Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals

www.nature.com/npjpcrm ARTICLE OPEN Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals 1234567890():,; Ping Yein Lee 1 ✉, Ai Theng Cheong 2, Sazlina Shariff Ghazali2, Hani Salim3, Jasmine Wong 2, Norita Hussein4, Rizawati Ramli4, Hilary Pinnock 3, Su May Liew4, Nik Sherina Hanafi4, Ahmad Ihsan Abu Bakar4, Azainorsuzila Mohd Ahad5, Yong Kek Pang 6, Karuthan Chinna 7 and Ee Ming Khoo 4 Asthma self-management is a crucial component of asthma management. We sought to explore healthcare professionals’ (HCPs’) perceptions on barriers to asthma self-management implementation in primary care. We recruited 26 HCPs from six public primary care clinics in a semi-urban district of Malaysia in 2019. The analysis was done inductively. HCPs described barriers that resonated with the “COM-B” behaviour change framework. Capability-related issues stemmed from a need for specific self-management skills training. Opportunity-related barriers included the need to balance competing tasks and limited, poorly tailored resources. Motivation-related barriers included lack of awareness about self-management benefits, which was not prioritised in consultations with perceived lack of receptiveness from patients. These were compounded by contextual barriers of the healthcare organisation and multilingual society. The approach to implementation of asthma self-management needs to be comprehensive, addressing systemic, professional, and patient barriers and tailored to the local language, health literacy, and societal context. npj Primary Care Respiratory Medicine (2021)31:38 ; https://doi.org/10.1038/s41533-021-00250-y INTRODUCTION Supported self-management is a crucial component of long-term asthma management1,2 in adults that improves clinical outcomes and reduces healthcare costs3. Patient-centred, collaborative care that permits effective patient–practitioner communication improves adherence to treatment and outcomes4,5. However, studies have shown that, globally, support for asthma selfmanagement is not embedded in routine practice and only a minority of people with asthma have an action plan6–8. In Malaysia, the prevalence of adult asthma was estimated at 5% with asthma-related deaths responsible for 1.2% of all deaths in the 2006 National Health and Morbidity survey9. This survey also reported that 20% of adult asthma patients visited the emergency department for acute exacerbations, 10% were admitted, and 27% reported school/work days’ loss with a mean duration of 6 (4–8) days in the past 12 months9. Less than half of adult asthma patients had regular long-term follow-up9–11. In addition, studies have reported under-utilisation of controller medications10,11, while the use of oral short-acting beta-agonist was common among adults with poor asthma control in Malaysia10–12. A wide range of barriers to implementing supported selfmanagement were described in a recent systematic review— these include, poor patient–professional partnership, lack of patient education and concerns regarding medication safety, insufficient professional training, and negative views regarding asthma self-management, compounded by competing priorities and limited time in consultations13. Underpinning many of these barriers are challenges to effective communication13,14. All but 1 of the 56 papers included in this review were from high-income healthcare systems, reflecting a gap in the understanding of barriers faced in the socio-cultural context of low- and middleincome countries (LMICs), such as Malaysia. Malaysia’s multicultural and multilingual society may also present different barriers to the implementation and delivery of asthma selfmanagement education in primary care settings. As the country is composed of three major ethnicities, Malay (70%), Chinese (22%), and Indian (7%), as well as several minority ethnicities (1%)15, a significant proportion of the population reads, writes, and converses in their respective native tongues and exhibit varying levels of fluency in English and the country’s national language, Malay16–19. Additionally, the populations’ predominantly “low” to borderline “sufficient” health literacy20 and low general literacy skills among the elderly21 may have some influence in the barriers experienced. We therefore aimed to explore healthcare professionals’ (HCPs’) views of the barriers faced in implementing supported self-management for asthma in adults in a primary care setting in Malaysia, taking into consideration the country’s cultural and socioeconomical contexts. RESULTS Participants We recruited 26 participants. Six focus group discussions (FGDs; 4–6 HCPs in each group) were conducted between July and August 2019 at the Klang District Health Office (5 family physicians, 5 medical officers, 4 each of assistant medical officers, pharmacists, assistant pharmacists, and nurses). Table 1 outlines 1 UM eHealth Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. 2Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia. 3NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK. 4 Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. 5Klinik Kesihatan Lukut, Ministry of Health Malaysia, Port Dickson, Negeri Sembilan, Malaysia. 6Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. 7School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya, Selangor, Malaysia. ✉email: Published in partnership with Primary Care Respiratory Society UK PY Lee et al. 2 Table 1. Demographic data of participants (N = 26). Number Age (years) <30 6 30–39 12 40–49 5 50+ 3 Sex Female 21 Ethnicity Male Malay 5 18 Chinese 2 Indian Time in current clinical role (years) <5 1234567890():,; Position 6 6 5–9 8 10–14 3 15–19 5 20–24 25+ 1 3 Medical officer 5 Nurse 4 Pharmacist 4 Fig. 1 Barriers to implementing asthma self-management education in primary care. Practice-based and contextual barriers to implementing asthma self-management education in primary care. Assistant medical officer 4 Used asthma action plans with patients? Assistant pharmacist 4 Family physician 5 No Yes 10 16 the demographic data of the participants. There was only one mixed sex focus group among the pharmacists (one male, three females). Other focus groups were all female (family physicians, medical officers, nurses, assistant pharmacists) or all male (assistant medical officers). We identified practice-based and contextual barriers to implementing asthma self-management in primary care practice. Practice-based barriers related to HCPs’ capability, opportunity, and motivation and how these factors influenced their behaviour (COM-B framework). (...truncated)