Usability of the Test of Adherence to Inhalers Toolkit to patients with COPD in Kyrgyzstan

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Boven, Asel Budaichieva, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7498911/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2026 Read the published version in npj Primary Care Respiratory Medicine → Version 1 posted 11 You are reading this latest preprint version Abstract Background COPD remains a major health burden worldwide, with adherence to inhaled therapy being a key determinant of treatment success. The Test of Adherence to Inhalers (TAI) is a validated tool for assessing adherence, but does not provide tailored interventions. The TAI Toolkit was developed to address this gap by offering individualized adherence-enhancing strategies. We aimed to assess the usability of the TAI Toolkit among healthcare professionals in Kyrgyzstan. Methods This observational study was conducted at the National Center of Cardiology and Internal Medicine in Bishkek, Kyrgyzstan. The TAI Toolkit was translated and adapted for the local context. Nine physicians and three residents applied the TAI Toolkit in routine practice with 100 COPD patients. Healthcare professionals received training and later assessed the TAI Toolkit's usability using the System Usability Scale (SUS). Primary outcomes included usability and feasibility, while secondary outcomes focused on adherence-enhancing interventions provided and patient and physician satisfaction. Results The mean SUS score was 74.6 (SD = 5.7), indicating good usability. Overall, 91.7% of physicians were satisfied with the Toolkit. The most frequently provided interventions were medication plans (91.7%), reminders and/or counseling (83.3%), and education and/or counseling (83.3%). Patients and physicians reported high satisfaction, with mean ratings of 8.8 (SD = 1.3) and 8.6 (SD = 1.9), respectively. Conclusion The TAI Toolkit demonstrated good feasibility and usability among Kyrgyz healthcare professionals. Both patients and physicians found it beneficial for improving inhaler adherence management in COPD. Future research should explore its long-term clinical outcomes. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research COPD medication adherence feasibility TAI Toolkit Kyrgyzstan Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Chronic obstructive pulmonary disease (COPD) is a chronic disease characterized by irreversible disorders of the respiratory tract, accompanied by airflow limitation. 1 Long-term inhalation therapy is effective treatment for COPD. 2 Despite advances in modern medicine, the emergence of more effective drugs and the development of high-tech medical care, mortality from COPD is still high, especially in low and middle income countries (LMIC). 3 Patient’s insufficient adherence to the prescribed therapy may be one of the reasons. 4 Indeed, patient’s adherence with agreed treatment plan plays an important role in achieving treatment success 5 while adherence enhancing interventions have been proven to be a cost-effective strategy. 6 The Test of Adherence to Inhalers (TAI) has been developed and validated to assess adherence to inhaled medication and was one of the recommended tools in a recent systematic review. 7 , 8 In Kyrgyzstan, we previously used the validated Russian version of the TAI 7 and showed high rates of nonadherence. However, the TAI only showed the nonadherence barriers, without recommending specific adherence enhancing interventions. Van de Hei et al. integrated all effective adherence-enhancing strategies as identified in their review into a practical Toolkit that provides tailored recommendations for each adherence barrier. 9 The Toolkit can guide health care professionals to effective interventions based on the main behavioural phenotypes 10 and the individual barriers. The Toolkit consists of a wheel that can be used digitally or printed on paper. The TAI Toolkit was well-received by health care professionals in the Netherlands, a high-income setting. 11 Further research is however required to test its validity, practicality, and effectiveness in LMIC respiratory practice. The primary aim of the study was to assess the feasibility of the TAI Toolkit among healthcare workers at primary and tertiary level in Kyrgyzstan, a low-middle income country in Central Asia. Ultimately, implementation of the Toolkit should raise the level of knowledge and training of medical workers on management of adherence of COPD patients, inform Standard Operating Procedures (SOPs), and local clinical guidelines. Methods Study design & setting This observational, feasibility and usability study of a locally adapted version of the TAI Toolkit was conducted in the primary healthcare center (PHC) of the National Center of Cardiology and Internal Medicine in the capital city of Kyrgyzstan, Bishkek. It is the largest PHC for COPD and asthma patients in Kyrgyzstan. Typically, in winter time, when this study was performed, it is visited by patients from all seven Kyrgyz regions including patients treated at the Pulmonology Department of NCCIM. Study phases First, the original English TAI Toolkit (Fig. 1 ) was translated into Russian (most spoken language in Kyrgyzstan) using translation and back translation. Researchers and respiratory physicians interviewed selected patients and the physician team to assess validity and feasibility in the local Kyrgyz context, and incorporated feedback where needed, resulting in a final version (Fig. 2 ). The physician team included nine physicians and three residents, each of whom used the TAI Toolkit in their regular day practice. The second stage included an observational study with the adapted Kyrgyz version of the TAI Toolkit in patients with COPD. COPD patients who visited the primary health care center (PHC) were included, as well as patients with confirmed COPD who were registered at the PHC of the NCCIM and from the Pulmonology Department. Patient inclusion and exclusion criteria The following patient inclusion criteria were used: age ≥ 18 years, born, raised and living or currently living for at least 15 years in Kyrgyzstan, confirmed COPD by spirometry (FEV1/FVC < 0.7), agreed to sign an informed consent to participate in the study. Participants under 18 years, who lived in Kyrgyzstan for less than 15 years, had a congenital or acquired pathology of the musculoskeletal system, participants with severe congenital or acquired diseases of the cardiovascular, urinary and nervous systems, as well as participants who refused to sign informed consent were excluded from the study. Study procedures First, physicians received a one hour training on the use of TAI and TAI Toolkit in hybrid format, i.e. offline and online. After providing written informed consent, patients visiting the PHC completed a questionnaire (Appendix 1) with demographics and minimum clinical data (age, sex, inhaled medication used, COPD severity) and the Russian version of the TAI. Note that the TAI consists of 10 patient questions on different adherence barriers that can be rated from 1 (always a problem) to 5 (never a problem) and sums up to 50 in case of perfect adherence (i.e. the TAI-10 score ranges from 5 to 50). 7 Additionally, there are two questions the physician has to complete (on patient’s knowledge of dosing regimen and inhaler technique, each scored as 1 (insufficient knowledge) or 2 (good knowledge) (i.e., the TAI-12 score ranges from 7 to 54). Subsequently, the physician assessed the answers of the TAI and used the TAI Toolkit to select, provide and document an adherence enhancing intervention, especially in cases were TAI items scored a 3 or lower. Interventions included (1) reminders (for TAI-1 and TAI-2 problems); (2) reminders and/or counseling (for TAI-3-5 problems); (3) education and/or counseling (for TAI 6–10 problems); (4) medication plan (for TAI-11 problems) or (5) inhalation instruction (for TAI-12 problems). After completing data collection, an individual interview was conducted with the physicians and usability of the TAI Toolkit was assessed using the System Usability Scale (SUS). 