Implementing asthma management guidelines in public primary care clinics in Malaysia

Implementing asthma guideline recommendations is challenging in low- and middle-income countries. We aimed to explore healthcare provider (HCP) perspectives on the provision of recommended care. Twenty-six HCPs from six public primary care clinics in a semi-urban district of Malaysia were purposively sampled based on roles and experience. Focus group discussions were guided by a semi-structured interview guide and analysed thematically. HCPs had access to guidelines and training but highlighted multiple infrastructure-related challenges to implementing recommended care. Diagnosis and review of asthma control were hampered by limited access to spirometry and limited asthma control test (ACT) use, respectively. Treatment decisions were limited by poor availability of inhaled combination therapy (ICS/LABA) and free spacer devices. Imposed Ministry of Health programmes involving other non-communicable diseases were prioritised over asthma. Ministerial policies need practical resources and organisational support if quality improvement programmes are to facilitate better management of asthma in public primary care clinics.

We obtained contact information of HCPs involved in the management of patients with asthma from the Family Medicine Specialists in charge of the six public primary care clinics. Potential participants were approached via telephone call, text messages or email and invited to participate in the study. The purpose of the study was explained to the HCPs and a participant information sheet was sent to them to understand the study. For those who agreed to participate in the study, an appointment was made for a focus group discussion at which written consent was obtained.Prior to the group discussion, participants completed a sociodemographic questionnaire that provided the context for the data analysis. Focus groups were held in the six clinics or meeting rooms in the district health office. A semi-structured interview guide (Appendix 1), informed by literature on implementing guidelines was used to assist and facilitate discussion about participants' experiences of management and challenges faced in delivering asthma care. Opinions were explored without restriction from the guide. Each session was moderated by a researcher (ATC, SSG or PYL) with the help of a note taker. All sessions were audio-taped with a voice recorder with consent.

July to August 2019
No data were excluded from analysis.
No participants dropped out/declined participation.
Randomization is not relevant to our study as it is a qualitative study.
Ecological, evolutionary & environmental sciences study design All studies must disclose on these points even when the disclosure is negative. Note the sampling procedure. Describe the statistical methods that were used to predetermine sample size OR if no sample-size calculation was performed, describe how sample sizes were chosen and provide a rationale for why these sample sizes are sufficient.
Describe the data collection procedure, including who recorded the data and how.
Indicate the start and stop dates of data collection, noting the frequency and periodicity of sampling and providing a rationale for these choices. If there is a gap between collection periods, state the dates for each sample cohort. Specify the spatial scale from which the data are taken If no data were excluded from the analyses, state so OR if data were excluded, describe the exclusions and the rationale behind them, indicating whether exclusion criteria were pre-established.
Describe the measures taken to verify the reproducibility of experimental findings. For each experiment, note whether any attempts to repeat the experiment failed OR state that all attempts to repeat the experiment were successful.
Describe how samples/organisms/participants were allocated into groups. If allocation was not random, describe how covariates were controlled. If this is not relevant to your study, explain why.
Describe the extent of blinding used during data acquisition and analysis. If blinding was not possible, describe why OR explain why blinding was not relevant to your study.
Describe the study conditions for field work, providing relevant parameters (e.g. temperature, rainfall).
State the location of the sampling or experiment, providing relevant parameters (e.g. latitude and longitude, elevation, water depth).
Describe the efforts you have made to access habitats and to collect and import/export your samples in a responsible manner and in compliance with local, national and international laws, noting any permits that were obtained (give the name of the issuing authority, the date of issue, and any identifying information).
Describe any disturbance caused by the study and how it was minimized. Tick this box to confirm that the raw and calibrated dates are available in the paper or in Supplementary Information.

Ethics oversight
Note that full information on the approval of the study protocol must also be provided in the manuscript.

Animals and other organisms
Policy information about studies involving animals; ARRIVE guidelines recommended for reporting animal research Laboratory animals

Wild animals
Field-collected samples

Ethics oversight
Note that full information on the approval of the study protocol must also be provided in the manuscript.

