https://orcid.org/0000-0001-8183-0855
Correction
5 Jan 2026: Loh ZC, Hussain R, Ababneh BF, Muneswarao J, Ong SC, et al. (2026) Correction: Perceptions and practices of community pharmacists towards the use of short-acting beta-2 agonists inhalers in Malaysia: A cross-sectional survey. PLOS ONE 21(1): e0340305. https://doi.org/10.1371/journal.pone.0340305 View correction
Figures
Abstract
Background
There has been a relative lack of exploration into the perceptions and practices regarding the use of SABA inhalers among healthcare professionals in Malaysia. The study aimed to determine community pharmacists’ perceptions and practices towards using SABA inhalers at community pharmacies in Malaysia.
Methods
It was a cross-sectional study conducted using a self-administered, web-based survey (Google Form) among community pharmacists in Malaysia between 26th December 2022 and 25th May 2023. Descriptive statistics were used to summarize the participants’ socio-demographic characteristics, and the Kruskal-Wallis and Mann-Whitney U tests were applied to continuous data and p < 0.05 was considered significant. Regression analysis was carried out to identify associated predictors of socio-demographic characteristics of the participants regarding perception of asthma control and management.
Results
A total of 312 community pharmacists completed the survey. Most of the participants were females (64.1%, n = 200), aged between 29 and 38 years (51.0%, n = 159). The majority of community pharmacists agreed that achieving good asthma control led to minimal asthma symptoms (n = 263, 84.3%) and fewer requirements for medical interventions (n = 204, 65.4%). Additionally, most participants were engaged in educating their patients about the correct techniques for using asthma inhalers (93.6%, n = 292) and provided sufficient information about the safe use of SABA inhalers (79.5%, n = 248). The most frequently perceived facilitator (n = 235, 75.4%) was providing additional follow-up sessions, and the primary perceived barrier (n = 232, 74.4%) was the lack of patients’ awareness of the provided asthma care services.
Conclusion
Community pharmacists acknowledged that good asthma control was associated with minimal medical assistance and symptoms. However, some concerns were expressed over asthma patients’ purchase of non-prescription SABA inhalers. The participants perceived some barriers, such as lack of patient awareness regarding the asthma care services availability that might hinder the safe use of SABA inhalers.
Citation: Loh ZC, Hussain R, Ababneh BF, Muneswarao J, Ong SC, ur-Rehman A, et al. (2025) Perceptions and practices of community pharmacists towards the use of short-acting beta-2 agonists inhalers in Malaysia: A cross-sectional survey. PLoS One 20(6): e0324982. https://doi.org/10.1371/journal.pone.0324982
Editor: Abdallah Y. Naser, Isra University Faculty of Pharmacy, JORDAN
Received: February 26, 2025; Accepted: May 5, 2025; Published: June 11, 2025
Copyright: © 2025 Loh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Chronic obstructive pulmonary disease (COPD) and asthma are the most common chronic respiratory diseases [1]. COPD is a chronic lung condition of persistent airflow limitation commonly associated with acute exacerbations [2,3]. In 2019, COPD caused 3.23 million deaths worldwide, standing as the third leading cause of death globally [4]. Asthma is a chronic respiratory disorder characterized by airway inflammation and bronchoconstriction, affecting millions of individuals globally, contributing to significant morbidity and mortality [5]. In 2019, about 260 million people had poorly controlled asthma, and 461,000 deaths occurred due to asthma during the same year [6]. The cornerstone of asthma management is bronchodilation, with short-acting beta-2 agonists (SABA) representing a fundamental component in the treatment regimen [7]. SABA provides rapid relief from bronchoconstriction and is commonly prescribed both as rescue medication and as a pretreatment before exercise-induced bronchoconstriction [8]. SABA relievers are categorized under Group C items (medicines that pharmacists can dispense without a prescription) in Malaysia [9].
According to the literature, SABA overuse and SABA monotherapy have been linked to increased asthma exacerbations and asthma-related mortality [10,11]. Proper SABA use hinges on multiple factors, including adequate patient education, accurate diagnosis, and adherence to inhaled corticosteroids (ICS) [12]. The safe use of SABA requires attention, as individuals who overuse SABA often fail to acknowledge that frequent SABA usage may exacerbate their symptoms, and they may develop psychological reliance on SABA [13]. In line with this, the Global Initiative for Asthma (GINA) 2019 report recommended the as-needed low-dose ICS-formoterol as a preferred reliever for adult asthma patients, even in steps one and two of asthma treatments, whereas SABA-only treatment was no longer suggested [10,14]. Step 1 treatment is recommended for individuals experiencing symptoms less than twice per month without any significant risk factors for exacerbations, such as substantial environmental triggers, socioeconomic challenges, or severely impaired lung function [14]. On the other hand, step 2 treatment is intended for those patients who experience symptoms two or more times per month [14]. Also, the availability of SABA inhalers as over-the-counter (OTC) medicine has raised concerns regarding potential overuse [10]. According to a recent systematic review, 1.4% to 39.6% of OTC users worldwide were SABA inhaler users, and 14% to 66.4% of them were over users [15]. The risks of using OTC medicines included inaccurate self-diagnosis, reliance issues upon prolonged use, and adverse drug reactions [16]. Therefore, striking a balance between accessibility and responsible use through public education, pharmacist consultation, and clear usage guidelines is crucial to prevent the inadvertent escalation of SABA inhalers’ misuse due to increased availability [15,17,18].
