Using a knowledge translation framework to identify health care professionals’ perceived barriers and enablers for personalised severe asthma care

Background Whilst multidimensional assessment enables the detection of treatable traits in severe asthma and has the potential to improve patient outcomes, healthcare disparities exist, and little is known about the factors influencing optimal management in severe asthma. This study aimed to explore perceived barriers, and enablers to implementing personalised care in severe asthma, from the healthcare professionals’ perspective. Methods A descriptive, qualitative study involving a single focus group (n = 7) and semi-structured interviews (n = 33) with multidisciplinary healthcare professionals involved in severe asthma care was conducted. A hybrid thematic and content analysis was undertaken to identify themes, which were then deductively mapped to the Theoretical Domains Framework (TDF). Results Overall, three emergent themes were identified: (1) Barriers- (2) Enablers- to optimal management; (3) Desired model of care. Across all TDF domains, 6 constructs influenced development and implementation of optimal care: (1) belief about consequences, (2) environmental context and resources, (3) belief about capabilities, (4) social/professional role and identity, (5) goals and (6) knowledge. Conclusion Implementation of personalised care in severe asthma is complex and non-linear. The use of a theory-based approach effectively demonstrated how a variety of behaviours could be targeted to optimise and promote personalised care in different clinical setting.


Introduction
Meeting the healthcare needs of people with severe asthma requires comprehensive and personalised approaches (individualised therapy based on genetic, biomarker, phenotypic or psychological features that distinguishes a specific patient from other individuals with comparable presentations) [1] involving multidisciplinary teams (MDT) [2]. Whilst severe asthma guidelines recommend systematic/multidimensional assessment to improve health-related quality of life and asthma control and to reduce acute attacks, the translation of this approach to practice remains a challenge [3,4]. Furthermore, fragmented care has been reported by clinicians involved in severe asthma management, leading to inconsistent and delayed referral and access to specialist care [5,6]. Healthcare professional (HCP)-related barriers have been identified and reported for several areas of asthma management [7,8]. Among these barriers are a lack of familiarity with guidelines [9], clarity of role [10] and poor communication [11]. The limitation of these studies, from a severe asthma perspective is that these report HCPs' perceptions of only general asthma care rather than their views or beliefs related to severe asthma management. As severe asthma presents as a different disease in terms of heterogeneity and complexity it would be erroneous to extrapolate these data and apply them in the severe asthma setting. Therefore, attention to factors that impede HCPs in implementing optimal management of severe asthma is an immediate priority.
Effective implementation of personalised care in severe asthma requires an understanding of determinants that influence behaviour change [12]. The Theoretical Domains Framework (TDF) has been proposed as a mechanism to understand the factors that influence HCP behavioural change [12] and has been used in different clinical areas [13][14][15][16]. The TDF comprises 14 domains, which can be used to explore influencing factors and support tailored interventions [17]. This study aims to identify and describe HCPs' perceived barriers and enablers to implementing personalised care in severe asthma through in-depth qualitative interviews and a focus group. Determinants were then mapped to the domains of the TDF to understand management behaviours and propose a model of care for severe asthma.

Design
We conducted a descriptive qualitative inquiry, combining a focus group and semi-structured interviews with multidisciplinary HCPs involved in the care of severe asthma patients. The Consolidated Criteria for Reporting Qualitative Research (COREQ) [18] was used to guide reporting (S1 Table in S1 File). Ethics approval was obtained from the Hunter New England Health Human Research Ethics Committee 2019/ETHO0143/H-2019-0208.

Participants and recruitment
HCPs were selected using a stratified purposive sampling strategy to ensure heterogeneity across professions, organisations and experience. Inclusion and exclusion criteria are provided in Table 1.
HCPs from the Severe Asthma Clinic of John Hunter Hospital (JHH) were invited to participate in a focus group. When interested participants were unable to attend, individual interviews were offered. Interview participants were recruited from the Australasian Severe Asthma Registry (ASAR), Australian Mepolizumab Registry, The Thoracic Society of Australia and New Zealand (TSANZ), and professional networks. Study invitations were sent via email, the intranet or newsletters enclosing the study information and consent form. All interested participants directly contacted the researcher to indicate their interest and written or digital consent was gained prior to the focus group or interview.

