Are we ready for climate-friendly inhaler prescription and usage? A qualitative study among primary and secondary care patients, healthcare professionals and healthcare insurers in the Netherlands

This study explored the knowledge and awareness of Dutch patients, healthcare professionals (HCPs) and healthcare insurers on the climate impact of inhalers as well as (factors influencing) their attitude towards climate-friendly inhaler prescription.

We recruited participants for this qualitative study with purposive sampling. We conducted four online focus groups with patients, six with HCPs and two interviews with healthcare insurer representatives. Determinants were analysed with the Framework Approach.

21 patients, 27 HCPs and two healthcare insurer representatives.

Knowledge and awareness on the climate impact of inhalers varied and was generally lower among patients and healthcare insurers than among HCPs. The attitude towards climate-friendly inhaler prescription was variable among patients and mainly positive among HCPs. Both patients and HCPs assigned a greater role to HCPs than to patients in considering climate impact and agreed that patients’ interest must remain paramount. Factors influencing implementation were mainly related to outcome expectancies, such as expected effect on freedom of choice, expected response of patients and expected effect on patients’ health. The latter is partly influenced by beliefs about different types of inhalers. HCPs expressed a need for information and training on the topic and for collaboration with other stakeholders in the field of pulmonary care. Healthcare insurers assign themselves a role in a more climate-friendly healthcare but are reluctant to direct the preference policy on climate impact.

Both patients and HCPs feel climate-friendly inhaler prescription is important. Implementation can be promoted by enhancing awareness and providing HCPs with information on inhaler climate impact, how to safely practice climate-friendly prescription and how to inform patients about its benefits. Both patients and HCPs emphasise the significance of preserving freedom of choice in prescription and highlight the need for a consensus approach on climate-friendly prescribing endorsed by all pulmonary care stakeholders.

Data are available upon reasonable request.

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The multiple eco-crisis affects human health globally, and people with respiratory diseases are particularly vulnerable to the effects of climate change.1 Hence, addressing climate change by reducing greenhouse gas emissions is vital to limit the burden of respiratory disease.

Paradoxically, the healthcare sector itself accounts for 7% of the Dutch carbon equivalent footprint (CO2eq).2 Inhaler devices, used in asthma and chronic obstructive pulmonary disease (COPD) treatment, account for 0.4% of the CO2eq footprint of Dutch healthcare. This is mainly due to the usage of pressurised metered dose inhalers (pMDIs), which contain propellants with a high global warming potential.3 Given the policy aim to lower carbon emissions of the Dutch healthcare sector by at least 55% by 2030, responsibly reducing MDI usage is a factor to consider critically.4

Remarkable differences in inhaler prescription exist between European countries, with pMDI prescription rates of 70% in the UK, 50% in the Netherlands and 13% in Sweden.5–7 An estimated 70% of the Dutch pMDI users could safely be prescribed a non-propellant inhaler (NPI) such as a dry powder inhaler (DPI) or soft-mist inhaler (SMI) as an equally cost-effective, more climate-friendly alternative.6 8

Since 2020, the British Thoracic Society recommends healthcare professionals (HCPs) to prescribe a DPI when a new class of inhalers is commenced. Also, they recommend prioritising the DPI class device if patients use several classes of inhalers, a poor inhaler technique is identified and the patient can use a DPI safely.9 Similarly, the Dutch College of General Practitioners has recently adopted climate-related objections concerning the use of pMDIs in their guidelines for asthma and COPD. They recommend that the environmental impact of greenhouse gases from pMDIs should be taken into account when choosing an inhaler.10 11 Despite this, and notwithstanding the ambition of the Dutch Federation of Healthcare Insurers (Zorgverzekeraars Nederland) and the desire of the Dutch Patient Federation for more climate-friendly medication prescription, the prescription rates of pMDIs have increased in recent years.7 12 Which factors explain this discrepancy?