Human research participants
Policy information about studies involving human research participants

Population characteristics
Describe all antibodies used in the study; as applicable, provide supplier name, catalog number, clone name, and lot number.
Describe the validation of each primary antibody for the species and application, noting any validation statements on the manufacturer's website, relevant citations, antibody profiles in online databases, or data provided in the manuscript.
State the source of each cell line used.
Describe the authentication procedures for each cell line used OR declare that none of the cell lines used were authenticated.
Confirm that all cell lines tested negative for mycoplasma contamination OR describe the results of the testing for mycoplasma contamination OR declare that the cell lines were not tested for mycoplasma contamination.
Name any commonly misidentified cell lines used in the study and provide a rationale for their use.
Provide provenance information for specimens and describe permits that were obtained for the work (including the name of the issuing authority, the date of issue, and any identifying information).
Indicate where the specimens have been deposited to permit free access by other researchers.
If new dates are provided, describe how they were obtained (e.g. collection, storage, sample pretreatment and measurement), where they were obtained (i.e. lab name), the calibration program and the protocol for quality assurance OR state that no new dates are provided.
Identify the organization(s) that approved or provided guidance on the study protocol, OR state that no ethical approval or guidance was required and explain why not.
For laboratory animals, report species, strain, sex and age OR state that the study did not involve laboratory animals.
Provide details on animals observed in or captured in the field; report species, sex and age where possible. Describe how animals were caught and transported and what happened to captive animals after the study (if killed, explain why and describe method; if released, say where and when) OR state that the study did not involve wild animals.
For laboratory work with field-collected samples, describe all relevant parameters such as housing, maintenance, temperature, photoperiod and end-of-experiment protocol OR state that the study did not involve samples collected from the field.
Identify the organization(s) that approved or provided guidance on the study protocol, OR state that no ethical approval or guidance was required and explain why not.
26 healthcare providers (5 medical officers, 4 nurses, 4 pharmacists, 4 medical assistants, 4 assistant pharmacists, 5 family medicine specialists) from 6 primary care clinics. Policy information about dual use research of concern

Hazards
Could the accidental, deliberate or reckless misuse of agents or technologies generated in the work, or the application of information presented in the manuscript, pose a threat to:

Experiments of concern
Does the work involve any of these experiments of concern: No Yes Confirm that both raw and final processed data have been deposited in a public database such as GEO.
Confirm that you have deposited or provided access to graph files (e.g. BED files) for the called peaks.

Data access links
May remain private before publication.

Files in database submission
Contact information of HCPs involved in the management of patients with asthma were obtained from the Family Medicine Specialists in charge of the six public primary care clinics. Potential participants were approached via telephone call, text messages or email and invited Recruitment was stopped after six focus group discussion when researchers agreed that the analysis had reached thematic saturation.
This study received ethical approval from the Medical Research and Ethics Committee of the Ministry of Health, Malaysia (NMRR ID: NMRR-18-2683-43494) and sponsorship approval from the Academic and Clinical Central Office for Research & Development (ACCORD) at the University of Edinburgh. All participants provided written informed consent.
Provide the trial registration number from ClinicalTrials.gov or an equivalent agency.
Note where the full trial protocol can be accessed OR if not available, explain why.
Describe the settings and locales of data collection, noting the time periods of recruitment and data collection.
Describe how you pre-defined primary and secondary outcome measures and how you assessed these measures.
For "Initial submission" or "Revised version" documents, provide reviewer access links. For your "Final submission" document, provide a link to the deposited data. Provide a link to an anonymized genome browser session for "Initial submission" and "Revised version" documents only, to enable peer review. Write "no longer applicable" for "Final submission" documents.
Describe the experimental replicates, specifying number, type and replicate agreement.
Describe the sequencing depth for each experiment, providing the total number of reads, uniquely mapped reads, length of reads and whether they were paired-or single-end.
Describe the antibodies used for the ChIP-seq experiments; as applicable, provide supplier name, catalog number, clone name, and lot number.
Specify the command line program and parameters used for read mapping and peak calling, including the ChIP, control and index files used.
Describe the methods used to ensure data quality in full detail, including how many peaks are at FDR 5% and above 5-fold enrichment.
Describe the software used to collect and analyze the ChIP-seq data. For custom code that has been deposited into a community repository, provide accession details.
Describe the sample preparation, detailing the biological source of the cells and any tissue processing steps used.
Identify the instrument used for data collection, specifying make and model number.
Describe the software used to collect and analyze the flow cytometry data. For custom code that has been deposited into a community repository, provide accession details.
Describe the abundance of the relevant cell populations within post-sort fractions, providing details on the purity of the samples and how it was determined.
Describe the gating strategy used for all relevant experiments, specifying the preliminary FSC/SSC gates of the starting cell population, indicating where boundaries between "positive" and "negative" staining cell populations are defined.
Indicate task or resting state; event-related or block design.
Specify the number of blocks, trials or experimental units per session and/or subject, and specify the length of each trial or block (if trials are blocked) and interval between trials.
State number and/or type of variables recorded (e.g. correct button press, response time) and what statistics were used to establish that the subjects were performing the task as expected (e.g. mean, range, and/or standard deviation across subjects).