Data collection
Recruitment took place between September 2019 and June 2020. A single focus group (n = 7) was conducted by trained and experienced qualitative researchers (EM and VC). The focus group took place in a private room at the Hunter Medical Research Institute (HMRI) and its duration was 50 minutes. All in-depth interviews (n = 33) were conducted by EM, either faceto-face or via teleconference, in a private room at the JHH/HMRI. Interview duration ranged from 13-49 (mean 26, SD 10) minutes. The focus group and all interviews were guided by the same interview schedule developed around the study aims and a literature review [2,3,5,6,[19][20][21][22][23][24][25][26][27][28][29][30] (S2 Table in S1 File), and were digitally recorded with field notes. All participants were asked what design or ideal model of care they would want to have in severe asthma. They were asked to either draw or describe descriptively what the model should look like. The focus group participants were given a sheet of paper to outline the elements of their model. In-depth interviews were conducted until reaching data saturation. This was established when no new codes are identified or when the participants' perspectives became recurrent and corresponded to previously obtained data. There were no relationships established between the participants and the interviewer (EM) prior to the study. No incentives were given, nor repeat interviews conducted. Interviews were conducted until no new themes emerged.

Data analysis
Focus group and interview data were combined for the purpose of analysis. Digital interview recordings were deidentified and transcribed verbatim by professional transcription services via a secure encrypted cloud service. NVivo Pro version 12 software was used to aid data management. Transcripts were verified against the original sound file by EM for accuracy. Data analysis followed a two-stage process combining thematic analysis and frequency content analysis (Fig 1).
Firstly, an inductive thematic approach [31] was used to identify the themes. Codes and emerging themes were then reviewed and discussed with co-investigators (VM and VC) with qualitative research expertise. Major themes and subthemes were refined and grouped until consensus was obtained between co-authors. Secondly, we undertook a deductive approach whereby we linked the themes to the TDF domains. We followed the recommended procedure for TDF analysis [32] to identify the relevant TDF domains that were most likely to influence HCP behaviour/beliefs (Fig 1). To facilitate visual interpretability, descriptive statistics were used to summarise the frequency of belief statements across TDF domains. Transcripts were frequently revisited throughout the analysis to confirm the consistency of themes. Table 2 describes participant characteristics. A total of 40 multidisciplinary HCPs participated in the study. Focus group participants were predominantly female (86%), aged 29-57, working from a public hospital within a specialist severe asthma clinic in New South Wales (NSW). There were equal numbers of male and female interviewed, they were aged 31-67, mostly working in a public hospital, with a range of 5-20 years of clinical experience. Participants represented six health professional groups, mostly from the respiratory medicine and nursing.

Inductive and deductive themes
We identified three major themes, (i) Barriers to optimal management, (ii) Enablers to optimal management and (iii) Desired Model of Care, and 12 sub-themes (Fig 2).
The TDF mapping identified six predominant TDF domains: (1) belief about consequences; (2) environmental context and resources; (3) belief about capabilities; (4) social/professional role and identity; (5) goals; and (6) knowledge. Several less dominant TDF domains were identified within themes and subthemes. These less dominant yet nonetheless important TDF domains are described below. All TDF domains are underlined, and subthemes are shown in italics.
Descriptive accounts of all themes and dominant and less dominant TDF domains are summarised in Tables 3 and 4. Additional illustrative quotations are contained in the online supplement (S3 Table in S1 File).

Theme 1 barriers to optimal management
Barriers to personalised care included three sub-themes and refers to the complex nonlinear interactions that occur between what HCPs perceived as patient-, system-and provider-related factors.

Barriers to optimal management
4.1.1 HCPs perceived patient related factor. Within this sub-theme, the dominant TDF domains was 'belief about consequences' 'behavioural regulation', 'knowledge' and 'goals',