The country-specific context of healthcare delivery and the practices of healthcare professionals can significantly impact patient care [15,16]. Like many other countries, Malaysia faces challenges in managing asthma effectively [19–22]. Despite the crucial roles that community pharmacists play in promoting appropriate SABA use and asthma management, the perceptions and practices of these healthcare professionals in Malaysia regarding the use of SABA inhalers remain relatively underexplored [16–19]. This study aimed to explore the community pharmacists’ perceptions and practices towards using SABA inhalers in the community pharmacy setting in Malaysia. Additionally, socio-demographic factors affecting the community pharmacists’ perceptions and practices towards using SABA inhalers in the community pharmacy setting were also explored.
Methods
Study design and setting
A descriptive cross-sectional study was conducted in Malaysia between 26th December 2022 and 25th May 2023. A combination of purposive and convenience sampling techniques was employed to collect data. These approaches aimed to encompass individuals with specific expertise while ensuring ease of accessibility [23]. A self-administered instrument using an online Google Form was utilized as a data-collecting tool, and was optimized as well to be easily filled while using computers and smartphones. It was then distributed by the authors to the community pharmacists through different social media platforms, including Facebook, WhatsApp, and Telegram applications, and emails. The time taken to complete the instrument was approximately 5–7 minutes. This study’s protocol was approved by the Human Research Ethics Committee of Universiti Sains Malaysia, namely Jawatankuasa Etika Penyelidikan Manusia (JEPeM) under the reference number of USM/JEPeM/22090575. Moreover, the participants who agreed to participate in the study, signed the consent form electronically before proceeding to the first section of the survey. The Google Form was optimized to receive one response from each participant. Additionally, the participation was voluntary and no incentives were provided for the participants.
Participants
The sampling frame of the current study was 5271 community pharmacists in Malaysia [24]. The inclusion criteria were full-time community pharmacists registered with the Pharmacy Board of Malaysia, were proficient in English and provided informed consent to participate in this study. Part-time pharmacists, assistant pharmacists, and pharmacy technicians were excluded. A sample size of 312 community pharmacists was determined using the Cochran formula [25]:
e: desired level of precision
p: estimated proportion of the population
Study instrument
To assess the perceptions and practices of community pharmacists regarding the safe use of SABA inhalers, based on an extensive literature review, a closed-ended questionnaire (S1 Appendix) was designed, validated, and presented in English [13,15,26–29]. An evaluation team comprising four academics and field experts in clinical pharmacy and pharmacy practice at Universiti Sains Malaysia (USM) and Hospital Pulau Pinang evaluated the content validity of the questionnaire before distributing it to the participants. Any amendments were made based on the feedback and suggestions received. A content validity form was developed with a five-point Likert scale and emailed to the experts. They were requested to determine whether all items referred to the relevant aspects of constructs to be measured (1 = relevant, 5 = irrelevant), the importance of each item (1 = essential, 5 = not necessary), and any items missing in the questionnaire. After that, a pilot test using the online Google Form was performed among 40 community pharmacists who were selected conveniently from community pharmacies and excluded from the final analysis. The pilot test was conducted to identify and resolve the potential problems, such as identifying flaws, and deficiencies in the instrument [30]. Regarding face validity, participants provided insights on items’ degree of clarity (1 = the sentence is very vague, 5 = the sentence is very clear) and comprehension (1 = the sentence is tough to understand, 5 = the sentence is very easy to understand) by using a five-point Likert scale. To ensure the reliability of the instrument, internal consistency (which measures how closely related the items are for each scale) was calculated using Cronbach’s alpha coefficient, with values of 0.70 and above indicating good internal consistency [31].
The questionnaire was comprised of five sections, which were further divided based on 26 questions [32]. Participants’ demographics were obtained before the participants filled in the online survey. The first section consisted of six questions concerned with perceptions of asthma control and management, while the second part was comprised of seven questions that focused on risk perceptions of asthma reliever inhalers. The third section had four questions focused on practices regarding the use of SABA inhalers. The fourth and fifth sections of the survey each consisted of four and five questions, respectively, focused on facilitators and barriers to the safe use of SABA inhalers. A five-point Likert scale was used to measure responses: “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree”.
Data analysis
Data analysis was conducted using IBM Statistical Package for the Social Sciences (SPSS)® v.20. Descriptive statistics were used to summarize the socio-demographic characteristics of participants. To assess the normality of the data, the Kolmogorov–Smirnov test was performed [33,34]. Since the data did not support parametric assumptions, the Mann-Whitney U test and the Kruskal-Wallis test were performed, as the Mann-Whitney U test was used to determine the differences between two groups of an independent variable, while the Kruskal-Wallis test determined the differences between more than two groups of an independent variable [35]. Categorical variable data were presented as frequency and percentage. The median and interquartile range were reported for continuous data. On the other hand, the overall perceptions and practices of community pharmacists were categorized by using Bloom’s cut-off point. Ratings fell into the ‘good’ range if the score ranged from 80 to 100%, ‘moderate’ if it spanned from 60 to 79%, and ‘poor’ if it was below 60% [36,37]. The total score was calculated by summing the item scores. The median total score, of 25, was used as the cutoff point for multiple logistic regression. Demographic characteristics were included as independent variables in the regression model. The findings of the regression analysis were presented as odds ratios (OR) with their corresponding 95% confidence intervals. A p-value of 0.05 was used for all statistical tests and was two-tailed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (S2 Appendix), which consisted of 22 items, was used for the reporting of this study.
