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International Journal of Chronic Obstructive Pulmonary Disease logoLink to International Journal of Chronic Obstructive Pulmonary Disease
. 2026 Aug 19;21:623486. doi: 10.2147/COPD.S623486

Interventions Evaluated to Improve Inhaler Adherence in Patients with Chronic Obstructive Pulmonary Disease: A Scoping Review

Yuxin Zhu 1,*, Jing Chen 2,*, Shuyuan Li 3, Bo Liu 4, Min Huang 4, Liang Xue 5, Silin Zheng 6,✉, Houqiang Huang 6,✉
PMCID: PMC13499992  PMID: 42634798

Abstract

Background

Inhalation therapy is central for chronic obstructive pulmonary disease (COPD) management. However, poor inhaler adherence is associated with increased mortality, decreased quality of life, and increased costs. Existing interventions, particularly their design and delivery across urban and rural settings, have not been comprehensively mapped.

Objective

To map the available interventions evaluated to improve inhaler adherence among patients with COPD and characterize their components, delivery approaches, reported outcomes, and variation across urban and rural settings.

Methods

Following the Arksey and O’Malley framework, nine databases were searched from inception to March 22, 2026, including PubMed, Cochrane Library, Embase, Medline, Web of Science, CNKI, WanFang Data, CBM, and CQVIP. Two researchers independently screened the literature, extracted data, and synthesized findings.

Results

The 24 included studies were from seven countries (19 randomized controlled trials, 2 quasi-experimental studies, 1 prospective cohort study, and 2 pre-post studies); 16 were published in Chinese and 8 in English. Six categories were identified according to the primary intervention component: education-focused (n=8), behaviour-focused (n=4), inhaler technique-focused (n=4), multicomponent (n=3), transitional care-focused (n=4), and reminder-focused interventions (n=1). Five studies used digital delivery, including videoconferencing, telemedicine, SMS, a gamified website, and a WeChat mini-program. Most studies reported improved inhaler adherence, while one found no statistically significant difference. Twenty-two studies were conducted in urban settings; only two Chinese studies targeted rural populations, both used transitional care with face-to-face education, telephone follow-up, and family involvement.

Conclusion

The combined evidence suggests that interventions were diverse and predominantly in urban settings. Theory-informed design, ongoing follow-up, technique reassessment, digital support, and caregiver involvement were frequently identified across interventions reporting improved adherence. However, heterogeneity in intervention characteristics and adherence measures limited comparability, while evidence from rural populations remained scarce. Future research should consider longer follow-up and digital technologies to deliver personalized, sustainable interventions, particularly in rural settings.

Keywords: inhaler, medication adherence, chronic obstructive pulmonary disease

Introduction

Chronic obstructive pulmonary disease (COPD) affects more than 400 million people and continues to be the third leading cause of death worldwide.1 The China Pulmonary Health Study2 reported that the prevalence of COPD among individuals aged 40 years and above was 13.7%. The number of COPD cases in China accounted for 99.9 million, approximately one-quarter of the global burden. COPD is currently regarded as a substantial and growing public health concern globally.3 Due to the continued use of biomass fuels, inadequate household ventilation, and occupational exposure to dust, which are more prominent in rural areas.4–6 Rural regions may have a higher prevalence and burden of COPD than non-rural regions, especially in poorer communities that lack healthcare and health education. Global Initiative for Chronic Obstructive Lung Disease7 recommends inhalation therapy as the preferred treatment for alleviating COPD symptoms, reducing acute exacerbations, and lowering mortality risk. Its effectiveness depends largely on sustained adherence to inhaled medications in addition to correct inhaler technique. Medication adherence, as defined by the World Health Organization (WHO),8 refers to “the degree to which the use of medication by patients corresponds with the prescribed regimen”. Inhaler technique denotes the specific inhaler handling with critical steps such as device positioning/priming, adequate inspiratory flow rate, and breath control.9 Although these two constructs are interrelated, they represent distinct domains that inhaler technique refers to the accuracy of device operation, whereas medication adherence encompasses the broader behavioral pattern of following the prescribed dosing regimen over time. Despite the known efficacy of these medications, inhaler nonadherence rates exceed 50% in over half of the studies.10–13 Rural COPD patients may face additional barriers to sustained inhaler adherence, such as long travel distances,14 limited COPD services at the primary healthcare level,15 fragmented care,14 and inadequately trained primary care providers,15,16 which may impede optimization of inhaler regimens and undermine continuity. Additionally, poor health literacy17 and financial burdens18 may further reduce engagement in long-term self-management. These intersecting barriers may make it difficult to apply interventions designed for urban healthcare settings directly to rural patients. In recent years, with the emphasis on standardized treatment of COPD, the number of studies on intervention measures for inhaler adherence has been increasing worldwide. Aung, et al19 conducted a systematic review and meta-analysis that included ten studies, demonstrating that healthcare provider-led adherence interventions combined with electronic inhaler monitoring improved the mean adherence rate by 18%. A 2025 systematic review20 of shared decision-making interventions found positive effects on medication adherence in three of four randomized controlled trials among asthma and COPD patients, although considerable heterogeneity in intervention characteristics and relatively low study quality limit definitive conclusions. Given the breadth and heterogeneity of inhaler-adherence interventions, a scoping review was appropriate to map the available evidence, characterize intervention evaluated components, and particularly identify gaps across rural COPD populations and Chinese-language evidence. In accordance with the Joanna Briggs Institute (JBI) methodology,21 we conducted a preliminary search of PROSPERO, the OSF registries, and JBI Evidence Synthesis to identify any published or ongoing reviews. No published or registered review addressed the full scope of the present review. Consequently, it is essential to conduct a scoping review to map the characteristics, components, delivery approaches, and reported outcomes of the inhaler-adherence interventions internationally among patients with COPD, and to compare the available evidence between urban and rural settings.