Years working in profession
the biggest problem is the non-compliance of patients, with regards to their medications (oral and inhaled corticosteroids).
(GP, P31) The perception of some HCPs was the patients did not 'take ownership' when prescriptions were due, or they wanted a 'quick fix' therapy; this was a source of frustration for some clinicians.
So, it's a little bit frustrating that patients, not all patients, but a lot of patients aren't taking that responsibility to-or they don't have insight to when their scripts run out, so that's a very -for me personally, that's a bit frustrating, because you want to be the best you can be for the patient, provide the best care [sic].     (Respiratory specialist, P27) HCPs raised a growing concern about comorbidities (i.e., obesity, dysfunctional breathing, anxiety and depression) as a rising challenge, increasing the complexity of asthma management. An additional belief within this TDF domain, from the HCPs' perspective, was the urgent need to address obesity-related comorbidities. The importance of multidimensional assessment and timely access to allied health services to address such comorbidities was also recognised.  (Table 3). The TDF domain 'belief about consequences' was also identified. Clinicians discussed how they saw healthcare systems as a barrier to providing optimal severe asthma care. Clinicians discussed the ways healthcare systems were a barrier to providing optimal severe asthma care.
4.1.2.1. TDF domain: Environmental context and resources. HCPs consistently described a system 'plagued' by long waiting times, inadequate resources, and delays in care.
It's lack of resources . . . there's limited access to space and to additional team members and so on. That's our biggest problem.
(Respiratory specialist, P15) Many reported inadequate staffing and resources as a barrier, including access to services (pulmonary function test, links to electronic health records and, inaccessible parking areas). There was a concern regarding excessive workload or increased paperwork requirements for 'bureaucratic' processes associated with biologic therapies, increasing HCPs' occupational stress or burnout.

TDF domain:
Belief about consequences. Some respiratory specialists felt frustrated when they were viewed as a 'last resort'. This related to their perception that the GP referred too late. Referral delays were viewed as a barrier causing dissatisfaction among respiratory specialists and preventing review in a timely manner. This feeling of dissatisfaction was shared among emergency specialists, due to limited referral pathways for rapid access. Other HCPs believed that to facilitate patient uptake and engagement in services, efforts to reduce waiting lists were necessary. Another 'belief about consequences' pertained to the absence of standardised asthma guidelines, specifically for assessing and managing obesity-related comorbidities. This left some HCPs feeling 'incompetent'.
Some HCPs indicated that the absence of key performance measures for severe asthma was a driver of patients not being able to access care in a timely manner. Poor communication between clinicians was proposed as hindering MDT functioning and positive patient outcomes. Some rural GPs reported difficulties streamlining referral processes when respiratory specialists did not accept telehealth consultations. Rural GPs perceived that this is a barrier to effective referral and optimal care. However, a few specialists expressed concern that some aspects of care could only be attended face-to face, such as physical examination for very sick and new patients. Several HCPs expressed reluctance collaborating with other clinicians who have been identified as having difficult personality traits.
There's a particular physician locally who can be quite difficult to speak to, and I think people are reluctant to call when there's a personality type at the end of the phone that would make people reluctant.
(ED specialist, P8) Additionally other HCPs reported a concern that some GPs were unwilling to refer older asthma patients to specialist care.
Some GPs, particularly with older clients, are not even happy about sending them off to a specialist, because they think, 'well they're 80 or 90 so, you know? I'll handle it. I'll handle it'. Once again, it's people not being listened to.
(Nurse, P22) A great concern perceived by some respiratory specialists was the over 'promotion' of short-acting beta-agonist (SABA) therapy in the ED. These specialists perceived that this was partly driven by the' 4-hour rule' to either admit, transfer or discharge patients within the ED. This performance indicator was perceived to have contributed excessive pressure on the ED staff, resulting in the delivery of maximal therapy to patients regardless of their need, which was believed to have contributed to SABA overuse.

TDF domain: Environmental context and resources.
Whilst many HCPs believed in the benefits of applying a 'treatable traits' approach, they felt that this approach failed to address the main barriers of time constraints. Limited and highly variable access to allied health across settings remained a significant issue. Many reported that fluctuating staff levels or reduced staffing was an ongoing barrier and a struggle for HCPs to deliver best-practice care.

TDF domain: Knowledge and skills.
Whilst knowledge and skills are determinants for effective and efficient MDTs, some HCPs reported a lack of knowledge relating to new asthma treatments and approaches to care. For example, some HCPs highlighted their desire for increased training in counselling and cognitive behavioural therapy.

Theme 2: Enablers to optimal management
Within the enablers theme, there were five sub-themes. Between the barriers to and enablers for optimal management themes, there was an overlap of identified TDF domains. Participant quotes for these sub-themes are presented in Table 4.

TDF domain: Knowledge and skills.
HCPs described individual clinical expertise and the discipline-specific 'knowledge' and 'skills' as facilitators to providing the highest standard of care.