Results
Demographic characteristics of the participants
The online survey response was collected until it reached the desired sample size of 312 participants. The majority of the participants were females (64.1%, n = 200), aged between 29 and 38 years old (51.0%, n = 159), Chinese (60.3%, n = 188), had a bachelor’s degree (95.8%, n = 299), had 5–10 years of work experience (44.9%, n = 140), and were from Penang (25.6%, n = 80), as shown in Table 1.
Reliability and validity of the study instrument
The study instrument was amended according to the expert panel review. The Cronbach’s alpha coefficient for the instrument was 0.731, which showed that the data exhibited strong internal consistency in the format used.
Perceptions of asthma control and management.
Most of the community pharmacists (65.4%, n = 204) agreed that good asthma control was achieved when asthma could be managed with medical assistance, and when minimum asthma symptoms were present (84.3%, n = 263). The majority of participants expressed concerns (61.8%, n = 193) regarding the purchase of non-prescription SABA inhalers by asthma patients at community pharmacies who may not attend asthma reviews at hospitals. Additionally, 62.2% of the community pharmacists (n = 194) perceived that asthma patients would discuss their asthma-related concerns with community pharmacists.
Further data analysis revealed that approximately 25.9% and 65.5% of participants had good and moderate perceptions of asthma control and management, respectively, with only 8.6% reporting poor perceptions (Fig 1). Notably, age was found to be significantly associated with the perception that good asthma control can be achieved with medical assistance (p = 0.005), the concern that asthma patients solely relying on SABA inhalers from community pharmacies may lead to poor asthma control (p = 0.036), and the positive outlook on asthma patients’ willingness to engage in discussions with community pharmacists (p = 0.037) (Table 2).
Risk perceptions of SABA inhalers
Most participants (69.9%, n = 218) perceived that asthma patients may develop an attachment to SABA inhalers. Additionally, around two-thirds of the participants, (74.3%, n = 232) perceived that asthma patients may experience side effects from using SABA inhalers.
In terms of risk perceptions related to SABA inhalers usage, it was found that 39.5% of participants exhibited scores greater than 80%, indicating good perceptions. Additionally, 56.7% scored between 60% to 79%, reflecting moderate perceptions, while only 3.8% scored below 60%, indicating poor perceptions (Fig 1). Furthermore, participants’ age and academic qualification revealed significant associations with two specific statements, as shown in Table 3. Firstly, there was a strong association between age and the perception that individuals using two or more puffs per day likely indicated uncontrolled asthma (p = 0.001). Secondly, participants’ age was also significantly linked to the belief that there is a high chance that asthma patients overuse SABA inhalers, which are requested from community pharmacies, compared with inhalers which are obtained from hospitals or clinics (p = 0.004). Moreover, there was a strong association between academic qualification and the perception that individuals using two or more puffs per day likely indicated uncontrolled asthma (p = 0.013). Lastly, there was an association between participants’ academic qualifications and the concerned perception about the frequencies and doses of asthma patients’ SABA usage compared with the techniques of utilizing SABA inhalers (p = 0.036).
Practices towards the use of SABA inhalers
Most participants reported that they were involved in educating their patients on the correct techniques for using asthma inhalers (93.6%, n = 292) and provided sufficient information about the safe use of SABA inhalers (79.5%, n = 248). According to Fig 1, approximately 34.6% of participants exhibited good practices, 61.2% demonstrated moderate practices, and only 4.2% showed poor practices. According to Table 4, age was found to have a significant association (p = 0.009) with pharmacists’ practices regarding dispensing SABA inhalers to asthma patients when they perceived potential overuse. Conversely, a slight association (p = 0.048) was observed between the state of residence of the pharmacists, and their ability to provide adequate information on the safe use of SABA inhalers.
Facilitators of the safe use of SABA inhalers
Offering more follow-up sessions (75.4%, n = 235) for asthma patients was identified as the most agreed facilitator for the safe use of SABA inhalers. The second most agreed facilitator among the participants (74.0%, n = 231) was the improvement of the duration of asthma counseling. Subsequently, 66.3% (n = 207) of the participants identified a monitoring system to track SABA inhalers purchases in community settings as a key facilitator, which was found to be significantly associated with gender (p = 0.011) and academic qualification (p = 0.047) (Table 5).
