Evaluation of inhaler satisfaction and medication adherence in patients with chronic obstructive pulmonary disease: A cross-sectional study.

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Learn more: PMC Disclaimer | PMC Copyright Notice Medicine (Baltimore) . 2026 May 29;105(22):e48854. doi: 10.1097/MD.0000000000048854 Evaluation of inhaler satisfaction and medication adherence in patients with chronic obstructive pulmonary disease: A cross-sectional study Geetha Kandasamy a , Thangamani Subramani b, * , Khalid Orayj a , Mona Almanasef a , Rayah Asiri a , Asma M Alshahrani c , Rajalakshimi Vasudevan d , Saleh F Alqifari e , Rehab Ahmed f , Vasudevan Mani g , Asma Alzaydani h , Rushda Sajith b , Karema Abu-Elfotuh i, j , Kousalya Prabahar e Author information Article notes Copyright and License information a Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Kingdom of Saudi Arabia b Department of Pharmacy Practice, Grace College of Pharmacy, Palakkad, India c Department of Clinical Pharmacy, College of Pharmacy, Shaqra University, Dawadimi, Kingdom of Saudi Arabia d Department of Pharmacology, College of Pharmacy, King Khalid University, Abha, Kingdom of Saudi Arabia e Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Kingdom of Saudi Arabia f Department of Natural Products and Alternative Medicine, Faculty of Pharmacy, University of Tabuk, Tabuk, Kingdom of Saudi Arabia g Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah, Kingdom of Saudi Arabia h Department of Pharmacy, Rijal Almaa General Hospital, Ministry of Health (MOH), Rijal Almaa, Aseer Region, Kingdom of Saudi Arabia i Department of Clinical Pharmacy, Faculty of Pharmacy (Girls), Al-Azhar University, Cairo, Egypt j College of Pharmacy, Al-Ayen Iraqi University, An Nasiriyah, Iraq. * Correspondence: Thangamani Subramani, Department of Pharmacy Practice, Grace College of Pharmacy, Kodunthirapully, Palakkad 678004, Kerala, India (e-mail: thangamanipharma@gmail.com ). Received 2026 Jan 8; Revised 2026 Apr 25; Accepted 2026 Apr 28; Collection date 2026 May 29. Copyright © 2026 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC) , where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. PMC Copyright notice PMCID: PMC13225567  PMID: 42216328 Abstract A cornerstone of treatment for chronic obstructive pulmonary disease (COPD) is inhalation therapy. However, incorrect use of inhalers can increase the risk of exacerbations. Adherence to inhaled medications and patient satisfaction are interrelated and play critical roles in achieving optimal symptom control. This study aimed to evaluate patient satisfaction with and adherence to inhalers among individuals with COPD. A prospective single-center observational study was conducted in a South Indian hospital, assessing inhaler adherence using the Test of Adherence to Inhalers and patient satisfaction using the Feeling of Satisfaction with Inhaler (FSI-10) questionnaire. A logistic regression model was used to identify factors associated with high inhaler satisfaction. Among 377 COPD patients (mean age = 61.8 ± 10.7 years), 57.3% reported high inhaler satisfaction (FSI-10 ≥ 43), which was associated with older age, male sex, longer disease duration, fewer current smokers, comorbidities, milder disease (global initiative for chronic obstructive lung disease I–II), dry powder inhaler use, single-inhaler therapy, long-acting beta 2 -agonist/long-acting muscarinic antagonist regimens, and fewer exacerbations (all P < .05). Good adherence (Test of Adherence to Inhalers [10-item questionnaire] = 50) was observed in 32.9%, associated with adequate inhaler knowledge, absence of forgetfulness or fear, single-inhaler use, and higher satisfaction (all P < .001). In multivariable analyses, high satisfaction was independently associated with age >60 years (Adjusted Odds Ratio [aOR] = 3.84; confidence interval [CI] = 2.12–6.97), comorbidities (aOR = 1.67; CI = 1.04–2.68), whereas multiple inhaler use (aOR = 0.62; 95% CI = 0.39–0.99) and global initiative for chronic obstructive lung disease III to IV (GOLD III to IV) (aOR = 0.48; 95% CI = 0.29–0.79) were associated with lower satisfaction.. Good adherence was independently associated with higher education (aOR = 3.12; CI = 1.94–5.02), inadequate inhaler knowledge (Adjusted aOR = 0.31; CI = 0.14–0.69), and higher FSI-10 scores (aOR per unit = 1.18; CI = 1.11–1.26). Satisfaction and adherence were moderately correlated (r = 0.46; P < .001). This study found that high inhaler satisfaction was common among patients with COPD, whereas full adherence was less frequent. Satisfaction and adherence were associated with age, disease severity, inhaler regimen complexity, education, and inhaler knowledge. The moderate positive correlation between satisfaction and adherence suggests a potential relationship that warrants further