12 The widely used SUS consists of 10 statements on a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree) with a maximum score of 100. Scores above 68 typically are deemed as good usability. Outcomes Primary study outcomes focused on the usability of the Kyrgyz TAI Toolkit as assessed by physicians using the SUS. Secondary outcomes included the number and type of adherence enhancing interventions provided, as well as patient and physician satisfaction (scored from 1 to 10). Statistical analysis Data were analysed using SPSS version 29.0 (IBM SPSS Corp., Armonk, NY, USA). Socio-demographic, SUS scores and clinical data were described as mean ± SD for continuous variables and absolute and relative frequencies for categorical variables. Ethical considerations Written informed consent for participation was obtained from each patient and recorded in the questionnaire. Ethical approval (No 5) was obtained from the Ethical Committee of the National Center of Cardiology and Internal Medicine on October 2, 2023. Results Patient characteristics In Table 1 , patient’s socio-demographic and clinical characteristics are shown. Of the 100 COPD patients, the mean age was 63.9 (SD = 12.9), with 58% being male. Average CAT score was 18.8 (SD = 5.1), and mMRC score was 2.7 (SD = 0.9). Overall TAI-10 score was 39.9 (SD = 8.9), indicating room for improvement in adherence. In particular, TAI-3 (stop taking the inhaler when feeling well), 7 (stop taking the inhaler because you experience little help in treating the disease), 8 (take fewer than prescribed), 11 (take not the right dose and frequency) and 12 (critical errors in inhaler technique) scored relatively low (Fig. 3 ). Note that most patients used short-acting inhaled medication used as maintenance therapy (i.e. with dosing regimen of 4 times daily). Table 1 Socio-demographic and clinical characteristics of COPD patients (N = 100) Total (n = 100) Characteristic Mean (SD) or % of total Age 63.9 (12.9) Gender (male) 58.0% Educational level Secondary school 17.0% Vocational school 35.0% Higher education 46.0% BMI 29.2 (7.6) Smoking status Smoker 20.0% Ex-smoker 32.0% Non-smoker 48.0% Biomass use for heating/cooking 78.0% SpO 2 90.7 (6.9) Heart rate 86.7 (15.9) Lung function FEV 1 % 53.9 (18.6) Medication usage SABA 11.0% SAMA 99.0% LAMA 1.0% ICS/LABA 4.0% SABA/SAMA 1.0% Medication adherence (%) TAI-10 39.9 (8.9) TAI-12 43.0 (9.3) CAT score 18.8 (5.1) mMRC score 2.7 (0.9) Comorbidities CVD 86.0% Allergic rhinitis 3.0% Bronchiectasis 6.0% Diabetes 9.0% Depression 2.0% Post-TB 4.0% Other 42.0% Regular walking 75.0% BMI, Body Mass Index; CAT, COPD Assessment Test; CVD, Cardio-vascular Diseases; FEV 1 , Forced Expiratory Volume in 1 second; ICS: inhaled corticosteroid; LAMA: long-acting muscarinic antagonist; mMRC, modified Medical Research Council; SABA: short-acting beta agonist; SAMA: short-acting muscarinic antagonist; TAI, Test of Adherence to Inhalers; TB, Tuberculosis. Physician characteristics Table 2 shows the physician characteristics. Mean age was 30.1 years (SD = 5.9), 58.3% were female, and on average they saw 9.7 (SD = 8.5) COPD patients per week. TAI Toolkit usability and satisfaction by physicians The mean System Usability Score (SUS) of the TAI Toolkit was 74.6 (SD = 5.7), indicating overall good usability. Additionally, physicians rated the TAI Toolkit positively, with a mean score of 8.58 (SD = 1.89). Overall, 91.7% (n = 11) of the doctors were satisfied with the TAI Toolkit, while only one was not, reporting that some of the recommendations were too lengthy and should be shortened for easier use in daily practice. Table 2 Healthcare professional characteristics (N = 12) and SUS score Variable Total (%) or Mean (SD) Age 30.1 (5.9) Gender Male 5.0 (41.7) Female 7.0 (58.3) Patients per week 9.7 (8.5) Satisfied with TAI Toolkit Yes 11.0 (91.7) No 1.0 (8.3) SUS total 74.6 (5.7) Satisfaction TAI Toolkit 8.6 (1.9) SD: standard deviation; SUS, the System usability scale; TAI: Test of Adherence to Inhalers Adherence interventions provided For TAI-identified adherence barriers with scores ≤ 3 (i.e., always, almost always, or sometimes a problem), 91.7% of healthcare professionals reported providing a “Medication Plan”, 83.3% provided “Reminders” and/or “Counseling” as well as “Education” and/or “Counseling”, and 58.3% provided “Reminders” and “Inhalation instructions” (Fig. 4 ). When TAI items scored 4 or 5, the frequency of interventions was markedly lower. Patient satisfaction Patient feedback was positive, with 100% (n = 12) reporting satisfaction with their physician’s advice. Moreover, patients rated the TAI Toolkit highly, with a mean score of 8.8 (SD = 1.3). These results suggest that both physicians and patients find the TAI Toolkit useful and effective, with high satisfaction and usability ratings across both groups. Discussion The findings of this study demonstrate a good feasibility and usability of the locally adapted TAI Toolkit among healthcare professionals managing COPD patients in lower-middle income country Kyrgyzstan. Both physician and patient satisfaction were high, confirming the TAI Toolkit’s applicability in clinical practice of an LMIC setting. The mean System Usability Scale (SUS) score indicated good usability, aligning with previous research conducted in high-income settings, such as the Netherlands, where the Toolkit was initially developed and evaluated. 9 This suggests that the TAI Toolkit can be effectively adapted and implemented across diverse healthcare systems, including those in LMICs such as Kyrgyzstan. Importantly, the Toolkit bridges the gap between identifying adherence barriers and providing actionable interventions. The high satisfaction rates among both healthcare professionals (91.7%) and patients (100%) underscore its practical utility in clinical practice. The most frequently recommended interventions − reminders, counseling, and medication plans − reflect the Toolkit’s ability to address, using low-cost interventions, common adherence challenges in LMIC, such as forgetfulness and lack of patient education. These findings highlight the importance of integrating tailored adherence enhancing strategies into routine COPD management. This is particularly relevant in resource-limited settings where nonadherence rates are often high and interventions can have significant clinical and economic benefits e.g. by reducing hospitalizations. 13 – 17 Although overall satisfaction with the TAI Toolkit was high, it is important to note that one physician reported being dissatisfied. The main reason was the perception that some of the recommendations provided in the Toolkit were too lengthy, suggesting the need to shorten and simplify the content for easier application in routine clinical practice. This feedback highlights that, while the Toolkit was generally well accepted, further refinement and adaptation of the intervention materials may enhance usability, particularly in busy clinical settings where time constraints are common. The success of the TAI Toolkit in this study may be attributed to its structured and practical design, as well as the training provided to healthcare professionals, which addressed potential barriers to implementation. It may also reflect the value of combining adherence assessment tools with concrete, practical and evidence-based recommendations to improve patient outcomes. Nonetheless, adherence interventions are only effective when patients have access to affordable medicines. In many LMICs, unavailability and unaffordability of inhaled medicines remain major barriers to adherence. 