Barriers to the safe use of SABA inhalers
The majority of community pharmacist participants (74.4%, n = 232) perceived that the lack of patients’ awareness regarding asthma care services was a major barrier to the safe use of SABA inhalers. According to Table 6, this perception was found to be significantly associated with age (p = 0.037), academic qualification (p = 0.017), and state of residence (p = 0.025). Following this, lack of time was identified as the second most significant barrier (68.9%, n = 215) among the participants. The least perceived barrier (39.8%, n = 124) was the absence or insufficiency of incentives.
The logistic regression analysis was carried out to identify associated predictors of socio-demographic characteristics of the participants with perception of asthma control and management. According to Table 7, none of the variables showed a statistically significant association with perception of asthma control and management (p > 0.05).
Discussion
This study provided an overview regarding the perceptions and practices of community pharmacists towards the safe use of non-prescription SABA inhalers among asthma patients in the community pharmacy setting of Malaysia.
Most of the community pharmacists (84.3%) agreed that good asthma control was achieved when minimum asthma symptoms were present. This concurs with the literature’s indication that people with well-controlled asthma would not need SABA inhalers and would have few or no asthma symptoms [38]. The majority of the participants of this study (62.2%) perceived that asthma patients would discuss their asthma-related concerns with community pharmacists on their own, suggesting the potential for pharmacist-patient engagement to promote good asthma control. According to a study, patients prefer pharmacists’ active involvement in asthma management, including asthma education, lung function tests, and monitoring [39]. In Saudi Arabia, nearly half (43.9%) of patients were satisfied with the counseling provided by community pharmacists [40]. In New Zealand, asthma patients experienced reduced reliance on SABA inhalers and increased adherence to ICS following interventions by community pharmacists, with most of them (78%) also reporting that the information provided by pharmacists was easy to understand [41].
In this study, most participants (68.6%) perceived that patients who consistently purchase non-prescription SABA inhalers may have a higher chance of developing uncontrolled asthma. Moreover, the majority of the community pharmacists (69.9%) stated that asthma patients may develop attachments to SABA inhalers and may experience side effects from using SABA inhalers (74.3%). Given this, community pharmacists, as the primary medical experts, play a crucial role as ‘gatekeepers’ in identifying potential medication safety issues, particularly concerning non-prescription medicines like SABA inhalers [15]. Additionally, various community pharmacist-led interventions have resulted in reduced reliance on SABA medicines and increased ICS adherence [41,42]. It has become evident that some asthma patients develop a psychological attachment to SABA inhalers due to their efficacy in rapidly alleviating asthma symptoms [13,15,28]. Considering the risks of frequent use of SABA inhalers, the GINA 2019 guidelines no longer recommend using SABA inhalers as monotherapy in the initial treatment of asthma [14]. Instead, using ICS and formoterol as preferred reliever options is encouraged [14]. Alternatively, a combination of a SABA and a low dose of ICS can be used, either in the same inhaler or separate inhalers, for symptom relief as the first step of asthma treatment in adults, even with mild asthma [14]. Notably, a recent meta-analysis indicated that when used within prescribed limits for symptom relief, the use of SABA as reliever therapy did not increase mortality or serious adverse events in adult asthma patients [7]. Therefore, community pharmacists’ understanding of the risks associated with frequent or improper use of non-prescription SABA inhalers can help prevent potential safety issues [15].
Community pharmacists should leverage their clinical expertise to identify potential overuse of SABA inhalers that were dispensed without prescription and engage patients in dialogue [43]. In this study, the majority of community pharmacists perceived that they had adequately provided education to their patients about the proper techniques for using SABA inhalers (93.5%) and had provided them with sufficient knowledge about asthma (79.5%). This concurs with a study done in Morocco and Saudi Arabia, where 75% and 85% of the community pharmacists respectively, reported that they teach their asthma patients about asthma and its management [44,45]. Community pharmacists may perceive themselves as effective educators and source of information for patients in managing their asthma [46]. However, patients may interpret or remember information differently, misunderstand instructions, or simply forget important details [46,47]. This scenario may be related to the low health literacy of certain asthma patients, for reasons such as inadequate reading, understanding, and comprehending medical information [48,49]. Several health literacy interventions such as Teach-Back, Simple Language, and Chunk and Check can bridge this gap [50]. The Teach-Back method entails patients repeating health information to ensure comprehension [48,51]. Utilizing Simple Language facilitates understanding by simplifying medical terminology [48,52]. The Chunk and Check strategy deconstructs complex information into smaller segments, aiding comprehension and confirmation [48].
Regarding the perceived facilitators for the safe use of SABA inhalers among the participants, the highly suggested facilitators were offering more follow-up sessions (75.4%) for asthma patients and improving the duration of asthma counseling (74.0%). Previous studies concurred with our findings that facilitators for the safe use of non-prescription SABA inhalers were frequent follow-up visits that were associated with regular updates and practical demonstrations, which were critical for effective asthma management [53]. In this case, community pharmacists can assess patients’ asthma control, monitor treatment compliance, and refer them to specialist medical consultants when necessary [54]. Sufficient counseling time has been shown to improve patient understanding and therapeutic outcomes, especially for those with complex treatment regimens, with sessions of around 30 minutes covering various aspects of asthma management [55,56]. However, challenges such as insufficient professional development and access to up-to-date medication information limit pharmacists’ ability to provide extensive counseling [55,57]. Additionally, 66.3% of participants suggested the need for a monitoring system to track purchases of SABA inhalers in the community setting, as evidence suggests a high tendency among asthma patients to overuse non-prescription SABA inhalers due to the lack of such a system [58]. Studies conducted in Australia indicated that about 73.9% of asthma patients purchasing non-prescription SABA were over-users, with 14% to 66.4% purchasing three or more SABA canisters OTC [26,27].
