Abstract
Chronic respiratory diseases (CRDs), particularly asthma and chronic obstructive pulmonary disease (COPD), impose significant burdens on patients and their families in low- and middle-income countries (LMICs). Little is known about the experience of living with CRD in low- and middle-income countries (LMIC), and the impact of systemic inequities in primary care settings. To explore patient experiences of systemic inequities in CRD care in Klang District, Malaysia. We employed an adapted qualitative Photovoice study conducted between December 2023 and October 2024. The study involved adult patients with self-reported CRDs from five primary care clinics in Klang District, Malaysia. In-depth interviews were conducted at two time points using an interview guide and focused on the topics chosen by participants in their photographs. We transcribed audio-recordings verbatim, checked for accuracy and analysed them thematically. Patient and public involvement (PPI) was integral throughout the study, enhancing cultural relevance and ethical oversight. Fourteen participants (mean age 54 years; 57.1% men, 42.9% Malay, 50% diagnosed with asthma) completed the study. Four interconnected themes emerged: (1) indoor and outdoor air pollution (e.g. smoking and haze) worsened respiratory symptoms; (2) financial strain due to out-of-pocket expenses despite provision of universal healthcare; (3) occupational vulnerabilities, including transitions to precarious informal work due to health limitations; and (4) gendered caregiving burdens, including caring responsibilities while ill, pregnancy-related vulnerability, stigma, and household misunderstanding. Participants consistently showed resilience, proactively adopting coping strategies despite systemic barriers. This study highlights intersectional inequities faced by people with CRDs in Klang, Malaysia, emphasising environmental, financial, occupational, and gender-specific challenges. The use of participatory visual methodologies like Photovoice gives voice to people, allowing their narratives to advocate for culturally sensitive change to the lived environment supported by equitable provision of healthcare.
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Data Availability
All relevant data supporting the findings of this study are included within the manuscript. De-identified excerpts of participant narratives may be made available upon reasonable request to the corresponding author, subject to ethical approval and participant confidentiality agreements. Full interview transcripts will not be shared due to consent restrictions and the sensitive nature of the data.
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Acknowledgements
We would like to thank all the participants and caregivers who participated in this study, as well as their families, and the healthcare professionals who made this study possible. We are grateful to the Ministry of Health Malaysia for granting permission to carry out this study at their facilities and to the RESPIRE collaborations for their support in this work. The RESPIRE collaboration comprises the UK and LMIC Grant holders, Partners and research teams as listed on the RESPIRE website (www.ed.ac.uk/usher/respire). RESPIRE research was funded by the NIHR (Global Health Research Unit on Respiratory Health (RESPIRE); NIHR16/136/109 and NIHR132826) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. The RESPIRE collaboration comprises the UK Grant holders, Partners, and research teams as listed on the RESPIRE website (www.ed.ac.uk/usher/respire).
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H.S., H.P., and N.S.H. conceived the study and drafted the initial protocol with input from all site team members (H.C.B., B.K.H., S.M.I., Z.Z.Z.R., H.A., Z.A., S.F.A.). H.S. and A.F. conducted the interviews. Data analysis was performed by H.S. and A.F. in consultation with A.T.C., S.G.S. and F.M. H.S. led the drafting of the manuscript, which was critically reviewed by N.S.H., S.N.R., R.R., E.M.K. and revised by all authors. All authors approved the final version of the manuscript.
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E.M.K. reports grants from the National Institute for Health Research Global Health Research Unit on Respiratory Health (RESPIRE) UK and UK Medical Research Council; personal fees from AstraZeneca, Board of Directors of the International Primary Care Respiratory Group; the President of the Primary Care Respiratory Group Malaysia, Council Member and Ethics Committee Member of Hospis Malaysia. The other authors declare no competing interests.
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Written consent for publication was obtained from all participants for the use of their interview data and participant-generated photographs. All photographs included in this manuscript are de-identified and published with explicit, non-commercial consent.
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Salim, H., Hanafi, N.S., Cheong, A.T. et al. Revealing inequities in chronic respiratory disease (CRD) care: An adapted Photovoice qualitative study in Malaysian primary care settings. npj Prim. Care Respir. Med. (2026). https://doi.org/10.1038/s41533-025-00476-0
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DOI: https://doi.org/10.1038/s41533-025-00476-0
