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The ‘vicious cycle’ of personalised asthma action plan implementation in primary care: a qualitative study of patients and health professionals’ views

Ring, Nicola; Booth, Hazel; Wilson, Caroline; Hoskins, Gaylor; Pinnock, Hilary; Sheikh, Aziz; Jepson, Ruth


Hazel Booth

Caroline Wilson

Gaylor Hoskins

Hilary Pinnock

Aziz Sheikh

Ruth Jepson


Background: Personal asthma action plans (PAAPs) have been guideline recommended for years, but consistently
under-issued by health professionals and under-utilised by patients. Previous studies have investigated sub-optimal
PAAP implementation but more insight is needed into barriers to their use from the perspective of professionals,
patients and primary care teams.
Methods: A maximum variation sample of professional and patient participants were recruited from five demographically
diverse general practices and another group of primary care professionals in one Scottish region. Interviews were digitally
recorded and data thematically analysed using NVivo.
Results: Twenty-nine semi-structured interviews were conducted (11 adults with asthma, seven general practitioners, ten
practice nurses, one hospital respiratory nurse). Three over-arching themes emerged: 1) patients generally do not value
PAAPs, 2) professionals do not fully value PAAPs and, 3) multiple barriers reduce the value of PAAPs in primary care. Six
patients had a PAAP but these were outdated, not reflecting their needs and not used. Patients reported not wanting or
needing PAAPs, yet identified circumstances when these could be useful. Fifteen professionals had selectively issued
PAAPs with eight having reviewed one. Many professionals did not value PAAPs as they did not see patients using these
and lacked awareness of times when patients could have benefited from one. Multi-level compounding barriers emerged.
Individual barriers included poor patient awareness and professionals not reinforcing PAAP use. Organisational barriers
included professionals having difficulty accessing PAAP templates and fragmented processes including patients not being
asked to bring PAAPs to their asthma appointments.
Conclusions: Primary care PAAP implementation is in a vicious cycle. Professionals infrequently review/update PAAPs
with patients; patients with out-dated PAAPs do not value or use these; professionals observing patients’ lack of interest
in PAAPs do not discuss these. Patients observing this do not refer to their plans and perceive them to be of little value
in asthma self-management. Twenty-five years after PAAPs were first recommended, primary care practices are still not
ready to support their implementation. Breaking this vicious cycle to create a healthcare context more conducive to PAAP
implementation requires a whole systems approach with multi-faceted interventions addressing patient, professional and
organisational barriers.


Ring, N., Booth, H., Wilson, C., Hoskins, G., Pinnock, H., Sheikh, A., & Jepson, R. (2015). The ‘vicious cycle’ of personalised asthma action plan implementation in primary care: a qualitative study of patients and health professionals’ views. BMC Family Practice, 16(1),

Journal Article Type Article
Acceptance Date Oct 4, 2015
Online Publication Date Oct 21, 2015
Publication Date 2015-12
Deposit Date Aug 7, 2017
Publicly Available Date Aug 8, 2017
Journal BMC Family Practice
Print ISSN 1471-2296
Publisher BMC
Peer Reviewed Peer Reviewed
Volume 16
Issue 1
Keywords Barriers, Implementation, Personalised asthma action plans, Primary care, Qualitative, Self-management plans,
Public URL
Contract Date Aug 7, 2017


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