Despite the availability of effective asthma treatments and updated international guidelines, many asthmatic patients remain largely uncontrolled according to Global Initiative for Asthma (GINA) criteria [14].

Pharmacists drug expertise and their easy accessibility to patients often represent an underutilized resource for proper asthma management. Therefore, current national and international guidelines continually endorse pharmacists’ promising role for the provision of ongoing asthma care. However, pharmacists specific interventional role in these guidelines is yet not clearly articulated [8]. Moreover, their provided quality of asthma care greatly depends on their interventional knowledge, attitudes, and practices which may not be completely consistent with GINA recommendations [15].

Therefore, this study aimed to investigate pharmacists’ knowledge, attitudes, practices, and perceived barriers towards asthma management in Egypt, based on current asthma management guidelines.

The results of this study showed that less than half of the pharmacists (28.5%) who had good asthma knowledge with a significant higher knowledge score were reported for hospital pharmacists Vs community pharmacists and for pharmacists with longer experience years. A good knowledge score was reported for knowing asthma symptoms (94.4%), how to use the PFM (92%), and assessing asthma severity (77.5%).

This finding of poor pharmacists’ knowledge was in agreement with other previous studies conducted in France [16], Qatar [17], and Saudi Arabia [18]. Consistently, a previous study from Pakistan reported that community pharmacists failed to acknowledge most aspects of the primary asthma signs, its triggers, or correct inhalers use. Moreover, a previous study among Nigerian community pharmacists reported that only 34.8% and 11.2% of pharmacists had good knowledge and demonstrated good practice with GINA reports, respectively [19]. Another study among Turkish pharmacists’ reported them to have insufficient or incorrect asthma knowledge and further suggested adopting different educational methods to correct asthma misconceptions [20]. In addition, a majority of Sudanese pharmacist in another study lacked the basic knowledge to properly educate their asthma patients about their disease or correct inhalers use [21].

GINA guidelines are considered the gold standard for asthma diagnosis and management. Several previous studies have strongly correlated high level of asthma practice with good knowledge of asthma guidelines [12, 22]. Using guidelines in practice was reported to minimize treatment inconsistencies and reduce avoidable hospitalizations and costs [23].

It is of note in this study that only 33.3% of pharmacists were aware of the most updated GINA guidelines. This is consistent with several previous studies that either reported lack of pharmacists knowledge [10, 12] or compliance with asthma clinical guidelines in practice [22].

Recently, GINA 2020 guidelines have published a drastic change in step 1 mild asthma management. Based on scientific evidence GINA no longer supports short acting beta agonist (SABA) monotherapy for mild asthmatic patients, an approach that has been used for the last 30 years. The current evidence recommends receiving symptom driven (mild asthma) or daily inhaled corticosteroids (ICS) to reduce exacerbations risk. However, in this study, pharmacists were not aware about GINA recent SABA concerns (63.7%) or that GINA no longer recommends SABA alone with ICS even in mild intermittent asthma (77.5%). Indeed, regularly updating healthcare professionals (HCPs) and especially pharmacists with recent guidelines will be extremely valuable at all levels to easily apply the evidence-based strategies for better patient care.

Currently, the worldwide COVID-19 outbreak is highly challenging in asthma patients’ management: First, the dilemma of the possible substantial overlaps between the clinical presentation of uncontrolled asthma and COVID-19; second the possibility of spreading COVID-19 easily through asthma drug aerosols. In that context, GINA guidelines now recommend not using any aerosolization procedure, such as nebulization, spirometry or peak expiratory flow meter (PEFM) for asthmatic patients with suspected or confirmed COVID-19 due to the potential risk of its transmission [25].

This study showed that only 38.3% of pharmacists knew that they should avoid spirometry with confirmed or suspected COVID 19 cases. This is somehow worrisome, as insufficient pharmacist knowledge about this important update in guidelines jeopardizes many vulnerable patients for COVID-19 transmission, taking into consideration that aerosol droplets can remain for hours in the air [23].

This poor knowledge about the current GINA guidelines in this study reflects the importance of conducting educational asthma programs that should keep pharmacists with the needed up to date knowledge. Indeed, a well-informed pharmacist who comply with the clinical guidelines should be able to make proper therapeutic decisions for more effective asthma management [10, 12]. In order to design better educational strategies for pharmacists, their understanding of the relevant guidelines should be regularly assessed.

