A cross-sectional observational study was performed from November 1, 2023, to May 28, 2024, through interviews of registered pharmacists. They answered a semistructured questionnaire containing questions about their sociodemographic information, professional details, and INCS counseling steps. STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) principles were adhered to in the study’s reporting [17,18].

The sample was selected from pharmacists registered at the Nepal Pharmacy Council working at community pharmacies registered at the Department of Drug Administration (DDA) in Kathmandu, Nepal. Being Nepal’s capital, Kathmandu is a heavily populated city. The respective site had a large number of community pharmacies, about 4000, with many registered pharmacists [19].

Simple random sampling of the community pharmacies in different wards of Kathmandu district, Nepal, was done using Statistical Package for Social Sciences software (version 26; IBM Corp). The details of all the registered community pharmacies were obtained from the DDA database. No ward-level sampling was performed to avoid geographical clustering.

This cross-sectional study identified potential participants from the registered pharmacists working at community pharmacies. If the community pharmacy had more than one pharmacist, one pharmacist was selected for the study randomly. If the community pharmacy was closed or the pharmacist was not available, a total of three visits were made on different dates; if a pharmacist was still not available, another pharmacy was selected based on a pregenerated reserved list of random samples. These potential participants were approached and the study’s purpose, procedures, and potential risks and benefits were explained to them. The same interviewer interviewed all the participants to overcome interobserver variability in participants’ responses.

The survey study was completed using the Raosoft sample size calculator to capture the appropriate sample size [20]. A minimum of 363 samples was required for a 95% confidence interval and a 5% margin of error for the population distribution of 21,000 registered pharmacists at a 40% response distribution [21]. Thus, a total of 365 registered pharmacists participated in this study.

After the pharmacist’s sociodemographic and professional information were obtained through interviews, the 12-step nasal spray application technique as given in Textbox 1 was demonstrated by the participant and examined by the researcher [12,13,22-24]. Each correct step was assigned 1 mark, while incorrect or missed steps were assigned 0 marks. Hence, the maximum score obtained was 12 marks. Five steps in INCS counseling (indicated in Textbox 1) were considered critical based on their impact on patient outcomes and the risk of adverse drug reactions. The median value of the total marks scored was 6.

To determine the cutoff score, a sensitivity analysis was conducted for alternate cutoffs (ie, >5 and >7). The direction and significance of the main predictors remained stable at >5 and >6, indicating robustness of the findings as shown in Table S1 in Multimedia Appendix 1. The >7 cutoff produced unstable estimates due to small cell sizes. Based on a study conducted by Kc et al [25], expert suggestions, the median value, and sensitivity analysis, more than 6 marks was established as the cutoff score. Therefore, anyone with a score higher than 6 marks was categorized as performing adequately, and anyone with marks equal to or less than 6 was categorized as performing inadequately.

The initial questionnaire was validated by a panel of subject experts, composed of advisors, professors, and teachers, for correctness, clarity, appropriateness, and jargon use. This validation was conducted using face validity approaches. An interrater reliability test was conducted on 15 participants and found a Cronbach α value of 0.758.

This study only took into account pharmacists aged 18 years and above who were registered with the Nepal Pharmacy Council and employed in community pharmacies. Participants needed to have a Diploma in Pharmacy (DPharm), Bachelor of Pharmacy (BPharm) degree, Doctor of Pharmacy (PharmD) degree, or Master of Pharmacy degree. Participants needed to have a minimum of 1 year of experience. No unregistered pharmacists, pharmacy students, or interns were considered for this study.

The essential information was then gathered from participants using a semistructured questionnaire administered through an in-person interview. A standardized protocol was followed during interviews. Prior to their enrollment in the study, all participants were informed of its purpose, and their consent was acquired.

Using Microsoft Excel (Microsoft Corp) and Statistical Package for Social Sciences software (version 26; IBM Corp), the gathered data were analyzed. Factors related to the administration technique were evaluated using multivariate binary logistic regression to understand their independent impact. The decision tree analysis was done using Chi-square automatic interaction detector to explore hierarchical relationships and interactions among predictors of INCS counseling proficiency and to complement the findings of binary logistic regression. When P<.05 and the confidence level was 95%, it was deemed statistically significant.