Methods

The study was designed according to the reference framework developed by Arksey and O’Malley.22 The main five stages were followed: (1) identify the research question, (2) identify relevant studies, (3) study selection, (4) charting the data, (5) summarize and report the results. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.23

Identify the Research Question

The main question of this review was: (1) What interventions have been evaluated to improve inhaler adherence among patients with COPD? (2) What are the key components and delivery characteristics of these intervention s? (3) What outcomes are reported in the included studies? (4) How are these evaluated interventions distributed, and what are their characteristics, across urban and rural settings?

Identify Relevant Studies

A comprehensive search was conducted in PubMed, Embase, Medline, Cochrane Library, Web of Science, CNKI, WanFang Data, CBM, and CQVIP databases. The search formula was constructed using subject headings plus free words and Boolean logic connectives. A citation tracing strategy was implemented to ensure the comprehensiveness of the search, and the search time spanned all relevant literature data up to March 22, 2026. See the Supplementary Material 1 for the search strategy.

Study Selection

The inclusion criteria were the following: (1) Population: patients who met the international diagnostic criteria for COPD, aged ≥18 years old;7 (2) Intervention strategy: any strategy to improve the compliance of inhaler use in different settings; (3) Control: no limit; (4) Outcome measures: medication adherence as the outcome (primary or secondary); (5) Study type: randomized controlled trials (RCTs), cohort, quasi-experimental studies and pre-post studies published in full text. The exclusion criteria were: (1) No full-text literature was available in Non-Chinese or English or duplicate literature; (2) Literature of the study protocol only; (3) Meeting abstracts and reports that could not be extracted or had incomplete data.

Data Extraction and Charting

EndNote X9 was used for reference deduplication and management. Two reviewers independently screened the literature according to the established inclusion and exclusion criteria. By reading the title and abstract of the literature, after excluding the literature that obviously did not conform to the theme, the remaining literature was read in full for further screening. Disagreements were resolved through discussion or consultation with a third reviewer. The final data was extracted from the included studies according to the following fields: (1) general information: author, country, area setting, publication year, (2) study characteristics: study designs, sample size, personnel, intervention methods, outcome measures, findings, (3) Inhalers adherence assessment tools. Additionally, a inhalers adherence intervention strategy form was developed to summarize the details of the interventions, including age of the study population, components of intervention, inhalers, duration, follow-up, theoretical model, and primary outcomes of the intervention. Two reviewers worked on data analysis and synthesis. The included studies were described in the form of quantity and distribution, and the results were summarized by descriptive methods.

Results

Results of the Search

A total of 4300 literatures were collected by preliminary searching the database and citation tracing. After removing duplicate literatures, 2335 literatures were left, and 135 literatures were left after further excluding literatures that could not obtain full text. By carefully reading the title, abstract, and full text of the remaining literature, 24 literatures were finally selected for inclusion, of which 8 English-language and 16 Chinese-language studies. The literature screening process is shown in Figure 1.

Figure 1.

A PRISMA flowchart of study selection process from identification to inclusion. The PRISMA flowchart illustrates the study selection process. It begins with the identification of records from English databases, totaling 3931 and Chinese databases, totaling 369. This results in 4300 total records identified. After removing 1965 duplicates, 2335 records are screened. Of these, 2200 records are excluded. The remaining 135 full-text articles are assessed for eligibility. Exclusions include 111 reports, 13 not original articles, 34 with outcomes not reported, 53 with irrelevant topics and 11 with unavailable full text. Finally, 24 studies are included in the review.