An essential step in the implementation of new (prescription) behaviour in practice is identifying factors influencing implementation.13 Several frameworks have been developed to help identify and categorise implementation determinants.14–16 The Theoretical Domains Framework (TDF) is a validated and highly cited implementation determinant framework based on behaviour change theory.17 It comprises 14 domains of determinants that influence implementation behaviour, ranging from social influencing to knowledge and outcome expectancies. Previous studies have identified common factors related to general practitioners’ (GPs) guideline adherence, such as professional responsibility, GPs’ experience and practical issues.18

The awareness and knowledge of patients, HCPs and healthcare insurers on the climate impact of inhalers and their attitude towards more climate-friendly inhaler prescription and usage have hardly been investigated.19–21 This study aims to help bridge this gap and will explore

    In addition, we will illustrate a healthcare insurers’ perspective on the climate impact of inhalers.

    We conducted a qualitative study, using semi-structured focus groups and interviews. Three topic guides were designed for patients, HCPs and healthcare insurers’ representatives partially following the TDF domains (online supplemental file 1). The Medical Ethics Committee at Leiden University Medical Centre determined that the Dutch Medical Research Involving Human Subjects Act did not apply to the study (22–3037) (online supplemental file 2). Reporting follows the Standards for Reporting Qualitative Research guidelines (online supplemental file 3).22

    First, all groups and interviews started with exploring participants’ knowledge and awareness on inhalers’ climate impact. Participants were then informed about the carbon equivalent footprint of both the healthcare sector and inhalers specifically.

    Subsequently, participants discussed the topic using two case studies. HCPs were first shown a case study of a patient who was newly prescribed an inhaler and a second case study in which a patient was already using an MDI and could possibly switch to a more climate-friendly inhaler. Patients were asked to think about their experience of choosing an inhaler and how they would feel if their HCP suggested switching to a more climate-friendly inhaler. All participants were invited to discuss their current decision-making process and attitudes towards more climate-friendly inhaler prescription. General open-ended questions were combined with probing questions on the role, perceived competence and priorities.

    At last, all participants were asked to react to the presentation of a proposed guideline recommendation on more climate-friendly inhaler prescription (box 1).

    Box 1

    Patients

    How would you feel if the guideline recommendation for your HCP is changed to ‘prescribe a climate-friendly inhaler, unless it is not appropriate for the patient (for example, if the patient is unable to use it according to the instructions for use)’.

    Healthcare professionals/healthcare insurers

    What would you think if the guideline recommendation for treatment of asthma and COPD is to ‘treat patients requiring an inhaler with a DPI or SMI and use an MDI only if this is impossible or undesirable’.

    Healthcare insurers were asked more generally about the extent to which they consider climate impact of inhalers in their current policy on inhalers or are planning to do so, what their attitude is towards considering climate impact in policy decisions and how they perceive their role in climate-friendly inhaler prescription.

    The topic guide was presented to and reviewed by a group of experts in the field of respiratory medicine and climate impact of inhalers, including primary and secondary HCPs. Moreover, the quality and appropriateness of the topic guide were checked by two qualitative research experts. Patients were not actively involved in reviewing the topic guide.

    Participants were recruited with purposive sampling techniques via several online and offline channels. These included digital newsletters and e-mail or social media posts of the CAHAG (COPD and Asthma GP Advisory Group), ELAN (Extramural LUMC Academic Network), LAN (Lung Alliance Netherlands), LANA (Leiden Academic Network of Pharmacists) and Lung Foundation Netherlands. We aimed for diversity in the focus groups. To include participants with different views on the topic, the climate impact of inhalers was mentioned in the recruitment materials but not presented as the main topic of the focus group. After obtaining written informed consent, demographic data and data on availability to attend the focus group were collected using a survey. The eligibility criteria for participation are mentioned in box 2.

    Box 2

    For all participants:

    For patients:

    For HCPs:

    An exclusion criterion for patients was using a nebuliser as the only inhaler device.

    • COPD, chronic obstructive pulmonary disease; GP, general practitioner; HCPs, healthcare professionals.