Ethical approval reference number 210 (6-11) E2, 080/081, was provided by the institutional review committee of the Institute of Medicine, Tribhuvan University, before the commencement of the study. Written informed consent was provided by participants before any data were collected from the study site (Multimedia Appendix 2). The identity of participants will not be revealed in any information that will be published or released to third parties. The participants were not compensated for this study.

Pharmacists’ professional and demographic traits are listed in Table 1. The study involved 365 registered pharmacists as participants. Of the 365 pharmacists, 216 (59.2%) were ≤26 years old, and 239 were men (65.5%). In addition, 244 (66.8%) were single. Only 110 participants (30.1%) had a BPharm degree or above, whereas 255 (70%) had a DPharm degree. Moreover, 267 participants (73.2%) were early career (1‐4 y), whereas 98 (26.8%) were mid-career or late career (5 y and above). In all, 194 participants (53.2%) reported counseling patients on intranasal corticosteroids 1 to 4 times per week, but only 30 participants (8.2%) acknowledged any formal training in INCS administration. Additionally, only 75 participants (20.5%) used leaflets to counsel the patients.

Among 365 participating pharmacists, adherence to INCS administration steps varied widely, as shown in Table 2. High adherence (>80%) was observed in 4 basic steps: removing the dust cap, replacing the cap, shaking the spray, and holding the bottle upright. In addition, moderate adherence (40%‐80%) was noted for 3 steps: inhaling while spraying, finger positioning, and nozzle insertion. However, low adherence (<40%) was observed for 5 steps, of which 4 were critical: blowing the nose, pointing the nozzle away from the septum, exhaling through the mouth, proper head positioning, and wiping the nozzle after use.

The participants’ median score across all 12 steps was 6. However, the 5 crucial steps only had a mean score of 1.9 (SD 1.09). Twelve points were awarded for completing all INCS counseling steps, of which 5 points were awarded for the 5 critical steps. Just 22 participants (6%) were able to accurately complete all 5 critical steps. We found that 193 (52.9%) of the registered pharmacists were inadequately knowledgeable on INCS patient counseling. Only 172 participants (47.1%) had adequate knowledge of INCS counseling.

Several professional and sociodemographic factors were shown to be substantially correlated with the degree of administration technique proficiency by the multivariate binary logistic regression analysis (Table 3). Years of experience, training, and marital status did not show statistically significant relationships, while sex, age, qualification, frequency of patient counseling weekly, and the utilization of information material were found to be significant predictors.

The likelihood of male pharmacists exhibiting proper technique was about 2 times higher than that of female pharmacists (P=.02). The probability of using an inappropriate INCS counseling technique was 89% lower for individuals who were older than 26 years (P=.001). Proficiency was substantially predicted by having used educational materials. Pharmacists who used educational materials were 96% less likely to perform inadequately (P=.005). Pharmacists with a BPharm degree or higher were also around 97% less likely to counsel inappropriately than those with a DPharm (P<.001). According to this study, individuals who advise patients on INCS 1‐4 times per week were 11 times more likely to demonstrate proficiency as opposed to those who counsel occasionally (P=.002).

The classification tree (Chi-square automatic interaction detector method), as shown in Figure 1, was developed to identify key predictors of pharmacist proficiency in INCS counseling. The final pruned classification included 5 levels with 9 terminal nodes, achieving an overall classification accuracy of 81.6%. The root node shows the entire study population, and subsequent splits identify variables that best differentiate proficiency levels. Terminal nodes represent final subgroups, displaying the proportion of pharmacists classified as proficient or nonproficient within each subgroup.

The first and the most significant split was based on the participants’ educational qualifications. Only 65 of 255 (pass rate: 25.5%) pharmacists with a DPharm degree had adequate proficiency. However, of 110 pharmacists with a BPharm degree or higher, 107 had adequate proficiency (pass rate: 97.3%). Among the DPharm group, age was another significant predictor. Among those aged less than 26 years, only 20 of 166 participants (12%) had adequate proficiency, whereas among the older peers, 45 of 89 had adequate proficiency. Similarly, among the BPharm group, another major factor was gender. Male pharmacists were found to be 100% proficient in INCS counseling, with all 95 participants demonstrating adequate proficiency, whereas only 12 of 15 female participants had adequate proficiency.