In this study, the most perceived barrier to promoting the safe use of SABA inhalers was a lack of patients’ awareness about the asthma care services offered by community pharmacists (74.4%). Nonetheless, the result of this study was aligned with the findings from other studies indicating patients’ limited awareness of community pharmacy-based asthma services and other services [39,59,60]. Some participants were unaware of the services offered by community pharmacists beyond their traditional dispensing roles [59,60]. However, upon learning about enhanced services, such as vaccinations and treatment advice for minor illnesses, they expressed interest in utilizing these options [59,60]. Enhancing patients’ understanding of specialized pharmacy services is crucial for service adoption and sustainability, leading to improved asthma outcomes in primary care [39]. Patients unaware of pharmacists’ asthma services may have lower expectations and express high satisfaction despite minimal services [39]. Additionally, community pharmacists’ constrained time may drive their preference for expedited dispensing; thus, having more technicians available to assist with dispensing duties would increase pharmacists’ time for asthma intervention [61–64]. On the other hand, the lack of incentives had been identified by 39.8% of the community pharmacists as a barrier to effective asthma management. Remuneration was crucial in motivating pharmacists to adopt a patient-centered approach to service delivery [65,66]. Notably, community pharmacists in France, Scotland, England, and certain states in the United States received remuneration for providing a range of asthma care services, including improving inhaler technique, offering asthma-enhanced services, providing education to patients, and monitoring the ongoing status of asthma patients [67,68].
Study limitations
This is the first study to explore the perceptions and practices of community pharmacists concerning the use of non-prescription SABA inhalers by asthma patients in Malaysia. However, there were some limitations in this study that need to be acknowledged. The instrument for this study was distributed online, which targeted individuals with internet access, and responses from areas lacking such accessibility may not be captured. This may lead to demographic selection bias. Also, the majority of study participants were females and Chinese. Social desirability bias may still exist even though participant identities were kept confidential because they might have given answers they believed would be more socially acceptable rather than ones that really reflected their experiences or viewpoints. There were no right or wrong answers, and participants were guaranteed complete confidentiality and anonymity to minimize this bias. To prevent leading responses, the questions were written in neutral language, and no identifying information about the participants was connected to the collected data. Additionally, the instrument relied on participants’ self-rated assessment of their perceptions, which may have resulted in an overestimation of the results. Nevertheless, by encompassing participants from across Malaysia, this study remains a valuable source of insights into the perceptions and practices of community pharmacists regarding the use of SABA inhalers.
Conclusion
Community pharmacists acknowledged that good asthma control was associated with minimal medical assistance and symptoms but expressed concerns over the purchase of non-prescription SABA inhalers by asthma patients. Most community pharmacists reported providing adequate education for asthma patients. They suggested raising awareness and educating asthma patients regarding risk perceptions and side effects associated with SABA inhalers. Additionally, the suggested facilitators among the community pharmacists for safe SABA inhaler use were increasing follow-up sessions and enhanced counseling, offering potential strategies for improving asthma care. Future studies are needed to explore the perceptions of other healthcare professionals towards the use of SABA inhalers at different healthcare settings in Malaysia.
Supporting information
S2 Appendix. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.
https://doi.org/10.1371/journal.pone.0324982.s002
(DOC)
Acknowledgments
We are grateful to all the community pharmacists who participated in this study. Also, we would like to thank the Research and Innovation Division (RMCO) of Universiti Sains Malaysia for supporting this research through a Short Term Research Grant [reference number 304/PFARMASI/6315769]. We would like to thank the Director General of Health Malaysia for his permission to publish this article.