4 , 18 , 19 In this study, patients mostly used short-acting bronchodilators as maintenance therapy, i.e. 4 times daily. Previous research has shown that medicines with less frequent dosing regimens, such as long-acting bronchodilators (LABA +/- LAMA) with once or twice daily regimens could improve medication adherence. 20 , 21 These are however not always available or affordable. Finally, adherence interventions using innovative digital technologies, such as smart inhalers and spacers, 22 , 23 may not be feasible in LMIC settings. Despite some strengths, such as this being the first study focusing on evaluating a locally and culturally adapted adherence Toolkit for inhaled medicines use in LMICs, the study also has some limitations. Firstly, the small sample size of healthcare professionals (n = 12), being mostly physicians, may limit the generalizability of the findings. For example, the Toolkit may also be of use for nurses and pharmacists but this was not assessed. This may require more extensive training, especially to deliver more complex behavioural interventions. 24 Secondly, the short-term nature of the study precludes assessment of the TAI Toolkit’s long-term impact on clinical outcomes, such as exacerbation rates or quality of life. Future research should address these limitations by conducting larger, longitudinal studies to evaluate the TAI Toolkit’s effectiveness in improving adherence and COPD outcomes over time. Additionally, exploring the TAI Toolkit’s applicability in other low-resource settings would further validate its global utility. A final observation was the relatively high proportion of COPD patients that reported to be never smokers. However, almost 80% was exposed to biomass, reflecting a COPD population typical of this and other LMIC settings 25 , 26 with a predominantly COPD-P etiotype. 27 We do not expect that this directly impacted the usability of the TAI Toolkit, but the underlying effectiveness of the inhaled medication may be somewhat different and that could indirectly impact adherence. In conclusion, this study provides evidence that the TAI Toolkit is a feasible and applicable tool for improving adherence management in COPD patients in LMIC Kyrgyzstan. Its successful adaptation and high satisfaction rates among users highlight its potential for broader implementation. However, further research is warranted to assess its long-term clinical benefits and scalability in diverse healthcare systems. By addressing these gaps, future studies should explore the role of the TAI Toolkit in optimizing COPD therapy outcomes worldwide. Declarations Funding The study was supported by a grant from the International Primary Care Respiratory Group (IPCRG). Author contributions Aizhamal Tabyshova: Conceptualization, Methodology, Data collection and management, Formal analysis, Writing – original draft preparation. Tursunai Turarova: Data collection and management, Project administration. Job F. M. van Boven: Conceptualization, Methodology, Supervision, Writing – review and editing. Asel Budaichieva: Supervision, Writing – review and editing. Talant M. Sooronbaev: Supervision, Resources, Writing – review and editing. Acknowledgements The authors would like to thank all patients and healthcare professionals who participated in this study. Competing interests The authors declare no financial or non-financial competing interests. Data availability The datasets generated and analysed during the current study are stored in SPSS format and are not publicly available due to ethical and privacy restrictions. De-identified data may be made available from the corresponding author on reasonable request and with permission of the National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan. Ethics declarations The study protocol was reviewed and approved by the Ethical Committee of the National Center of Cardiology and Internal Medicine, Bishkek, the Kyrgyz Republic (Approval No. 5, dated October 2, 2023). Written informed consent was obtained from all participants prior to enrolment in the study, in accordance with the principles of the Declaration of Helsinki. References Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD: 2025 report. (2025). Available at: https://goldcopd.org/2025-gold-report/ Pleasants, R.A., Hess, D.R. Aerosol Delivery Devices for Obstructive Lung Diseases. Respir Care . 63(6); 708-733 (2018). doi:10.4187/respcare.06290. Vestbo, J., Anderson, J.A., Calverley, P.M.A., et al. 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Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2026 Read the published version in npj Primary Care Respiratory Medicine → Version 1 posted Editorial decision: Revision requested 31 Oct, 2025 Reviews received at journal 28 Oct, 2025 Reviewers agreed at journal 20 Oct, 2025 Reviewers agreed at journal 20 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviewers agreed at journal 28 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers invited by journal 04 Sep, 2025 Editor assigned by journal 31 Aug, 2025 Submission checks completed at journal 31 Aug, 2025 First submitted to journal 31 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7498911","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":512633445,"identity":"b59da05c-0857-4872-b041-527524139745","order_by":0,"name":"Aizhamal Tabyshova","email":"data:image/png;base64,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","orcid":"","institution":"National Center of Cardiology and Internal Medicine","correspondingAuthor":true,"prefix":"","firstName":"Aizhamal","middleName":"","lastName":"Tabyshova","suffix":""},{"id":512633446,"identity":"71add9d6-4f84-441e-9193-c51c33da2384","order_by":1,"name":"Tursunai Turarova","email":"","orcid":"","institution":"Kyrgyz-Turkish Manas University","correspondingAuthor":false,"prefix":"","firstName":"Tursunai","middleName":"","lastName":"Turarova","suffix":""},{"id":512633447,"identity":"40f06927-5791-46a9-968a-759c2359b981","order_by":2,"name":"Job F.M. Boven","email":"","orcid":"","institution":"Medication Adherence Expertise Center of the northern Netherlands (MAECON)","correspondingAuthor":false,"prefix":"","firstName":"Job","middleName":"F.M.","lastName":"Boven","suffix":""},{"id":512633448,"identity":"007f2399-084c-4663-aba8-ca981d0b94c2","order_by":3,"name":"Asel Budaichieva","email":"","orcid":"","institution":"National Center of Cardiology and Internal Medicine","correspondingAuthor":false,"prefix":"","firstName":"Asel","middleName":"","lastName":"Budaichieva","suffix":""},{"id":512633449,"identity":"ca6a9191-64dd-4be8-8aa8-ed4ae1193f9e","order_by":4,"name":"Talant Sooronbaev","email":"","orcid":"","institution":"National Center of Cardiology and Internal Medicine","correspondingAuthor":false,"prefix":"","firstName":"Talant","middleName":"","lastName":"Sooronbaev","suffix":""}],"badges":[],"createdAt":"2025-08-31 07:08:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7498911/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7498911/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41533-026-00480-y","type":"published","date":"2026-03-11T15:59:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91078160,"identity":"94b9bd3c-8231-4640-a068-2f4687077d31","added_by":"auto","created_at":"2025-09-11 11:17:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1454172,"visible":true,"origin":"","legend":"\u003cp\u003eThe\u003cstrong\u003e \u003c/strong\u003eTAI Toolkit adapted from van de Hei SJ et al.