Authors: Rabia Hussain, Zhe Chi Loh, Bayan Faisal Ababneh, Jaya Muneswarao, Siew Chin Ong, Bandana Saini, Anees ur-Rehman, Vibhu Paudyal
Categories: Research Article, Beta-2 agonists, pharmacy, community pharmacist, asthma, inhalers, over-the-counter
Source: Journal of Pharmaceutical Policy and Practice
Authors: Rabia Hussain, Zhe Chi Loh, Bayan Faisal Ababneh, Jaya Muneswarao, Siew Chin Ong, Bandana Saini, Anees ur-Rehman, Vibhu Paudyal
Short-acting beta-2 agonists (SABA) are bronchodilators that offer rapid relief for asthma patients experiencing acute symptoms. The availability of SABA inhalers without a prescription may exacerbate the overuse of SABA. This study aimed to explore the perceptions, practices, and experiences of asthma patients and community pharmacists toward using SABA inhalers in Malaysia.
A qualitative study was conducted among eleven asthma patients and twelve community pharmacists using semi-structured individual interviews. All interviews were audio-recorded and transcribed verbatim and then analyzed by thematic analysis. The findings were reported using the COREQ checklist.
Thematic analysis yielded eight major themes, (1) perceptions and understanding of good asthma control; (2) perceptions and experience towards asthma follow-up review; (3) perceptions of SABA’s reliance; (4) practices towards the proper use of inhalers; (5) over-the-counter availability of SABA inhalers; (6) provision of pharmacists in SABA use assessment; (7) patients-healthcare professionals communication; and (8) recommendations for policymakers.
Most asthma patients and community pharmacists agreed that good asthma control was associated with reduced SABA usage and minimum asthma symptoms. The majority of patients claimed that visiting physicians for asthma follow-up reviews was unnecessary. Moreover, community pharmacists have raised concerns regarding patients’ reliance on SABA inhalers due to the immediate relief effects, however, the majority of interviewed patients claimed that they did not rely on SABA inhalers. Additionally, community pharmacists were generally concerned about the frequency, dosage, and techniques using SABA inhalers. These concerns need to be addressed to improve the safe use of SABA inhalers. Language barriers, health literacy, long waiting times, and public education were the most important believed determinants of the safe use of SABA inhalers.
Asthma is a chronic respiratory condition, estimated to impact 262 million people worldwide (Global Initiative for Asthma [GINA], 2023; Li et al., 2020). Pathophysiology of asthma is established to be a process of airway inflammation, with bronchoconstriction as one of the remarkable symptoms in addition to cough and wheezing (GINA, 2024). Short-acting beta-2 agonists (SABA) are bronchodilators that can provide prompt relief to patients experiencing acute symptoms and are commonly recommended as symptom relievers to be used only when required (GINA, 2023).
For many years, asthma management guidelines suggested that as-needed SABA use was sufficient in cases of mild asthma with infrequent symptoms (GINA, 2024). SABAs are also often used in first aid for people who experience an acute exacerbation. This has led to a high degree of reliance on SABAs by asthma patients (Nwaru et al., 2020; Wang et al., 2021). Data further highlighted that patients who were treated with SABA monotherapy (i.e. without accompanying anti-inflammatory medicines) have a higher chance of experiencing asthma exacerbations requiring systematic corticosteroid treatment (Kaplan et al., 2020).
Although GINA suggested that SABA use should be as-needed only with anti-inflammatory treatment, however, use of SABA inhalers by the patients remains high (the use of three or more SABA canisters per year) (Ban et al., 2024; Loh et al., 2023a, 2023b). While there is a need to address these issues comprehensively at all levels of health care, community pharmacists play a crucial role in asthma management (Alyas et al., 2024; Seston et al., 2022). Given the accessibility, clinical expertise, and no consultation fee charges for the advice provided, community pharmacists play an indispensable role within Malaysia's primary healthcare system (Alabid et al., 2021; Seston et al., 2022). Asthma is an important non-communicable disease requiring pharmacist focus in Malaysia. The prevalence of asthma in Malaysia is between 8.9% and 13.0% in children and up to 6.3% in adults, implying frequent presentations of people with asthma (Ahad & Ming Khoo, 2017; Chan et al., 2015; Pearce et al., 2007). Further, pharmacists in Malaysia and many other countries such as Australia, Russia, and Italy dispense SABA inhalers over-the-counter (OTC) (Avdeev et al., 2022; Bateman et al., 2022; Loh et al., 2023b). This availability of SABA inhalers without a prescription in community pharmacies adds a layer of complexity to the safe and effective use of SABA inhalers by patients (Ban et al., 2023; Price et al., 2024; Reddel et al., 2017). According to an Australian study, 73.9% of asthma patients who purchased SABA inhalers OTC were SABA overusers (Azzi et al., 2019, 2022). Additionally, most SABA overusers considered that SABA was safe to use (Loh et al., 2023a; Visser et al., 2024).
However, little to no information is known about the community pharmacists’ perspectives toward the purchase of SABA inhalers. An unexplored area exists concerning the perceptions, practices, and experiences related to SABA usage among asthma patients and community pharmacists in Malaysia. This study aimed to explore the perceptions, practices, and experiences of both asthma patients and community pharmacists toward the use of SABA inhalers in Malaysia.
This study is reported by using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Appendix A) (Tong et al., 2007).
This was an exploratory qualitative study of a descriptive nature. Qualitative interviews were used to explore the experiences of participants regarding the use of non-prescription SABA inhalers at community pharmacy setting. The qualitative approach was selected due to its adaptability in exploring the experiences, and intentions of respondents as well as its ability to help develop comprehensive perspectives on the topic in question (Cleland, 2017; Howard Lune B.L.B., 2017). It’s also an ideal choice for poorly covered study fields to fill in the gaps that survey-based research methodologies fail to (Mullen & Reynolds, 1978). Using a phenomenological approach, this study explored the participants’ comments to figure out their experiences from their point of view.
