Revealing inequities in chronic respiratory disease (CRD) care: An adapted Photovoice qualitative study in Malaysian primary care settings

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.