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7498911/v1/dd329af4cf02bd2630d19c4f.png"},{"id":91076415,"identity":"d6ac34c9-a5d3-4b8b-96dc-09a7d510245b","added_by":"auto","created_at":"2025-09-11 11:09:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1600372,"visible":true,"origin":"","legend":"\u003cp\u003eRussian version of the TAI Toolkit, adapted for use in Kyrgyzstan\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7498911/v1/8badb3c2ffb98f57d751916f.png"},{"id":91079806,"identity":"527d45a8-fab9-4be0-941a-f1f422c25413","added_by":"auto","created_at":"2025-09-11 11:25:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81346,"visible":true,"origin":"","legend":"\u003cp\u003eThe mean scores of the individual barriers to medication adherence (12-item TAI) in Kyrgyzstan\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7498911/v1/cd7abf1b7910acbd2632ba83.png"},{"id":91078162,"identity":"1153d92d-72f1-41fc-ab92-77cf0cb34e8a","added_by":"auto","created_at":"2025-09-11 11:17:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":86370,"visible":true,"origin":"","legend":"\u003cp\u003eProvided adherence interventions based on the Kyrgyz TAI Toolkit\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7498911/v1/e12c32b64960d5e1c298e110.png"},{"id":104739579,"identity":"2b366570-a220-42fc-a614-e7a1eb97721e","added_by":"auto","created_at":"2026-03-16 16:09:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4732039,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7498911/v1/77febb25-6e06-42e7-aa5f-21a52b4b48db.pdf"},{"id":91076426,"identity":"8c50544a-b4a7-4c32-adc9-65039339e4fe","added_by":"auto","created_at":"2025-09-11 11:09:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":3837701,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7498911/v1/711bb8af76b23dae5b26b609.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Usability of the Test of Adherence to Inhalers Toolkit to patients with COPD in Kyrgyzstan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic obstructive pulmonary disease (COPD) is a chronic disease characterized by irreversible disorders of the respiratory tract, accompanied by airflow limitation.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Long-term inhalation therapy is effective treatment for COPD.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Despite advances in modern medicine, the emergence of more effective drugs and the development of high-tech medical care, mortality from COPD is still high, especially in low and middle income countries (LMIC).\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Patient\u0026rsquo;s insufficient adherence to the prescribed therapy may be one of the reasons.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Indeed, patient\u0026rsquo;s adherence with agreed treatment plan plays an important role in achieving treatment success\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e while adherence enhancing interventions have been proven to be a cost-effective strategy.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe Test of Adherence to Inhalers (TAI) has been developed and validated to assess adherence to inhaled medication and was one of the recommended tools in a recent systematic review.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In Kyrgyzstan, we previously used the validated Russian version of the TAI\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e and showed high rates of nonadherence. However, the TAI only showed the nonadherence barriers, without recommending specific adherence enhancing interventions. Van de Hei et al. integrated all effective adherence-enhancing strategies as identified in their review into a practical Toolkit that provides tailored recommendations for each adherence barrier.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The Toolkit can guide health care professionals to effective interventions based on the main behavioural phenotypes\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and the individual barriers. The Toolkit consists of a wheel that can be used digitally or printed on paper. The TAI Toolkit was well-received by health care professionals in the Netherlands, a high-income setting.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Further research is however required to test its validity, practicality, and effectiveness in LMIC respiratory practice.\u003c/p\u003e\u003cp\u003eThe primary aim of the study was to assess the feasibility of the TAI Toolkit among healthcare workers at primary and tertiary level in Kyrgyzstan, a low-middle income country in Central Asia. Ultimately, implementation of the Toolkit should raise the level of knowledge and training of medical workers on management of adherence of COPD patients, inform Standard Operating Procedures (SOPs), and local clinical guidelines.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design \u0026amp; setting\u003c/h2\u003e\u003cp\u003e This observational, feasibility and usability study of a locally adapted version of the TAI Toolkit was conducted in the primary healthcare center (PHC) of the National Center of Cardiology and Internal Medicine in the capital city of Kyrgyzstan, Bishkek. It is the largest PHC for COPD and asthma patients in Kyrgyzstan. Typically, in winter time, when this study was performed, it is visited by patients from all seven Kyrgyz regions including patients treated at the Pulmonology Department of NCCIM.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy phases\u003c/h3\u003e\n\u003cp\u003eFirst, the original English TAI Toolkit (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was translated into Russian (most spoken language in Kyrgyzstan) using translation and back translation. Researchers and respiratory physicians interviewed selected patients and the physician team to assess validity and feasibility in the local Kyrgyz context, and incorporated feedback where needed, resulting in a final version (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The physician team included nine physicians and three residents, each of whom used the TAI Toolkit in their regular day practice. The second stage included an observational study with the adapted Kyrgyz version of the TAI Toolkit in patients with COPD. COPD patients who visited the primary health care center (PHC) were included, as well as patients with confirmed COPD who were registered at the PHC of the NCCIM and from the Pulmonology Department.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003ePatient inclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe following patient inclusion criteria were used: age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, born, raised and living or currently living for at least 15 years in Kyrgyzstan, confirmed COPD by spirometry (FEV1/FVC\u0026thinsp;\u0026lt;\u0026thinsp;0.7), agreed to sign an informed consent to participate in the study.\u003c/p\u003e\u003cp\u003e Participants under 18 years, who lived in Kyrgyzstan for less than 15 years, had a congenital or acquired pathology of the musculoskeletal system, participants with severe congenital or acquired diseases of the cardiovascular, urinary and nervous systems, as well as participants who refused to sign informed consent were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eStudy procedures\u003c/h3\u003e\n\u003cp\u003eFirst, physicians received a one hour training on the use of TAI and TAI Toolkit in hybrid format, i.e. offline and online. After providing written informed consent, patients visiting the PHC completed a questionnaire (Appendix 1) with demographics and minimum clinical data (age, sex, inhaled medication used, COPD severity) and the Russian version of the TAI. Note that the TAI consists of 10 patient questions on different adherence barriers that can be rated from 1 (always a problem) to 5 (never a problem) and sums up to 50 in case of perfect adherence (i.e. the TAI-10 score ranges from 5 to 50).