Primary healthcare professionals’ perceptions, attitudes and ideas regarding asthma management in Greece: A mixed-method study

Abstract

Background

Implementing asthma guideline recommendations is challenging and there is variation between countries, and different healthcare professionals (HCPs). The International Primary Care Respiratory Group (IPCRG) has introduced the Asthma Right Care (ARC) programme implemented in 24 low, middle, and high countries, including Greece. It offers a promising approach drawn from social movements for health to improve asthma care by engaging HCPs in implementing guideline-based asthma care.

Objectives

To explore HCPs’ perspectives on current provision of asthma care and their willingness to improve implementation of recommended guidelines using ARC programme tools in Greece.

Methods

A mixed methods study conducted from September 2020 to April 2021. A convenience sample of 30 pharmacists, and 10 General Practitioners (GPs), responded to a questionnaire investigating perceptions, and attitudes, towards implementation of asthma guidelines. Then, a qualitative survey followed with semi-structured interviews to evaluate the feedback obtained from HCPs to assess the content, and applicability of the ARC tools. Data were analysed using thematic analysis.

Results

A range of practical challenges in implementing guideline-recommended interventions, improving asthma control and management were described by all HCPs, including lack of time and education, high workload, patients’ perceptions, and poor communication contributing to poor management and inadequate follow-up of people with asthma. However, most HCPs were willing to use ARC interventions to improve guideline implementation.

Conclusion

HCPs in Greece encounter challenges in implementing asthma guidelines; however, they can overcome these challenges by using ARC interventions and engagement tools to address barriers and implement efficient asthma management strategies.

KEY MESSAGES

• There are data indicating unwarranted variation in asthma guideline implementation between healthcare professionals (HCPs) leading to avoidable harm.

• Understanding HCPs’ and patients’ perspectives of asthma control is essential to asthma management.

• HCPs can change their behaviour and improve clinical outcomes by utilising IPCRG Asthma Right Care interventions and engagement tools.

Introduction

Asthma is a prevalent chronic inflammatory airway disease affecting upwards of 4% of the population [1,2]. Treatment focuses on achieving effective control of asthma while minimising adverse drug effects [3]. Short-acting beta-agonists (SABAs) were prescribed for decades to provide cheap, effective rapid symptomatic relief, before the introduction of inhaled corticosteroid (ICS) as the mainstay controller inhaled medication [3]. The perceived benefit of symptom improvement led to excessive reliance on the SABA inhaler by both patients, prescribers, and dispensers, increasing the risk of exacerbations [4] and asthma-related deaths [5].

To address these issues, the 2019 update of the Global Initiative for Asthma (GINA) strategy document and subsequent annual releases no longer recommend the use of SABA inhalers alone as the preferred medication for asthma control [6]. Despite this, overuse of SABA alone remains prevalent, resulting in the use of ICS limited to only 25–60% of the prescribed doses [7–9].

In Greece, where approximately 8.6% of the population is estimated to have asthma [10] and the healthcare system faces a substantial financial burden [11], there is a lack of evidence regarding adherence to asthma guidelines. However, prior research indicates poor adherence to guidelines, with a significant number of patients with asthma experiencing exacerbations (50%), ongoing symptoms (78%) [11], and an increased frequency of emergency department visits due to incorrect or inconsistent medication use and underestimation of the disease’s impact [12]. Whilst there are currently no Greek data on SABA overuse, the perception is that there is a significant overuse, and this is mainly because SABA inhalers are cheap compared to ICS and available over the counter. To promote evidence-based guideline-based care, the International Primary Care Respiratory Group (IPCRG) has introduced the Asthma Right Care (ARC) programme, offering engagement and education tools that can be adapted to the local context [13–15]. Therefore, the aim of our study was to (1) explore community healthcare professionals’ (HCPs) (mainly Pharmacists’ and secondly General Practitioners’) perceptions, behaviours and ideas towards implementation of asthma guidelines; and (2) assess willingness to improve implementation of recommended guidelines using interventions of the Asthma Right Care (ARC) programme in Greece.

