NIHR Global Health Research Unit on Respiratory Health (RESPIRE)

Barriers to implementing asthma self-management in Malaysian primary care

A RESPIRE qualitative study has identified significant challenges in the implementation of supported asthma self-management in primary care practice, in Malaysia.

26 Malaysia-based healthcare professionals were recruited to describe ‘practice-based’ and ‘contextual’ barriers to implementing asthma self-management in primary care.

Why is asthma self-management important?

Supported asthma self-management can improve clinical outcomes and reduce healthcare costs. Yet, there is currently a lack of support for self-management, globally.

In Malaysia, adult asthma equated to around 5% of the population, with asthma-related deaths being responsible for 1.2% of all deaths in the 2006 National Health and Morbidity survey. This further stresses the importance of asthma self-management.

In high-income countries, it has been found that there is a multitude of barriers to implementing successful asthma self-management. In low- and middle-income countries (LMICs), these barriers are only exacerbated. For Malaysia specifically, this is primarily on account of the language barriers presented by a multi-ethnic and -lingual society, as well as low health literacy. 


The 26 healthcare professionals who participated in this study were recruited from attendees of an asthma training workshop. They were selected to attend because of their direct involvement in the care of patients with asthma.

Practice-based barriers to asthma self-management:

The participating healthcare professionals described capability barriers, whereby without proper training they would not be able to facilitate self-management. Not even all the participants had the required training.

Opportunity-related barriers were also identified, whereby healthcare professionals lacked the opportunity to facilitate self-management because of limited opportunity to do so. This involved heavy workloads that limited available time; limited resources like asthma action plans that prevented the appropriate facilitation of self-management; these limited resources being unsuitable and not up-to-standard in the first place; and poor documentation like up-to-date medical records that made it unclear if a self-management plan had already been implemented.

Additionally, motivational barriers were described. This ranged from a lack of awareness regarding the benefits of asthma self-management and the concept that it was not within their job remit, which stemmed from the lack of training available, to the view that it would be difficult empower patients to self-manage their asthma.

Contextual barriers to asthma self-management:

Societal context was first identified. Especially among older patients, it was considered that low education and health literacy kept patients from understanding explanations of self-management. This was only worsened by language barriers.

Organisational context was then identified. Manpower, budget, and time were limited that side-lined self-management as a priority; asthma in general as it is an acute management compared to chronic disease. This in part stemmed from the fact that other conditions and topics were favoured over asthma management.


The factors that contributed to the challenges of implementing asthma self-management in a Malaysian primary care setting were multifactorial. Interventions will need to adopt a comprehensive approach tailored to the local healthcare system and address the societal context.

Professor Ping Yein LeeCorresponding Author

The study suggests that training and extending assistant pharmacist and nurse roles within healthcare may alleviate capability- and opportunity-related barriers. Furthermore, improved training can improve motivation. To address this, blended learning, like using web-based, mobile applications, was proposed as one option for improving training delivery because it increases accessibility and interactivity.

The use of pictures or videos and the provision of multilingual resources were proposed as potential ways to overcome both language and literacy barriers. Comprehensive education about asthma and promotion of self-management, which is culturally appropriate and tailored to both education and literacy level, was also considered necessary.

To maximise patient engagement with their asthma action plans, a mobile monitoring intervention was suggested. This would take the form of a mobile application, with graphic icons representing asthma symptoms as visual aids to log daily symptoms. However, globally, this may not be feasible, and future studies will need to investigate digital support for asthma self-management.

Theme lead for Optimising management of asthma attacks at Asthma UK Centre for Applied Research, also contributed to this study.

Many of the challenges that Ping Yein and colleagues from Malaysia have highlighted as barriers to implementing supported self-management will resonate within the UK and around the world. Patients need appropriately targeted information and action plans, professionals need motivation and skills, and the organisation needs to provide an environment in which self-management is valued and supported. A different context, but these are exactly the challenges that IMP2ART is addressing in UK primary care.

Professor Hilary PinnockProfessor of Primary Care Respiratory Medicine, University of Edinburgh, RESPIRE

Read the full paper

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

Cite as

Lee, P.Y., Cheong, A.T., Ghazali, S.S. et al. Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals. npj Prim. Care Respir. Med. 31, 38 (2021). 

Key words

asthma self-management; challenges; healthcare professionals; qualitative; low- and middle-income country (LMIC)

Related links 

Project: IMP²ART | The University of Edinburgh