investigation in longitudinal or interventional studies. Keywords: barriers to adherence, COPD, education, FSI-10, inhalation therapy, inhaler adherence, patient satisfaction, TAI-10 1. Introduction Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation, and is one of the leading causes of diseases associated with parenchymal destruction (emphysema). [ 1 ] The global prevalence of COPD is estimated to be 12.2%, affecting 300 million individuals. It is predicted that by 2030, COPD will rise from the fifth to the fourth-largest cause of mortality worldwide. [ 2 ] According to the World Health Organization, 90% of COPD-related cases and 66% of COPD-related deaths occur in low- and middle-income countries. [ 3 ] Smoking is the primary cause of COPD; however, 25% of COPD patients are nonsmokers. [ 4 ] Other significant risk factors include indoor air pollution, exposure to coal dust, silica, and asbestos in the workplace, low birth weight, recurrent infections, chronic childhood cough, advanced age, living in rural areas, and a family history of respiratory disorders. [ 5 , 6 ] The incidence and mortality rates of COPD continue to rise globally and are likely to increase further due to increased smoking rates among women and adolescents compared to previous decades. [ 7 ] The cornerstone of treatment for patients with COPD is inhalation therapy, which, according to international guidelines, includes inhaled bronchodilators (such as beta-2 agonists and antimuscarinic agents) and inhaled corticosteroids. [ 8 ] COPD patients often exhibit very low adherence rates, with reported nonadherence ranging from 50% to 80%. [ 9 ] Inadequate adherence to the prescribed medication regimen has been associated with worsening symptoms, exacerbations, hospitalizations, and a decline in quality of life. [ 10 ] Inappropriate techniques and nonadherence to inhalers have been identified as factors contributing to suboptimal COPD management. [ 11 ] Adherence consists of 3 key components: initiation of the prescribed therapy, proper implementation of the therapy (including accurate dosage, inhalation technique, and frequency), and persistence, which involves obtaining refills to maintain adherence over time. Numerous factors, including patient-specific and societal determinants, can influence adherence. [ 12 ] Prioritizing patient preferences when selecting an inhaler is another recommendation made by the guidelines. In COPD patients, poor inhaler satisfaction is a significant cause of inhaler handling errors and inadequate adherence. [ 13 ] Treatment adherence is closely linked to patient satisfaction with their inhaler. [ 14 ] Recent evidence supports the importance of inhaler satisfaction and correct device handling in COPD management. Harb et al reported that patient satisfaction with inhaler devices is associated with proper inhaler technique and adherence, suggesting that device-related factors may influence treatment effectiveness and outcomes. [ 15 ] Similarly, findings from the REAL survey by Price et al indicate that nonadherence and incorrect inhaler use are important barriers to optimal COPD care, and that inhaler technique training and follow-up assessment may support proper use and adherence. [ 16 ] In addition, Man et al showed that satisfaction, preference, and error occurrence vary across inhaler devices, highlighting the role of device attributes and user experience in how patients perceive and use their inhalers. [ 17 ] Together, these studies reinforce the value of evaluating both inhaler satisfaction and adherence in COPD populations. It is estimated that $300 billion is wasted annually in the United States due to nonadherence among patients with chronic illnesses, with COPD exhibiting one of the highest rates of nonadherence; improved adherence has been associated with better clinical outcomes and reduced healthcare costs. [ 18 , 19 ] In addition to adherence challenges, the majority of patients prefer once-daily inhalational therapy. [ 20 ] Incorrect use of inhaler medication by COPD patients has been associated with decreased disease control, higher risk of exacerbations, reduced quality of life, and increased healthcare utilization. [ 21 ] Inhalation devices are often used improperly, depending on the type of device, the patient’s proficiency, and the prescribing individual’s level of training. [ 22 ] Reports indicate that adherence to COPD treatment regimens is alarmingly low, with rates ranging from 15% to 30%. [ 23 ] Numerous observational studies have found low adherence to inhaled medications in COPD patients. In some instances, better adherence to inhaled treatments has been associated with a reduced risk of mortality. [ 24 ] Patients who do not follow their prescribed COPD medication regimen may experience less favorable clinical and economic outcomes. [ 25 ] The most