Methods

Study design and sample

This study used a mixed methods design, meaning that both qualitative and quantitative data were collected in parallel, analysed separately, and finally interpreted together [16]. It involved a quantitative survey and qualitative one-on-one semi-structured interviews of community based HPCs conducted from September 2020 to April 2021. The selection of HCPs from the regional unit of Heraklion, Crete in Greece was based on their accessibility and availability to the researcher, resulting in a convenience sample of 30 pharmacists and 10 GPs. We opted to recruit more pharmacists than GPs due to several factors. Firstly, in Greece, pharmacists tend to have a lower level of investment in their professional training and ongoing development. Additionally, patients have greater accessibility to pharmacies compared to GPs. Furthermore, SABA inhalers are conveniently available over the counter at pharmacies. Lastly, previous encounters with patients in primary care indicate that Greek patients are likely to have faith in the advice given by pharmacists. To gain a comprehensive insight into asthma management in Greece, the sample was carefully obtained from both urban and rural areas. The inclusion criteria for HCPs only required them to have given informed consent for their participation in the study.

At first, a questionnaire was administered to participants to gather information about their perceptions and behaviours related to the implementation of asthma guidelines, with a specific emphasis on the issue of over-relying on SABA medication. Then, a short introduction was given about the ARC engagement tools [13–15] (Table 1), after receiving approval on 23 March 2021 (Supplement). This was followed by a qualitative survey consisting of semi-structured interviews to evaluate the feedback received from HCPs regarding the content, effectiveness, preference, and applicability of the ARC interventions. All subjects provided written informed consent and ethical approval was obtained from the University of Crete Ethics Committee Scientific Board.

Table 1.

Asthma right care programme.

Asthma right care programme (ARC)

ARC’s primary goal is to engage healthcare professionals (HCPs) to commit to following international or national asthma guidelines. This engagement and education programme is based on the concepts of social movements for health, “right care” and adult learning principles. It aims to gain stakeholder acceptance that there is a problem that they need to solve. A range of engagement and education interventions to assist in this programme includes videos, Asthma Right Care Slide Rule, Reliever Reliance Test questionnaire, Question and Challenge cards and other materials, such as the image gallery illustrating the right use of medicines and devices. In this study, we utilised Question and Challenge cards, that are useful for initiating discussions and the Asthma Right Care Slide Rule, which explores how many puffs of SABA inhaler the patient is using and the sense of importance and confidence of the HCPs to guide conversations about personal behaviour change.

Questionnaires

The questionnaire (available upon request) was handed out by a trained researcher, who explained the purpose of the study. This questionnaire was designed and validated by the Department of Social Medicine, Faculty of Medicine, University of Crete, in Greece. The questionnaire consisted of 20 statements about: (1) awareness of asthma management guidelines, (2) prescription of asthma controller and reliever medication, (3) barriers to the implementation of asthma management guidelines, (4) alternatives to overcome the barriers to inhaler prescription and (5) the most appropriate HCPs to deal with SABA use. A Likert scale was used to measure responses, typically along five points: (1) Strongly disagree; (2) Disagree; (3) Neither agree nor disagree; (4) Agree; (5) Strongly agree.

Statistical analysis

For the quantitative study, categorical data were described with ratios (percentages) and continuous data with median and interquartile range (IQR). Mann-Whitney U-test was applied for comparisons between HCP groups. Results were deemed significant if p-values were < 0.05. Statistical analysis of the data was performed using SPSS software (version 25, SPSS Inc., Chicago, IL).

Semi-structured interviews

The final outcome of this study was to explore the value of the two ARC tools for GPs and pharmacists by conducting semi-structured interviews with them. We conducted interviews without a fixed sample size until we reached thematic saturation. Specifically, the study examined challenges in (1) Implementing guideline-recommended interventions, (2) Improving asthma control, (3) Challenges faced by GPs in asthma management, (4) Challenges faced by Pharmacists in asthma management.

Thematic analysis

Data were analysed using thematic analysis with an inductive approach [17]. All audio recordings were transcribed verbatim in the original language (Greek) to preserve semantics as much as possible and these served as source data for the analysis. Quotes were translated into English for the original. The transcribed interviews were assessed by all authors, who then annotated them and tentatively identified themes. The authors reached an agreement on selecting and naming themes through productive discussions. Concepts generated were then examined, compared and merged into themes and subthemes.

Results

The study population included 40 HCPs: 30 pharmacists (75%) and 10 GPs (25%). The respondents’ median and interquartile range (IQR) age was 42 years (13) [Pharmacists 45 (11) vs GPs 38 (16) years, p = 0.312]; 61% identified as female and 49% as males.