The sample size for the qualitative study was estimated until reaching the point of data saturation, wherein no further significant insights emerged from the data that was predetermined by the researchers (Fusch & Ness, 2015). The targeted participants were both community pharmacists and asthma patients. The inclusion criteria for community pharmacists were full-time registered community pharmacists with the Pharmacy Board of Malaysia, and proficient in English. Pharmacy technicians, trainees, and non-registered pharmacists were excluded from the study. Consenting community pharmacists were subsequently involved in selecting the participants at the point of SABA inhaler purchase in their pharmacies by inviting these consenting asthma patients if they met the study criteria. For asthma patients, the inclusion criteria were being ≥18 years old, having purchased SABA inhalers, being proficient in English, and being able to self-report doctor-diagnosed asthma. On the other hand, vulnerable individuals. i.e. pregnant women and those coping with other severe health conditions were excluded. The process of selecting participants for the qualitative study was employed through purposive and snowball sampling techniques (Smith, 2010). Most participants were from the Malaysian states of Perak and Penang. All participants gave their informed consent, and their participation was completely voluntary. Moreover, no incentives were offered. Figure 1 shows the detailed process of selection and recruitment of participants. Figure 1.Participants’ selection process.
Two separate semi-structured interview guides were developed for asthma patients (Appendix B) and community pharmacists (Appendix C) based on a thorough literature review (Azzi et al., 2019, 2022; Blakeston et al., 2021; Loh et al., 2023a, 2023b; Muneswarao et al., 2019) and considering expert opinions from an asthma and a subject specialist. A panel of academics further reviewed both interview guides, and each guide was then pilot-tested with two asthma patients and two community pharmacists (who were later excluded from the final results). The interview guide for asthma patients focused on asthma control and management, communication about the safe use of SABA inhalers, and future perspectives. On the other hand, the interview guide of community pharmacists highlighted asthma control and management, risk perceptions towards the use of SABA inhalers, communication with asthma patients, and future perspectives. The data collection form of demographics for asthma patients is presented in Appendix D and for community pharmacists in Appendix E.
Semi-structured interviews were conducted individually by a researcher (ZCL) who had prior training in conducting qualitative interviews. The researcher (ZCL) introduced herself to the participants as a postgraduate student, and no prior acquaintance existed between the interviewer and the participants before the interviews. Face-to-face interviews were prioritised at the preferred time and suggested location by the participants, or else these were facilitated by the Zoom® application version 5.14.11 (17466).
A sample of 11 asthma patients (three face-to-face interviews) and 12 community pharmacists (eight face-to-face interviews) were interviewed. Whilst data saturation was achieved after nine patients’ and 10 pharmacists’ interviews, a further two interviews were carried out in both sets of participants to verify saturability. The interviews for both community pharmacists and asthma patients were conducted between December 2022 and April 2023. The researcher took additional field notes during the interviews to record the contextual information. Each interview lasted about 40 minutes for asthma patients and about 30 minutes for community pharmacists.
Digital recordings of the data were accessible to the study team, and they had been transcribed professionally to ensure accuracy. A qualified and experienced qualitative researcher (ZCL) served as the primary researcher and was responsible for all interviews to ensure consistency in how the questions were asked. There was no collaboration between the researchers and the subjects in this study. The study team had access to digital recordings of the data that had been transcribed professionally to guarantee correctness. Coding was compared and discussed among researchers until reaching consensus. To increase the confirmability of this study, the whole study was overseen by two additional researchers (JM & OSC) well-versed in qualitative research techniques. To enhance credibility, another two researchers (AUR & BA), with expertise in qualitative research methodologies, confirmed the themes and performed a thematic analysis. In this study, there were no collaborations between the subjects and researchers. Some participants’ interview transcripts were returned to them via WhatsApp for review to ensure the researchers’ reflexivity, they were satisfied by the transcribed words.
An inductive approach was employed for data analysis, and the primary data analysis for this study followed the techniques outlined by Braun and Clarke (2006) (Braun & Clarke, 2006), as given in Table 1. A researcher (ZCL) completed verbatim transcriptions using Microsoft Word® for all the interviews in the English language. The coding method involved a constant-comparative method between two researchers (ZCL and RH). Line-by-line coding on all the transcripts was conducted by using NVivo® software. Meaningful segments (words, phrases, or sentences) in the transcribed data were identified and assigned with appropriate codes, which serve as labels or tags representing specific concepts or themes (Naeem et al., 2023). For each interview, the two coders compared their codes, and any disagreement between the two coders was resolved by mutual discussion. The codes were continuously refined and reviewed as the analysis progressed. Another two team members (SCO & BA) were tasked with spot-checking the coding process to ensure the quality of data analysis. Emerging themes from the complete data set were developed by clustering coded data representing similar issues/ideas. Table 1.Braun and Clarke’ six-phase thematic analysis framework.Analysis phaseTasks completedFamiliarization with the dataTranscription, reading, and re-reading of the interview transcriptsGeneration of initial codesInitial, open coding of the entire data setCategorization of initial codesCategorizing generated codes into groupsSearching for themes and merging categoriesMerging generated categories into potential themesReviewing of themesConfirming themes – ensuring the internal homogeneity and external heterogeneity of themesDefining and naming themesFurther refinement of themesReport finalisationProduction of the manuscript, selection of illustrative quotes
We understand the importance of comprehending the significance of this qualitative study exploring the practices and experiences of SABA inhaler use among patients and pharmacists, as researchers with backgrounds in both clinical pharmacy and pharmacy practice. It also needs caution to prevent biases from being introduced into the research. So, during this study, the researchers committed to be transparent and truthful about their positionality and presumptions. We used a reflective technique for data collection and thematic analysis to ensure that the safe use of SABA inhalers in Malaysia was evaluated objectively and thoroughly.