References
- 1. Alwafi H, Naser AY, Ashoor DS, Aldhahir AM, Alqahtani JS, Minshawi F, et al. Trends in hospital admissions and prescribing due to chronic obstructive pulmonary disease and asthma in England and Wales between 1999 and 2020: an ecological study. BMC Pulm Med. 2023;23(1):49. pmid:36726097
- 2. Alqarni AA, Badr OI, Aldhahir AM, Alqahtani JS, Siraj RA, Naser AY, et al. Obesity prevalence and association with spirometry profiles, ICU admission, and comorbidities among patients with COPD: retrospective study in two tertiary centres in Saudi Arabia. Int J Chron Obstruct Pulmon Dis. 2024;19:111–20. pmid:38249824
- 3. Awwad O, Abu Farha R, Altaharwah A, Sharaya S, Naser AY, Tabaza H. Acute COPD exacerbations and in-hospital treatment-related problems: An observational study. PLoS One. 2024;19(6):e0305011. pmid:38843229
- 4. World Health Organization. Chronic obstructive pulmonary disease (COPD) [Internet]. 2020 [cited 2025 Apr 11]. Available from: https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)
- 5. Wang Z, Xin L, Zhang W. Study effect of azithromycin and doxycycline in mucus producing and inflammatory signaling pathways of allergic asthma. Iran J Allergy Asthma Immunol. 2022;21(2):119–27. pmid:35490266
- 6. Song P, Adeloye D, Salim H, Dos Santos JP, Campbell H, Sheikh A, et al. Global, regional, and national prevalence of asthma in 2019: a systematic analysis and modelling study. J Glob Health. 2022;12:04052. pmid:35765786
- 7. Sriprasart T, Waterer G, Garcia G, Rubin A, Andrade MAL, Roguska A, et al. Safety of SABA Monotherapy in Asthma Management: a Systematic Review and Meta-analysis. Adv Ther. 2023;40(1):133–58. pmid:36348141
- 8. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2023 [Internet]. 2023 [cited 2023 Jun 17]. Available from: https://ginasthma.org/2023-gina-main-report/
- 9. Laws of Malaysia. Act 758. Financial Service Act 2013. Date of Royal Assent. 2013. [cited 2024 Oct 02]. Available from: https://pdf4pro.com/view/act-758-financial-services-act-2013-bank-negara-malaysia504a55.html
- 10. Muneswarao J, Hassali MA, Ibrahim B, Saini B, Ali IAH, Verma AK. It is time to change the way we manage mild asthma: an update in GINA 2019. Respir Res. 2019;20(1):183. pmid:31412856
- 11. Kaplan A, van Boven JFM, Ryan D, Tsiligianni I, Bosnic-Anticevich S, REG Adherence Working Group. GINA 2020: potential impacts, opportunities, and challenges for primary care. J Allergy Clin Immunol Pract. 2021;9(4):1516–9. pmid:33373689
- 12. Hogan MB, Zhao W. High SABA using and poor asthma control: blaming poor adherence or missing the phenotype? J Allergy Clin Immunol Pract. 2022;10(8):2084–5. pmid:35961733
- 13. Loh ZC, Hussain R, Balan S, Saini B, Muneswarao J, Ong SC, et al. Perceptions, attitudes, and behaviors of asthma patients towards the use of short-acting β2-agonists: A systematic review. PLoS One. 2023;18(4):e0283876. pmid:37079594
- 14. Global Initiative for Asthma. Global strategy for asthma management and prevention [Internet]. 2019 [cited 2022 Aug 16]. Available from: www.ginaasthma.org
- 15. Loh ZC, Hussain R, Ong SC, Saini B, Muneswarao J, Ur-Rehman A, et al. Over-the-counter use of short-acting beta-2 agonists: a systematic review. J Pharm Policy Pract. 2023;16(1):119. pmid:37814312
- 16. Sansgiry SS, Bhansali AH, Bapat SS, Xu Q. Abuse of over-the-counter medicines: a pharmacist’s perspective. Integr Pharm Res Pract. 2016;6:1–6. pmid:29354545
- 17. Alyas S, Hussain R, Ababneh BF, Ong SC, Babar Z-U-D. Knowledge, perceptions, facilitators, and barriers towards asthma self-management among patients: A systematic review of the literature. Explor Res Clin Soc Pharm. 2024;17:100558. pmid:39850827
- 18. Hussain R, Loh ZC, Ababneh BF, Muneswarao J, Ong SC, Saini B, et al. Perceptions, practices, and experiences of asthma patients and community pharmacists on short-acting beta-2 agonists inhaler use: A qualitative study. J Pharm Policy Pract. 2025;18(1):2455065. pmid:39911587
- 19. Wadhawan S, Muthukumaru UA, Loh LC. Burden and unmet needs in asthma care in the Asia‐Pacific region. Public Health Challenges. 2022;1(3).
- 20. Tabaza H, Abu Farha R, Naser AY, Awwad O. Treatment-related problems and their cost among patients hospitalised with asthma exacerbation. J Pharmaceutical Health Serv Res. 2023;14(3):359–66.
- 21. Alqahtani JS, Aldhahir AM, Siraj RA, Alqarni AA, AlDraiwiesh IA, AlAnazi AF, et al. A nationwide survey of public COPD knowledge and awareness in Saudi Arabia: A population-based survey of 15,000 adults. PLoS One. 2023;18(7):e0287565. pmid:37406018
- 22. Aldhahir AM, Alqahtani JS, Alghamdi SM, Alqarni AA, Khormi SK, Alwafi H, et al. Physicians’ attitudes, beliefs and barriers to a pulmonary rehabilitation for COPD patients in Saudi Arabia: a cross-sectional study. Healthcare (Basel). 2022;10(5):904. pmid:35628041
- 23. Stratton SJ. Population research: convenience sampling strategies. Prehosp Disaster Med. 2021;36(4):373–4. pmid:34284835
- 24. Chu KE, Goh M. Malaysia Community Pharmacies Report 2022 [Internet]. 2022 [cited 2023 May 12]. Available from: https://aipharm.xyz/articles/malaysia-community-pharmacies-report-2022
- 25. Krejcie RV, Morgan DW. Determining sample size for research activities. Educ Psychol Measure. 1970;30(3):607–10.