Questionnaires

Table 2 illustrates the percentage of GPs and pharmacists who agreed with each survey statement on guideline implementation and asthma management barriers. Pooled results showed that 17 out of 40 HCPs supported the belief that there is no adherence to asthma guidelines and current therapeutic options. Less than one-third (11/40) felt they did not invest enough time in asthma patient education. Nearly half (18/40) of the respondents also acknowledged lack of time to educate patients about non-pharmaceutical interventions such as weight loss, exercise, and smoking cessation.

Table 2.

Percentages of agreement (strongly agree and agree) of GPs and pharmacists on 20 statements, regarding awareness and implementation of guidelines on asthma management.

	Agree/strongly agree
HCPs	GPs (n = 10)	Pharmacists (n = 30)
Awareness of asthma management guidelines
Implementation of guidelines in Greece	6 (60%)	11 (37%)
Prescribing low dose ICS could keep the use of SABA low and improve outcome	10 (100%)	24 (80%)
Prescription of asthma controller and reliever medications
The number of SABA inhalers in a year is an indicator of poor asthma control	4 (40%)	14 (47%)
The ratio of SABA to ICS that is typically recommended over the course of a year is more likely to be 2:1, rather than the ideal ratio of 1:6.	4 (40%)	4 (13%)
SABA abuse is a problem in asthma, but not in COPD	4 (40%)	13 (43%)
Increasing awareness among patients about the side effects of using SABA could be an effective strategy to curb its excessive use	10 (100%)	28 (93%)
Awareness of actual mechanism of SABA action (temporary effect)	7 (70%)	26 (87%)
Patients who use more than three SABAs within a year should undergo a follow-up examination with their doctor	10 (100%)	22 (73%)
Referral to ER in case of SABA shortage of SABA - doctor’s office is closed	0 (0%)	7 (23%)
Emergency SABA supply from pharmacy without a prescription when doctor’s office is closed	3 (30%)	18 (60%)
Barriers to the implementation of asthma management guidelines
The social stigma could potentially exacerbate the management of asthma, for instance, due to fear or hesitation in using a respiratory device in public areas.	7 (70%)	9 (30%)
The fear of experiencing unwanted side effects from inhaled corticosteroids can actually make asthma control worse.	7 (70%)	18 (60%)
Healthcare professionals often do not devote time for patient education about asthma, assuming that patients can easily find information elsewhere and they are too busy to dedicate time to it.	0 (0%)	13 (43%)
Healthcare professionals often do not devote enough time to educate about non-pharmaceutical interventions, such as weight loss and, exercise	3 (30%)	15 (50%)
Alternatives to overcome the barriers to inhaler prescription
Healthcare professionals spend enough time educating patients for asthma	0 (0%)	11 (37%)
Collaboratively creating and following a Personal Asthma Action Plan with the physician could enhance the treatment and management of asthma exacerbations, while also reducing the overuse of SABA medications	10 (100%)	26 (87%)
The most appropriate HCPs to deal with SABA use
GPs	3 (30%)	15 (50%)
Pulmonologist	7 (70%)	26 (87%)
Nurses	3 (30%)	14 (47%)
Pharmacists	0 (0%)	23 (77%)

The number of SABAs in one year was considered a reliable indicator of inadequate asthma control by 18 out of 40 of the participants. Additionally, 33 out of 40 HCPs indicated that clarifying how SABAs work in asthma could help. It is also important to highlight that 23 out of 40 HCPs disagreed with the notion that ‘SABA abuse is only an issue in asthma, not COPD’. However, the results were inconclusive in determining HCPs’ attitudes towards the shift from a ratio of 1 ICS canister to 6 canisters of relievers to IPCRG’s preferred ratio of 2:1.

The reluctance to use ICS due to patient concerns about side effects was identified as a contributing factor to inadequate asthma control by more than half (25/40) of HCPs. Moreover, a significant majority (38/40) agreed that providing accurate information about the risks and side effects of SABAs could decrease their utilisation. On the other hand, 34 out of 40 of respondents agreed on prescribing low dose ICS to reduce SABA use and improve outcomes. Out of the total of 40, only 7 agreed to refer patients to the emergency department in case of SABA shortage and doctor’s office closure, while almost half indicated that pharmacies should provide emergency SABA supply if the doctor’s office is closed. Additionally, more than half (24/40) disagreed that social stigma worsens asthma control.