This study was approved by the Human Research Ethics Committee of the Universiti Sains Malaysia, namely Jawatankuasa Etika Penyelidikan Manusia (JEPeM) under the reference number USM/JEPeM/22090575. All participants provided informed consent to participate in this study. No one's identity or participation in the research was revealed to maintain the participants’ privacy. Each person had a special identifier (the codes of participants). Before the interviews, participants were briefed about the interviewer’s background, objectives, methodology, and voluntary nature of this study. All interviews were audio recorded and stored safely on the principal researcher's computer. The recordings were erased as soon as the data processing was complete.
Most asthma patients aged 18–28 years (n = 8), were females (n = 8), of Chinese ethnicity (n = 6), and had a Bachelor's degree (n = 9). For community pharmacists, the majority were aged 29–38 years (n = 7), females (n = 9), Chinese (n = 9), and had a Bachelor's degree (n = 11). Socio-demographic data for participants is indicated below in Table 2. Table 2.Demographics of participants.CharacteristicsnAsthma patients N = 11Community pharmacistsN = 12Age (years)18–288229–382739–481149 years old and above-2GenderMale33Female89NationalityMalaysian1112AreaPenang62Perak510EthnicityMalay41Chinese69Indian12Education levelSecondary education20Bachelor’s degree911Master’s degree01Working statusFull time712Student40Working experienceLess than 5 yearsNA35–10 yearsNA410 years and aboveNA5N = Sample size, n = frequency, NA = not available.
The final data analysis resulted in eight major themes and six subthemes. The themes (1) perceptions and understanding of good asthma control; (2) perceptions and experience towards asthma follow-up review; (3) perceptions of SABA’s reliance; (4) practices towards the proper use of inhalers; (5) over-the-counter availability of SABA inhalers; (6) provision of pharmacists in SABA use assessment; (7) patients – healthcare professionals communication; and (8) recommendations for policymakers. The themes, subthemes, and verbatim quotes are presented in Table 3. Additionally, the description of themes based on participants’ demographics is presented in Table 4. Table 3.Description of themes, subthemes, and verbatim quotes.ThemesSubthemesVerbatim quotesAsthma patientsCommunity pharmacists1. Perceptions and understandings of good asthma control ‘Good asthma control means not having to take SABA inhalers anymore.' (Female, Patient-01)‘Patients with good asthma control are those who have asthma attacks (symptoms) less than three times a week.' (Female, Pharmacist-02)‘I considered my asthma to be well controlled because I haven’t experienced any asthma symptoms lately, even though it is the rainy season’ (Female, Patient-02)‘I consider a patient to have good asthma control if they have fewer asthma attacks (symptoms), perhaps less than five in a month. In that case, their asthma can be considered well-controlled.' (Female, Pharmacist-08)2. Perceptions and experiences towards asthma reviewsPerceptions towards asthma reviews‘My asthma is very good now, so I don’t think I need to see the doctors. I use my medicines very less often also.' (Female, Patient-05)‘Maybe patients’ asthma status was not diagnosed accurately. Their asthma condition might worsen, and they need some add-on therapy, but the patients themselves did not realise this and nobody told them about this, so they just keep using the SABA inhalers. We have to ask them to go back to their doctors and follow their doctor's prescriptions.' (Female, Pharmacist-08)‘I think it is not necessary to visit doctors to just get a pump (SABA inhaler).' (Female, Patient-10)‘Their symptoms are not really assessed, so they might overuse it, but then they are not sure when to go and see a doctor. And then some of the patients are like, they refused to see a doctor no matter what their conditions are.' (Male, Pharmacist-12)Experiences with physicians and pharmacists‘Excellent. Because each time when I go to see them (physicians) and tell them I have asthma, they will use their stethoscope to check my lungs.' (Male, Patient-07)‘If we observe individuals excessively using SABA inhalers, we usually attempt to intervene, even though it may not be entirely allowed. In Malaysia, pharmacists are not authorised to initiate steroid inhaler prescriptions. However, in cases where it appears necessary, we still strive to provide interventions.' (Female, Pharmacist-02)‘Excellent. They (physicians) will check my conditions in very detail and give professional advice to me.' (Female, Patient-09)‘If I notice any concerns, I suggest they schedule a follow-up review with their doctors, without alarming them.' (Female, Pharmacist-10)‘Excellent. All their (pharmacists) suggestions are very useful. They will demonstrate to me how to use the pumps and all.’ (Female, Patient-03)‘We advise them that the use of steroid-based inhalers offers a more effective long-term treatment.' (Male, Pharmacist-07)‘There is an additional check-up when I go to the pharmacy. She (pharmacists) will give advice on the dosage, each and how much should be used.' (Female, Patient-06)‘I encourage them to undergo a comprehensive asthma review with physicians, as there may be underlying issues with their asthma.' (Female, Pharmacist-08)‘They are good, but they (pharmacists) cannot check my condition in detail, such as listening to my lungs’ sounds all that.’ (Male, Patient-07)‘I recommend that they visit the clinic for better care. They may also need to consider nebulizer treatments or update their regimen to include ICS.' (Female, Pharmacist-06)‘Good, but they (pharmacists) cannot check my body or lungs. I will look for pharmacists if I just need to buy the medicines.' (Female, Patient-09)‘I would suggest they see their doctors for a thorough reassessment of their condition, so that they can be prescribed an appropriate steroid inhaler. This is because rescue inhalers alone do not provide a long-term solution.' (Female, Pharmacist-03)3. Perceptions about reliance on SABA inhalers ‘I don’t think I rely on it. Unless I feel sick when I have fever or flu, I will use it more frequently.' (Female, Patient-03)‘SABA inhalers can provide immediate relief for their symptoms, unlike budesonide beclomethasone, which doesn't offer immediate effects. They don't notice the impact. Therefore, we need to continue counseling them and encourage reduced reliance on SABA inhalers.' (Female, Pharmacist-05)‘I've been using it for over 3 years now. And now, it seems to have become somewhat of a reliance. It's become habitual.' (Female, Patient-04)‘From what I observe in the community, patients are unaware that SABA is solely for short-term relief. Once they experience the comforting sensation upon inhalation, they become attached to what brings them comfort.' (Male, Pharmacist-07)‘Typically, I would not use the pump (SABA inhaler) until I have an attack (asthma symptoms).' (Female, Patient-05)‘I believe most asthma patients are unaware that SABA is a reliever, which lacks anti-inflammatory effects. They depend on it because it effectively alleviates their symptoms. They are unaware that frequent use of SABA inhalers can lead to an increase in asthma exacerbations.' (Female, Pharmacist-09)4. Practices towards proper use of inhaler ‘They (Pharmacists and physicians) demonstrated how to use the inhaler to me and then they asked me to demonstrate it in front of them.' (Female, Patient-02)‘The frequency of their usage is what I care about the most. The second concern is dosage, and techniques come last. In terms of techniques, patients have made significant improvements. They all know how to use it now.' (Female, Pharmacist-04)‘The doctors and pharmacists have told me how to use the inhalers. They said I have to use the chocolate pump (inhaled corticosteroids) at night, and the blue one (SABA inhaler) for all the other conditions.' (Female, Patient-09)‘My main concerns are the frequency and dosage of SABA inhaler use because excessive usage can lead to poor asthma control.' (Female, Pharmacist-09)‘Pharmacists taught me how to use this (SABA) inhaler.' (Female, Patient-10)5. Over-the-counter availability of SABA inhalers ‘When I need the inhalers, I will just go over-the-counter.' (Female, Patient-01)‘They don't really follow up with their doctors; they simply come and purchase the medication. They use it quite frequently.' (Female, Pharmacist-03)‘I think it is easier to buy this from pharmacy.’ (Female, Patient-03)‘Patients can purchase SABA inhalers over-the-counter from nearby pharmacies at any time, contributing to their ease of access.' (Female, Pharmacist-09)‘I could not go back to the hospital Taiping to get a new one, so I just buy it from the pharmacy.' (Male, Patient-07)‘Within hospital or Klinik Kesihatan (government health clinic) settings, patients are closely monitored for their SABA usage. The government provides a one-to-one exchange system for inhalers, where patients must return their empty canister to receive a new one. Pharmacists keep records on appointment cards, and if they notice frequent visits, they take action. However, in the community setting, there is limited monitoring due to the ease of obtaining SABA inhalers from retail pharmacies for around RM 20 (USD 4)’ (Female, Pharmacist-10)‘If I buy this from pharmacy, it will be more affordable and convenient for me.' (Female, Patient-09)‘Maybe they are recommended by their friends. They did not go through their doctors first, to see whether they need it or not, they straight away listen to what their friends said to buy SABA inhalers from pharmacies.' (Male, Pharmacist-11)6. Provision of pharmacists regarding SABA use assessment ‘Pharmacist also has asked me to show them the ways on how I use this pump.' (Female, Patient-04)‘I will keep a record of how frequently the SABAs are being used by those who rely on them.' (Female, Pharmacist-05)‘Community pharmacists have concerned about the frequency I used SABA inhalers. When I purchase this inhaler, they will ask whether I have used this or not, and how frequent I use it.' (Female, Patient-05)‘I've noticed that most patients are using their inhalers incorrectly. When they don't use the correct techniques, it's useless for them to use SABA inhalers because they can't effectively control their asthma.' (Female, Pharmacist-06)‘Initially, we will inquire about the frequency of inhaler use. Additionally, I will help them recognize potential triggers such as air pollution, allergens from pets’ fur, and so on.' (Male, Pharmacist-07)‘If I suspect patients are excessively using SABA inhalers, I will refrain from dispensing them and instead reassess the situation to identify any potential issues.' (Female, Pharmacist-10)7. Communication between patients and healthcare professionalsLanguage barrier‘I think the language barrier could be happened while communicating with a pharmacist from different races. I prefer to visit Chinese pharmacy because I can communicate easily.' (Female, Patient-09)‘At times, they face challenges communicating with their doctors, especially those in government hospitals where there may be language differences, particularly for Chinese or Indian patients who are less familiar with the Malay language.' (Female, Pharmacist-05)‘I think the doctors should take care of the patients who have low literacy level. When I go to Klinik Kesihatan, I can see many people having difficulty communicating with doctors. For example, a Chinese old lady unable to speak to an Indian doctor due to language barrier.’ (Female, Patient-10)‘I believe it comes from communication errors, where misunderstandings can occur when Malay patients interact with Chinese healthcare professionals, or vice versa. Both parties may struggle to fully understand each other due to dialect and language differences during counselling sessions. Patients may simply say ‘yes’ to what the healthcare provider says without fully understanding the message. This ‘yes’ response might lead the healthcare provider to assume complete comprehension.' (Male, Pharmacist-07)Health literacy‘I think the doctors should have a more detailed consultation with us. Sometimes, when I tell them my problem, they just be like, ‘Yes, yes, yes’ you know, then asked me go to get my medicines.' (Female, Patient-03)‘I believe that individual counselling could enhance communication between patients and pharmacists. Written instructions alone are not effective, as patients may struggle to understand the intended message.' (Female, Pharmacist-02)‘I think the doctors should take care of the patients who have low literacy level.' (Female, Patient-10)‘Another thing is about the elderly and children. In this case, we will ask the caretakers to come along and counsel them together. So that at least there is someone to take care of this and beware of this, to avoid misuses. Then we to use simple language to explain to them, avoid those medical words.' (Female, Pharmacist-10)8. Recommendations for policymakersLong waiting time‘If I go to the hospital, I have to wait for a long time to get my medicines.' (Female, Patient-03)‘Considering everyone's busy schedules, most patients simply come to obtain their prescriptions and have limited time for extended interactions.' (Female, Pharmacist-09)‘When I go to the government hospital, I need to queue up for a long time.' (Female, Patient-04)‘If there are no customers, perhaps we can allocate more time for counselling. However, we often find ourselves busy, resulting in shortened counselling sessions.' (Female, Pharmacist-11)‘I think the Ministry of Health should increase the working staff at government hospital so that the waiting time could be reduced. Some patients have to wait quite a long time even though in the emergency department.’ (Male, Patient-07)Foster public education‘I think Ministry of Health could implement an asthma education program, by setting up a team to go into each primary or secondary school to teach the students about this.' (Female, Patient-10)‘I think the Ministry of Health could do several things. To ensure that pharmacists have the skills necessary to work well in the counselling section, the training should first be made compulsories for all pharmacists, and they have to at the very least pass the exams.'(Male, Pharmacist-07)‘I believe the Ministry of Health should increase public awareness about asthma by promoting educational materials on the internet or through television. This will help to increase the public's understanding of asthma and reduce the chances of individuals misusing asthma medications.' (Male, Patient-11)‘I think government hospitals should provide detailed and extended counselling sessions for asthma patients.' (Female, Pharmacist-08)‘Government must periodically offer training courses and invite community pharmacists to participate. They may learn how to communicate with asthma patients more effectively at one of these training sections. The pharmacists should be trained to improve their listening skills, as well as introduction to strategies like ‘teach-back’ or ‘show-back’ method.' (Female, Pharmacist-09) Table 4.Description of themes based on participants’ demographics.ThemePatientNAgesGenderEthnicEducationWorking status11,2,4,5,8,9,1075 (18–28 years old)1 (29–38 years old)1 (39–48 years old)1 Male6 Female3 Malay3 Chinese1 Indian2 Secondary7 Bachelor degree2 Students5 Full–time2 subtheme11,2,3,4,5,6,7,8,9,10,11118 (18–28 years old)2 (29–38 years old)1 (39–48 years old)3 Male8 Female4 Malay6 Chinese1Indian2 Secondary9 Bachelor degree4 Students7 full–timeSubtheme2Satisfy with physicians-1,2,4,6,7,8,9,10,1198 (18–28 years old)1 (29–38 years old)3 Male6 Female4 Malay5 Chinese1 Secondary8 Bachelor degree4 Students5 Full–timeSatisfy with pharmacist-1,2,3,6,7,8,9,10,1197 (18–28 years old)2 (29–38 years old)3 Male6 Female4 Malay5 Chinese1 Secondary8 Bachelor degree4 Students5 Full–timeLimitation of pharmacist-2,4,7,8,9,10,1176 (18–28 years old)1 (29–38 years old)3 Male4 Female3Malay4 Chinese1 Secondary6 Bachelor degree3 Students4 Full–time3Rely-1,9,1033 (18–28 years old)3 Female2 Malay1 Chinese3 Bachelor degree2 Students1 Full–timeNot-rely-2,3,4,5,6,863 (18–28 years old)2 (29–38 years old)1 (39–48 years old)1 Male5 Female1 Malay1 Indian4 Chinese2 Secondary4 Bachelor degree1 Students5 Full–time41, 2,3, 4, 5,8,9,1085 (18–28 years old)2 (29–38 years old)1 (39–48 years old)1 Male7 Female4 Malay1 Indian3 Chinese2 Secondary6 Bachelor degree2 Students6 Full–time51,3,4,5,6,7,8,9,1097 (18–28 years old)1 (29–38 years old)1 (39–48 years old)2 Male7 Female4 Malay1 Indian4 Chinese2 Secondary7 Bachelor degree3 Students6 Full–time61,4,5,943 (18–28 years old)1 (39–48 years old)4 Female2 Malay1Indian1 Chinese1 Secondary3 Bachelor degree1 Student3 Full–time7 subtheme19,1022 (18–28 years old)2 Female1 Malay1 Chinese2 Bachelor degree2 Studentssubtheme21,3,4,8,1054 (18–28 years old)1 (29–38 years old)1 Male4 Female2 Malay3 Chinese1 Secondary4 Bachelor degree1 Student4 Full–time8 subtheme 13,4,732 (18–28 years old)1 (29–38 years old)1 Male2 Female3 Chinese3 Bachelor degree3 Full–timeSubtheme26,9,10,1144 (18–28 years old)1 Male3 Female1 Malay3 Chinese4 Bachelor degree4 StudentsThemePharmacistNAgesGenderEthnicEducationWorking experience11,2,3,4,5,6,7,8,9,10,11,12122 (18–28 years old)7 (29 −38 years old)1 (39–48 years old)2 (>49 years old)3 Male9 Female1 Malay9 Chinese2 Indian1 Master degree11 Bachelor degree3 (<5 years)4 (5–10 years)5 (>10 years)2 subtheme 12,3,8,11,1251 (18–28 years old)3 (29 −38 years old)1 (39–48 years old)2 Male3 Female4 Chinese1 Indian5 Bachelor degree2 (<5 years)2 (5–10 years)1 (>10 years)Subtheme 21,2,3,4,5,6,7,8,9,10,11,12122 (18–28 years old)7 (29 −38 years old)1 (39–48 years old)2 (>49 years old)3 Male9 Female1 Malay9 Chinese2 Indian1 Master degree11 Bachelor degree3 (<5 years)4 (5–10 years)5 (>10 years)33,5,6,7,9,10,1172 (18–28 years old)4 (29 −38 years old)1 (>49 years old)2 Male5 Female6 Chinese1 Indian1 Master degree6 Bachelor degree2 (<5 years)3 (5–10 years)2 (>10 years)41,2,3,4,5,6,7,8,9,10,11,12122 (18–28 years old)7 (29 −38 years old)1 (39–48 years old)2 (>49 years old)3 Male9 Female1 Malay9 Chinese2 Indian1 Master degree11 Bachelor degree3 (<5 years)4 (5–10 years)5 (>10 years)53,6,7,9,10,1162 (18–28 years old)3 (29 −38 years old)1 (>49 years old)2 Male4 Female5 Chinese1 Indian6 Bachelor degree2 (<5 years)3 (5–10 years)1 (>10 years)64,5,6,7,8,10,1172 (18–28 years old)4 (29 −38 years old)1 (>49 years old)2 Male5 Female5 Chinese2 Indian1 Master degree6 Bachelor degree2 (<5 years)2 (5–10 years)3 (>10 years)7 subtheme 15,6,732 (29 −38 years old)1 (>49 years old)1 Male2 Female2 Chinese1 Indian1 Master degree2 Bachelor degree1 (5–10 years)2 (>10 years)Subtheme 22,6,9, 10,1251 (18–28 years old)2 (29 −38 years old)1 (39–48 years old)1 (>49 years old)1 Male4 Female5 Chinese5 Bachelor degree2 (<5 years)1 (5–10 years)2 (>10 years)8 subtheme 19,1121 (18–28 years old)1 (29 −38 years old)1 Male1 Female2 Chinese2 Bachelor degree1 (<5 years)1 (5–10 years)subtheme 24,6,7,8,10,1261 (18–28 years old)4 (29 −38 years old)1 (>49 years old)2 Male4 Female4 Chinese2 Indian6 Bachelor degree2 (<5 years)2 (5–10 years)2 (>10 years)N = sample size.
The participants were asked about their understanding of good asthma control. Most asthma patients (n = 7) and all community pharmacists were aware of good asthma control, as they agreed that good asthma control is related to reduced SABA usage and having minimum asthma symptoms. One asthma patient mentioned that he had not experienced any symptoms even if the weather had changed. Community pharmacists also revealed that patients with good asthma control referred to those who have asthma symptoms less than three to five times a week.
All asthma patients perceived follow-up visits as unnecessary since they considered their asthma status well-controlled. They thought it unnecessary to visit physicians to receive a new SABA inhaler. In concordance with the asthma patients’ views, most community pharmacists (n = 5) identified that frequent SABA users needed to be more aware of the necessity of asthma follow-ups to monitor their current asthma status, and they may need to receive additional treatments such as inhaled corticosteroids. Therefore, community pharmacists recognised their essential roles in reminding and advising patients to have regular asthma reassessment.
The majority of patients (n = 9) indicated their satisfaction with the high-quality care provided by physicians, specifically using stethoscopes for lung examinations. Besides, they were confident with pharmacists’ consultations for their medication advice. Although the interaction between patients and pharmacists was excellent, seven patients claimed that the checkups provided by pharmacists were less detailed than those provided by physicians. Community pharmacists aligned with patients’ statements by urging patients to get a comprehensive asthma review with their physicians. After a thorough checkup, physicians may prescribe inhaled corticosteroids as a long-term treatment option.
About half of patients (n = 6) stated that they did not develop an attachment to SABA inhalers, as they only used them when necessary. However, few patients admitted they had relied on SABA inhalers, as they had used them for a very long time. On the other hand, more than half of the community pharmacists (n = 7) raised concerns regarding asthma patients who tend to depend on the use of SABA inhalers for immediate relief effects. According to them, community pharmacists must monitor and counsel asthma patients properly, as overuse of SABA inhalers will increase asthma exacerbations.
The majority of patients (n = 8) highlighted the crucial role of healthcare professionals, particularly pharmacists, in guiding the appropriate use of SABA inhalers. These professionals provided instructions on both the frequency of SABA and inhaled corticosteroid (ICS) uses and proper inhalation techniques. This finding was corroborated by responses from all community pharmacists, who expressed particular concern regarding the correct dosage, frequency, and technique employed by asthma patients when using SABA inhalers.
Participants reported uniform responses regarding the availability of SABA inhalers as over-the-counter medications. Most asthma patients (n = 9), mentioned that when they needed SABA inhalers, they would purchase them from community pharmacists due to the ease of access and affordable prices. These findings aligned with community pharmacists’ perceptions that patients prefer to purchase SABA inhalers at community pharmacies. Additionally, community pharmacists perceived that the most frequent SABA users who purchased OTC inhalers were less likely to follow up with physicians. One of the pharmacist participants mentioned that there was a lack of a monitoring system to trace SABA uses in community pharmacy settings. However, patients were monitored in the government setting because patients must return their empty canisters to receive a new one in Malaysia.
Asthma patients shared their experiences about the role of community pharmacists in their SABA use assessment. Around a third of asthma patients (n = 4) mentioned that the community pharmacists were concerned about the frequency and techniques of using the SABA inhalers, and some community pharmacists particularly asked them to demonstrate how to use SABA inhalers. On the other hand, most community pharmacists (n = 7) whether their experience was less than 5 years or more than 10 years, mentioned that they always inquire about their patients’ frequency of SABA use. One of the pharmacist participants highlighted that she always keeps a record of patients who purchased inhalers from her pharmacy. Some of them also investigated the potential reason for SABA overuse.