common causes of nonadherence to inhaled medication in COPD patients include low economic status, unemployment, fear of medication, forgetfulness, social stigma, lack of knowledge, improper inhalation techniques, and the complexity of therapy. [ 26 , 27 ] Long-term adherence to inhaled drugs is crucial for the effective treatment of COPD, but adherence remains difficult to quantify, and the factors influencing adherence are not fully understood. [ 28 ] To prevent or delay the effects of respiratory diseases, such as exacerbations, and to manage and control symptoms, adherence to and satisfaction with inhaled medications are important for effective disease management. Therefore, this study was conducted to evaluate satisfaction with and adherence to inhalers among COPD patients. 2. Methodology 2.1. Study design and setting This cross-sectional observational study was conducted in the Department of Pulmonology at Karuna Medical College Hospital, Kerala, South India, from January 15, 2023, to May 28, 2023, to evaluate inhaler satisfaction and medication adherence among patients with COPD in routine clinical practice. 2.2. Participants/eligibility criteria Patients aged ≥18 years with COPD, diagnosed by a pulmonologist based on spirometry (post-bronchodilator forced expiratory volume in 1 second/forced vital capacity ratio <0.70, as per the global initiative for chronic obstructive lung disease [GOLD] criteria), [ 29 ] who had been prescribed daily maintenance inhaler therapy (dry powder inhalers [DPIs], soft mist inhalers [SMIs], or pressurized metered-dose inhalers [pMDIs]) for >3 months, were eligible for inclusion. Exclusion criteria included: inability to complete the questionnaire, communication difficulties, declining to provide informed consent, terminal illnesses where treatment was primarily palliative (e.g., end-stage malignancy), and other primary pulmonary diseases not caused by COPD (e.g., standalone bronchiectasis). However, we included patients who had bronchiectasis identified as a complication of COPD. 2.3. Sample size and participant flow Consecutive sampling was employed, whereby all eligible COPD patients attending the Department of Pulmonology during the study period were invited to participate. Out of 412 patients evaluated for eligibility, 395 met the inclusion criteria. Of these, 13 were excluded due to incomplete questionnaires, and 9 did not provide consent. Ultimately, 377 participants were included in the final analysis. 2.4. Data collection and outcome assessment Data were collected through direct interviews using a structured questionnaire. The questionnaire consisted of 3 sections. Section 1 captured sociodemographic and clinical characteristics, including age, sex, place of residence, occupation, educational status, monthly income, smoking habits, alcohol consumption, symptom frequency (daily, weekly, monthly, or seasonal/occasional), allergy history, duration of COPD, history of coronavirus disease 2019 (COVID-19) infection, comorbid conditions (hypertension, diabetes mellitus, ischemic heart disease, heart failure, chronic kidney disease, osteoporosis, depression, anxiety disorders, and malignancies), and COPD severity according to GOLD staging. Information on inhaler-related variables, including type of inhaler device (pMDI, DPI, or SMI), number of inhalers used (single vs multiple), prescribed drug regimen (long-acting beta 2 -agonist/long-acting muscarinic antagonist or triple therapy), and history of exacerbations in the past year, was also recorded. Section 2 assessed inhaler satisfaction using the Feeling of Satisfaction with Inhaler (FSI-10) questionnaire. The FSI-10 is a validated 10-item self-administered instrument scored on a 5-point Likert scale ranging from 1 (“hardly at all”) to 5 (“very”), yielding a total score between 10 and 50. An FSI-10 score of ≥43 was considered indicative of high inhaler satisfaction, as described in previous studies. [ 30 – 33 ] Section 3 evaluated medication adherence using the validated Test of Adherence to Inhalers (TAI-10) questionnaire. The TAI-10, developed by Plaza et al (2016), consists of 10 items scored on a 5-point Likert scale, with total scores ranging from 10 to 50. Adherence was categorized as poor (≤45), intermediate (46–49), or good (50), according to established criteria. [ 34 , 35 ] Behavioral factors potentially influencing adherence, including inhaler knowledge (adequate vs inadequate), forgetfulness, and fear of side effects, were also assessed. All participants were prescribed daily maintenance inhaler therapy, and adherence was evaluated based on regular daily use as recommended by the treating pulmonologist, in alignment with the structure of the TAI questionnaire. 