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PRISMA flow diagram of study selection.

Article Characteristics

2424–47studies included in this review. These studies originated from 7 countries: China24,25,27–29,31–37,39–42,44,46 (n=18), England45 (n=1), Turkey47 (n=1), Jordan43 (n=1), South Korea38 (n=1), the United States30 (n=1), and Spain26 (n=1). Most studies (n=22, 91.7%) were conducted in urban areas. Two studies (8.3%) were conducted in rural areas. Among the reviewed articles, study designs ranged from: 19 were RCTs,26,27,29,31–37,39–47 2 were quasi-experimental designs,25,28 1 was a prospective cohort study,38 and 2 were pre-post studies.24,30 Sample sizes of the intervention groups ranged from 15 to 630, and control groups from 15 to 672.39,45 The characteristics of each study are summarized in Table 1.

Table 1.

Summary of the Study Characteristics

Author Year Country Study Design Sample Size Area
IG/CG
Flahavan, et al45 2025 England RCT 630 672 Urban
Wang, et al46 2025 China RCT ①: 74 ②: 70 64 Urban
Dogan and Kokturk47 2025 Turkey RCT 37 37 Urban
Huang, et al44 2025 China RCT 51 51 Urban
Al-Kharouf, et al43 2023 Jordan RCT 51 52 Urban
Zhang, et al42 2022 China RCT 63 63 Urban
Wang, et al41 2022 China RCT 70 70 Urban
Yao, et al40 2021 China RCT 68 65 Urban
Shao37 2020 China RCT 20 20 Urban
To, et al39 2020 (Hong Kong) China Pilot RCT 15 15 Urban
Ahn, et al38 2020 South Korea Prospective cohort study 261 – Urban
Zheng and Fu36 2019 China RCT 42 42 Rural
Xia34 2019 China RCT 23 23 Urban
Pan, et al35 2019 China RCT 36 37 Urban
Xu, et al33 2018 China RCT 35 35 Urban
Wu, et al32 2018 China RCT 61 60 Urban
Ou and Huang29 2017 China RCT 62 62 Urban
Ge31 2017 China RCT 50 50 Urban
Thomas, et al30 2017 USA Pre-post study 41 – Urban
Shen28 2016 China Quasi-Experimental Design 46 41 Rural
Shen, et al27 2015 China RCT 43 42 Urban
Leiva-Fernández, et al26 2014 Spain RCT 72 74 Urban
Song25 2013 China Quasi-Experimental Design 27 26 Urban
Cai24 2012 China Pre-post study 96 – Urban
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Notes: ①, Home-visit group; ②, Digital remote-management group.

Abbreviations: IG, intervention group; CG, control group; RCT, randomized controlled trial.

Characteristics and Classification of the Included Interventions

Interventions were classified according to their primary intervention component and delivery approach. Based on the dominant component around which the intervention was designed, the 24 included studies were classified into six categories: (1) Education-focused intervention (n=8);25,31,32,35,37,41,44,46 (2) Behaviour-focused Intervention (n=4);29,39,40,42 (3) Inhaler technique-focused Intervention (n=4);30,38,43,47 (4) Multicomponent Intervention (n=3);24,26,34 (5) Transitional care-focused Intervention (n=4);27,28,33,36 (6) Reminder-focused Intervention (n=1).45 Five studies used digital remote approaches to deliver the intervention components,30,44–47 including Internet-based home videoconferencing, a gamified website, one-way SMS reminders, a WeChat mini-program, and telemedicine via video call. Table 2 summarizes the categories and delivery approaches of the interventions, with detailed characteristics provided in Supplementary Material 2.

Table 2.