\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Additionally, there are two questions the physician has to complete (on patient\u0026rsquo;s knowledge of dosing regimen and inhaler technique, each scored as 1 (insufficient knowledge) or 2 (good knowledge) (i.e., the TAI-12 score ranges from 7 to 54).\u003c/p\u003e\u003cp\u003eSubsequently, the physician assessed the answers of the TAI and used the TAI Toolkit to select, provide and document an adherence enhancing intervention, especially in cases were TAI items scored a 3 or lower. Interventions included (1) reminders (for TAI-1 and TAI-2 problems); (2) reminders and/or counseling (for TAI-3-5 problems); (3) education and/or counseling (for TAI 6\u0026ndash;10 problems); (4) medication plan (for TAI-11 problems) or (5) inhalation instruction (for TAI-12 problems).\u003c/p\u003e\u003cp\u003eAfter completing data collection, an individual interview was conducted with the physicians and usability of the TAI Toolkit was assessed using the System Usability Scale (SUS).\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The widely used SUS consists of 10 statements on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;Strongly Disagree, 5\u0026thinsp;=\u0026thinsp;Strongly Agree) with a maximum score of 100. Scores above 68 typically are deemed as good usability.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003ePrimary study outcomes focused on the usability of the Kyrgyz TAI Toolkit as assessed by physicians using the SUS. Secondary outcomes included the number and type of adherence enhancing interventions provided, as well as patient and physician satisfaction (scored from 1 to 10).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData were analysed using SPSS version 29.0 (IBM SPSS Corp., Armonk, NY, USA). Socio-demographic, SUS scores and clinical data were described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for continuous variables and absolute and relative frequencies for categorical variables.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e Written informed consent for participation was obtained from each patient and recorded in the questionnaire. Ethical approval (No 5) was obtained from the Ethical Committee of the National Center of Cardiology and Internal Medicine on October 2, 2023.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePatient characteristics\u003c/h2\u003e\u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, patient\u0026rsquo;s socio-demographic and clinical characteristics are shown. Of the 100 COPD patients, the mean age was 63.9 (SD\u0026thinsp;=\u0026thinsp;12.9), with 58% being male. Average CAT score was 18.8 (SD\u0026thinsp;=\u0026thinsp;5.1), and mMRC score was 2.7 (SD\u0026thinsp;=\u0026thinsp;0.9). Overall TAI-10 score was 39.9 (SD\u0026thinsp;=\u0026thinsp;8.9), indicating room for improvement in adherence. In particular, TAI-3 (stop taking the inhaler when feeling well), 7 (stop taking the inhaler because you experience little help in treating the disease), 8 (take fewer than prescribed), 11 (take not the right dose and frequency) and 12 (critical errors in inhaler technique) scored relatively low (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Note that most patients used short-acting inhaled medication used as maintenance therapy (i.e. with dosing regimen of 4 times daily).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSocio-demographic and clinical characteristics of COPD patients (N\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean (SD) or % of total\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.9 (12.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eGender (male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEducational level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVocational school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigher education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.2 (7.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSmoking status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSmoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEx-smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBiomass use for heating/cooking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSpO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.7 (6.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHeart rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e86.7 (15.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLung function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.9 (18.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMedication usage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSABA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSAMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e99.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLAMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eICS/LABA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSABA/SAMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMedication adherence (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTAI-10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.9 (8.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTAI-12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.0 (9.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCAT score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.8 (5.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003emMRC score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.7 (0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eComorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCVD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e86.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAllergic rhinitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBronchiectasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-TB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRegular walking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBMI, Body Mass Index; CAT, COPD Assessment Test; CVD, Cardio-vascular Diseases; FEV\u003csub\u003e1\u003c/sub\u003e, Forced Expiratory Volume in 1 second; ICS: inhaled corticosteroid; LAMA: long-acting muscarinic antagonist; mMRC, modified Medical Research Council; SABA: short-acting beta agonist; SAMA: short-acting muscarinic antagonist; TAI, Test of Adherence to Inhalers; TB, Tuberculosis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePhysician characteristics\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the physician characteristics. Mean age was 30.1 years (SD\u0026thinsp;=\u0026thinsp;5.9), 58.3% were female, and on average they saw 9.7 (SD\u0026thinsp;=\u0026thinsp;8.5) COPD patients per week.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTAI Toolkit usability and satisfaction by physicians\u003c/h2\u003e\u003cp\u003eThe mean System Usability Score (SUS) of the TAI Toolkit was 74.6 (SD\u0026thinsp;=\u0026thinsp;5.7), indicating overall good usability. Additionally, physicians rated the TAI Toolkit positively, with a mean score of 8.58 (SD\u0026thinsp;=\u0026thinsp;1.89). Overall, 91.7% (n\u0026thinsp;=\u0026thinsp;11) of the doctors were satisfied with the TAI Toolkit, while only one was not, reporting that some of the recommendations were too lengthy and should be shortened for easier use in daily practice.