2.5. Pilot testing and reliability of questionnaires To ensure cultural and linguistic suitability for the local population, the FSI-10 and TAI instruments were translated into Malayalam by 2 independent bilingual experts fluent in English and Malayalam, both with experience in pulmonary care and public health. A back-translation procedure was conducted to verify translation accuracy: an independent translator, blinded to the original versions, translated the Malayalam questionnaires back into English, and these back-translations were compared with the originals by an expert panel. Discrepancies were resolved to ensure conceptual equivalence. A pilot study was conducted with 20 native Malayalam-speaking COPD patients to assess clarity, cultural relevance, and comprehensibility. Minor modifications were made based on participant feedback. The internal consistency of the translated instruments was evaluated using Cronbach alpha, with values of 0.82 for FSI-10 and 0.80 for TAI, indicating good reliability. 2.6. Statistical analysis Statistical analysis was performed using IBM Statistical Package for the Social Sciences Statistics version 28.0. Continuous variables were expressed as mean ± standard deviation and compared using the independent samples t test, while categorical variables were analyzed with the χ 2 test. Multivariable logistic regression identified independent predictors of inhaler satisfaction and adherence, with adjusted odds ratios (aORs) and 95% confidence intervals (CIs) reported. Pearson correlation assessed the relationship between satisfaction and adherence scores. A two-tailed P < .05 was considered statistically significant. For analyses involving up to 5 degrees of freedom, an effect size of 0.3 and a study power of 0.80 were considered in the study design to ensure adequate sample size. This study was conducted at a single center and relied on self-reported questionnaires to assess inhaler satisfaction and adherence. These factors may limit the generalizability of the findings and introduce potential recall or social desirability bias, which are common in observational studies. Given the cross-sectional and observational design, analyses are limited to identifying associations rather than establishing causal relationships, and residual confounding cannot be excluded. Future studies may consider incorporating objective adherence measures, such as pharmacy refill data or electronic monitoring, to complement self-reported assessments and improve the accuracy of adherence evaluation. 2.7. Ethical approval The research received approval from the Institutional Ethics Committee of Karuna Medical College (KMC/IHEC/22/2022). All methods were conducted in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants, who were also informed of their right to withdraw from the study at any time. All data were handled with strict confidentiality and used solely for academic purposes. 3. Results 3.1. Participant characteristics A total of 377 patients with COPD were included. The mean age was 61.84 ± 10.72 years, and 61.5% were male. Overall, 216 (57.3%) patients reported high inhaler satisfaction, while 161 (42.7%) reported low satisfaction. Good adherence was observed in 124 (32.9%) patients, with the remaining 253 (67.1%) classified as having poor–intermediate adherence. 3.2. Inhaler satisfaction Patients with high inhaler satisfaction were significantly older than those with low satisfaction (64.32 ± 9.21 vs 58.41 ± 11.32 years, P < .001), and a higher proportion were aged >60 years (62.0% vs 35.4%, P < .001). Males were more likely to report high satisfaction (68.5% vs 52.2%, P = .002). Educational attainment differed across groups, with degree-level education more common among patients with high satisfaction (36.1% vs 23.5%, P = .001). High satisfaction was also associated with longer disease duration (15.91 ± 7.12 vs 12.84 ± 8.43 years, P = .001), presence of comorbidities (69.9% vs 59.0%, P = .031), and lower smoking prevalence (52.8% vs 65.2%, P = .017). Disease severity (GOLD stage) differed significantly between satisfaction groups ( P < .001), with patients in GOLD stages I to II more frequently reporting high satisfaction. No significant differences were observed regarding occupation, income, place of residence, history of allergy, COPD symptom frequency, or prior COVID-19 infection (Table 1 ). Regarding inhaler type, patients using DPIs reported higher satisfaction (66.2%) compared with pMDIs (51.9%) or SMIs (60.5%; P = .012). Satisfaction was also higher among patients using a single inhaler (66.4%) compared with multiple inhalers (54.6%; P < .001) and among those receiving long-acting beta 2 -agonist/long-acting muscarinic antagonist therapy (66.7%) versus triple therapy ( P = .004). Patients reporting ≥2 exacerbations in the previous year were more frequently represented in the low satisfaction group (61.8%; P < .001; Table 2 ). Multivariable analysis showed that age >60 