Two patients who were students reported facing language barriers when communicating with healthcare professionals of different ethnicities. Similarly, three community pharmacists noted that language barriers in healthcare settings can hinder effective communication and message delivery.
Some patients (n = 5) requested detailed consultation with healthcare professionals and highlighted that physicians should be more attentive to patients with low literacy levels. This was in accordance with the declared practices of some community pharmacists especially females (n = 5), who were involved in the counseling sessions and used simple language to explain to the patients.
Patients complained that when they visited government hospitals, they would need to wait for a long time. Therefore, three patients who were Chinese highly recommended that the government should increase the number of working staff in the hospitals, as there would be more staff to cater to the patients, especially during emergencies. On the other hand, only two Chinese community pharmacists claimed that in their place of work, the job routine was very busy and they seldom had time for detailed counseling of asthma patients.
The asthma patients and community pharmacists, especially females suggested that the government should implement asthma education programs to increase awareness of asthma patients. A third of asthma patients (n = 4) suggested promoting educational materials through online social media would be beneficial. Similarly, half of the community pharmacists suggested establishing training programs for community pharmacists regularly. It would improve their communication skills to introduce techniques such as the ‘teach back’ or ‘show back’ method.
The present study has explored asthma patients’ and community pharmacists’ perceptions and practices regarding the safe use of SABA inhalers. The study found that the majority of asthma patients and community pharmacists agreed that good asthma control was related to reduced SABA usage and minimum asthma symptoms. Most interviewed patients claimed visiting physicians for asthma reviews was unnecessary since their asthma conditions were well-controlled. Community pharmacists have raised concerns regarding patients’ reliance on SABA inhalers due to the immediate relief effects, but this was not aligned with most patients’ statements claiming not to rely on SABA inhalers. Additionally, community pharmacists were concerned about the frequency, dosage, and techniques of SABA users. This was in line with the majority of interviewed patients’ statements, where they indicated that healthcare professionals usually demonstrate how to use SABA inhalers. Since most interviewed patients preferred to purchase SABA inhalers OTC, interviewed community pharmacists were concerned that patients who always purchased SABA inhalers OTC rarely followed up with physicians and were seldom monitored for their SABA uses. Both patients and community pharmacists believed that language barriers, health literacy, long waiting times, and public education were important determinants of the safe use of SABA inhalers.
Asthma patients and community pharmacists in this study agreed that good asthma control is related to minimum asthma symptoms and reduced SABA usage. This was in concordance with the GINA report, which stated that patients with well-controlled asthma should use SABA reliever relievers less than twice per week and have daytime and nighttime symptoms less than twice per week (GINA, 2024).
Most participants (patients) in this study stated that they reduced follow-up visits as they believed visiting physicians was unnecessary when they had good asthma control. Individuals with irregular check-ups often have a lack of timely information about their condition and lower adherence to ICS (Park et al., 2018; Reddel et al., 2017). It was ideal for healthcare providers to review asthma symptoms control, asthma exacerbations, adverse events arising from the use of medicines, and patients’ techniques to use their inhalers from each follow-up visit (GINA, 2024). Participants’ failure to follow up on their condition may stem from a lack of recognition that asthma is a chronic disease (Alyas et al., 2024; Alzayer, 2023). It was worth noting that general practitioners observed that only uncontrolled asthma patients attended three-month scheduled follow-up visits (Bouloukaki et al., 2024). Community pharmacists could play a crucial role in this context by providing patient education and encouraging regular asthma reviews (Cork & White, 2022; Melani et al., 2011).
The findings in this study showed that while most community pharmacists were concerned that patients may develop a reliance on SABA inhalers, only one-third of patients admitted they relied on the use of SABA inhalers. Previously, patients with mild asthma were prescribed SABA inhalers only for symptomatic relief as step 1 or 2 treatment (GINA, 2024). In these steps, SABA inhalers are used for an as-needed basis without any controller therapy, reflecting a management approach that prioritizes immediate symptom relief (Reddel et al., 2019). Recent guidelines have suggested mild asthma patients should use ICS-containing treatment/ a controller alongside as-needed SABA inhalers (GINA, 2024). However, patients tend to overuse SABA and underuse ICS for immediate symptomatic relief (Cho & Oh, 2019). Therefore, the GINA report recommended the use of low-dose ICS-formoterol as the preferred reliever option for both steps 1 and 2 (GINA, 2024). Besides, researchers suggested that only ‘persistent controller users’ (patients at risk of asthma exacerbations and/ or patients who failed to discontinue a controller) should use a controller for a lifetime (Cho & Oh, 2019).
Community pharmacists in this study were concerned about the dose, frequency, and techniques of SABA inhaler use, which aligned with patients’ claims that healthcare professionals inquired about usage frequency and demonstrated proper techniques. Additionally, community pharmacists reported their usual assessment of patients’ SABA usage frequency and techniques regardless of their duration of experience. It was documented in the literature that community pharmacy-delivered intervention was feasible and showed a positive effect in promoting the safe use of SABA inhalers (Foot et al., 2024). For example, community pharmacies in Denmark provided an Inhaler Technique Assessment Service to both new and experienced patients utilising inhalation devices. This service, conducted by either a pharmacist or a pharmacy technician, was designed to enhance patient outcomes by evaluating the patient's inhalation technique through demonstration and teach-back sessions (Hansen et al., 2021). Correct inhaler technique maximised the absorption of the medication into the lungs so that patients were less likely to require additional doses of SABA to achieve the desired therapeutic effect (Jahedi et al., 2017). Additionally, asthma education provided by community pharmacists led to improvements in asthma control, quality of life, asthma inhaler administration, and medication adherence (AL-awaisheh et al., 2023; Mahdavi & Esmaily, 2021).