Summary of the Categories and Delivery Approaches

Study (Year, Country) Category Delivery Approach
Cai,24 2012, China Multicomponent intervention Face-to-face
Song,25 2013, China Education-focused intervention Face-to-face
Leiva-Fernández, et al26 2014, Spain Multicomponent intervention Face-to-face
Shen et al,27 2015, China Transitional care-focused intervention Face-to-face
Shen,28 2016, China Transitional care-focused intervention Face-to-face
Ou and Huang,29 2017, China Behaviour-focused intervention Face-to-face
Thomas et al,30 2017, USA Inhaler technique-focused intervention Video conferencing
Ge,31 2017, China Education-focused intervention Face-to-face
Wu et al,32 2018, China Education-focused intervention Face-to-face
Xu et al,33 2018, China Transitional care-focused intervention Face-to-face
Xia,34 2019, China Multicomponent intervention Face-to-face
Pan et al,35 2019, China Education-focused intervention Face-to-face
Zheng and Fu,36 2019, China Transitional care-focused intervention Face-to-face
Shao,37 2020, China Education-focused intervention Face-to-face
Ahn et al,38 2020, South Korea Inhaler technique-focused intervention Face-to-face
To et al,39 2020, (Hong Kong) China Behaviour-focused intervention Face-to-face
Yao et al,40 2021, China Behaviour-focused intervention Face-to-face
Wang et al,41 2022, China Education-focused intervention Face-to-face
Zhang et al,42 2022, China Behaviour-focused intervention Face-to-face
Al-Kharouf et al,43 2023, Jordan Inhaler technique-focused intervention Face-to-face
Huang et al,44 2025, China Education-focused intervention Gamified website
Flahavan et al,45 2025, England Reminder-focused intervention One-way SMS reminder
Wang, et al,46 2025, China Education-focused intervention We Chat mini program
Dogan and Kokturk,47 2025, Turkey Inhaler technique-focused intervention Telemedicine via video call
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Education-Focused Intervention

Eight studies focused on the impact of knowledge education on medication adherence in COPD.25,31,32,35,37,41,44,46 Six interventions were delivered through face-to-face sessions, such as written materials (brochures, cards),31,32,35,37,41 videos32,41 and device models.31,32 Two used digital remote delivery through a gamified website44 and a WeChat mini program.46 Some studies combined multiple formats. Educational content covered disease knowledge (causes, symptoms, mechanisms, complications), purpose and role of inhalation therapy, importance of adherence, device structure and correct operation steps, side effects and precautions, and acute exacerbation prevention. Details regarding exact content varied across studies. The duration of education ranged from 1 month to 12 months, with follow-up periods from 3 months to 12 months. The education-focused interventions through face-to-face reported higher adherence than the control groups. Regarding digital remote delivery, the gamified website did not produce immediate between-group differences in adherence scores post-intervention; however, a statistically significant between-group difference was observed at 2 months and persisted throughout follow-up (median adherence score: 51.00 vs 50.00, p=0.04). Similarly, in the WeChat-based remote-management study, no significant change was observed at 3 months; however, by 12 months, the proportion of patients with good adherence increased to 90.0%, the proportion was statistically higher the home-visit group (82.4%) and the control group (54.7%) (both p <0.05).

Behaviour-Focused Intervention

Four studies evaluated behaviour-focused interventions, all of which were primarily delivered face-to-face. The Health Belief Model (HBM) intervention40 targeted patients and their caregivers, focusing on perceived susceptibility, severity, benefits, and barriers, along with self-efficacy. The intervention group received group education, case analysis, and WeChat messaging reinforcement, and adherence scores were higher in the intervention group at both 3 months (intervention: 9.51±1.33 vs control: 7.34±1.53, p<0.05) and 6 months (intervention: 9.66±1.63 vs control: 7.38±1.56, p<0.05). Two studies adopted the Information-Motivation-Behavioral Skills (IMB) Model.29,39 The first39 used a 4-week program that included an individual face-to-face session and two telephone sessions at 2 weeks apart, focusing on information provision, motivation enhancement, and inhalation skills training. At six weeks, the proportion of participants achieving at least 80% medication adherence was higher in the intervention group (intervention: 33.3% to 85.7% vs control: 60.0% to 71.4%, p<0.05). The second29 delivered health education, motivational interviewing (tailored to Willingness level), demonstration/return demonstration, and telephone follow-ups every 2 weeks. At 1 and 3 months, the intervention group had higher inhaler adherence scores (intervention: 9.62±0.63 vs control: 6.52±1.08 at 1 month; intervention: 9.78±0.59 vs control: 7.49±0.85 at 3 months, p=0.001). The Action-Oriented Teaching intervention42 comprised three phases (task proposal, planning, implementation), adopting one-to-one coaching, repeated skill practice, and continuous behavioral supervision to shape patients’ correct inhaler use behavior. After one month, the intervention group adherence improved (85.71%) higher than the control group (74.60%) (p <0.05).

Inhaler Technique-Focused Intervention

Four studies focused on improving inhaler technique in COPD patients.30,38,43,47 Two were delivered face-to-face,38,43 one through Internet-based home videoconferencing,30 and one through telemedicine video follow-up.47 Thomas, et al30 delivered three monthly pharmacist-led home videoconferencing sessions using the teach-to-goal method. At 2 months, the adherence score improved from 1.6 at baseline to 1.1 (P=0.045). Similarly, Ahn, et al38 employed the “teach-back” technique, requiring patients to demonstrate and explain the technique back to providers. Over six months, critical errors reduced from 43.2% to 8.8% (p<0.001) and increased good adherence from 81.6% to 87.7% (p=0.005). Al-Kharouf et al43 showed video-based teach-to-goal education increased correct technique rates (from 49.5% to 93.4%) and concurrently improved adherence rates from 66.7% to 88.2% (p=0.003). However, Dogan and Kokturk47 observed that despite significantly better technique in the telemedicine group (91.4% vs 65.7%, p=0.02), adherence did not differ significantly (70.6% vs 55.9%, p>0.05).