years (aOR = 3.84; 95% CI = 2.12–6.97; P < .001), presence of comorbidities (aOR = 1.67; 95% CI = 1.04–2.68; P = .034), GOLD stages III to IV (aOR = 0.48; 95% CI = 0.29–0.79; P = .004), and use of multiple inhalers (aOR = 0.62; 95% CI = 0.39–0.99; P = .046) were associated with inhaler satisfaction levels (Table 3 ). Table 1. Baseline sociodemographic and clinical characteristics of COPD patients according to inhaler satisfaction (N = 377). Variables Category Total (N = 377) High satisfaction (n = 216) Low satisfaction (n = 161) P value Age (yr) Mean ± SD 61.84 ± 10.72 64.32 ± 9.21 58.41 ± 11.32 <.001 * Age group 20–40 32 (8.49) 9 (4.17) 23 (14.29) <.001 41–60 154 (40.85) 73 (33.80) 81 (50.31) >60 191 (50.66) 134 (62.04) 57 (35.40) Gender Male 232 (61.54) 148 (68.52) 84 (52.17) .002 Female 145 (38.46) 68 (31.48) 77 (47.83) Occupation Business 46 (12.20) 28 (12.96) 18 (11.18) .213 Skilled worker 121 (32.10) 74 (34.26) 47 (29.19) Employed 62 (16.45) 38 (17.59) 24 (14.91) Unemployed 148 (39.26) 76 (35.19) 72 (44.72) Education Degree 109 (28.91) 78 (36.11) 31 (19.25) .001 Higher secondary 86 (22.81) 53 (24.54) 33 (20.50) Secondary school 104 (27.59) 55 (25.46) 49 (30.43) Uneducated 78 (20.69) 30 (13.89) 48 (29.81) Income (INR/month) <10,000 82 (21.75) 43 (19.91) 39 (24.22) .287 10,001–20,000 118 (31.30) 66 (30.56) 52 (32.30) 20,001–30,000 94 (24.93) 57 (26.39) 37 (22.98) >30,000 83 (22.02) 50 (23.15) 33 (20.50) Duration of COPD (yr) Mean ± SD 14.62 ± 7.91 15.91 ± 7.12 12.84 ± 8.43 .001 * Residence Rural 292 (77.45) 168 (77.78) 124 (77.02) .861 Urban 85 (22.55) 48 (22.22) 37 (22.98) Allergy history Yes 221 (58.62) 128 (59.26) 93 (57.76) .777 No 156 (41.38) 88 (40.74) 68 (42.24) Frequency of symptoms Daily 231 (61.27) 128 (59.26) 103 (63.98) .541 Weekly 59 (15.65) 31 (14.35) 28 (17.39) Monthly 21 (5.57) 11 (5.09) 10 (6.21) Seasonal/occasional 66 (17.51) 46 (21.30) 20 (12.42) COVID-19 history Positive 219 (58.09) 127 (58.80) 92 (57.14) .742 Negative 158 (41.91) 89 (41.20) 69 (42.86) Comorbidities Present 246 (65.25) 151 (69.91) 95 (59.01) .031 Absent 131 (34.75) 65 (30.09) 66 (40.99) Smoking status Smoker 219 (58.09) 114 (52.78) 105 (65.22) .017 Nonsmoker 158 (41.91) 102 (47.22) 56 (34.78) GOLD stage I 48 (12.73) 36 (16.67) 12 (7.45) <.001 II 156 (41.38) 98 (45.37) 58 (36.02) III 123 (32.62) 62 (28.70) 61 (37.89) IV 50 (13.27) 20 (9.26) 30 (18.63) Open in a new tab COPD = chronic obstructive pulmonary disease. * Independent samples t test. Rest all – chi-square test. Table 2. Inhaler satisfaction (FSI-10) by clinical and treatment-related parameters. Variable Category High satisfaction, n (%) Low satisfaction, n (%) P value Inhaler device pMDI 78 (48.15) 84 (51.85) .012 DPI 92 (66.19) 47 (33.81) SMI 46 (60.53) 30 (39.47) Number of inhalers Single 142 (66.36) 72 (33.64) <.001 Multiple 74 (45.40) 89 (54.60) Drug regimen LABA/LAMA 112 (66.67) 56 (33.33) .004 Triple therapy 76 (50.00) 76 (50.00) Exacerbations (past yr) ≥2 58 (38.16) 94 (61.84) <.001 Open in a new tab DPI = dry powder inhaler, FSI-10 = Feeling of Satisfaction with Inhaler (10-item questionnaire), LABA = long-acting beta 2 -agonist, LABA/LAMA = combination of long-acting beta 2 -agonist + long-acting muscarinic antagonist, LAMA = long-acting muscarinic antagonist, Multiple = combination inhaler (contains 2 or more medications), pMDI = pressurized metered-dose inhaler, Single = single-drug inhaler (contains 1 medication), SMI = soft mist inhaler, triple therapy = combination of LABA + LAMA + inhaled corticosteroid. Table 3. Multivariable logistic regression analysis for high inhaler satisfaction (FSI-10 ≥ 43). Variable Adjusted OR 95% CI P value Age >60 yr 3.84 2.12–6.97 <.001 GOLD III–IV 0.48 0.29–0.79 .004 Multiple inhalers 0.62 0.39–0.99 .046 Comorbidities present 1.67 1.04–2.68 .034 Open in a new tab aOR = adjusted odds ratio, CI = confidence interval, FSI-10 = Feeling of Satisfaction with Inhaler (10-item questionnaire). 3.3. Inhaler adherence Adherence also varied according to behavioral factors. Patients with adequate inhaler knowledge more frequently demonstrated good adherence (59.9% vs 14.5%, P < .001). Forgetfulness ( P < .001) and fear of side effects ( P = .002) were more prevalent among patients with poor–intermediate adherence. Use of multiple inhalers was associated with lower adherence ( P < .001), while higher inhaler satisfaction was observed among good adherers ( P < .001; Table 4 ). Multivariable analysis indicated that higher educational attainment (aOR = 3.12; 95% CI = 1.94–5.02; P < .001), inadequate inhaler knowledge (aOR = 0.31; 95% CI = 0.14–0.69; P = .004), GOLD stages III to IV (aOR = 0.39; 95% CI = 0.22–0.69; P = .001), and higher inhaler satisfaction scores (aOR per unit increase = 1.18; 95% CI = 1.11–1.26; P < .001) were associated with better adherence (Table 5 ). Correlation analysis