    To recruit healthcare buyers of healthcare insurance companies, engaged in inhaler policies, we contacted three insurance companies by e-mail using contact information obtained from Nivel (Netherlands Institute for Health Services Research).

    In September and October 2022, focus groups were conducted with patients (n=4), primary care professionals (n=3) and secondary care professionals (n=3). The focus groups were conducted online as participants preferred participating online, allowing us to include participants from different Dutch regions. We used Jitsi Meet, a free open-source video-conferencing software.23 The focus groups comprised 4–6 participants and lasted 50–80 min. Also, two semi-structured interviews, lasting 40–50 min, were held with healthcare buyers from healthcare insurance companies. The focus groups and interviews were moderated by BO, a female GP in training with experience in inhaler prescription and research in sustainable healthcare and assisted by ER. Two focus groups were observed by RK and JB, researchers experienced in qualitative research, to optimise the moderator’s interview techniques. The interviews were audio-recorded and transcribed ad verbatim.

    We used different qualitative analysis methods for the different research questions.24 First, BO and ER developed a concept coding scheme, based on the TDF domains, the items of the topic guide (eg, considerations in choosing an inhaler) and concepts and themes noted by the researchers during the focus groups and interviews (eg, the role and support from healthcare insurers). Second, the researchers independently coded one transcript from a focus group with patients and one with HCPs using ATLAS.ti 22. They deductively coded the transcript with the existing coding scheme and inductively developed new codes when new themes emerged during the coding or rephrased the existing codes. Afterwards, they thoroughly discussed the applicability of the concept coding scheme and the new and rephrased codes until they reached consensus on the final coding scheme (online supplemental file 4). During this process, RK was involved in reviewing the coded transcripts and the coding schemes. Subsequently, all transcripts were coded with this coding scheme, and afterwards crosstabs were created. For answering the first research question, we applied content analysis on the codes on level of awareness, level of knowledge and the subcodes on climate impact under the code current considerations. For the second research question, we used open and axial coding to capture participants’ attitudes towards the proposed guideline recommendation. In the third research question, we aimed to identify determinants of climate-friendly inhaler prescription and usage, mainly by analysing the codes related to the TDF domains, incidentally supplemented with more specific codes (eg, differentiating between beliefs about DPIs and MDIs). Afterwards, BO and RK identified the most relevant determinants and themes (eg, freedom of choice) represented by one or more codes with relevant, overlapping or contrasting data. We did not aim to reach consensus. We included frequently mentioned opposing views and those that provided valuable insights. Quotations were not assigned to individual participants to retain anonymity. Therefore, we cannot provide exact numbers of participants who made a statement, but we can provide the number of focus groups. When writing about most focus groups, we mean three focus groups with patients and four or five with HCPs.

    21 patients (table 1) and 27 HCPs (table 2) participated in the focus groups. Patients were predominantly female (71.4%), highly educated (61.9%) and diagnosed with asthma (66.7%). Most patients (90.5%) used an MDI, of which 68.4% in combination with at least one other device. HCPs were mainly female (93%), working in primary care (59%) and had a working experience of 10+ years in pulmonary care (51.9%).

    Table 1

    Characteristics of patients (n=21)

    Table 2

    Characteristics of healthcare professionals (HCPs) (n=27)

    Knowledge and awareness

    The level of awareness of the climate impact of inhalers among participants was variable. In most focus groups with patients and in all focus groups with HCPs, several participants were aware of the climate impact of pMDIs. However, in the majority of focus groups, there were some participants that indicated they had never heard it before. Despite the awareness, specific knowledge on the topic was lacking among most participants.

    After sharing information about the climate impact of inhalers, several patients in three focus groups were shocked by the information that was shown. HCPs were shocked as well as surprised. Patients in three focus groups indicated that the impact was higher than they had expected. Only one HCP mentioned being cognizant of the information shown.