Multicomponent Intervention

Three studies investigated the effects of multicomponent interventions on adherence to inhaled therapy in COPD patients.24,26,34 All were delivered primarily face-to-face in community, hospital, or primary care settings. Two subtypes of multicomponent interventions were identified: (1) nursing-led care interventions,24,34 led by clinical and community nurses, and characterized by comprehensive nursing coverage and focus on holistic care and long-term medication management (eg, psychological counseling, environmental adjustment, disease education, inhaled medication guidance and supervision, rehabilitation training, and family support mobilization). In the community-based study,24 a 12-month comprehensive nursing intervention increased adherence to prescribed inhaled therapy from 16% (15/96) to 96% (92/96), although statistical significance for this outcome was not reported. Similarly, Xia34 delivered a hospital-based nursing intervention, and the adherence rates were higher compared with usual care (95.65% vs 73.91%, p<0.05). (2) Trained primary care professionals,26 who were physicians and nurses specially trained in motivational techniques and inhaler devices—demonstrated a highly focused and specialized approach. The intervention directly addressed evidence-based, modifiable barriers to inhaled therapy adherence through three components: motivational interviewing, cognitive education, and skills training. As a result, medication adherence improved significantly, with the proportion of good adherers reaching 48.6% compared with 32.4% in the control group (p=0.046).

Transitional Care-Focused Intervention

Four Chinese studies examined the impact of transitional care on inhaler adherence in COPD patients.27,28,33,36 All were delivered through face-to-face, in-hospital education followed by post-discharge telephone follow-up, and all reported higher inhaler adherence compared with routine care at one or more follow-up points. Shen, et al27 reported no significant between-group differences in inhaler adherence at 1 month after discharge (P>0.05); however, significant improvements were observed at 3 and 6 months (P<0.01). Xu, et al33 reported that, at 3 months, the adherence was higher in the transitional care group than in the control group (94.3% vs 71.4%, χ2=6.437, P<0.05). Similarly, Zheng and Fu36 observed that, at 6 months, adherence was significantly greater in the transitional care group compared with routine care (97.6% vs 47.6%, χ2=26.40, P<0.001). Shen28 delivered a caregiver-centred transitional care intervention to older rural patients with COPD, in which family caregivers received guidance and assisted with supervision of daily inhaler use. At follow-up, the inhaler adherence rate was higher than in the control group (82.6% vs 48.7%, χ2=11.16, P<0.05).

Reminder-Focused Intervention

One study45 utilized a standalone reminder-focused intervention delivered through one-way SMS messages. Flahavan, et al45 carried out a large-scale RCT across 89 general practices in the United Kingdom, sending 24 theory-based (PaPA/MINDSPACE) SMS reminders over 26 weeks. The messages targeted common adherence barriers, including forgetfulness, insufficient perceived necessity of maintenance therapy, unclear information, and difficulties with inhaler technique. The intervention incorporated behavior change techniques such as prompts and cues, habit formation, information about health consequences, and instructions on how to perform the behavior. At 26 weeks, the intervention group showed a greater improvement in self-reported medication adherence than the control group (0.10 points, p=0.040).

Digital Remote Delivery Approaches

Five studies adopted digital remote interventions to improve inhaler adherence in COPD.30,44–47 The digital formats covered Internet-based home videoconferencing,30 a gamified educational website,44 one-way SMS reminders,45 a WeChat mini-program46 and telemedicine via video call.47 Thomas, et al30 conducted home videoconferencing visits using the “teach-to-goal” methodology. Huang, et al44 created the “Inhaling-Health” gamified education website founded on the Fogg Behavior Model (FBM), with game elements like points and real-time feedback. Flahavan, et al45 delivered theory-informed SMS reminders targeting forgetfulness, perceived necessity of maintenance treatment, information needs, and inhaler technique. Wang, et al46 combined home-based pharmaceutical care with a WeChat mini-program to achieve remote management of COPD. Dogan and Kokturk47 implemented a telemedicine video follow-up, enabling remote assessment of vital signs, symptoms, inhaler technique, and adherence. Four studies reported improvements in adherence. In contrast, only telemedicine47 showed that the difference in adherence was not statistically significant.