- 26. Azzi E, Kritikos V, Peters M, Price D, Cvetkovski B, Alphonse PS, et al. Perceptions, attitudes, and behaviors of short-acting beta2 agonist users: an Australian cross-sectional community pharmacy-based study. J Asthma. 2022;59(1):178–88. pmid:33086885
- 27. Azzi EA, Kritikos V, Peters MJ, Price DB, Srour P, Cvetkovski B, et al. Understanding reliever overuse in patients purchasing over-the-counter short-acting beta2 agonists: an Australian community pharmacy-based survey. BMJ Open. 2019;9(8):e028995. pmid:31412998
- 28. Blakeston S, Harper G, Zabala Mancebo J. Identifying the drivers of patients’ reliance on short-acting β2-agonists in asthma. J Asthma. 2021;58(8):1094–101. pmid:32469667
- 29. Cole S, Seale C, Griffiths C. “The blue one takes a battering” why do young adults with asthma overuse bronchodilator inhalers? A qualitative study. BMJ Open. 2013;3(2):e002247. pmid:23427203
- 30. Hassan ZA, Schattner P, Mazza D. Doing a pilot study: why is it essential? Malays Fam Physician. 2006;1(2–3):70.
- 31. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16(3):297–334.
- 32. Elmahi OKO, Musa RAE, Shareef AAH, Omer MEA, Elmahi MAM, Altamih RAA, et al. Perception and practice of self-medication with antibiotics among medical students in Sudanese universities: A cross-sectional study. PLoS One. 2022;17(1):e0263067. pmid:35081149
- 33. Mishra P, Pandey CM, Singh U, Gupta A, Sahu C, Keshri A. Descriptive statistics and normality tests for statistical data. Ann Card Anaesth. 2019;22(1):67–72. pmid:30648682
- 34. Ahad NA, Yin TS, Othman AR, Yaacob CR. Sensitivity of normality tests to non-normal data. Sains Malays. 2011;40(6):637–41.
- 35.
Okoye K, Hosseini S. Mann–Whitney U Test and Kruskal–Wallis H Test Statistics in R. In: Okoye K, Hosseini S, editors. R Programming: Statistical Data Analysis in Research. Singapore: Springer Nature Singapore; 2024. p. 225–46. https://doi.org/10.1007/978-981-97-3385-9_11
- 36. Wang L, Abualfoul M, Oduor H, Acharya P, Cui M, Murray A, et al. A cross-sectional study of knowledge, attitude, and practice toward COVID-19 in solid organ transplant recipients at a transplant center in the United States. Front Public Health. 2022;10:880774.
- 37. Barqawi HJ, Kampani DD, Haddad ES, Al-Roub NM, Abu-Gharbieh E. Readiness of physicians and medical students to cope with the COVID-19 pandemic in the UAE. PLoS One. 2021;16(5):e0251270. pmid:33956910
- 38. Sekerel BE, Gemicioglu B, Soriano JB. Asthma insights and reality in Turkey (AIRET) study. Respir Med. 2006;100(10):1850–4. pmid:16564685
- 39. Naik Panvelkar P, Armour C, Saini B. Community pharmacy-based asthma services--what do patients prefer? J Asthma. 2010;47(10):1085–93. pmid:21039206
- 40. AlShayban DM, Naqvi AA, Islam MA, Almaskeen M, Almulla A, Alali M, et al. Patient satisfaction and their willingness to pay for a pharmacist counseling session in hospital and community pharmacies in Saudi healthcare settings. Front Pharmacol. 2020;11:138. pmid:32194400
- 41. Foot H, Beyene K, Horne R, Fingleton J, Harrison J, Chan AHY. Evaluating the feasibility of a community pharmacy-delivered behaviour change intervention to reduce reliever reliance in asthma. Patient Prefer Adherence. 2024;18:361–71. pmid:38344153
- 42. Putman B, Coucke L, Vanoverschelde A, Mehuys E, Lahousse L. Community pharmacist counseling improves adherence and asthma control: a nationwide study. BMC Health Serv Res. 2022;22(1):112. pmid:35081939
- 43. Turcotte C, Fénélon-Dimanche R, Lemière C, Beauchesne M-F, Abou-Atmé B, Chabot I, et al. Development of a community pharmacy-based intervention for patients with uncontrolled asthma. Explor Res Clin Soc Pharm. 2022;7:100167. pmid:36051610
- 44. Iraqi B, Jroundi I, Iraqi A, Mahraoui C. The pharmacist’s role in managing and ameliorating childhood’s asthma care: a descriptive and transversal study about 104 pharmacists in the city of Rabat in Morocco. Pan Afr Med J. 2018;30:101. pmid:30364337
- 45. Alotaibi HS, Shivanandappa TB, Nagarethinam S. Contribution of community pharmacists in educating the asthma patients. Saudi Pharm J. 2016;24(6):685–8. pmid:27829811
- 46. Graham S, Brookey J. Do patients understand? Perm J. 2008;12(3):67.
- 47. Kessels RPC. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219–22. pmid:12724430
- 48. Cork T, White S. Exploring community pharmacists’ use of health literacy interventions in their everyday practice. Res Social Adm Pharm. 2022;18(11):3948–52. pmid:35810054
- 49.