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHealthcare professional characteristics (N\u0026thinsp;=\u0026thinsp;12) and SUS score\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal (%) or Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.1 (5.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0 (41.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.0 (58.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePatients per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.7 (8.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSatisfied with TAI Toolkit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.0 (91.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0 (8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSUS total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.6 (5.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSatisfaction TAI Toolkit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.6 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eSD: standard deviation; SUS, the System usability scale; TAI: Test of Adherence to Inhalers\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eAdherence interventions provided\u003c/h2\u003e\u003cp\u003eFor TAI-identified adherence barriers with scores\u0026thinsp;\u0026le;\u0026thinsp;3 (i.e., always, almost always, or sometimes a problem), 91.7% of healthcare professionals reported providing a \u0026ldquo;Medication Plan\u0026rdquo;, 83.3% provided \u0026ldquo;Reminders\u0026rdquo; and/or \u0026ldquo;Counseling\u0026rdquo; as well as \u0026ldquo;Education\u0026rdquo; and/or \u0026ldquo;Counseling\u0026rdquo;, and 58.3% provided \u0026ldquo;Reminders\u0026rdquo; and \u0026ldquo;Inhalation instructions\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). When TAI items scored 4 or 5, the frequency of interventions was markedly lower.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePatient satisfaction\u003c/h2\u003e\u003cp\u003ePatient feedback was positive, with 100% (n\u0026thinsp;=\u0026thinsp;12) reporting satisfaction with their physician\u0026rsquo;s advice. Moreover, patients rated the TAI Toolkit highly, with a mean score of 8.8 (SD\u0026thinsp;=\u0026thinsp;1.3).\u003c/p\u003e\u003cp\u003eThese results suggest that both physicians and patients find the TAI Toolkit useful and effective, with high satisfaction and usability ratings across both groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study demonstrate a good feasibility and usability of the locally adapted TAI Toolkit among healthcare professionals managing COPD patients in lower-middle income country Kyrgyzstan. Both physician and patient satisfaction were high, confirming the TAI Toolkit\u0026rsquo;s applicability in clinical practice of an LMIC setting.\u003c/p\u003e\u003cp\u003eThe mean System Usability Scale (SUS) score indicated good usability, aligning with previous research conducted in high-income settings, such as the Netherlands, where the Toolkit was initially developed and evaluated.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e This suggests that the TAI Toolkit can be effectively adapted and implemented across diverse healthcare systems, including those in LMICs such as Kyrgyzstan. Importantly, the Toolkit bridges the gap between identifying adherence barriers and providing actionable interventions. The high satisfaction rates among both healthcare professionals (91.7%) and patients (100%) underscore its practical utility in clinical practice. The most frequently recommended interventions \u0026minus; reminders, counseling, and medication plans \u0026minus; reflect the Toolkit\u0026rsquo;s ability to address, using low-cost interventions, common adherence challenges in LMIC, such as forgetfulness and lack of patient education. These findings highlight the importance of integrating tailored adherence enhancing strategies into routine COPD management. This is particularly relevant in resource-limited settings where nonadherence rates are often high and interventions can have significant clinical and economic benefits e.g. by reducing hospitalizations.\u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAlthough overall satisfaction with the TAI Toolkit was high, it is important to note that one physician reported being dissatisfied. The main reason was the perception that some of the recommendations provided in the Toolkit were too lengthy, suggesting the need to shorten and simplify the content for easier application in routine clinical practice. This feedback highlights that, while the Toolkit was generally well accepted, further refinement and adaptation of the intervention materials may enhance usability, particularly in busy clinical settings where time constraints are common.\u003c/p\u003e\u003cp\u003eThe success of the TAI Toolkit in this study may be attributed to its structured and practical design, as well as the training provided to healthcare professionals, which addressed potential barriers to implementation. It may also reflect the value of combining adherence assessment tools with concrete, practical and evidence-based recommendations to improve patient outcomes. Nonetheless, adherence interventions are only effective when patients have access to affordable medicines. In many LMICs, unavailability and unaffordability of inhaled medicines remain major barriers to adherence.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e In this study, patients mostly used short-acting bronchodilators as maintenance therapy, i.e. 4 times daily. Previous research has shown that medicines with less frequent dosing regimens, such as long-acting bronchodilators (LABA +/- LAMA) with once or twice daily regimens could improve medication adherence.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e These are however not always available or affordable. Finally, adherence interventions using innovative digital technologies, such as smart inhalers and spacers,\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e may not be feasible in LMIC settings.\u003c/p\u003e\u003cp\u003eDespite some strengths, such as this being the first study focusing on evaluating a locally and culturally adapted adherence Toolkit for inhaled medicines use in LMICs, the study also has some limitations. Firstly, the small sample size of healthcare professionals (n\u0026thinsp;=\u0026thinsp;12), being mostly physicians, may limit the generalizability of the findings. For example, the Toolkit may also be of use for nurses and pharmacists but this was not assessed. This may require more extensive training, especially to deliver more complex behavioural interventions.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Secondly, the short-term nature of the study precludes assessment of the TAI Toolkit\u0026rsquo;s long-term impact on clinical outcomes, such as exacerbation rates or quality of life. Future research should address these limitations by conducting larger, longitudinal studies to evaluate the TAI Toolkit\u0026rsquo;s effectiveness in improving adherence and COPD outcomes over time. Additionally, exploring the TAI Toolkit\u0026rsquo;s applicability in other low-resource settings would further validate its global utility. A final observation was the relatively high proportion of COPD patients that reported to be never smokers. However, almost 80% was exposed to biomass, reflecting a COPD population typical of this and other LMIC settings\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e with a predominantly COPD-P etiotype.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e We do not expect that this directly impacted the usability of the TAI Toolkit, but the underlying effectiveness of the inhaled medication may be somewhat different and that could indirectly impact adherence.