    Focus group, primary care HCPs, no. 3

    I find it quite surprising (information on climate impact of inhalers). I really didn’t know that. I think a lot of people don’t know that. I think that’s a pity. I do think they are useful things, the MDIs. I do support it, but when I see this, I think, you might have to choose between treatment or the environment. I still favor treatment then, because I still think they (MDIs) are more effective. They are easy to use. A spacer is not even needed.

    In most focus groups with patients and HCPs, there was annoyance or amazement regarding the waste generation of inhalers, both due to the lack of refillable inhalers and the size and quantity of inhaler packaging.

    Focus group, patients, no. 4

    I am always surprised, that when I pick up my refill prescriptions, I get a new one. So not just a refill, but a new device every other time. I think that could be reduced.

    Role of climate impact on current inhaler prescription and usage

    Only very few patients indicated having asked for a DPI because of its climate impact. In most focus groups, some HCPs reported considering climate impact when choosing an inhaler, for example, by presenting the lower climate impact as an added benefit of DPIs to patients.

    HCPs described other ways in which they try to limit the impact of inhalers, for example, by reducing the number per prescription during the trial period or prescribing combination inhalers when possible. In two focus groups, patients made the effort to write to or visit the manufacturer to raise the issue of waste generation of inhalers.

    HCPs had a predominantly positive perception of the proposed guideline recommendation. They mentioned that it provides clarity and raises awareness among HCPs about the climate impact of their prescriptions. Nonetheless, some were also critical of the possible negative consequences of the recommendation for the freedom of choice regarding inhalers and patients’ health and on its scientific rationale, both regarding the effectiveness of both types of inhalers and their carbon equivalent footprints.

    A remarkable difference was seen in how patients responded to the guideline recommendation between and within focus groups. However, in one focus group, a positive attitude towards a climate-friendly prescribing policy (‘yes, good move’) was expressed, whereas in two other groups, negative reactions were observed (‘worthless’, ‘ridiculous’).

    Besides this, there was a striking discrepancy in patients’ views on a more climate-friendly prescribing policy. The response to the presented patient case was sometimes contrary to the response to the proposed guideline recommendation. This discrepancy was observed both in groups and within individual participants.

    The relevant domains related to climate-friendly inhaler prescription and associated beliefs are shown in tables 3 and 4.

    Table 3

    Relevant Theoretical Domains Framework domains, belief statement and representative quotes in patients

    Table 4

    Relevant Theoretical Domains Framework domains, belief statement and representative quotes in healthcare professionals

    Knowledge and awareness

    Most HCPs mentioned that their awareness and knowledge and that of colleagues on the climate impact of inhalers was insufficient for climate-friendly inhaler prescription. The importance of increasing awareness among HCPs was mentioned in five focus groups. The importance of awareness on the topic among patients was specifically mentioned once. HCPs expressed the need for more knowledge and education with evidence-based information on the subject both on the climate impact of inhalers and the effectivity of the different types of devices.

    Role identity

    In the majority of the focus groups, patients assigned themselves either no role or a very minimal role in choosing an inhaler. Patients indicated having a limited insight into the pros and cons, and they expected to have little influence on the policy regarding inhalers.

    HCPs shared the view that the patient’s role is limited. They do believe they have a role in a more climate-friendly prescribing policy but also emphasised the role of other parties such as healthcare insurers, manufacturers and guideline- and formulary developers.

    Focus group, patients, no. 4

    I think (the patient) might have difficulty overseeing that because besides the fact that you are already discussing with your doctor or nurse which medication is right for you, you would also have to assess the environmental impact of all these different drugs. I don’t think that’s up to the patient.

    Focus group, secondary care HCPs, no. 2

    We really look at the precepts for people and how to deal with them. And as a nursing specialist, you look at quality and we don’t include this. While for people with asthma and COPD, this can impact their lives. So I think our role is bigger than I realized.

    Relative importance of climate impact

    The majority of participants across all focus groups believe that the patient’s interests must remain paramount in a more climate-friendly inhaler-prescribing policy. For example, it should not compromise the effectiveness or compliance of treatment. But when explicitly asked about the ease of use and costs, some participants mentioned these factors as possible concessions. HCPs would additionally consider making more concessions if that would be the patients’ preference.