TDF domain: Belief about capabilities.
HCPs reported awareness of their strengths and competences when treating patients during acute attacks. HCPs noted that their ability to ascertain patient needs and understand the evidence supporting treatments empowered them to promote optimal care.

TDF domain: Social professional role and identity.
HCPs acknowledged their expertise, role, and scope of practice in determining their function in severe asthma care. For example, respiratory specialists strongly emphasised that their role included confirming and assessing severe asthma, identifying comorbidities, and prescribing pharmacotherapy including biological therapies, whilst ED specialists highlighted their role in managing acute asthma attacks. GP and other allied HCPs reported referring patients to respiratory specialists. Allied HCPs saw that they had a designated role in working with patients to improve asthma control with self-management education, and in addressing comorbidities (e.g., laryngeal pathology). Each group expressed a strong disciplinary role identity and was supportive of each other's professional skills and contribution. These disciplinary roles and their unique clinical expertise drove HCPs' motivation to provide the best practice and maintain clinical excellence. Some HCPs also described their clinical research roles as enabling to drive improvements in evidence-based care.

TDF domain: Belief about capabilities.
The support and active involvement of multidisciplinary HCPs in severe asthma management was an important enabler. Most HCPs believed that working in collaborative teams reduced inefficiencies and errors.

TDF domain: Belief about consequences.
Team engagement brought together HCPs from diverse disciplines to deliver personalised and holistic care. This multidisciplinary approach was perceived to counteract any 'silo effect'; that is working in isolation.

TDF domain: Reinforcement.
Collaborative and systematic care resulted in a positive experience for most HCPs, generating a synergistic influence of collective knowledge and skills. This was perceived as a critical enabler in improving patient outcomes.

TDF domain: Goals.
HCPs wanted the best outcome for their patients, highlighting their intention to provide systematic approaches to care; this was considered as one of the most important enablers to ensure correct diagnosis and identification of treatable traits in severe asthma.

TDF domain: Belief about capabilities.
HCPs recounted their experience of involving patients and their families in treatment and care planning. Person-centred care was encouraged within clinical practice through positive role modelling and respecting patient values and preferences. The increase in HCPs' confidence in communicating with patients, active listening and empathy was highlighted and are believed to be effective approaches to managing patients.
HCPs reported numerous encounters with carers wanting to advocate for their loved ones. Whilst there was no doubt that support roles are valuable, a few HCPs found some carers 'difficult to gauge' and other carers questioned treatment efficacy, and some thought their care recipients were exaggerating their symptoms. HCPs believed that engaging carers when devising a care plan would likely lead to the best outcome for the person they care for.

TDF domain: Intentions.
HCPs highlighted their intention to offer education sessions and training to build the knowledge and skills that carers need to support optimum care.

TDF domain: Goals.
HCPs raised awareness of carers' well-being needs, particularly when witnessing acute severe attacks. Meeting the mental health needs of carers was a goal for many HCPs, but they reported gaps in the system for carer support.

TDF domain: Environmental context.
HCPs identified a range of clinical resources they used in their practice. For example, respiratory physicians seemed to widely access the severe asthma toolkit [33]. Other professions (GPs, ED specialist, Nurses and Allied HCPs) used online tools like (National Asthma Council, Asthma Australia, Global Initiative for Asthma, Therapeutic Guidelines and The Royal Children Hospital (RCH) -Clinical Practice Guidelines). These HCPs reported that such resources boosted their clinical competence and enhanced clinical decision-making.

TDF domain: Belief about consequences.
Most HCPs saw an opportunity to embed telehealth into their practice, thereby promoting timely access to healthcare, particularly in rural and remote regions. Delivering healthcare via telehealth videoconferencing was perceived by some HCPs as enabling and extending day-to-day clinical practice whilst allowing simultaneous, timely and efficient collaboration with local healthcare teams.

TDF domain: Intentions.
Respiratory specialists who regularly referred to allied health networks (physiotherapist and speech pathologist) noted their intent to use the bespoke approach to refer as often as possible. Respiratory specialists believed that dealing with the most troublesome and burdensome treatable traits is an effective strategy for promoting a systematised process.

TDF domain: Memory, attention and decision-making.
HCPs noted factors that influenced their decision to refer. GPs referred to specialist services specifically when a patient is unable to attain asthma control and when comorbidities complicate their asthma. Some factors that lead to a lack or delay of referral related to clinical judgement, assessment and the magnitude of comorbid problems.