Recurring Characteristics of Interventions Reporting Improved Adherence

Across intervention categories, several characteristics recurred among studies reporting improved inhaler adherence, including theory-informed design, repeated follow-up, digital support, repeated technique assessment, and caregiver involvement. Theory-informed approaches were identified in behaviour-focused interventions based on the HBM40 and IMB Model,29,39 an education-focused intervention based on the FBM,44 and a reminder-focused intervention informed by PaPA/MINDSPACE.45 These interventions incorporated strategies such as motivation enhancement, self-efficacy support, prompts, feedback, and repeated skills practice.

Repeated follow-up and reinforcement were reported across all four transitional care studies,27,28,33,36 which combined in-hospital education with post-discharge telephone follow-up and showed improved adherence compared with routine care. Similar elements were also included in several behaviour-focused interventions.29,39,40,42

Digital support was delivered through a gamified website,44 one-way SMS reminders,45 a WeChat mini program,46 videoconferencing,30 and telemedicine.47 Four of the studies reported improvements in adherence, whereas one telemedicine study47 improved inhaler technique without a statistically significant change in adherence.

Repeated technique assessment using teach-to-goal or teach-back methods was reported in studies showing improvements in both technique and adherence.30,38,43 Caregiver involvement was described in a limited number of studies24,28,34,40 involving older or rural patients and included education, supervision, and assistance with daily inhaler use.

Differences in the Included Interventions Between Urban and Rural Settings

Differences were observed in the volume of evidence, intervention diversity, delivery approaches, and caregiver involvement between urban and rural settings. Of the 24 included studies, 22 (91.7%) were conducted in urban settings, whereas only two studies (8.3%), both from China, explicitly targeted rural COPD populations.28,36 Urban studies evaluated a broader range of intervention strategies, including digital remote approaches (e.g, WeChat mini program,46 gamification website,44 SMS-based reminder systems,45 telemedicine47 and home videoconferencing30), as well as multicomponent strategies incorporating motivational interviewing and audio-visual materials.26 In contrast, both rural interventions used transitional care models combining in-hospital face-to-face instruction with telephone follow-up. Differences were also observed in the involvement of family caregivers. Structured caregiver involvement was reported in both rural studies, with family members reinforcing education and supervising or assisting patients with daily inhaler use, whereas such involvement was rarely described in urban studies.

Evaluation Tool for Inhaled Medication Compliance

Among the 24 included studies, a variety of tools were used to measure inhaled medication adherence in COPD patients. These tools can be categorized into three main types: (1) self-designed or unvalidated criteria (n=13, 54.2%),2,24,25,28,30,31,33–35,37,38,41,42 (2) validated questionnaires or scales (n=9, 37.5%),27,32,36,40,43–47 (3) dose or pill counts (n=2, 8.3%).26,39 Validated scales were used in nine studies (37.5%). The most frequent was the Eight-Item Morisky Medication Adherence Scale (MMAS-8), which appeared in four studies.27,32,40,46 Other validated instruments included the Medication Adherence Report Scale-5 (MARS-5);45 the 6-item Inhaler Adherence Scale (IAS);47 the Test of Adherence to Inhalers (TAI),44 specifically designed for inhaler adherence; the 4-item Morisky Green Levine scale (MGLS),43 and a modified Morisky scale.36

Self-designed or unvalidated criteria were used in 13 studies (54.17%), tailored to specific intervention settings or local clinical workflows. Notably, the content, scoring methods, and definitions of adherence for these self-designed tools varied significantly across different studies, limiting comparability.

Two studies incorporated dose or pill counts (8.33%). To, et al39 used electronic monitoring devices with built-in dose counters, while Leiva-Fernández, et al26 employed a low-cost manual counting of remaining capsules.

Discussion

Intervention Diversity and Recurring Characteristics Among Studies Reporting Improved Adherence

The included interventions were heterogeneous in their primary components, delivery approaches, intensity, duration, and personnel involved. Although nineteen of the included studies were RCTs, several common methodological characteristics were observed, including single-center designs, relatively small sample sizes, limited reporting of pre-specified power calculations, allocation concealment and blinding procedures, and generally short follow-up periods. These characteristics should be considered when interpreting the reported intervention effects.

Education-focused interventions were the most frequently reported conventional approaches for improving inhaler adherence among COPD patients. These interventions are typically delivered through in-person education, interviews, written or video materials, and telephone calls. Although most studies reported favorable adherence outcomes, the intervention content, intensity, duration, and outcome measures varied considerably, limiting direct comparisons between intervention categories. Therefore, the available evidence does not establish the superiority of any single intervention category; instead, it identifies several characteristics that recur in reports of improved adherence.