    Beliefs about consequences

    Negative effects on freedom of choice

    HCPs and patients highlighted the importance of their freedom of choice when selecting an inhaler. Patients expressed this with statements such as ‘not being forced’ and ‘deciding together with the HCP’. Patients repeatedly mentioned they want to keep the ability to switch back to the current inhaler if they are not satisfied with the more climate-friendly inhaler. According to most participants, HCPs should not be hindered in prescribing pMDIs.

    Opinions differed on the extent to which the proposed recommendation provided sufficient freedom of choice. Some participants mentioned that patient and HCPs could still decide if the DPI is suitable for the patients, while others felt the recommendation was too much directing HCPs’ choice. The influence of healthcare insurance companies on the reimbursement of inhalers is viewed as a risk to HCPs’ and patients’ freedom of choice if the proposed guideline recommendation were to be implemented. Participants mention negative experiences with the current inhaler policy, where patients have to switch inhalers due to a change in preference policies.

    Focus group, secondary HCPs, no. 2

    You have to keep space for the other group as well, you can steer a bit. But there is also a group of patients for whom the MDI is the first choice. And it should remain possible to prescribe it (pMDI) to them. And if it is stated so firmly, we are afraid, knowing our healthcare insurers, that they will simply buy the […] open-label alternative devices on a very large scale. And (they will say) that MDI we’ll only do for ten percent (of the patients). You can choose which ten percent, but we can’t do more. I don’t want that, that’s not good, there should be a bit more space, bandwidth.

    Focus group, patients, no. 4

    I think in the end you should decide together what is best for the patient. And if there is any doubt, you should at least, as we just mentioned, allow a trial period to see if that is indeed the best option, but keep the flexibility to be able to return to what you responded well to and what has been the best treatment so far.

    Fear of negative response from patients

    In four focus groups, HCPs expected a negative response from patients regarding climate-friendly inhaler prescriptions. For instance, HCPs were concerned that patients might think the climate is prioritised over their health or that there is a financial incentive. In one focus group, the risk of jeopardising the relationship of trust with the patient is mentioned.

    However, some HCPs indicated that they had received mostly positive reactions from patients after mentioning climate impact in the decision process. HCPs expressed the need for clear visual patient education material to facilitate communication.

    Focus group, secondary HCPs, no. 2

    Sometimes you are already glad you managed to get a certain part of your message across. So with more information, it just gets even more confusing. Because then you will get these stories of, I don’t want that, but the doctor makes me take another inhaler because of the climate.

    Negative effects on patients’ health

    Participants discussed the effect of climate-friendly inhaler prescription on patients’ health in three focus groups with HCPs and all focus groups with patients. They mentioned risks for patient’ health but did not always specify the extent to which they expect these risks.

    Patients mentioned the fear of receiving medication which is less effective or less easy to use.

    HCPs’ name the risk of deterioration when inhalers are changed in frail patients, the risk of patients making a choice that is less beneficial to their health for climate reasons. HCPs mentioned the specific risk of the proposed guideline recommendation that without careful consideration, HCPs might prescribe a DPI in new patients even when it is inappropriate for that patient.

    Overall, both patients and HCPs thought that the proposed guideline would be most feasible for new patients, since they already need to learn how to use their new inhaler and do not yet have any comparison with a current inhaler.

    Beliefs about pMDIs versus DPIs as the mediating factor

    We previously described how patients and HCPs prioritised patients’ interest regarding the choice of an inhaler. A notable difference is seen in beliefs about the effectiveness and eligibility of DPIs and pMDIs among HCPs. Both HCPs who prefer the DPI and those who prefer a pMDI gave overlapping reasons for this, such as higher effectiveness, greater ease of use and lower risk of critical errors. HCPs suggested several factors associated with these variations in beliefs. They mentioned differences in the patient population they serve (patients with more severe pulmonary diseases using pMDIs more often), the level of experience in choosing inhalers (less-experienced HCPs choosing pMDIs more often) and the culture surrounding inhaler prescription in which prescribing a pMDI is most common. The promotion of pMDIs by the pharmaceutical industry in past years was mentioned as a contributing factor. It was also mentioned that prescription behaviour has not yet evolved with the improved ease of use of DPIs.