TDF domain: Social/Professional role and identity.
HCPs believed that a timely referral was a critical component of their role. A relationship of trust and confidence amongst HCPs influenced referral processes. Referring HCPs indicated that having an awareness of how they can access services ultimately influenced their referral choices.

Theme 3: Desired model of care
Clinicians discussed a desired model of care that reflected MDT-based proactive care, supported by adequate resources, effective systems, enabling technology, and a culture of personcentred care, irrespective of geographical remoteness to better meet the health care needs of people with severe asthma. Participant quotes relating to this are presented in Table 5 and online supplement (S4 Table in S1 File).
Based on the HCPs' responses, a conceptual care pathway in severe asthma has been proposed (Fig 3).
The Desired Model of Care theme included the following sub-themes:

Approach to personalised care
Respiratory specialists proposed a standardised MDT approach as a way of optimising care. Having a 'one-stop-shop' with nurses and key allied health (Fig 3) embedded in dedicated severe asthma centres to provide efficient care in a timely manner.

if I had a magic wand in my hand, I would want a multidisciplinary team available in the clinic.
(Respiratory specialist, P23) This view was shared by other disciplines who felt that a collaborative team approach improved patient satisfaction and health outcomes. As the COVID-19 pandemic accelerated, some HCPs believed that optimising partnerships between the public and private health sectors are critical to meeting the needs of patients and mitigating short or long-term challenges in accessing health services.

Referral pathways
To streamline referral from both primary and tertiary care streams, it was proposed that 'discrete criteria' should be established to prompt GPs or ED specialists to refer to specialist care.
Maybe having referral criteria that-for when a GP should be provoked to think to refer it to a respiratory specialist. Because I think, at the moment, a lot of it's on their vibe of, 'oh, I'm not managing'.

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Specialists indicated their preferences for what should be included in referrals, suggesting relevant clinical history (i.e., exacerbation history, corticosteroid use), investigation results (fractional exhaled nitric oxide (FeNO), Pulmonary Function Test), and a detailed reason for referral. Patients meeting the proposed criteria could be expedited to the severe asthma service. There was a consensus that GP education was needed regarding the treatable traits that commonly coexist in severe asthma, and that the outcomes from assessments and planned interventions should be communicated back to the referring GP. Other HCPs proposed the inclusion of pulmonary rehabilitation as part of the management plan for severe asthma.

Management plan
A pre-screening process and a combined MDT meeting and discussion were viewed as critical to enhancing management and treatment plans in specialist clinics. Depending on the outcomes and decisions arising from the assessment, targeted therapy can be initiated with regular follow-up thereafter that includes inhaler technique and medication adherence (Fig 3).

Elements to optimal management (suggested enablers)
HCPs were invited to suggest possible enablers for implementing optimal management. Table 6 summarises the five sub-themes of categorised recommendations and their alignment to the enablers theme and to the TDF domains.
A severe asthma identification card (passport) and bracelet were believed to be important in improving care needs by providing HCPs timely health care information thus promoting personalised care. Resource sharing across severe asthma clinics was viewed as an important

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step to improve services. Knowledge gained through benchmarking different services can be used as a guiding principle to optimise care.

Discussion
Personalised care in severe asthma is both desirable and challenging (4). We sought to determine HCPs' perceived barriers and enablers that influence the implementation of personalised care. The findings shows that barriers span multiple levels, including HCPs' perceived patient-, system-, and provider related factors. Using the TDF as a tool to further understand these barriers and enablers we found six overarching TDF domains: (i) belief about consequences, (ii) environmental context and resources, (iii) belief about capabilities, (iv) social/professional role and identity, (v) goals and (vi) knowledge. Analysis using the TDF has generated an increased awareness of the HCPs' perceived barriers and enablers from a severe asthma perspective and defined which barriers need to be targeted to better implementation of a personalised care approach. This study provides an important insight in understanding the main drivers to the uptake of personalised care and guides the development of effective strategies to improve practice. To our knowledge this is the first study in severe asthma to use a theorybased framework to investigate an implementation approach.