\u003c/p\u003e\u003cp\u003eIn conclusion, this study provides evidence that the TAI Toolkit is a feasible and applicable tool for improving adherence management in COPD patients in LMIC Kyrgyzstan. Its successful adaptation and high satisfaction rates among users highlight its potential for broader implementation. However, further research is warranted to assess its long-term clinical benefits and scalability in diverse healthcare systems. By addressing these gaps, future studies should explore the role of the TAI Toolkit in optimizing COPD therapy outcomes worldwide.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by a grant from the International Primary Care Respiratory Group (IPCRG).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAizhamal Tabyshova: Conceptualization, Methodology, Data collection and management, Formal analysis, Writing \u0026ndash; original draft preparation.\u003c/p\u003e\n\u003cp\u003eTursunai Turarova: Data collection and management, Project administration.\u003c/p\u003e\n\u003cp\u003eJob F. M. van Boven: Conceptualization, Methodology, Supervision, Writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eAsel Budaichieva: Supervision, Writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eTalant M. Sooronbaev: Supervision, Resources, Writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all patients and healthcare professionals who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or non-financial competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are stored in SPSS format and are not publicly available due to ethical and privacy restrictions. De-identified data may be made available from the corresponding author on reasonable request and with permission of the National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Ethical Committee of the National Center of Cardiology and Internal Medicine, Bishkek, the Kyrgyz Republic (Approval No. 5, dated October 2, 2023). Written informed consent was obtained from all participants prior to enrolment in the study, in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal Initiative for Chronic Obstructive Lung Disease (GOLD). \u003cem\u003eGlobal strategy for the diagnosis, management, and prevention of COPD: 2025 report.\u003c/em\u003e (2025). Available at: https://goldcopd.org/2025-gold-report/\u003c/li\u003e\n\u003cli\u003ePleasants, R.A., Hess, D.R. Aerosol Delivery Devices for Obstructive Lung Diseases. \u003cem\u003eRespir Care\u003c/em\u003e. 63(6); 708-733 (2018). doi:10.4187/respcare.06290.\u003c/li\u003e\n\u003cli\u003eVestbo, J., Anderson, J.A., Calverley, P.M.A., et al. Adherence to inhaled therapy, mortality and hospital admission in COPD. \u003cem\u003eThorax\u003c/em\u003e. 64(11); 939-943 (2009). doi:10.1136/THX.2009.113662.\u003c/li\u003e\n\u003cli\u003eGaur, V., Sorano, A., Sankrityayan, H., Gogtay, J., Lavorini, F. Adherence to asthma and COPD inhaled therapies in low- and middle-income countries: a narrative review. \u003cem\u003eExpert Rev Pharmacoecon Outcomes Res\u003c/em\u003e. (Published online June 19, 2025). doi:10.1080/14737167.2025.2520898.\u003c/li\u003e\n\u003cli\u003eTur\u0026eacute;gano-Yedro, M., Trillo-Calvo, E., Navarro, I. Ros. F., et al. Inhaler Adherence in COPD: A Crucial Step Towards the Correct Treatment. \u003cem\u003eInt J Chron Obstruct Pulmon Dis\u003c/em\u003e. 18, 2887-2893 (2023). doi:10.2147/COPD.S431829.\u003c/li\u003e\n\u003cli\u003evan Boven JFM, Lavorini F, Agh T, Sadatsafavi M, Patino O, Muresan B. Cost-Effectiveness and Impact on Health Care Utilization of Interventions to Improve Medication Adherence and Outcomes in Asthma and Chronic Obstructive Pulmonary Disease: A Systematic Literature Review. \u003cem\u003eJ Allergy Clin Immunol Pract\u003c/em\u003e. 12(5), 1228-1243 (2024). doi:10.1016/j.jaip.2023.12.049.\u003c/li\u003e\n\u003cli\u003ePlaza, V., Fern\u0026aacute;ndez-Rodr\u0026iacute;guez, C., Melero, C., et al. Validation of the \u0026ldquo;Test of the Adherence to Inhalers\u0026rdquo; (TAI) for Asthma and COPD Patients. \u003cem\u003eJ Aerosol Med Pulm Drug Deliv\u003c/em\u003e. 29(2), 142-152 (2016). doi:10.1089/JAMP.2015.1212.\u003c/li\u003e\n\u003cli\u003eQuirke-McFarlane, S., Weinman, J., d\u0026rsquo;Ancona, G. A Systematic Review of Patient-Reported Adherence Measures in Asthma: Which Questionnaire Is Most Useful in Clinical Practice? \u003cem\u003eJ Allergy Clin Immunol Pract\u003c/em\u003e. 11(8), 2493-2503 (2023). doi:10.1016/J.JAIP.2023.03.034.\u003c/li\u003e\n\u003cli\u003evan de Hei, S.J., Dierick, B.J.H., Aarts, J.E.P., Kocks, J.W.H., van Boven, J.F.M. Personalized Medication Adherence Management in Asthma and Chronic Obstructive Pulmonary Disease: A Review of Effective Interventions and Development of a Practical Adherence Toolkit. \u003cem\u003eJ Allergy Clin Immunol Pract\u003c/em\u003e. 9(11), 3979-3994 (2021). doi:10.1016/J.JAIP.2021.05.025.\u003c/li\u003e\n\u003cli\u003eChan, A.H.Y., De Keyser, H.H., Horne, R., Szefler, S.J. Viewpoint: defining adherence phenotype and endotypes to personalise asthma management. \u003cem\u003eEur Respir J\u003c/em\u003e. 65, 2401357 (2025). doi:10.1183/13993003.01357-2024.\u003c/li\u003e\n\u003cli\u003eAchterbosch, M., van de Hei, S.J., Dierick, B.J.H., et al. Usability and feasibility of the Test of Adherence to Inhalers (TAI) Toolkit in daily clinical practice: The BANANA study. \u003cem\u003eNPJ Prim Care Respir Med\u003c/em\u003e. 34, 13 (2024). doi:10.1038/S41533-024-00372-Z.\u003c/li\u003e\n\u003cli\u003eBrooke, J. SUS: A \u0026lsquo;quick and dirty\u0026rsquo; usability scale. In Usability Evaluation in Industry (eds. Jordan, P. W. et al.) 189\u0026ndash;194 (Taylor \u0026amp; Francis, 1996).\u003c/li\u003e\n\u003cli\u003eBischof, A.Y., Cordier, J., Vogel, J., Geissler, A. Medication adherence halves COPD patients\u0026rsquo; hospitalization risk \u0026ndash; evidence from Swiss health insurance data. \u003cem\u003eNpj Prim Care Respir Med\u003c/em\u003e. 34, 1 (2024). doi:10.1038/S41533-024-00361-2.\u003c/li\u003e\n\u003cli\u003eVan Boven, J.F.M., Chavannes, N.H., Van Der Molen, T., Rutten-Van M\u0026ouml;lken, M.P.M.H., Postma, M.J., et al. Clinical and economic impact of non-adherence in COPD: A systematic review. \u003cem\u003eRespir Med\u003c/em\u003e. 108, 103-113 (2014). doi:10.1016/j.rmed.2013.08.044.\u003c/li\u003e\n\u003cli\u003eTabyshova, A., Sooronbaev, T., Akylbekov, A., et al. Medication availability and economic barriers to adherence in asthma and COPD patients in low-resource settings. \u003cem\u003eNPJ Prim Care Respir Med\u003c/em\u003e. 32(1), 20 (2022). doi:10.1038/S41533-022-00281-Z.\u003c/li\u003e\n\u003cli\u003eVizel, A.A.V., Vizel, I.Yu.V., Salakhova, I.N.S., Vafina, A.R.V. Adherence in bronchial asthma and chronic obstructive pulmonary disease: from a problem to a solution. \u003cem\u003ePharmateca\u003c/em\u003e. 26(5), 122-126 (2019). [in Russian] doi:10.18565/pharmateca.2019.5.122-126\u003c/li\u003e\n\u003cli\u003eMalykhin, F.T., Baturin, V.A. Treatment compliance of elderly patients with chronic obstructive pulmonary disease. \u003cem\u003eKazan Med Journal. \u003c/em\u003e95(5), 626-631 (2014). doi:10.17816/KMJ2204.\u003c/li\u003e\n\u003cli\u003eStolbrink, M., Thomson, H., Hadfield, R.M., et al. The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 10(10), e1423-e1442 (2022). doi:10.1016/S2214-109X(22)00330-8.\u003c/li\u003e\n\u003cli\u003eStolbrink, M., Ozoh, O.B., Halpin, D.M.G., et al. Availability, cost and affordability of essential medicines for chronic respiratory diseases in low-income and middle-income countries: A cross-sectional study. \u003cem\u003eThorax\u003c/em\u003e. 79, 676-679 (2024). doi:10.1136/THORAX-2023-221349.