Most of the surveyed participants (36/40) agreed that a Personal Asthma Action Plan could reduce asthma exacerbations and SABA overuse. Most responders (32/40) supported scheduling a medical appointment for asthma patients using ≥3 SABAs inhalers annually.

Finally, when asked which of the following HCPs would be the most appropriate to deal with SABA overuse, the majority (33/40) of GPs and pharmacists selected pulmonologists as the most appropriate HCPs for addressing SABA overuse.

Semi-structured interviews

Despite the availability of asthma guidelines, HCPs faced challenges in implementing recommended care. Challenges identified through structured interviews are summarised in Table 3 and examples of HCPs’ responses are quoted in Table 4.

Table 3.

Challenges for implementing asthma care recommendations in Greece (identified through structured interviews with pharmacists and General Practitioners).

Theme	Challenge
(1) Implementing guideline-recommended interventions	Importance of a more comprehensive education of all HCPs. Lack of time and high workload.
(2) Improving asthma control	Lack of patient education, time and information. Patient’s attitudes and different forms of trust, depending on the HCP. Poor communication between patients and HCPs. Patient compliance with treatment. Not intense follow up. Inadequate control of electronic prescriptions and dispersion of SABA despite existence of legal protocols.
(3) Challenges faced by GPs in asthma management	Challenges in prescription of SABA as a reliever. Patients only attend the clinic for follow up when symptomatic. Challenges in delivering more extensive conversations regarding asthma education.
(4) Challenges faced by Pharmacists in asthma management	Lack of time and willingness to collaborate with GPs in case of identifying non-adherence to prescribed medication. Dispersion of SABA inhalers without prescription in case of exacerbation and in order to satisfy patient’s wills. Lack of proper education and time to educate patients about inhalation techniques. A need to strengthen pharmacist and GPs communication

Table 4.

Illustrative quotes of key healthcare professionals’ responses regarding the content, effectiveness, and applicability of the ARC interventions.

Theme/subtheme	Quotes
Challenges in implementing guideline-recommended interventions
Importance of a more comprehensive education of all HCPs regarding the ideal SABA prescription dispersion yearly	“…we need proper education…” 49 years old, Pharmacist. “…if a specialist could educate us; however, in that case who will pay him/her?…” 36 years old, Pharmacist. “…time is needed for these changes and appropriate information from the beginning…” 47 years old, GP.
Lack of time and high workload	“…if only there was time and willingness…” 41 years old Pharmacist. “…it is difficult to find time for these activities…” 47 years old GP. “…It’s impressive how much you can do when you are organized…” 49 years old, Pharmacist.
Challenges in improving asthma control
Lack of patient education, time and information	“… first we have to be well-educated and then try to educate our clients…” 45 years old Pharmacist. “…you don’t have the time to explain everything when at least 10 patients are waiting outside…”, 42 years old, GP. “…it is so cheap and easily obtained, without prescription or anything else needed…” 36 years old, GP “…right care depends on appropriate education and guidance of the patient…” 33 years old, GP.
Patient’s attitudes and different forms of trust, depending on the HCP	“…how to change one’s mind in a population that have learnt this way to manage the problem….easily and quickly…you cannot cope with this old-fashioned attitudes…” 42 years old GP.
Poor communication between patients and HCPs	“if you explain to him the risks that cannot understand by himself…” 49 years old, Pharmacist. “…he asks about his current problem…if this is related to inhalers, then we will discuss it…” 40 years old, Pharmacist.
Patient compliance with treatment	“…if there were asthma medical clinics, prescription monitoring and a more intense follow up, we could achieve a better asthma control…”, 42 years old, GP. “…it is not my responsibility…there are many reasons that they don’t take them, financial, lack of effectiveness…”, 38 years old Pharmacist.
Not intense follow up	“… if you don’t ask him/her to come back for follow up then he/she will schedule a visit only in case of exacerbation or poor control…”, 55 years old GP. “…you can’t force the patient to attend follow up visits….as he buys it (SABA) very cheaply from the pharmacy…” 57 years old, GP. “…the patient came one year ago and since then I didn’t see him again…” 38 years old, GP.
Inadequate control of electronic prescriptions and dispersion of SABA despite existence of legal protocols	“…there is a way, but we just don’t use it…” 33 years old, GP. “…if I don’t dispense it he will go to the next pharmacy, and I will lose him as a customer…” 49 years old, Pharmacist.
Challenges faced by GPs in asthma management
Challenges in prescription of SABA as a reliever	“SABA…only for limited first aid use…”, 43 years old GP.
Patients only attend the clinic for follow up when symptomatic	“…as long as they feel well they don’t think of follow up…”, 57 years old, GP.
Challenges in delivering more extensive conversations regarding asthma education	“…most of the times it is spontaneous depending on the patient status…” 35 year old GP. “…unless they express questions so the conversation could be expanded …but they usually they avoid it…they probably feel ashamed…”, 47 years old, GP.
Challenges faced by Pharmacists in asthma management
Lack of time and willingness to collaborate with GPs in case of identifying non-adherence to prescribed medication	“…available time is so little that is not enough…” 41 years old Pharmacist. “…there is a way, but we just don’t use it…” 33 years old, GP.
Dispersion of SABA inhalers without prescription in case of exacerbation and in order to satisfy patient’s wills	“… I could not let the patient without medication until he reaches an emergence department or a primary health care center…” 38 years old Pharmacist. “…after telephone guidance from his doctor…”, 36 years old, Pharmacist. “… in case of asthma exacerbation …” 38 years old, Pharmacist.
Lack of proper education and time to educate patients about inhalation techniques	“…only advice without specialised knowledge is dangerous…” 49 years old Pharmacist. “…particularly if there are a lot of people, it is difficult to ask the patient to show how to use it…” 40 years old, Pharmacist. “…the patients asks for it, especially if it is his first time…”, 62 years old, Pharmacist. “…patient education is the doctor’s responsibility before the patient leaves his office…” 32 years old, Pharmacist.
A need to strengthen pharmacist and GPs communication	“…most doctors are difficult to communicate and if they think that your intervene in their work then things are getting worse…only with younger doctors communication is easier because they need you, at least at first…”, 49 years old, Pharmacist.