The majority of interviewed patients stated that they mainly get their SABA inhalers from pharmacies as OTC. Moreover, community pharmacists identified that asthma patients who frequently purchased SABA inhalers OTC were less likely to follow up with healthcare professionals. In Malaysia, SABA is classified as a ‘drug C' that could be easily purchased as OTC from community pharmacies (without a prescription) (Ministry of Health Malaysia, 2023). Community pharmacists were responsible for dispensing SABA medications, and it was mandatory to keep records of all SABA drugs dispensed through OTC purchases (Ministry of Health Malaysia, 2023). Data from 24 countries, including Malaysia, showed that 18% of SABA purchases were made without a prescription (Bateman et al., 2022). The easy accessibility of SABA inhalers as OTC and the absence of prescription monitoring may lead to under-treatment of asthma, as patients may use it without proper supervision (Bouloukaki et al., 2024; Loh et al., 2023a). Therefore, community pharmacists need to communicate about the safe use of SABA inhalers (Loh et al., 2023a, 2023b). Also, community pharmacists should be trained to assess whether an OTC medication is secure based on patients’ health conditions (Gilson et al., 2019).
Participants in this study acknowledged language barriers and health literacy as determinants of the safe use of SABA inhalers. Involving caregivers in the counseling process for translation and reinforcing healthcare providers’ instructions could reduce the impact of language barriers and limited health literacy (Divecha et al., 2020). Healthcare organisations should hire medical interpreters who are trained professionals to participate in the counseling process of patients who face difficulty in communicating with healthcare professionals (Squires, 2018). Effective asthma medication counseling involves varied educational resources and integrating visual aids in asthma action plans (Abrams, 2020). Additionally, healthcare providers should adhere to health literacy precautions such as slowing down during counseling, being specific about subjective terms, using illustrations to demonstrate important concepts, and using the ‘teach-back’ method (Hussain et al., 2023).
Many factors were addressed by the participants to enhance the safe use of SABA inhalers. Firstly, some participants urged the reduction of the long waiting times in healthcare settings. In Malaysia, long waiting times in healthcare settings resulted from the need for more human resources, insufficient equipment, a slow registration process, and a high patient volume (Sharif et al., 2016). This problem could be addressed by a smart management waiting system to schedule appointments (Sharif et al., 2016). Patients could obtain their registration numbers via mobile applications and stay in their preferred locations, with reminders ten minutes before their appointments to prevent missed ones (Nasrudin et al., 2023). Another suggested factor by the participants was public education. It was evident that a lack of education and awareness about asthma increased the burden of this chronic disease on the population (Pitrez, 2023). Social media is a platform that could be used to disseminate information about asthma and patients could improve asthma self-management and control (Poowuttikul & Seth, 2020). Furthermore, inadequate professional skills regarding inhaler use among community pharmacists from Turkey, Sudan, Nigeria, and India were primarily due to their limited knowledge of inhaler techniques (Gemicioglu et al., 2014; Nduka et al., 2016). Consequently, the implementation of a well-structured training program has become crucial for enhancing the knowledge and practices of community pharmacists in asthma management (Basheti et al., 2019). Beyond individual patient care, trained community pharmacists would also play a role in advocating for asthma awareness and public health initiatives by engaging in community outreach programs (Kritikos et al., 2005).
This study evaluated both asthma patients’ and community pharmacists’ perceptions and practices on the safe use of SABA inhalers. Moreover, this study used thematic analysis that generated a rich and descriptive account of participants’ experiences, opinions, and beliefs. However, recall bias, or social desirability bias, needs to be acknowledged. To address these issues, the interviewer employed probes and prompts to facilitate more precise event recall and underscored the anonymity and confidentiality of this study.
Limited sample size and generalisation beyond research participants remain issues, as they appear in qualitative research. Moreover, the study deliberately focused on English-speaking participants to ensure effective communication, precise data collection, and streamlined data analysis. Some confounding variables may have affected this study, such as the participants’ varied demographics, gender, and ethnicity. The participants’ experiences and attitudes were probably influenced by these circumstances, which resulted in a range of responses from them that would have compromised the consistency of the findings. For example, female community pharmacists were more willing to track the proper use of SABA inhalers. This could result in wildly disparate methods for monitoring patients’ proper SABA inhaler use. It is vital to recognise these confounders, and future studies need to find ways to control these confounders to ensure a clearer picture of how SABA inhalers are practiced regardless of the context. Last but not least, the included interviewees in this study were from two regions of Malaysia: Penang and Perak. Perak is the fourth largest in the nation, while Penang is the second largest. The current study's conclusions cannot be generalised to the entire country. Therefore, results from this study are unlikely to differ much from those from other regions of the country; nonetheless, more research is needed to validate this nationwide, particularly in rural areas.
Future studies should focus on developing effective practices to monitor and optimise SABA use in low-resource settings. In particular, effective approaches to identify and counsel patients at risk, for example, people with low health literacy, from deprived backgrounds, and those less likely to engage with asthma review, can optimise use and minimise adverse outcomes.
The study found that most asthma patients and community pharmacists agreed that good asthma control was associated with reduced SABA usage and minimum asthma symptoms. Most patients claimed visiting physicians for asthma reviews was unnecessary. Community pharmacists raised concerns regarding patients’ reliance on SABA inhalers due to the immediate relief effects, but the majority of patients claimed that they did not rely on SABA inhalers. Additionally, community pharmacists were generally concerned about the frequency, dosage, and techniques of SABA inhaler use. Since most patients preferred to purchase SABA inhalers OTC, community pharmacists were concerned that patients who always purchased SABA inhalers OTC rarely followed up with physicians and were seldom monitored for their SABA use. Language barriers, health literacy, long waiting times, and public education were the most important believed determinants of the safe use of SABA inhalers.