Finally, for younger DPharm degree holders (≤26 y old), the frequency of INCS counseling was another predictor. Those younger participants who counseled occasionally or more than 4 times per week had significantly lower proficiency (2/88 had adequate proficiency) compared to those who counseled 1-4 times per week (18/78 had adequate proficiency).

This study addresses a critical gap in pharmacist competency regarding INCS within resource-constrained health systems, where pharmacists are front-line care providers. This study is among the first in Nepal to assess pharmacists’ proficiency with INCS counseling. The survey revealed a significant gap in the participants’ understanding of INCS counseling, which helps in understanding its impact on the health outcomes of patients. Approximately 50% of the pharmacists lacked adequate INCS counseling abilities. According to this study, only 6% of pharmacists were able to complete all the essential patient counseling steps that are crucial for appropriate drug administration and to minimize the risk of adverse drug reactions. Classification tree analysis showed that educational degree was the primary predictor of INCS counseling proficiency. Those with BPharm degrees or higher were far more proficient than DPharm degree holders.

The survey’s conclusions about the inadequate INCS administration abilities of Nepali registered pharmacists are in line with the findings of patients and medical professionals worldwide [2,14,26]. Only 22 of 365 of pharmacists (6%) performed all recommended steps correctly, which was similar to a study of health care workers in Thailand [14]. However, even in a developed country like the Netherlands, it was found that only about 36% of health care workers were able to complete all the critical steps [26]. These observations suggest that there is a major gap in skill related to INCS counseling across nations, rather than it being a local issue. Due to this inadequate proficiency among pharmacists, there is a high risk of an increase in adverse drug reactions in patients. Therefore, the educational system must be improved to include simulation-based training and mandatory hands-on workshops that allow students and professionals to practice essential steps repeatedly and understand their rationale.

The high proportion of pharmacists demonstrating steps 1, 2, 4, and 12 correctly (>80%) likely reflects common-sense knowledge (shake, remove dust cap, hold the bottle, replace the cap) that is often taught in basic therapy discussions. However, steps like bending the head forward or cleaning the nozzle were rarely done correctly (<40%). This may cause improper drug disposition, irritation in the throat, and increased risk of contamination [27]. Similarly, only about 10% of participants were counseled about pointing the nozzle away from the nasal septum, which reduces the risk of nasal irritation, dryness, and epistaxis, and improves drug absorption from the lateral nasal wall [12,27]. In addition, the steps necessary to remove mucus or debris or obstruction from the nose and reduce throat irritation (ie, blowing the nose before use and exhaling through the mouth) were only performed by about 10% of participants [12]. Patients who are not taught to clean the spray tip may experience clogging or contamination.

These differences align with prior studies indicating that procedural complexity and a lack of continuing pharmacy education (CPE) or training contribute to inconsistent adherence to medical device protocols [28]. This study highlights that even pharmacists, who are trained professionals, often lack full mastery of device use and suggests there is a need to improve the pharmacy curriculum and landscape of CPE in Nepal.

One of the important differences was the pharmacist’s qualification. BPharm graduates were about 97% less likely to demonstrate incorrect technique than DPharm graduates. The latter finding reflects the differences in Nepal’s educational system. The 3-year DPharm program in Nepal has traditionally emphasized dispensing skills, whereas the BPharm and PharmD curricula include more clinical training.

Shrestha et al [29] found that Nepal’s conventional pharmacy education is mostly lecture-based and industry-oriented, with limited practical training in hospitals. Bhuvan et al [30] also documented the challenges in transitioning to PharmD in Nepal, with a focus on patient care and pharmaceutical care. This highlights a need for a gradual change in current policy. Medical devices training should be included in the DPharm degree, and seminars and workshops should involve DPharm students and graduates. Pharmacy regulators in Nepal, such as the Nepal Pharmacy Council or the DDA, may consider upgrading community pharmacists’ credentials or introducing minimum competency assessments for patient counseling.

In this study, it was found that pharmacists who used educational leaflets were much more proficient. This is similar to findings of other studies where pharmacist-led interventions with practical demonstrations and the use of leaflets dramatically improved patient technique [25,31]. These educational leaflets significantly reduce the cognitive load of pharmacists and ensure the completeness of all steps. These aids also engage patients through teach-back, reinforce learning beyond completeness, and boost the pharmacist’s confidence and professionalism. Therefore, pharmacists should be encouraged to use educational leaflets during counseling sessions on INCS use.

