Journal of General Internal Medicine

, Volume 27, Issue 2, pp 190–195 | Cite as

A Randomized Controlled Trial of a Literacy-Sensitive Self-Management Intervention for Chronic Obstructive Pulmonary Disease Patients

  • Katie Kiser
  • Daniel Jonas
  • Zachary Warner
  • Kelli Scanlon
  • Betsy Bryant Shilliday
  • Darren A. DeWalt
Original Research



Low literacy skills are common and associated with a variety of poor health outcomes. This may be particularly important in patients with chronic illnesses such as chronic obstructive pulmonary disease (COPD) that require appropriate inhaler technique to maintain quality of life and avoid exacerbations.


To explore the impact of a literacy-sensitive self-management intervention on inhaler technique scores in COPD patients and to determine if effects differ by literacy.


Randomized controlled trial.


Ninety-nine patients with COPD.


Patients were randomly assigned to a one-on-one self-management educational intervention or usual care. The intervention focused on inhaler technique, smoking cessation, and using a COPD action plan.

Main Measures

At baseline, an inhaler technique assessment, literacy assessment, health-related quality of life questionnaires, and pulmonary function tests were completed. Inhaler technique was re-evaluated after two to eight weeks.

Key Results

Mean age 63, 65% female, 69% Caucasian, moderate COPD severity on average, 36% with low literacy, moderately impaired health-related quality of life, and similar baseline metered dose inhaler technique scores. Patients in the intervention group had greater mean improvement from baseline in metered dose inhaler technique score compared to those in the usual care group (difference in mean change 2.1, 95% CI 1.1, 3.0). The patients in the intervention group also had greater mean improvements in metered dose inhaler technique score than those in the usual care group whether they had low health literacy (difference in mean change 2.8, 95% CI 0.6, 4.9) or higher health literacy (1.8, 95% CI 0.7, 2.9).


A literacy-sensitive self-management intervention can lead to improvements in inhaler technique, with benefits for patients with both low and higher health literacy.


COPD inhaler technique health literacy self-management randomized controlled trial 

Supplementary material

11606_2011_1867_MOESM1_ESM.pdf (2.2 mb)
Online Appendix 1Living With COPD Handout (PDF 2.20 MB)
11606_2011_1867_MOESM2_ESM.doc (88 kb)
Online Appendix 2Percentage of Subjects Achieving each Inhaler Technique Score at baseline and follow-up for the Intervention and Usual Care groups (DOC 87.5 KB)
11606_2011_1867_MOESM3_ESM.doc (90 kb)
Online Appendix 3Percentage of Subjects with Incorrect Inhaler Technique for each Item at baseline and follow-up for the Intervention and Usual Care groups (DOC 89.5 KB)