Challenges in implementing guideline-recommended interventions

While all participants acknowledged the importance of proper SABA use, they believed that additional education, particularly for the pharmacists, was important. The consensus among HCPs is that relying too heavily on SABA for asthma management may result in frequent use, dependence, and preference for a cheap solution rather than the evidence-based solution.

HCPs also agreed that the primary care doctor is responsible for patient information on SABA use but faced challenges like lack of time and patient’s education level. Despite challenges, HCPs recognised the importance of the ARC programme’s aim, philosophy, and engagement and education tools in asthma management, and required further education.

Challenges in improving asthma control

HCPs also acknowledged the importance of comprehensive education and information of patients as well as lack of time, poor communication with HCPs, compliance with treatment, SABA misuse and patient’s attitudes in improving asthma management. GPs also emphasised the importance of lacking follow-up and SABA prescription monitoring. On the other hand, improved patient communication can control SABA misuse and decrease refill requests and dispensed SABAs.

Challenges faced by GPs in asthma management

GPs typically acknowledge ICS as controller therapy and prescribe SABA for symptomatic treatment only. The 3 months schedule of a follow up visit seemed reasonable to GPs to reassess and review treatment, but they noted that only uncontrolled patients seek follow up visits. Conversation with the patients is limited only to basic use of inhalers and how to manage an exacerbation, unless the patient raises any questions.

Challenges faced by Pharmacists in asthma management

Time limitations and patient attitudes make it challenging for most pharmacists to control SABA dispensing and educate patients about inhalation techniques. Other pharmacists believed that the doctor is responsible for patient education. All pharmacists have provided SABA without prescription for asthma exacerbation or without doctor’s guidance. Despite noticing non-adherence to prescribed asthma medications, most pharmacists were either unwilling or lacked time to inform the attending physician. Another important challenge in asthma management is the poor communication between pharmacists and doctors.

Discussion

Main findings

Despite updated international and national guidelines for asthma management in primary care, HCPs in Greece face practical challenges to implement them and improve asthma control. Challenges are faced by both GPs and pharmacists. However, HCPs can overcome them by utilising the ARC interventions and engagement tools, leading to improved patient medication adherence and clinical outcomes.