Munsour EE, Mahmoud MA, Hussain R. Chapter 20 - Understanding the concepts of health literacy in the context of medication safety. In: Awaisu A, Munsour EE, Aslani P, Hussain R, Babar ZUD, editors. Health Literacy in Medicines Use and Pharmacy. Academic Press; 2025. p. 307–20.
- 50. Anderson KM, Leister S, De Rego R. The 5Ts for teach back: an operational definition for teach-back training. Health Lit Res Pract. 2020;4(2):e94–103. pmid:32293689
- 51. Shersher V, Haines TP, Sturgiss L, Weller C, Williams C. Definitions and use of the teach-back method in healthcare consultations with patients: A systematic review and thematic synthesis. Patient Educ Couns. 2021;104(1):118–29. pmid:32798080
- 52. Manchanayake MGCA, Bandara GRWSK, Samaranayake NR. Patients’ ability to read and understand dosing instructions of their own medicines - a cross sectional study in a hospital and community pharmacy setting. BMC Health Serv Res. 2018;18(1):425. pmid:29879961
- 53. Axelsson M, Ekerljung L, Lundbäck B. The significance of asthma follow-up consultations for adherence to asthma medication, asthma medication beliefs, and asthma control. Nurs Res Pract. 2015;2015:139070. pmid:26770823
- 54. Caminati M, Vaia R, Furci F, Guarnieri G, Senna G. Uncontrolled asthma: unmet needs in the management of patients. J Asthma Allergy. 2021;14:457–66. pmid:33976555
- 55. Alfadl AA, Alrasheedy AA, Alhassun MS. Evaluation of medication counseling practice at community pharmacies in Qassim region, Saudi Arabia. Saudi Pharm J. 2018;26(2):258–62. pmid:30166925
- 56. Kovačević M, Ćulafić M, Jovanović M, Vučićević K, Kovačević SV, Miljković B. Impact of community pharmacists’ interventions on asthma self-management care. Res Social Adm Pharm. 2018;14(6):603–11. pmid:28778676
- 57. Wabe NT, Angamo MT, Raju NJ. Knowledge, attitude and practice of patient medication counseling among drug dispensers in north west ethiopia. J Appl Pharm Sci. 2011;1(7):85–90.
- 58. Modi M, Mody K, Jhawar P, Sharma L, Padukudru Anand M, Gowda G, et al. Short-acting β2-agonists over-prescription in patients with asthma: an Indian subset analysis of international SABINA III study. J Asthma. 2023;60(7):1347–58. pmid:36519934
- 59. Hattingh L, Sim TF, Sunderland B, Czarniak P. Successful implementation and provision of enhanced and extended pharmacy services. Res Social Adm Pharm. 2020;16(4):464–74. pmid:31272922
- 60. Kember J, Hodson K, James DH. The public’s perception of the role of community pharmacists in Wales. Int J Pharm Pract. 2018;26(2):120–8. pmid:28543969
- 61. Emiru YK, Hammeso WW, Adelo ES, Siraj EA, Bizuneh GK, Adamu BA, et al. Role of community pharmacists in educating asthmatic patients: A multi-centered cross-sectional study in Ethiopia. Chron Respir Dis. 2020;17:1479973120952679. pmid:32856500
- 62. Bertilsson E, Serhal S, Emmerton L, Bosnic-Anticevich S, Krass I, Bereznicki B, et al. Pharmacists experience of and perspectives about recruiting patients into a community pharmacy asthma service trial. Res Social Adm Pharm. 2021;17(3):595–605. pmid:32448767
- 63. Chew C-C, Lim X-J, Letchumanan P, Narayanan MS, Rajan P, Chong CP. Development and validation of a pharmacist-led education model in allergic rhinitis management: a multi-phase study. J Pharm Policy Pract. 2023;16(1):116. pmid:37794504
- 64. Chew C-C, Chang C-T, Lim X-J, Yong W-Y, George D, Letchumanan P, et al. The management of allergic rhinitis by pharmacists in public services: a proposed PhaRmacISt-led Education Model (AR-PRISE). J Pharm Policy Pract. 2022;15(1):80. pmid:36348443
- 65. Kritikos VS, Reddel HK, Bosnic-Anticevich SZ. Pharmacists’ perceptions of their role in asthma management and barriers to the provision of asthma services. Int J Pharmacy Pract. 2010;18(4):209–16.
- 66. Fraeyman J, Foulon V, Mehuys E, Boussery K, Saevels J, De Vriese C, et al. Evaluating the implementation fidelity of New Medicines Service for asthma patients in community pharmacies in Belgium. Res Social Adm Pharm. 2017;13(1):98–108. pmid:26975932
- 67. Houle SKD, Carter CA, Tsuyuki RT, Grindrod KA. Remunerated patient care services and injections by pharmacists: An international update. J Am Pharm Assoc (2003). 2019;59(1):89–107. pmid:30195440
- 68. Hussain R, Babar Z-U-D. Global landscape of community pharmacy services remuneration: a narrative synthesis of the literature. J Pharm Policy Pract. 2023;16(1):118. pmid:37814349