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Our results demonstrate that barriers exist at multiple levels and highlight why implementation of personalised care in clinical practice may not have been achieved in all areas of asthma and severe asthma management. Although some barriers identified differed in scope, context, and strength, the majority were collectively identified by the multidisciplinary HCPs. Our results confirm and align with previous findings [34] that clinicians perceive lack of patient engagement, adherence to treatment (oral/inhaled corticosteroids), poor illness perception, beliefs, preferences, and expectations as significant barriers to optimal outcomes. This suggests that patients' non-adherence to prescribed medication [35,36] remains a difficult problem to resolve and continues to be a great concern for most HCPs. With the emergence of biological therapies, the complexity of treatments for asthma patients has increased even more [26]. Interestingly a similar pattern of insights was obtained from people with severe asthma themselves wherein they reported lack of awareness and self-management and poor treatment adherence as barriers to correct and timely diagnosis of severe asthma [37]. This highlights the importance of understanding the drivers of patient behaviour change [35] including trade-off preferences [38] for developing effective personalised strategies to promote medication adherence in severe asthma [35]. In a scoping review on barriers and facilitators to medication adherence, patient desired for more open communication and better information [34]. This also highlights the importance of effective patient-clinician partnership and multidisciplinary care in severe asthma to improve patient behaviours, as opposed to deferring 'blame' to patients [39]. Clark et al., proposed a model of clinician-patient partnership in asthma that would enhance patient perceptions and reduce health care use [40]. Ghimire et al. reported that a single home visit by a MDT improved patient adherence to medication, clinic visits, and reduced healthcare utilisation [41]. Most of our interviewees recognised the importance of collaborative work, identifying the pharmacist's role in promoting adherence [42].
It is not surprising that system-related factors, including waitlist and appointment delays, poor service availability and access to biomarker testing emerged as themes. These barriers are consistent and recognised in many areas of chronic disease management [43][44][45][46], and we acknowledge that whilst significant, they are not easily changed.
A review on barriers to healthcare access in Australia has focused mainly on health care access in the cancer-related research area and in understanding accessibility among metropolitan and regional populations [44]. A unique barrier highlighted by HCPs in this study was the perceived absence of key performance indicators (quality of care indicators) for asthma. A key performance indicator is a key metric that describes a situation concisely, aids in tracking development and performance, and serves as a guide to support decision making [47]. Key performance indicators can assist in identifying barriers to and enablers of the uptake of clinical guidelines for asthma management [48]. Barriers to quality improvement hinder the optimal flow of personalised care [49]. This result underpins the need to develop person-centred performance measures to address the complexity of care patients with severe asthma and their families require. From a healthcare provider level, lack of funded allied health services is a major limitation impacting practice. Standards of care are used in other countries to advocate and support the resource allocation for specialist severe asthma care. In the UK, an approach to specialised commissioning severe asthma (significant resources are focused towards a clearly defined pool of rare and complicated conditions, and small numbers of centres of excellence with broad catchment regions are especially supported) has been used [50] and this lesson could be adapted to the Australian health system. To support the commissioning of highly specialised severe asthma services, a hub and network model [50] offers the opportunity to extend equitable care in Australia [51]. The hub network provides a unique potential to improve efficiency and effectiveness by strategically centralising the most sophisticated medical services at a single site and distributing basic services via secondary sites [52]. A systematic review on innovative models of primary health care in rural and remote Australia suggests that a hub and network model may be necessary for delivering a full range of primary health care services to smaller and more remote communities [51]. A well-developed hub and network model can meet patient needs whilst promoting conservation of resources, investment returns, exceptional services, and improved market uptake [52].
Barriers resulting from sub-optimal interaction with healthcare teams and limited knowledge of new therapies were commonly reported and are consistent with previous studies [53][54][55]. Together, the findings from this study suggest that drivers of implementation change could both arise either intrinsically or extrinsically. 'Intrinsic factors' may be from within HCPs' values or social influences, whilst 'extrinsic factors' refer to environmental or system influences that are often beyond HCPs' control [56]. Given the emergence of new knowledge about patient's lived experience of severe asthma [57][58][59][60] lack of exploratory inquiry about HCPs involvement in severe asthma management, our study is unique. Our study filled an important gap in understanding healthcare professionals' insights, necessary to make severe asthma care more person-centred.