Across intervention categories, theory-informed design, ongoing follow-up, reinforcement, digital support, repeated assessment of inhaler technique, and caregiver involvement were identified in interventions that reported improved inhaler adherence. Theory-informed interventions based on the HBM, IMB Model, FBM, and PaPA/MINDSPACE incorporated strategies such as motivation enhancement, self-efficacy support, prompts, feedback, and repeated skills practice. These findings suggest that interventions addressing motivational, capability, and practical barriers may provide broader adherence support than knowledge provision alone. However, the independent contribution of the individual component could not be isolated from that of the accompanying intervention elements.

Digital delivery approaches expanded the available formats for education, feedback, monitoring, and follow-up. However, one telemedicine study47 improved inhaler technique without a statistically significant improvement in adherence, indicating that effects of the digital technology may depend on whether it provides sustained behavioural reinforcement, feedback, and support targeting specific adherence barriers. Although mHealth applications may facilitate health knowledge acquisition, symptom monitoring, medication recording, and treatment assessment, their direct applicability to older and rural populations requires careful consideration of internet access, digital literacy, interface complexity, cost, and caregiver support. Future mHealth interventions could integrate behaviour change theory with functions such as real-time inhaler-technique feedback, personalized medication reminders, and long-term adherence monitoring outside hospital settings.

Repeated technique assessment using teach-to-goal or teach-back methods was generally associated with improvements in both inhaler technique and adherence. But one study47 found significantly better technique in the intervention group without a corresponding improvement in adherence, suggesting that multiple factors beyond correct technique alone influence adherence. LaBedz, et al48 demonstrated that nearly half of patients with poor adherence exhibited proper inhaler technique but faced motivational conflicts (e.g, deeming medication unnecessary when asymptomatic or resisting the chronic illness label). This finding further suggests that technique-based intervention alone may have limited effects on sustained inhaler-adherence behaviour. Similarly, Chen, et al49 confirmed that social opportunity (family support, caregiver supervision) and physical opportunity (medication accessibility, environmental cues) influence adherence independent of technique mastery.

Caregiver involvement was reported in only a limited number of included studies among older or rural patients, in which caregivers reinforced education, supervision, and assistance with daily inhaler use. Although the evidence remains limited, caregiver support may be particularly relevant for patients with reduced self-management capacity or restricted access to continuous professional care. Overall, interventions that reported improved adherence commonly combined education or skills training with behavioural reinforcement, continued follow-up, and contextual support. These recurring characteristics should be regarded as potentially important intervention features rather than definitive determinants of efficacy, given the heterogeneity in intervention designs, adherence measures, and follow-up periods.

Urban-Rural Disparities in Inhaler Adherence Interventions

Within the included studies, there was a marked geographic imbalance, with 22 studies (91.7%) conducted in urban settings and only two studies (8.3%) conducted in rural settings. This evidence gap is particularly relevant because rural populations in many settings experience a higher COPD prevalence and face greater barriers to specialized respiratory care.50 Several urban studies30,44,46 evaluated digitally delivered approaches, including mHealth applications, gamification websites, and videoconferencing. These approaches may depend on smartphone access, digital literacy, and reliable internet connectivity in urban settings.51 Although these innovations reported potential for improving medication adherence, their transferability to resource-limited rural settings requires careful qualification.

Both included rural studies28,36 incorporated family caregivers, suggesting that informal support networks may help supplement limited professional healthcare resources in these settings.

Beyond these observed patterns, broader clinical and implementation considerations suggest that future interventions for rural patients with COPD may need to be adapted to local contexts rather than directly replicating urban digital models. Potential strategies for future evaluation include (1) incorporating family caregiver support as a core, structured intervention component; (2) integrating age-friendly and low-literacy digital features, such as simplified interfaces and voice guidance; and (3) maintaining structured transitional care to support continuity of long-term COPD management after hospital discharge. However, the feasibility of such hybrid approaches is likely to depend on local digital access, digital literacy, affordability, healthcare capacity, and the availability and willingness of family caregivers.

Heterogeneity of Adherence Measures

Considerable heterogeneity was observed in the tools used to measure inhaled medication adherence among COPD patients across the included studies. Thirteen studies employed self-designed or unvalidated criteria,24,25,28–31,33–35,37,38,41,42 nine utilized validated questionnaires or scales,27,32,36,40,43–47 and merely two used dose or pill counts.26,39 Although self-designed measures are feasible and widely applied in clinical and research settings, they are susceptible to recall bias and social desirability bias, which may lead to overestimation of adherence rates.52 Moreover, considerable variability persists in the content, scoring methods, and definitional criteria of adherence across them, limiting the comparability of findings. Among validated questionnaires or scales, most studies utilized generic adherence scales such as the MMAS-8 and MARS-5, which assess general medication-taking behaviors rather than inhaler-specific dimensions. In contrast, the Test of Adherence to Inhalers (TAI) and Inhaler Adherence Scale (IAS) were specifically developed and validated for inhaler adherence assessment. Compared with other inhaler adherence measures, the TAI offers the advantages of capturing inhaler-specific barriers, including forgetfulness, intentional non-adherence, and technique-related issues.53 Furthermore, existing evidence indicates that the 4-item Inhaler Adherence Questionnaire (IAQ) provides a briefer alternative that has been validated against the DoserCT electronic monitoring device.54 Certain included studies40,42 did not explicitly report adherence cut-off values or assessment time points.