    Emotions caused by conflicting attitudes and beliefs

    A tense atmosphere was noticed during two focus groups with patients. Some patients expressed conflicting beliefs. On the one hand, they expressed their motivation to reduce their climate impact, while on the other hand, they felt little space for this because of their need for medication. They do not want to compromise too much on their treatment and (expect to) have little influence on the inhaler prescription policy. Besides that, some patients felt unpleasantly surprised by the topic of the focus group, which was different from what they expected.

    Focus group, patients, no. 3

    I like being invited and I’m happy to participate, but I feel a bit tricked. For I am a patient and I need this and now I have to check- And that in itself is good, but […] I thought, gee, I am so happy with this thing and now I hear that it contains CO2, that doesn’t make me happy.

    Collaboration

    In four focus groups, HCPs emphasised the need for support from and collaboration with different stakeholders in the field of inhalers, such as peers, guideline developers, pharmacists and healthcare insurers, which some currently found insufficient.

    Both healthcare insurers mentioned that they and their healthcare insurance company are increasingly aware of the climate impact of healthcare and medication, though specific knowledge on the climate impact of inhalers is lacking. They see a role for healthcare insurers when it comes to sustainable healthcare, but encouraging a more climate-friendly prescribing policy for inhalers, as examined in this study, does not currently happen.

    Participants identified a number of barriers to adopting a more climate-friendly inhaler policy. At first, the difficulty in assessing the heterogeneous information about climate impact provided by manufacturers. Second, healthcare insurers’ hesitation to influence the prescription behaviour of HCPs, expecting resistance from patients, HCPs and manufacturers and the risk of decreasing treatment effectivity and lastly the risk of increasing insurance costs.

    To our knowledge, this is the first qualitative study exploring the level of knowledge and awareness on climate impact in patients and HCPs, their attitude towards climate-friendly inhaler prescription and usage and possible factors related to their attitude and behaviour.

    In general, participants expressed a generally high level of motivation for more climate-friendly inhaler prescription, which is an enabler for implementation. They endorsed the importance of considering climate impact, but currently rarely consider it when prescribing. We identified several possible factors influencing this discrepancy between perceived importance and motivation and current behaviour.

    First, knowledge and awareness of the climate impact of inhalers was clearly higher in HCPs than in patients. However, in line with previous research, HCPs still mention a lack of knowledge, information and perceived competence to consider climate impact when prescribing inhalers, which might hinder climate-friendly inhaler prescription.21 25

    Besides this, according to both patients, HCPs and previous studies, the patient’s interest and health must remain paramount and is prioritised above the climate impact of inhalers.19 20 25 Participants expressed concerns about the possible negative consequences of climate-friendly inhaler prescription for patients and HCPs, which may act as barriers to implementation. First, they expressed concerns about negative health effects for patients which were partly related to their beliefs about different inhalers. Interestingly, notable differences existed between HCPs’ perceptions of the effectiveness of different types of inhalers, while convincing evidence of a difference in effectiveness between DPIs and pMDIs is lacking.26 Second, regarding the proposed guideline recommendation in particular, HCPs and patients fear the risk of losing their freedom to choose the type of inhaler. This may be related to previous negative experiences with healthcare insurers changing the reimbursement of inhaler devices. Third, HCPs expressed the fear of negative response from patients when suggesting switching to a climate-friendly inhaler, though this was mostly not based on their own experiences discussing climate impact.