demonstrated a moderate positive association between inhaler satisfaction and adherence ( r = 0.46, P < .001), indicating that higher satisfaction scores tended to correspond with higher adherence scores (Table 6 and Fig. 1 ). Table 4. Inhaler adherence (TAI-10) by behavioral and clinical parameters Variable Category Good adherence n (%) Poor–intermediate n (%) P value Inhaler knowledge Adequate 91 (59.87) 61 (40.13) < .001 Inadequate 33 (14.47) 195 (85.53) Forgetfulness Present 19 (11.45) 147 (88.55) < .001 Fear of side effects Present 21 (18.26) 94 (81.74) .002 Multiple inhalers Yes 31 (19.02) 132 (80.98) < .001 FSI-10 category High satisfaction 86 (39.81) 130 (60.19) < .001 Open in a new tab Table 5. Multivariable logistic regression analysis for good inhaler adherence (TAI-10 = 50) Variable Adjusted OR 95% CI P value Higher education 3.12 1.94–5.02 < .001 GOLD III–IV 0.39 0.22–0.69 .001 Inadequate inhaler knowledge 0.31 0.14–0.69 .004 FSI-10 score (per unit increase) 1.18 1.11–1.26 < .001 Open in a new tab Table 6. Correlation analysis between inhaler satisfaction and adherence scores. Variables Correlation coefficient ( r ) P value FSI-10 total score vs TAI-10 total score 0.46 <.001 Open in a new tab FSI-10 = Feeling of Satisfaction with Inhaler (10-item questionnaire), TAI-10 = Test of Adherence to Inhalers (10-item questionnaire). Figure 1. Open in a new tab Correlation between inhaler satisfaction (FSI-10 score) and inhaler adherence (TAI-10 score) among COPD patients (n = 377). The scatter plot demonstrates a moderate positive correlation, indicating that higher inhaler satisfaction is associated with better adherence. COPD = chronic obstructive pulmonary disease, FSI-10 = Feeling of Satisfaction with Inhaler (10-item questionnaire), TAI-10 = Test of Adherence to Inhalers (10-item questionnaire). 4. Discussion The present study examined inhaler satisfaction and treatment adherence among patients with COPD, focusing on how these related but distinct constructs coexist in routine clinical care. Notably, high patient-reported inhaler satisfaction does not necessarily guarantee proper medication adherence, highlighting the need to assess both constructs independently. Poor adherence to inhaled therapy was frequently observed despite moderate to high levels of reported inhaler satisfaction. Specifically, 161 (42.7%) patients reported low inhaler satisfaction, while 253 (67.1%) demonstrated poor–intermediate adherence to at least 1 inhaler. In the total population, mean inhaler satisfaction and adherence scores were 41.8 ± 3.93 and 43.6 ± 5.72, respectively. Previous studies have reported that approximately 60% of patients with COPD exhibit suboptimal adherence to prescribed inhaled therapies. [ 36 ] Reduced adherence has been observed alongside poorer disease control in observational settings. [ 37 ] Nonadherence may occur unintentionally, reflecting challenges such as aging, social circumstances, or comorbid conditions that complicate regular medication use. [ 38 ] Assessment of inhaler satisfaction provides insight into patient experience and usability of inhaled therapies, yet satisfaction alone may not capture the behavioral aspects of adherence. Prior work has linked lower satisfaction and inhaler handling difficulties with poorer compliance, [ 39 ] while the GOLD 2025 report recognizes that adherence challenges are present across all stages of COPD and may be more pronounced in advanced disease. [ 40 ] Real-world studies suggest that device usability contributes to perceived satisfaction, [ 14 ] and systematic reviews emphasize that adherence behavior is multifactorial, influenced by clinical, psychological, and contextual factors. [ 41 ] In the current study, patients with more advanced disease reported relatively higher satisfaction but demonstrated lower adherence. This apparent discordance reinforces that satisfaction and adherence should not be interpreted as interchangeable indicators. While moderate correlation between the 2 constructs was observed ( R = 0.46, P < .001), the relationship suggests partial overlap rather than equivalence. Cross-national comparisons further illustrate variability in these measures. Studies from Vietnam, [ 42 ] Korea, [ 43 ] and Spain [ 44 ] reported inhaler satisfaction rates ranging from 42% to 62.5%, whereas a Colombian cohort documented good adherence in 56.6% of patients. [ 45 ] Satisfaction and adherence levels in the present cohort were comparatively lower, underscoring potential population-specific influences. 