Building Patient Knowledge, Buy-In, and Self-Efficacy with Inhalers and Nebulizers

This post was written by Kalli Mago.

Medication is central to managing chronic obstructive pulmonary disease (COPD), but as most health care providers know, prescribing the right medication is only half the battle. The real challenge is helping patients actually use their prescribed devices properly. When it comes to inhalers and nebulizers, studies consistently show high levels of non-adherence, with rates ranging from 23% to 93%.¹

Obstacles to Adherence

There are many reasons patients may struggle to follow their prescription. For example, sometimes the prescription itself is the problem. Providers should consider the patient's symptoms, preferences, financial situation, coordination, and dexterity when deciding which device is best. This blog post provides a more in-depth look at how to navigate different device options with your patients with COPD.

However, the right device offers limited benefits if the patient does not know how to use it correctly. One recent study determined that nearly 50% of patients used their inhaler differently than prescribed.² Another found that both providers and patients frequently show disinterest in proper device technique. For example, only 45% of providers reported assessing how newly diagnosed patients used their inhalers or nebulizers.³ Presumably, the number following up on patients' technique at later appointments is even lower.

A well-rounded approach to education can address the following obstacles to adherence:

• Lack of knowledge: The more patients know, the better. Of course, they need to know how and when to use their inhaler or nebulizer—and this alone is an obstacle for many. Patient education may be limited, and it often comes during a time of stress and information overload, which can reduce retention. Beyond technique, device users should also be well-informed about refills (for inhalers) or cleaning and maintenance (for nebulizers) to achieve long-term success.²
• Undeveloped routines: Patients are only human, and humans can be forgetful, distracted, or busy. If medication is not built into their routine, they may fail to use it regularly.²
• Missing confidence: When patients do not feel comfortable or confident with their device, they are less likely to use it.² This can be especially true when the patient is stressed, overwhelmed, or uncomfortable.
• Doubts about effectiveness:
• It should come as no surprise that if patients aren't fully on board with their treatment, they're less likely to use it. In one study, one-third of participants knowingly used their inhalers differently than how they were prescribed—often because they doubted the effectiveness of their medication.²

The Cost of Non-Adherence

These challenges matter because the stakes are high. Medication relieves symptoms and slows disease progression. Without it, patients are more likely to suffer from severe exacerbations. Patients who don't use their devices as they should often report a lower quality of life, and they are at greater risk of hospitalization and death.⁴ Helping patients use their inhalers or nebulizers can have a life-saving impact.

Providing Comprehensive Patient Education

A thoughtful, well-rounded approach to patient education will go beyond simple tutorials, which may only address the first hurdle: lack of knowledge. Instead, patient education should aim to overcome every barrier. The goal is not simply to provide knowledge, but also to generate buy-in and build self-confidence.

One way to integrate these three priorities is by using the information-motivation-behavioral skills (IMB) model.⁵ Research shows that using this model for COPD patient education can lead to significant improvements in device technique, adherence, and quality of life.⁶

The IMB model identifies three components which interact with and influence one another:

• Information: The knowledge a person has about a specific health behavior. In our case, this means information about device technique, the medication, dosage, and refills and/or maintenance.
• Motivation: The personal and social attitudes towards this health behavior. For a patient with COPD, a clear understanding of the medication's benefits and risks of non-adherence would support a strong sense of motivation.
• Behavioral Skills: The skills a person needs to carry out the behavior. For example, does the patient have the dexterity required to use their prescribed metered-dose inhaler? Here, the patient must be able to apply their knowledge of the technique to use the device correctly. This component also includes self-efficacy. Does the patient have confidence in their own skills?

You can imagine how all three components interact. For example, if a patient knows how to use their device and has all the necessary skills, will they still use it regularly if they don't think it's important? Or maybe a patient is highly motivated and spends hours studying the technique, but they simply don't have enough lung capacity to properly use their dry-powder inhaler. In either circumstance, the patient may not regularly use their device, and their health will suffer as a result.

Building Education into Your Process

The IMB model also offers a handy process for developing these three components over time: elicitation-intervention-evaluation.5 Essentially, this means:

• assessing where a patient currently stands in all three areas (information, motivation, behavioral skills)
• providing information, training, and resources
• checking back in later to assess their new position.

The key takeaway is that effective education is an ongoing process, and one that should meet each learner where they are.

Education for Knowledge, Buy-In, and Self-Efficacy

Drawing from our previous points, here are some general tips for providing education that will build your patients' knowledge, buy-in, and self-efficacy to support better, more consistent device use:

• Utilize diverse learning techniques. Different patients learn in different ways, so it can help to offer a variety of learning opportunities. This can include verbal explanations, visual aids, demonstrations, and more.
• Implement hands-on practice. Whenever possible, invite patients to physically demonstrate how they would use their inhaler or nebulizer. This provides a chance for you to spot any errors and confirm that the patient has the physical coordination/capacity to use their device correctly.
• Check for understanding. Assess your patient's grasp of key information. The teach-back method is often helpful. After you provide an explanation, invite your patient to repeat it back to you. This can help you identify gaps or clarify misunderstandings.
• Build patient education into every touch-point. Each time you see a patient who uses an inhaler or nebulizer, spend a moment on education. Check frequently on their device technique, and don't forget to ask how they feel about using their device. Do they agree it's helpful, and are they a confident device user?
• Offer tips to help patients build a routine. Suggest practical strategies, such as setting a phone alarm and keeping their device in an easily accessible place, like their bedside table.
• Provide positive reinforcement. Patients who feel confident about using their devices are more likely to succeed. Offer encouragement and assurance when they use their devices correctly.
• Send patients home with resources to help them learn and remember key information. The COPD Foundation offers many resources on inhaler and nebulizer usage. For example, the COPD Educational Video Series includes detailed videos on how to use various inhalers and nebulizers.

When patients understand their devices, believe in their treatment, and trust their abilities, they are more likely to reap the full benefits of medication. By integrating brief teaching moments into every appointment, you can help increase adherence and improve patient outcomes. Each time you assess technique, offer encouragement, or explain why inhalation therapy matters, you help your patients breathe better, longer.