Enhancing COPD management in Vietnam: the strategic imperative of validating the Test of Adherence to Inhalers and the Intention of Inhaled Medication Adherence Scale

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Introduction Chronic Obstructive Pulmonary Disease (COPD) represents a formidable global health challenge, exacting a heavy toll on healthcare systems and individual well-being worldwide 1,2. In Vietnam, like many rapidly developing nations undergoing epidemiological transitions, the burden of COPD is escalating, fueled by a complex interplay of persistent traditional risk factors such as tobacco smoking and increasing environmental pollution 3. The cornerstone of effective COPD management – crucial for alleviating symptoms, preventing exacerbations, and improving long-term prognosis – unequivocally lies in the consistent and technically proficient use of inhaled medications 4,5. However, suboptimal inhaler adherence remains a pervasive and deeply entrenched issue, inevitably leading to poorer clinical outcomes, increased rates of hospitalization, and a significant erosion of patients' quality of life 6. Crucially, the absence of culturally and linguistically validated measurement tools in Vietnam has historically hampered accurate assessment and effective intervention, often rendering current efforts to improve adherence inefficient. Accurately assessing, understanding, and subsequently influencing adherence behaviors are therefore paramount for both robust scientific inquiry and impactful clinical interventions. This viewpoint article critically examines the strategic importance of developing and rigorously validating culturally and linguistically appropriate inhaler adherence measurement tools, specifically the Test of Adherence to Inhalers (TAI) 7 and the Intention of Inhaled Medication Adherence Scale (IMAS) 8, within the unique Vietnamese healthcare and sociocultural landscape. We contend that these meticulously validated instruments – a process our team aims to complete in the near future through a dedicated research endeavor – are not merely academic pursuits but represent indispensable enablers for bridging critical measurement gaps, fostering a nuanced, context-specific understanding of patient behavioral determinants, and ultimately driving substantial, measurable improvements in COPD management outcomes across Vietnam. Although numerous instruments have been developed to assess medication adherence across chronic diseases, many of the most widely used scales are generic rather than therapy-specific. The Medication Adherence Report Scale (MARS) and the Adherence Starts with Knowledge (ASK-20) questionnaire, for example, have been frequently applied in chronic illness research and clinical practice. Their strengths lie in brevity, ease of administration, and broad applicability across diverse therapeutic areas. However, these tools were not originally designed for inhaler-based therapies and therefore may not capture critical dimensions such as inhaler technique, device-specific barriers, or the distinction between intentional and unintentional non-adherence. This limits their ability to provide a nuanced understanding of adherence in COPD populations, where incorrect technique and motivational barriers often coexist and jointly undermine treatment outcomes9,10 By contrast, the Test of Adherence to Inhalers (TAI) and the Intention of Inhaled Medication Adherence Scale (IMAS) were specifically developed to address these limitations. The TAI, validated across multiple international COPD and asthma cohorts, directly evaluates inhaler-related behaviors and distinguishes between active (deliberate) and passive (unintentional) forms of non-adherence, thereby offering practical clinical insights into patients' real-world use of inhalers.7,11 Complementing this, the IMAS is theoretically anchored in the Theory of Planned Behavior (TPB) and systematically captures the cognitive, attitudinal, and social determinants that shape patients' intentions to adhere. By exploring constructs such as attitudes toward treatment, perceived social norms, and perceived behavioral control, the IMAS sheds light on the psychological and motivational drivers of adherence.8,12 Taken together, TAI and IMAS offer a uniquely comprehensive framework: the former captures what patients do with their inhalers, while the latter provides insight into why they do it. This combination is particularly relevant in the Vietnamese context, where cultural, social, and health literacy factors strongly influence patient behaviors. The integration of these two instruments, once rigorously validated, therefore holds strong potential to guide both evidence-based research and the design of culturally tailored interventions for COPD management in Vietnam. The unmet need for culturally congruent adherence measurement in Vietnam Recent epidemiological and cost studies indicate that COPD imposes a substantial clinical and economic burden in Vietnam. Population-based surveys estimate COPD prevalence in Vietnamese adults at approximately 7–10%, with variation by region and sex.13–15 Acute exacerbations are common and are the principal driver of direct medical costs. In a tertiary-hospital sample of patients admitted with AECOPD in Hanoi, the mean total hospitalization cost per episode was 18.3 million VND (≈ USD 780–800 in 2018), with medication accounting for the largest share of inpatient expenses.16 In outpatient settings, a multicenter study across three clinics in northern Vietnam found that 52.9% of patients experienced at least one exacerbation in the prior year and 75.7% of those exacerbations required hospitalization; mean annual costs varied by care pathway from roughly USD 306 for routine outpatients to USD 1,275 for standard hospital admission and USD 2,132for emergency-department cohorts.17 These Vietnamese findings are consistent with regional and global evidence showing that hospital admissions and exacerbation management are the single largest contributors to COPD costs. A recent systematic review likewise underscores hospitalization as the dominant cost component and documents wide variation in per-patient costs across settings.18 Taken together, these data show a pattern familiar across the Asia–Pacific region: high prevalence, frequent exacerbations, and disproportionate inpatient costs that translate into substantial out-of-pocket spending and productivity losses for patients and caregivers. In this context, suboptimal adherence and incorrect inhaler technique, both documented problems in Vietnam, are not merely clinical issues but key economic drivers: poor adherence increases exacerbation risk, hospital use, and therefore costs. Despite the critical role of inhaler adherence in COPD management, a significant unmet need persists in Vietnam for culturally congruent and validated measurement tools. This imperative stems directly from the nation's distinctive demographic, socio-economic, and healthcare realities. Vietnam is currently undergoing a pronounced demographic shift, characterized by a rapidly aging population. This demographic segment is disproportionately affected by COPD, a chronic, progressive disease linked to both age-related physiological decline and cumulative exposure to pulmonary irritants. Concurrently, the nation continues to grapple with historically high rates of male smoking, alongside escalating concerns regarding ambient air pollution and occupational exposures, all contributing significantly to the escalating burden of respiratory ailments 3. Within this broad patient population, pronounced heterogeneity exists concerning educational attainment, socioeconomic status, and health literacy levels 19,20. These multifaceted factors profoundly influence individuals' capacity to comprehend complex medical information, master the intricate techniques required for correct inhaler use, and shape their fundamental beliefs about medication efficacy and necessity. In the absence of culturally and linguistically appropriate adaptation, generic, internationally developed adherence scales often prove inadequate or even misleading. They may contain idiomatic expressio

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