Enabling strategies included HCPs competence and knowledge, using evidence-based online resources and recommended guidelines as support tools. These enablers align with other literature in asthma and other diseases [16,54,61,62]. Our study also revealed that HCPs valued the importance of MDT in severe asthma. Therefore, if outcomes are to be optimised, all stakeholders including HCPs, patient and carers must engaged in goal setting concurrently [63,64]., Strategies that target both patients and their families and HCPs appear more likely to achieve better outcomes than those targeting either group in isolation [65]. Creating a person-centred approach to care that involves patients' families and their significant others, could facilitate partnerships between HCPs, and this was considered a significant enabler [66]. Participants also recognised the impact that severe asthma has on family carers particularly when dealing with sudden severe attacks, but felt they were limited in providing care pathways. A needs assessment designed for carers of people with severe asthma is warranted to ensure their critical needs are met [67].
We present the HCPs desired model of care in severe asthma. These findings expand on previous quantitative results where HCPs involved in severe asthma management report variability in their practice [24]. The results demonstrate two things: First the use of a multidimensional assessment to identify treatable traits in severe asthma is a highly desired approach to address the heterogeneity in severe disease. Additionally, an emphasis on the role of the GP in the MDT was also highlighted, as proposed in review and commentary articles [19,68]. GPs are central providers of care, coordinators and stewards in the healthcare system [19,69]; however, HCPs identified gaps in referral pathways between primary and tertiary care. Addressing these gaps could promote improved access, quality, and continuity of care [70]. Second, resource sharing amongst severe asthma clinics is desired amongst HCPs to learn what works differently in various locations and settings. This further highlights the need for severe asthma standards of care. A detailed proforma template on the referral process and electronic access to medical records are preferable to allow smooth transitioning of care. In conjunction, a proposed severe asthma passport or bracelet was proposed to enable patients with severe asthma to get the right therapy when they present to the ED with acute attacks, making hospital admission more streamlined. Greenberg et al have previously reported that an asthma patient passport increases patients' confidence in their ability to communicate their needs whilst in severe distress, and assisted HCPs in delivering timely and appropriate emergency care [71]. Under certain assumptions, this can be a solution to address gaps in delivering care in an acute care setting.
HCPs envisioned that strengthening public-private partnerships (voluntary cooperative arrangements between two or more public and private sectors agreeing to collaborate for a shared goal [72] complemented with telehealth for improved and increased health service accessibility particularly in times of crisis, such as the COVID-19 pandemic would better meet patient needs regardless of location. This suggests that proactive public-private partnerships are key elements to form sustainable health strategies to deliver optimal care [66].
Our study applied a validated theoretical framework to identify barriers to and enablers for implementing personalised care in severe asthma. Data saturation was achieved with the extensive citations and rigorous methodology, thereby combining a comprehensive inductive and deductive approach to ensure consistency and validity of the data. Using both techniques allowed for naturally identified themes to be determined and allocated to pre-selected theoretically driven domains to assist in addressing the study aims. A convergence of beliefs across different disciplines highlighted the consistencies of issues and gaps in current severe asthma management. We note several limitations. Firstly, most participants were from metropolitan regions within one geographical area of Australia, limiting generalisability to other regions. Some interviews with participants were generally shorter in duration compared to other interviews conducted after clinic hours. Additionally, perspectives from other allied HCPs might have provided additional views regarding the challenges of implementing personalised care in severe asthma. It is also possible that our focus group method may have incurred social desirability bias [73]. In addition, a focus group was conducted in a single institution. Despite these limitations, we mitigated such bias by conducting individual interviews with other disciplines which allowed further explanation of the phenomena. Nevertheless, the sample size and the combination of two qualitative data collection techniques enriched our understanding of HCPs experiences, perceptions, opinions, attitudes, and motivations in severe asthma management.
We also acknowledge that TDF is recognised as being most useful for individual level change [32]. Therefore, future research is warranted to apply other frameworks and theories such as the Capability, Opportunity and Motivation-Behavioural (COM-B) theory of change model, [74] to capture relevant factors within a system that influence behaviour change. Future research according to participant individual role (clinical roles, discipline, acute or non-acute) or gender may differ for these sub-groups therefore is warranted. Additionally, our findings could be used to inform implementation studies investigating strategies to overcome the barriers to implementing personalised care in severe asthma.

Conclusion
Barriers to personalised care in severe asthma are seen as multi-levelled. The use of theorydriven approach afforded a defined understanding of barriers and enablers that impact implementation of personalised severe asthma care. Without targeting these barriers at all three levels, it will not be possible to offer, deliver and achieve personalised care.