  1. 1.
    National Heart Lung and Blood Institute. Morbidity and Mortality: 2009 Chartbook on Cardiovascular, Lung, and Blood Diseases.Google Scholar
  2. 2.
    Menzin J, Boulanger L, Marton J, et al. The economic burden of chronic obstructive pulmonary disease (COPD) in a U.S. Medicare population. Respiratory Med. 2008;102(9):1248–56.CrossRefGoogle Scholar
  3. 3.
    Nielsen-Bohlman L, Panzer AM, Kindig DA, Committee on Health Literacy. Health literacy: a prescription to end confusion. Washington, D. C.: National Academies Press; 2004.Google Scholar
  4. 4.
    DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, Pignone M. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228–39.PubMedCrossRefGoogle Scholar
  5. 5.
    Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165(17):1946–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Sudore RL, Yaffe K, Satterfield S, et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med. 2006;21(8):806–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, eds. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Vol. NLM, Pub. No CBM 2000-1. 2000. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services. Available at: (accessed August 25, 2011).
  8. 8.
    Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–55.PubMedCrossRefGoogle Scholar
  9. 9.
    Melani AS, Zanchetta D, Barbato N, et al. Inhalation technique and variables associated with misuse of conventional metered dose inhalers and newer dry powder inhalers in experienced adults. Ann Allergy Asthma Immunol. 2004;93(5):439–46.PubMedCrossRefGoogle Scholar
  10. 10.
    Paasche-Orlow MK, Riekert K, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005;172(8): 980–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008–15.PubMedCrossRefGoogle Scholar
  12. 12.
    Blackstock F and Webster K. Disease-specific health education for COPD: a systematic review of changes in health outcomes. Health Educ Res. 2007;22(5):703–17.PubMedCrossRefGoogle Scholar
  13. 13.
    Lemmens KM, Nieboer AP, Huijsman R. A systematic review of integrated use of disease-management interventions in asthma and COPD. Respir Med. 2009;103(5):670–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. Am J Med. 2008;121(5):433–43.PubMedCrossRefGoogle Scholar
  15. 15.
    Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: A new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10(10):537–41.PubMedCrossRefGoogle Scholar
  16. 16.
    Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurse J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Jones PW, Quirk FH, Baveystock CM. The St. George's Respiratory Questionnaire. Respir Med. 1991;85 Suppl B:25-31, 33–7.Google Scholar
  18. 18.
    Doak CC, Doak LG, Root JH. Teaching patients with low literacy skills. 2nd ed. Philadelphia, PA: Lippincott; 1996.Google Scholar
  19. 19.
    McLaughlin GH. SMOG grading – a new readability formula. J Reading. 1969;12:639–46.Google Scholar
  20. 20.
    Schillinger D, Piette J, Grumback K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90.PubMedCrossRefGoogle Scholar
  21. 21.
    Gray SL, Nance AC, Williams DM, Pulliam CC. Assessment of interrater and intrarater reliability in the evaluation of metered dose inhaler technique. Chest. 1994;105(3):710–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Lee-Wong M and Mayo PH. Results of a programme to improve house staff use of metered dose inhalers and spacers. Postgrad. Med. J. 2003;79:221–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008–15.PubMedCrossRefGoogle Scholar
  24. 24.
    Molimard M, Raherison C, Lignot S, et al. Assessment of handling of inhaler devices in real life: An observational study in 3811 patients in primary care. J Aerosol Med. 2003;16(3):249–54.PubMedCrossRefGoogle Scholar
  25. 25.
    Hesselink AE, Penninx BW, Winjnhoven HA, et al. Determinants of an incorrect inhalation technique in patients with asthma or COPD. Scand J Prim Health Care. 2001;19(4):255–60.PubMedCrossRefGoogle Scholar
  26. 26.
    Van der Palen J, Klein JJ, Kerkhoff AH, et al. Evaluation of the effectiveness of four different inhalers in patients with chronic obstructive pulmonary disease. Thorax. 1995;50(11):1183–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Basheti IA, Armour CL, Bosnic SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Counc. 2008;72(1):26–33.CrossRefGoogle Scholar
  28. 28.
    Epstein SW, Manning CPR, Ashley MJ, Corey PN. Survey of the clinical use of pressurized aerosol inhalers. CMA Journal. 1979;120:813–6.Google Scholar
  29. 29.
    Interiano B and Guntupalli KK. Metered-dose inhalers. Do health care providers know what to teach? Arch Intern Med. 1993;153(1):81–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011;26:635–42.PubMedCrossRefGoogle Scholar
  31. 31.
    Rootmensen GN, van Keimpema ARJ, Jansen HM, de Haan RJ. Predictors of Incorrect Inhalation Technique in Patients with Asthma or COPD: A Study Using a Validated Videotaped Scoring Method. Journal of Aerosol Medicine and Pulmonary Drug Delivery. 2010;23(5):323–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Bosnic-Anticevich SZ, Sinha H, So S, Reddel HK. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010;47(3):251–6.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Katie Kiser
    • 1
    • 3
  • Daniel Jonas
    • 2
  • Zachary Warner
    • 2
  • Kelli Scanlon
    • 2
  • Betsy Bryant Shilliday
    • 2
  • Darren A. DeWalt
    • 2
  1. 1.School of PharmacyUniversity of MarylandBaltimoreUSA
  2. 2.Department of MedicineUniversity of North Carolina Chapel HillChapel HillUSA
  3. 3.University of Maryland School of PharmacyBaltimoreUSA

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