In our study, increasing age (>26 y) was significantly associated with improved INCS counseling proficiency. A study conducted in Korea also found that proficiency in patient counseling regarding topical corticosteroids significantly improved with increasing age [32]. Thus, suggesting increased clinical exposure, more trainings, mature communication skills, and more frequent patient interaction may contribute to better proficiency. In order to succeed in INCS counseling, younger pharmacists must receive sufficient training throughout their time in pharmacy school. They should also attend workshops on medical devices, communication techniques, and patient counseling.

Interestingly, participants counseling on INCS use 1‐4 times per week have a much higher proficiency (almost 11 times higher) compared with that of participants counseling only occasionally. This relationship likely reflects that a moderate counseling volume provides sufficient repetition to hone skills and confidence, while excessive patient load and task interruptions may reduce time for careful demonstration and feedback [33,34]. Simulation training could help low-counseling pharmacists achieve similar proficiency without relying on clinical exposure.

The analysis of this survey revealed that, among BPharm graduates, males have about 2 times higher odds of proficiency than females regarding INCS counseling. However, the existing literature does not present any conclusive or consistent evidence of sex-based differences in nasal spray or inhalation administration technique among pharmacists. Therefore, the observed difference may reflect contextual, educational, or practice-related factors rather than true gender-based differences.

In our study, 335 of 365 pharmacists (91.8%) lacked specific training. This suggests that continuing professional development for pharmacists in Nepal is sorely needed. According to a recent analysis of continuing professional development in Nepal, CPE is still in its infancy; therefore, working pharmacists are not informed of the latest treatments or best practices [35]. Establishing regular INCS technique workshops or integrating device training into the curriculum could narrow the gap. Given pharmacists’ accessibility in rural and urban Nepal [36,37], such measures could rapidly propagate correct practice.

Pharmacists’ poor INCS technique skills are concerning but can be resolved. Targeted training in Nepal could help pharmacists improve their skills quickly. Emphasizing AR and device technique in undergraduate pharmacy programs and requiring competency demonstrations during examinations could have a lasting impact. In addition, public health campaigns might encourage patients to ask pharmacists for a demonstration of INCS technique. In the long term, strengthening pharmacy education and integrating pharmacists into asthma/allergy care pathways will benefit Nepal’s health care system by improving primary-level management of chronic respiratory diseases.

This study was conducted in urban Kathmandu, so findings may not generalize to rural areas, where pharmacies are fewer and mainly operated by trained dispensers. This study has a cross-sectional design, so it cannot prove causality. Potential confounders like workload details were not measured, which may have partly contributed to the large adjusted odds ratio of some predictors. Some of the findings may be extreme due to small subgroups such as pharmacists who had received formal training or those providing frequent INCS counseling. A small sample count can result in unstable estimates and inflate the results. In addition, model overfitting can occur due to the inclusion of multiple interrelated predictors during logistic regression. This study used a small sample size for the reliability test and only used an expert-based face validity test, which may limit the robustness and generalizability of the study. Even with anonymized, behavior-focused questions, self-reported variables like the frequency of counseling and the usage of educational leaflets may be overestimated due to recall and social desirability bias, especially in in-person interviews. This shortcoming is highlighted and the necessity of objective assessment is supported by the observed difference between overall self-reported sufficiency and inadequate performance on critical steps. We recommend a weighted or competency-based scoring model in future studies. Finally, the presence of an interviewer might have influenced the participants’ performance (ie, the Hawthorne effect), possibly inflating technique scores. However, due to the low proficiency observed among the participants, any such effect was limited.

This study highlights that more than half of the participants did not have adequate skills to demonstrate proper INCS usage technique. This can lessen its effectiveness in treating AR and increase the likelihood of adverse drug reactions in patients, such as dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache. The lack of knowledge is mainly due to poor exposure to this topic in pharmacy school. In addition, training and seminars are limited both during school and after registration as a pharmacist. Resolving this problem should be one of the most important tasks for the Nepal Pharmacy Council and the Health Ministry as AR is very common in Nepal. Upgrading pharmacy curricula, mandating continuing education, and providing standardized counseling materials may empower pharmacists to counsel patients on the correct technique.