding the state of asthma medications and management, train patients on inhalation technique, address patients' concerns regarding possible medication side effects, and enhance patients' adherence to therapy.
In Türkiye, pharmacists typically provide patients with information on inhaler devices and asthma since they are the last link in the asthma therapy chain before patients self-administer medication. In our study, a high rate of pharmacists stated that they were faced with questions about asthma treatment and stated that they demonstrate to patients how to use inhaler devices. The findings of this study were consistent with a study conducted in Ethiopia among community pharmacists and reported that 78.7 % and 66.4 % of the participants were able to present their patients with the fundamental facts regarding asthma disease and counselling information about drugs for asthma patients (Emiru et al., 2020). Similarly, another study conducted in Australia by Deeks et al. (Deeks et al., 2018) found that the most frequently performed responsibilities by the community pharmacists included conducting an asthma control evaluation, and guidance on the proper use of devices. A study by Alotaibi et al. (Alotaibi et al., 2016) to evaluate the influence of community pharmacists in improving the quality of life of asthma patients found that pharmacists are adequately aware and competent to successfully counsel their asthma patients. Moreover, the study of Karle et al. (Karle et al., 2020) found that inhaler errors are reduced when pharmacists participate in care with other healthcare providers.
The current study was also concerned with pharmacists' attitudes about PC. Although there was no significant difference reported for the AAB questionnaire, the CP and HP reported a good level of asthma attitudes and behaviors. This was observed by the AAB mean score reported by CP and HP as 4.71 ± 0.446 and 4.74 ± 0.330, respectively. Optimistically, most of the enrolled pharmacists in this study had a good attitude towards asthma disease and its management. As pharmaceutical care is patient-centered, patients should participate to strengthen their collaboration and responsibility, resulting in better adherence to long-term prescription regimens.
Overall, pharmacists in this study reported the necessity for educational programs and an appreciation of their critical role in asthma management. Such a positive attitude is quite encouraging. Several earlier studies found that better knowledge and attitudes of pharmacists are necessary for effective asthma care, which allows patients to take a more active role in managing their condition. (Romero-Tapia et al., 2023, Senna et al., 2017, Jia et al., 2020, Hussain and Paravattil, 2020, Nguyen et al., 2018). Nevertheless, it is incorrect for pharmacists to think that providing PC ends up their involvement in patient care; as a result, they should concentrate on identifying treatment choices for asthma or monitoring and following up on therapy. In line with this, Mahdavi et al. (Mahdavi and Esmaily, 2021) in a systematic review and meta-analysis study found that pharmacist-led educational initiatives have the potential to enhance asthma control and severity, as well as medication adherence and quality of life.
Several earlier studies have indicated considerable increases in knowledge and attitude among pharmacists who attended educational programs, and maintaining an ongoing asthma education approach would assist ensure compliance with optimal asthma treatment practice (Nguyen et al., 2018, Lalloo et al., 2011). In our study, most of the participants agreed that the outcome of asthma treatment depends more on the patient's behavior than on the efforts of healthcare providers. In PC sessions, strategies should incorporate a patient-centered approach that actively involves patients in making decisions about their treatment and considers their concerns, goals, and preferences. It's also critical to have open channels of communication between patients and healthcare providers, to be proactive in discussing treatment alternatives and potential side effects, and to address any questions or concerns that may arise.
According to intragroup comparisons of the questionnaires with the sociodemographic characteristics, a statistically significance has been reported in age groups and professional experience with APCL questionnaire, in self-evaluation of asthma knowledge level and professional experience with AAB questionnaire regarding the HP group. Similarly, statistically significance has been also reported in self-evaluation of asthma knowledge level experience with APCL questionnaire, in age groups and self-evaluation of asthma knowledge level with AAB questionnaire regarding the CP group. The key to rationalizing PC and managing asthma is having a high level of knowledge. Experienced pharmacists are more likely to have higher knowledge about asthma PC or positive attitude towards asthma PC. Pharmacists with higher experience may have up-to-date knowledge, particularly in terms of latest treatment guidelines, due to continued education and training, which may have also influenced their attitudes towards asthma PC in the current study. On the other hand, the increasing number of patients may have boosted the staff's better attitude because pharmacy is a noble profession that offers services that enhance health and well-being. In the present study, there was no significant findings between the mean scores of the knowledge and attitudes with age groups, however, the HP who had an age between 21 and 40 had higher mean score as compare to other age groups. However, there were no significant findings observed between mean score of knowledge and attitude with difference of gender indicating that regardless of age or gender, pharmacists in Türkiye are least concerned about their role in disease management. These findings were in accordance with a previous study conducted by Said et al. (Said et al., 2022) which found that hospital pharmacists had a considerably higher mean knowledge score (5.69) than community pharmacists (5.01). Furthermore, pharmacists with more than ten years of experience had a higher knowledge score (6.35) than those with six to ten years (5.61) or fewer than five years (5.53). Consistently, the study found that hospital pharmacists reported a considerably higher mean practice score than community pharmacists (44.91 vs 41.11), as did pharmacists with more years of experience (44.28).
5. Limitations
This study provides current data and covers a wide range of areas regarding pharmacists' knowledge, attitudes, and PC practices on asthma. This enables a more thorough study of the elements impacting asthma management. Furthermore, the current study's findings will help health authorities develop and implement disease knowledge efforts in the asthma control programs. However, as with every research endeavor, this study had limitations. The findings of this study must be viewed in light of the fact that they are based on pharmacists' self-reports, and some of their responses may not reflect their real practice because of social-desirability bias. While the sample size of pharmacists was adequate for this study to strengthen the reliability and generalizability of the findings. In addition, the cross-sectional design used in this study limits the capacity to determine causation. Moreover, the application of an online questionnaire may result in selection sampling bias since it may attract participants who are more technologically savvy or have a specific interest in the issue, affecting the study sample's representativeness.
6. Conclusion
The current findings emphasize specific areas in pharmacists' knowledge, attitude, and asthma PC practice, since pharmacists are ideally positioned to assist with asthma treatment due to their clinical skills, regular interaction with patients, and ability to refer patients to health care professionals as needed. The study found that the majority of pharmacists had enough knowledge to detect the triggering factors of asthma and provide PC about the disease and the treatments to their patients. Optimistically, the majority of pharmacists in this study had a positive attitude towards asthma management and identified the need for educational programs as a potential future approach to narrowing the gap between recommended and actual asthma management practices for more effective asthma care. Furthermore, identifying areas of limitations in asthma PC is critical in developing improved asthma prevention and management techniques. This includes developing and implementing continuing education programs to provide pharmacists with the most recent asthma management guidelines, treatment options, counselling techniques, and proactive and ongoing pharmacist engagement with asthma patients and healthcare professionals.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki. Ethical approval for the study was obtained from the Bezmialem Vakif University local Ethics Committee, denoted by the reference number 2021/310.
Informed Consent Statement
An online written informed consent was obtained from all individual participants included in the study.
CRediT authorship contribution statement
Dilan Çakmak: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing. Muhammed Yunus Bektay: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing. Anmar Al‑Taie: Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Saad Ahmed Ali Jadoo: Conceptualization, Data curation, Project administration, Resources, Writing – original draft, Writing – review & editing. Fikret Vehbi Izzettin: Conceptualization, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (include name of committee + reference number) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Contributor Information
Saad Ahmed Ali Jadoo, Email: drsaadalezzi@gmail.com.
Fikret Vehbi Izzettin, Email: fvizzettin@hotmail.com.
Data Availability Statement:
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.