4.1. Age-related findings Age-related patterns were notable. Younger patients demonstrated higher adherence, whereas older individuals reported greater inhaler satisfaction but reduced adherence. This divergence may reflect age-associated cognitive or physical limitations, regimen complexity, or differing perceptions of medication necessity. [ 46 – 48 ] These observations suggest that patient-reported satisfaction should be considered alongside objective adherence assessment, particularly in older populations. Gender differences were also observed, with male patients reporting higher inhaler satisfaction. Biological and behavioral factors have been proposed to contribute to sex-related variation in COPD manifestations and treatment experiences. [ 49 – 53 ] Although adherence was numerically higher among males, this difference did not reach statistical significance. 4.2. Device-related factors Device characteristics are associated with patient experience and inhaler satisfaction, yet satisfaction alone may not reflect behavioral aspects of adherence. Prior work has linked lower satisfaction and inhaler handling difficulties with poorer compliance, [ 39 ] while the GOLD 2025 report notes that adherence challenges are present across all stages of COPD and may be more pronounced in advanced disease. [ 40 ] Real-world studies report that device usability is associated with perceived satisfaction, [ 14 ] and systematic reviews highlight that adherence behavior is multifactorial, shaped by clinical, psychological, and contextual factors. [ 41 ] 4.3. Behavioral determinants Smoking status was associated with both satisfaction and adherence patterns, with smokers more likely to report lower satisfaction and poorer adherence. Smoking remains a primary etiological factor in COPD progression, [ 54 , 55 ] and behavioral factors linked to tobacco use are associated with differences in treatment engagement. Data regarding nonsmokers and passive exposure remain limited, [ 56 ] emphasizing the complexity of adherence behaviors in heterogeneous patient populations. More than half of the cohort reported prior COVID-19 infection. Although trends toward lower satisfaction and adherence were observed in this subgroup, statistical associations were not significant, and interpretation is limited by the cross-sectional design and absence of multivariable adjustment. Existing literature suggests that maintaining inhaled maintenance therapy during the pandemic may be associated with disease stability, [ 57 , 58 ] but causal inference cannot be drawn from the present findings. Educational attainment demonstrated significant associations with both inhaler satisfaction and adherence, consistent with literature identifying health literacy and educational level as contributors to medication use behaviors in chronic disease. [ 59 , 60 ] Patients with comorbidities reported higher satisfaction yet poorer adherence, potentially reflecting treatment complexity and competing health priorities. [ 61 , 62 ] Together, these findings indicate that adherence behavior is shaped by multiple interacting factors and cannot be inferred solely from satisfaction measures. Importantly, while prior research has noted associations between inhaler satisfaction, adherence, and clinical outcomes, [ 63 ] the present cross-sectional data cannot establish causality or clinical superiority of specific approaches. 4.4. Clinical implications These findings highlight that inhaler satisfaction and adherence, while related, are distinct constructs. High patient satisfaction does not necessarily indicate proper adherence, particularly among older adults and those with comorbidities. These findings underscore the value of assessing both satisfaction and adherence as part of routine COPD management. Importantly, the results are exploratory and hypothesis-generating, suggesting potential avenues for targeted interventions, such as structured adherence assessment, inhaler technique reinforcement, and patient education, to potentially enhance engagement with therapy. Future longitudinal and interventional studies are warranted to explore their potential impact on clinical outcomes, without implying immediate changes to standard practice. 4.5. Limitations This study has several limitations. First, its single-center design may limit generalizability to the broader COPD population. Second, adherence and satisfaction were assessed via self-reported questionnaires, which may be influenced by self-report bias, including recall or cognitive biases. Third, although differences by inhaler device and drug regimen were explored, the study did not stratify all analyses by each device or combination, which may have influenced the outcomes. In addition, specific barriers to nonadherence or reasons for inhaler dissatisfaction beyond the questionnaire items were not explored. Fifth, objective measures of adherence, such as pharmacy refill data or electronic monitoring, were not used; future studies could incorporate such measures to complement self-reported assessments and improve the accuracy of adherence evaluation. Finally, the cross-sectional design prevents the establishment of causal relationships between inhaler satisfaction, adherence, and associated factors. 