\u003c/li\u003e\n\u003cli\u003eClaxton, A.J., Cramer, J., Pierce, C. A systematic review of the associations between dose regimens and medication compliance. \u003cem\u003eClin Ther\u003c/em\u003e. 23(8), 1296-1310 (2001). doi:10.1016/S0149-2918(01)80109-0.\u003c/li\u003e\n\u003cli\u003eDe Keyser, H., Vuong, V., Kaye, L., Anderson, W.C., Szefler, S., et al. Is Once Versus Twice Daily Dosing Better for Adherence in Asthma and Chronic Obstructive Pulmonary Disease? \u003cem\u003eJ Allergy Clin Immunol Pract\u003c/em\u003e. 11(7), 2087-2093.e3. (2023) doi:10.1016/j.jaip.2023.03.053.\u003c/li\u003e\n\u003cli\u003eAung, H., Tan, R., Flynn, C., et al. Digital remote maintenance inhaler adherence interventions in COPD: a systematic review and meta-analysis. \u003cem\u003eEur Respir Rev\u003c/em\u003e. 33(174), 240136 (2024). doi:10.1183/16000617.0136-2024.\u003c/li\u003e\n\u003cli\u003eDierick, B.J.H., Been-Buck, S., Klemmeier, T., et al. Digital spacer data driven COPD inhaler adherence education: The OUTERSPACE proof-of-concept study. \u003cem\u003eRespir Med\u003c/em\u003e. 201, 106940 (2022). doi:10.1016/j.rmed.2022.106940.\u003c/li\u003e\n\u003cli\u003eWileman, V., Steed, L., Pinnock, H., et al. Assessing competence of primary care respiratory healthcare professionals to deliver a psychologically-based intervention for people with COPD: results from the TANDEM study. \u003cem\u003eNpj Prim Care Respir Med\u003c/em\u003e. 35(1), 11 (2025). doi:10.1038/S41533-025-00416-Y.\u003c/li\u003e\n\u003cli\u003eBrakema, E.A., Tabyshova, A., Kasteleyn, M.J., et al. High COPD prevalence at high altitude: Does household air pollution play a role? \u003cem\u003eEur Respir J\u003c/em\u003e. 53(2), 1801193 (2019). doi:10.1183/13993003.01193-2018.\u003c/li\u003e\n\u003cli\u003eVan Gemert, F., Kirenga, B., Chavannes, N., et al. Prevalence of chronic obstructive pulmonary disease and associated risk factors in Uganda (FRESH AIR Uganda): A prospective cross-sectional observational study. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 3(1), e44-e51 (2015). doi:10.1016/S2214-109X(14)70337-7.\u003c/li\u003e\n\u003cli\u003eSoriano, J.B., Horner, A., Studnicka, M., et al. The GOLD 2023 proposed taxonomy: a new tool to determine COPD etiotypes. \u003cem\u003eEur Respir J\u003c/em\u003e. 61(6), 2300466 (2023). doi:10.1183/13993003.00466-2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"npj-primary-care-respiratory-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"npjpcrm","sideBox":"Learn more about [npj Primary Care Respiratory Medicine](https://www.nature.com/npjpcrm/)","snPcode":"41533","submissionUrl":"https://submission.springernature.com/new-submission/41533/3","title":"npj Primary Care Respiratory Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"NPJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COPD, medication adherence, feasibility, TAI Toolkit, Kyrgyzstan","lastPublishedDoi":"10.21203/rs.3.rs-7498911/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7498911/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCOPD remains a major health burden worldwide, with adherence to inhaled therapy being a key determinant of treatment success. The Test of Adherence to Inhalers (TAI) is a validated tool for assessing adherence, but does not provide tailored interventions. The TAI Toolkit was developed to address this gap by offering individualized adherence-enhancing strategies. We aimed to assess the usability of the TAI Toolkit among healthcare professionals in Kyrgyzstan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis observational study was conducted at the National Center of Cardiology and Internal Medicine in Bishkek, Kyrgyzstan. The TAI Toolkit was translated and adapted for the local context. Nine physicians and three residents applied the TAI Toolkit in routine practice with 100 COPD patients. Healthcare professionals received training and later assessed the TAI Toolkit's usability using the System Usability Scale (SUS). Primary outcomes included usability and feasibility, while secondary outcomes focused on adherence-enhancing interventions provided and patient and physician satisfaction.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean SUS score was 74.6 (SD\u0026thinsp;=\u0026thinsp;5.7), indicating good usability. Overall, 91.7% of physicians were satisfied with the Toolkit. The most frequently provided interventions were medication plans (91.7%), reminders and/or counseling (83.3%), and education and/or counseling (83.3%). Patients and physicians reported high satisfaction, with mean ratings of 8.8 (SD\u0026thinsp;=\u0026thinsp;1.3) and 8.6 (SD\u0026thinsp;=\u0026thinsp;1.9), respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe TAI Toolkit demonstrated good feasibility and usability among Kyrgyz healthcare professionals. Both patients and physicians found it beneficial for improving inhaler adherence management in COPD. Future research should explore its long-term clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Usability of the Test of Adherence to Inhalers Toolkit to patients with COPD in Kyrgyzstan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:09:53","doi":"10.21203/rs.3.rs-7498911/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-31T10:25:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-29T01:23:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167819808145656014605248491843927633408","date":"2025-10-20T14:29:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296119540110735399436588968580264891196","date":"2025-10-20T10:55:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T22:21:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259407948496589945369359968643527640138","date":"2025-09-28T11:25:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31978977662543641875793738543176556973","date":"2025-09-11T12:28:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T09:19:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-01T00:27:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-01T00:27:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"npj Primary Care Respiratory Medicine","date":"2025-08-31T07:06:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"npj-primary-care-respiratory-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"npjpcrm","sideBox":"Learn more about [npj Primary Care Respiratory Medicine](https://www.nature.com/npjpcrm/)","snPcode":"41533","submissionUrl":"https://submission.springernature.com/new-submission/41533/3","title":"npj Primary Care Respiratory Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"NPJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d81e0455-b361-49ea-8fcf-f7a689c71256","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":54454576,"name":"Health sciences/Diseases"},{"id":54454577,"name":"Health sciences/Health care"},{"id":54454578,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-03-16T16:05:12+00:00","versionOfRecord":{"articleIdentity":"rs-7498911","link":"https://doi.org/10.1038/s41533-026-00480-y","journal":{"identity":"npj-primary-care-respiratory-medicine","isVorOnly":false,"title":"npj Primary Care Respiratory Medicine"},"publishedOn":"2026-03-11 15:59:44","publishedOnDateReadable":"March 11th, 2026"},"versionCreatedAt":"2025-09-11 11:09:53","video":"","vorDoi":"10.1038/s41533-026-00480-y","vorDoiUrl":"https://doi.org/10.1038/s41533-026-00480-y","workflowStages":[]},"version":"v1","identity":"rs-7498911","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7498911","identity":"rs-7498911","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}