Interpretation and perspectives

This study included two groups of HCPs involved in asthma management: GPs and pharmacists. However, collaboration between them in Greece is currently minimal, adversely affecting asthma care [18]. Our main objective was to gain a deeper understanding of the difficulties encountered by HCPs, specifically pharmacists working in primary care. This is because in Greece, there is a variability of practice between pharmacists and GPs. Furthermore, like many countries, patients have easier access to pharmacies compared to having to make appointments with a GP and SABAs can be obtained without involving GPs, as they are readily available over the counter without a prescription. This means that pharmacist have the opportunity to identify a red flag when a SABA is requested over the counter and non-adherence to prescribed medication [19]. Therefore, the formal integration of pharmacists into clinical care pathways and their collaboration with GPs holds significant importance for the future. Multi-factorial challenges were also highlighted including HCP, patient, and organisational barriers. By focusing on these factors and promoting ARC principles, asthma care in Greece could be improved.

Comparison with existing literature

Keeping up with guidelines and therapies is essential for HCPs managing asthma patients. However, there are concerns about inconsistent adherence to guidelines among HCPs [20]. Our study underscores the significance of a more comprehensive education for all HCPs, especially pharmacists who lacked familiarity, knowledge, and compliance with guidelines compared to GPs. Furthermore, it was widely agreed by HCPs that the immediate relief provided by SABAs can lead to increased frequency of use, dependency, and a preference for them as an affordable solution. Nevertheless, all HCPs acknowledged the importance of a more comprehensive education and effective implementation of guidelines and principles of the ARC programme.

Literature highlights various factors that contribute to suboptimal asthma management, including poor patient-HCP communication and personal beliefs about symptom management and follow-up [21], and these were also identified in our population. Patient-provider communication is crucial for patient satisfaction, treatment adherence [22], and asthma control [23]. In our study, HCPs’ workload and lack of time emerged as the major obstacle for building up in patient-HCP. While it appeared reasonable to have follow-up visits it is typically only requested by patients whose asthma is not under control. ARC tools and interviews also revealed inadequate trust, and patient misperceptions impacting asthma care. Evidence has shown that the patient’s viewpoint on asthma control is crucial for effectively managing asthma and can present a significant challenge, particularly when patients have an exaggerated or underestimated perception of disease severity and appropriate treatment [24]. It has also been observed that patients receive scant information from their healthcare providers, especially regarding proper inhaler technique and instead turn to potentially unreliable sources for information. Furthermore, although the risks of SABA over-reliance are well-known, GPs and Pharmacists did not seem to seek ways to prevent SABA over-reliance of patients. Conversely, patients may hesitate to discuss their asthma with their healthcare providers because they perceive them judgmental instead of compassionate [25]. The absence of mandatory electronic SABA prescription and/or prescription monitoring, with easy over the counter SABA may also undermine right asthma care. However, even in countries where SABA is strictly prescription-based, its usage can remain high [26]. Thus, it is crucial to comprehend the factors that contribute to the excessive use of SABA in order to devise effective strategies to address this problem.

It is worth noting that there was also the belief that specialists are the most appropriate HCPs for addressing SABA overuse, which may be related to the reported lack of time for patient education. On the other hand, HCPs also acknowledged in qualitative interviews that GPs bear the responsibility of informing patients about SABA usage, despite the challenges they encounter.

Clinical implications

Our study is the first to examine the implementation of asthma guidelines, particularly in relation to SABA usage in Greece which is an important safety problem. Furthermore, taking into account the overall burden of asthma in Greece [11], it is important to prioritise investments in support to change, and in educational interventions aimed at controlling asthma and minimising acute exacerbations. Despite the update of GINA since 2019, providing a 4-year period for HCPs to establish a chronic care model for asthma patients, our study highlighted several basic areas where there is still room for improvement in Greece. Optimistically, most HCPs in this study had a positive attitude towards educational programmes for asthma management, which is in line with previous studies [27,28].

Limitations

Limitation of this study is the small non-random sample of HCPs and the unequal number of pharmacists and GPs hindering risk of selection bias; however, the addition of interviews confirmed the results of the survey and explored in depth the perceptions and behaviours of HCPs. Furthermore, despite the small number of GPs, content saturation was attained with respect to their perspectives.

Conclusion

In conclusion, HCPs in Greece encounter challenges in implementing guideline-recommended interventions and in effectively controlling and managing asthma. By taking advantage of the ARC interventions and tools, HCPs can improve patient safety by improving patient knowledge about asthma medication and its proper use, and clinical outcomes. Further research is needed into determining HCPs’ views of a feasible and acceptable approach to overcome barriers and implement effective asthma management.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Data availability statement

Research data is available upon request.