Language barriers in multiethnic countries28 37

Policy barriers: too many state and federal regulations35

Cooperation between the State or national health department and community organisations and clinics35

Time constraints/ heavy workload/PCPs shortage27 28 30–32 35 37 38

lack of administrative support/staff and administrative hassles associated with CPG implementation35 37

Technical improvement30: technical systems such as the payment system27, electronic health records28, flexible booking system37, integrated systems of promoting collaboration and clear communication between PCPs and other professionals eg, specialists, distant health professionals30 36

Perceived limited applicability of the CPGs in real-world practice28 32–34

Inconsistent guidelines35

Evidence/recommendations that are easy to use, cost-effective and time-saving29

Developing locally (context-specific) CPGs to overcome the uncertainty33

Lack of training, knowledge and/or skills about the CPGs or the recommended practice in CPGs27 31 32 35 37

Poor communication/language skills of PCPs contributing to unsatisfied conversations between GPs and patients27 31

Provision of timely education and training to PCPs28 30 33 35 36

Professional development of the PCPs such as maintaining existing skills, developing new skills and knowledge29

Lack of clear delineation about the role, identity and responsibility of PCPs for CPGs implementation30–32 34 37

Ensure ownership, flexibility and autonomy of PCPs to adapt the innovation29

Lack of self-confidence in their capacities and experiences to deal with health issue37

providing enough training to staff on the CPGs38to improve their confidence to deliver the intervention37 38

Doubts about treatment effectiveness27 37

Clinicians accept and have positive attitudes towards programmes and guidelines35

Feel overloaded with the volume of guidelines32, the information in CPGs and experienced ‘guideline fatigue”33

Lack of interest and poor adherence of patients for advice and care plans27 28 30 31 37

Provision of timely education and training to patients27 28 35 36

Improved patient’s expectations and their self-management capability via early education27

Patients’ low literacy and health literacy make it difficult to educate patients30 35

Dissonant patient expectations/goals with disease management27 28 32

Underestimate30 35or overestimate34the disease consequence; the disease consequence)

Patients’ socioeconomic characteristics31 35: age (motivation increases with age), psychological comorbidity37

Negative attitudes towards CPGs as the patients and/or caregivers were experienced for asthma management28

Lack of financial incentives for the healthcare practice or the professional37

Audit and feedback28 36