    Lastly, the perceived contradiction between the motivation of patients to reduce climate impact on the one hand and the concerns about (negative) consequences of climate-friendly inhaler prescription on the other hand caused cognitive dissonance. The limited influence patients attribute to themselves in inhaler prescription and their dependency on the medication might reinforce such feelings. Cognitive dissonance, defined as a feeling of discomfort that occurs when an individual behaves in a way that is inconsistent with his attitudinal beliefs, has previously been described in other studies on climate- and environment-friendly consumer choices and may hinder implementation.27

    Raising awareness and improving specific knowledge about inhalers’ climate impact in patients and HCPs is essential for successfully implementing a climate-friendly prescribing policy of inhalers. As participants assign a more significant role to HCPs than to patients, the focus should be on HCPs. They should be educated on both the effectiveness and climate impact of different inhaler devices and how to assess if patients can safely use a DPI. This education is most effective when it is personalised, evidence-based and provided for small and targeted groups of HCPs, like academic detailing and educational outreach.28 29 Moreover, (digital) decision support systems, for instance, implemented in the drug prescription programme, can guide and support HCPs in the decision process in a standardised way.30 Providing clear patient education material can support HCPs in discussing the topic with patients.

    Moreover, it is considered important by HCPs that the approach is multidisciplinary, broad-based and supported by policy- and guideline developers. In the Netherlands, a consensus statement from all stakeholders in the field of respiratory medicine about climate-friendly inhalers is lacking. Such a statement and broad-based prescription policy are necessary. In addition, climate-friendly prescribing can be improved by providing more guidance in the Dutch guideline for the treatment of asthma and COPD on how climate should be taken into account and how to assess whether someone can safely use a DPI. These interventions may help HCPs feel more competent and supported in prescribing in a more climate-friendly way and discussing the topic with patients. At a lower level, HCPs, for example, pharmacists and prescribers in general practice, can develop agreements on climate-friendly prescribing within their regional network. Here it may help to look for success stories and opinion leaders from regions or practices where this has been done before.

    Lastly, to gain support for the policy among patients, it is essential to ensure and communicate clearly that patients, who are often highly dependent on their inhaler medication, can keep using the inhaler that is best for them, without additional individual costs. To achieve this, involvement of healthcare insurers in the policy development is necessary, and a patient-centred approach in communication and patient education can enhance their support.31 32

    The design of our study had several strengths. First, a varied sample of patients and HCPs participated in this study, resulting in a multidimensional view on the topic. Second, due to the blind selection, the risk of selection bias regarding participants’ attitude towards climate-related topics is low.

    There were some limitations in our study as well. First, our topic guide is informed by the TDF, but we did not do a comprehensive TDF-based analysis and did not address all domains one by one for feasibility reasons. As a result, relevant domains might not have emerged. Nonetheless, the topic list mainly consisted of open-ended questions, leaving participants free to discuss the topics that were most relevant to them and providing a broad view on the topic. We expect that we have thereby identified the most important factors of influence. Second, in some focus groups, mainly those with patients, signs of conformism were observed, for there was little variation in opinions between participants.

    Due to the qualitative design of this study, it is unclear how strong the correlation is between the identified factors and willingness to adopt or implement a climate-friendly guideline recommendation. Also, it is unknown to what extent these factors are valid in a wider population. Further quantitative research is needed for triangulation of the results.

    Data are available upon reasonable request.

    Consent obtained directly from participants.

    This study involves human participants. The Medical Ethics Committee at Leiden University Medical Centre determined that the Dutch Medical Research Involving Human Subjects Act did not apply to the study (22-3037). Participants gave informed consent to participate in the study before taking part.

    The authors would like to acknowledge Eva Roos, BSc, medical student at Leiden University for her support in collecting and analysing the data; Niels H. Chavannes and Evelyn A. Brakema, Department of Public Health and Primary Care at Leiden University Medical Centre; Peter Th. W. van Hal, Pieter ten Have, Pauline de Heer and Geert-Jan van Kemenade from the National Health Care Institute; and Iris M. Wichers from the Dutch College of General Practitioners (NHG) for their support in the design of this study.

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