Therefore, future research should scientifically explore the standardization of inhaler-specific adherence measurement tools. Meanwhile, digital health technologies should be improved in the future, such as electronic dose-count monitoring devices, which can represent a promising approach to objective and real-time adherence tracking, thereby overcoming the limitations of subjective self-reported.

Long-Term Adherence Challenges

The findings of this scoping review indicate that diverse interventions were associated with reported improvements in inhaler medication adherence among patients with COPD in the included studies. However, because COPD requires sustained inhaled therapy, the durability of intervention effects is an important consideration. Several studies27,29,30,33,36,37,47 assessed inhaler adherence during hospitalization or within 3 to 6 months after discharge, whereas only four studies24,26,35,46 extended follow-up to 12 months. Consequently, the long-term sustainability, feasibility, and real-world effectiveness of interventions to support inhaler adherence remain insufficiently characterized. Previous research19,55 has similarly highlighted that short follow-up periods limit assessment of sustained behaviour change, and has recommended longer study durations, preferably 12 months or longer. Future studies should therefore examine longitudinal patterns of adherence and correct inhaler use, determine the durability of intervention effects under routine-care conditions, and identify appropriate intervals for intervention reinforcement and outcome assessment.

Conclusion

This paper included 24 studies and mapped six categories of interventions to improve inhaler adherence among patients with COPD: education-focused, behaviour-focused, inhaler technique-focused, multicomponent, transitional care-focused, and reminder-focused interventions. These interventions were delivered primarily through face-to-face, with a smaller number using digital remote delivery. Most studies reported inhaler adherence improvement, with theory-informed design, ongoing follow-up, reinforcement, technique reassessment, digital support, and caregiver involvement commonly observed in interventions that reported favourable outcomes. However, heterogeneity in intervention content, follow-up periods, and adherence measures limited comparisons across interventions. Evidence was predominantly derived from urban settings, whereas only two studies specifically targeted rural populations, both of which primarily used transitional care involving telephone follow-up and family support. Future research should evaluate longer-term, context-adapted interventions, particularly in underserved rural settings, using standardized inhaler-specific adherence measures.

Strengths and Limitations

This review followed the JBI methodology and PRISMA-ScR reporting guidance. A comprehensive search of nine English- and Chinese-language databases, supplemented by citation tracking, identified studies with diverse designs. Interventions were systematically mapped by their components, delivery approaches, and adherence outcomes. Also, this scoping review has several limitations. 18 of the 24 included studies were conducted in China, and only two specifically targeted rural populations, limiting transferability and urban–rural comparison. Heterogeneity in intervention content, follow-up duration, adherence measures, and outcome reporting also restricted direct comparisons. Consistent with scoping review methodology, no formal quality appraisal or risk-of-bias assessment was conducted; therefore, the findings describe the available evidence rather than establish comparative effectiveness. Future studies should improve reporting and use standardized, inhaler-specific adherence measures.

Clinical and Research Implications

Initially, multidisciplinary collaborative teams integrating physicians, nurses, pharmacists, and other allied health professionals should be established to provide more comprehensive and professional care. Additionally, future research should explore the real-world barriers to inhaler adherence among COPD patients in rural areas and develop context-adapted mHealth interventions that account for differences in age, health literacy, digital access, and patient preferences. Standardized, validated, inhaler-specific adherence measures should be used to improve comparability of outcomes. Overall, greater attention should also be given to rural patients and to strengthening the methodological rigor and reporting transparency of future trials.

Acknowledgment

Silin Zheng and Houqiang Huang are co-corresponding authors.

Funding Statement

This study was supported by the 2025 Research Project of the Chinese Nursing Association (ZHKYQ202525), Luzhou Science and Technology Bureau (2022-SYF-54) and funded by Science & Technology Department of Sichuan Province (2025ZNSFSC1570), Zigong Federation of Social Sciences (YDJKZ22-02) and the Southwest Medical University (2021ZKQN048).

Disclosure

The authors report no conflicts of interest in this work.

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