When the goal is to change clinical practice, targeting attitude and knowledge are equally important as without the proper pharmacist attitude, his knowledge will not be properly applied. Optimistically, a majority of pharmacists in this study had good attitude towards asthma management (80.2%) with female respondents expressed significantly higher positive attitude compared to males. Several previous studies have reported that improved pharmacist knowledge and attitude are a prerequisite to effective asthma care where patients are more empowered to be effective contributor in their disease management [7, 9, 26].

Overall pharmacists in this study showed high mean weighted response towards needing educational programs (4.37) and understanding their important role in asthma care (4.14). Such positive attitude is highly encouraging and consistent with a previous Turkish study that reported that 80% of the 52% pharmacists with poor knowledge reported the need for further education. Another Finnish study reported that 40% of pharmacist had poor knowledge, yet > 80% believed their important role in practice [16].

In addition, several previous studies have demonstrated significant improvements in knowledge and attitude among pharmacists who attended the educational programs [27]. Maintaining continuous asthma education approach would help ensure compliance with proper asthma care practice [28].

The good pharmacists practice in this study was illustrated by only 13.6% of studied pharmacists. Noteworthy in this study, hospital pharmacists showed significantly higher knowledge and better practice, compared to community pharmacists. These results were not surprising as hospital pharmacists are more existent active partners in clinical decision processes compared to community pharmacists. Other previous studies have also reported better knowledge and attitudes of hospital pharmacists vs community pharmacist in asthma care [29].

It is well known that PEFM is one of the commonest methods used for asthma initial evaluation and monitoring. Although, in our study, 92.5% reported knowing how to use the PEFM, the mean weighted score for using a PEFM for asthma patient follow-up was not as high (3.29). This is consistent with other previous studies that also reported poor PEFR use in patients follow-up [8]. Another previous study among Egyptian physicians’ showed that only 22.5% used PEFM for asthmatic patients follow-up [10]. Evidence has shown that patients with written asthma action plans that include PEFM assessment based on previous personal best readings consistently improved asthma outcome [30].

As noted, the lowest mean weighted score for pharmacists practice in this study was for asking patients about treatment side effects (2.5), discussing patients’ adherence (2.69), checking if patients have a written asthma plan (2.81), performing a detailed asthma history examination (2.64), or asking patients about their preference in asthma treatment (2.63). The episodic and chronic nature of asthma disease, which make pharmacists interventions in designing patients self-management plans, are a highly needed for sustained asthma control. Such poor pharmacists practice in guiding patients towards asthma self-management in this study needs urgent solutions.

It has been previously reported that pharmacists self-management education significantly improved asthma patients’ knowledge, attitudes, and adherence which translated to better asthma control [31]. Another previous study has reported that pharmacist education about adherence was identified as much better predictors of adherence than neither socioeconomic nor clinical factors [31]. In addition, several studies have correlated asthma fatality with insufficient asthma knowledge, noncompliance, and improper management [2]. Studies have persistently shown that educating asthma patients about self-management and using PFM significantly contributed to better QOL and asthma control [32]. Several studies in literature have correlated poor levels of knowledge and practice among pharmacists as barriers to effective asthma care [1, 33].

In this study, pharmacists identified most important and common barriers to providing asthma care. For pharmacist-related factors, the highest mean weighted score was for barriers, such as lack of pharmacist time (4.13), lack of pharmacist confidence in skills in asthma monitoring (3.56), management (3.16), counseling (2.69), and besides lack of financial incentive (3.43). Similarly, other previous studies have consistently reported lack of pharmacists time and education as major barriers to provision of asthma care services [3]. For patient-related factors the highest mean weighted score was for lack of patient time (4.13) plus patient perception that it is not the pharmacist role (3.84). Similar types of barriers were also identified in several previous studies [3, 34]. Understanding and addressing these barriers are of prime importance in developing tailored intervention asthma programs that achieve the desirable optimum asthma care.

The present study has several strengths and limitations. First, a relatively small sample size was studied, a single country, and therefore, the results cannot be generalized to other developing countries with different populations and economic conditions. Despite these limitations, we believe that this study was the first study to acknowledge pharmacists’ knowledge, attitude, practice, and barriers towards asthma management and their compliance with international GINA guidelines. The results of the study were helpful to understand the discrepancies between pharmacists’ good attitude and poor knowledge and practice. This study stressed on the importance of conducting asthma education programs to improve pharmacists’ knowledge that should translate to better practice. However, the real impact of these education programs on improving pharmacist practice and asthma outcomes still needs to be investigated.

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