5. Conclusion This study evaluated inhaler satisfaction and adherence among patients with COPD in routine practice. While most reported high satisfaction, full adherence was observed in only a subset. Older age, comorbidities, and fewer inhalers were linked to higher satisfaction, whereas advanced COPD was associated with lower satisfaction. Good adherence was more common among younger, better-educated patients, while knowledge gaps, forgetfulness, and side-effect concerns reduced adherence. A moderate positive correlation highlights their association without implying causality. These findings support patient-centered strategies, including tailored inhaler education and individualized support, with further research needed in longitudinal or interventional studies. Acknowledgments The authors reviewed and approved all content to ensure accuracy and integrity of the scientific work. The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through large Research Project under grant number RGP2/44/46. Author contributions Conceptualization: Geetha Kandasamy, Rushda Sajith, Kousalya Prabahar. Formal analysis: Geetha Kandasamy, Thangamani Subramani, Khalid Orayj, Mona Almanasef, Rayah Asiri, Asma M. Alshahrani, Rajalakshimi Vasudevan, Rehab Ahmed, Rushda Sajith, Karema Abu-Elfotuh. Funding acquisition: Geetha Kandasamy, Thangamani Subramani, Mona Almanasef, Rayah Asiri, Rajalakshimi Vasudevan, Saleh F. Alqifari, Rehab Ahmed, Asma Alzaydani, Karema Abu-Elfotuh, Kousalya Prabahar. Methodology: Geetha Kandasamy, Thangamani Subramani, Mona Almanasef, Rayah Asiri, Asma M. Alshahrani, Rajalakshimi Vasudevan, Rehab Ahmed, Vasudevan Mani, Asma Alzaydani, Kousalya Prabahar. Project administration: Geetha Kandasamy, Khalid Orayj, Vasudevan Mani, Rushda Sajith. Software: Geetha Kandasamy, Khalid Orayj, Mona Almanasef, Rayah Asiri, Asma M. Alshahrani, Rehab Ahmed, Rushda Sajith, Karema Abu-Elfotuh. Supervision: Geetha Kandasamy, Mona Almanasef, Rayah Asiri, Asma M. Alshahrani, Rajalakshimi Vasudevan, Saleh F. Alqifari, Rehab Ahmed, Rushda Sajith, Kousalya Prabahar. Validation: Geetha Kandasamy, Khalid Orayj, Mona Almanasef, Rajalakshimi Vasudevan, Saleh F. Alqifari, Rehab Ahmed, Vasudevan Mani, Asma Alzaydani, Kousalya Prabahar. Writing – original draft: Geetha Kandasamy, Thangamani Subramani, Khalid Orayj, Mona Almanasef, Rayah Asiri, Asma M. Alshahrani, Rajalakshimi Vasudevan, Saleh F. Alqifari, Rehab Ahmed, Vasudevan Mani, Asma Alzaydani, Rushda Sajith, Kousalya Prabahar. Writing – review & editing: Geetha Kandasamy, Thangamani Subramani, Khalid Orayj, Mona Almanasef, Rayah Asiri, Asma M. Alshahrani, Rajalakshimi Vasudevan, Saleh F. Alqifari, Vasudevan Mani, Asma Alzaydani, Rushda Sajith, Karema Abu-Elfotuh, Kousalya Prabahar. Data curation: Thangamani Subramani, Rushda Sajith. Visualization: Khalid Orayj, Mona Almanasef, Vasudevan Mani, Asma Alzaydani, Karema Abu-Elfotuh, Kousalya Prabahar. Investigation: Rayah Asiri, Saleh F. Alqifari, Rehab Ahmed, Vasudevan Mani, Kousalya Prabahar. Resources: Rushda Sajith, Thangamani Subramani. Abbreviations: AOR adjusted odds ratio CI confidence interval COPD chronic obstructive pulmonary disease COVID-19 coronavirus disease 2019 DPI dry powder inhaler FSI-10 Feeling of Satisfaction with Inhaler (10-item questionnaire) GOLD global initiative for chronic obstructive lung disease pMDI pressurized metered-dose inhaler SMI soft mist inhaler TAI-10 Test of Adherence to Inhalers (10-item questionnaire) The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through large research project under grant number RGP2/44/46. The authors have no conflicts of interest to disclose. The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request. How to cite this article: Kandasamy G, Subramani T, Orayj K, Almanasef M, Asiri R, Alshahrani AM, Vasudevan R, Alqifari SF, Ahmed R, Mani V, Alzaydani A, Sajith R, Abu-Elfotuh K, Prabahar K. Evaluation of inhaler satisfaction and medication adherence in patients with chronic obstructive pulmonary disease: A cross-sectional study. Medicine 2026;105:22(e48854). Contributor Information Geetha Kandasamy, Email: glakshmi@kku.edu.sa. Khalid Orayj, Email: korayj@kku.edu.sa. Mona Almanasef, Email: malmanasaef@kku.edu.sa. Rayah Asiri, Email: rassri@kku.edu.sa. Asma M. Alshahrani, Email: a.alshahrani@su.edu.sa. Rajalakshimi Vasudevan, Email: rajaa@kku.edu.sa. Saleh F. Alqifari, Email: salqifari@ut.edu.sa. Rehab Ahmed, Email: rahmed@ut.edu.sa. Vasudevan Mani, Email: V.SAMY@qu.edu.sa. Asma Alzaydani, Email: azoli@moh.gov.sa. Rushda Sajith, Email: rushdasajith@gmail.com. Karema Abu-Elfotuh, Email: Karimasoliman.pharmg@azhar.edu.eg. Kousalya Prabahar, Email: kgopal@ut.edu.sa. References [1]. 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