Barriers and facilitators to implementing guideline-based asthma management in Somaliland: a CFIR-informed cross- sectional study of physicians

Background Adherence to asthma management guidelines remains inconsistent in many healthcare settings, particularly in low-resource contexts. Identifying determinants that influence guideline implementation is essential for improving asthma care. This study assessed healthcare providers’ adherence to guideline-based asthma management in Somaliland and identified perceived barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR). Methods A cross-sectional survey was conducted among physicians in Somaliland. Data were collected using a structured questionnaire assessing provider characteristics, knowledge of asthma guidelines, attitudes toward guideline use, self-efficacy and practice behaviours, and perceived barriers to and facilitators of adherence. Descriptive statistics summarized responses, and logistic regression was used to examine associations between adherence and selected predictors. Findings were mapped to CFIR domains to identify multilevel implementation determinants. Results A total of 147 physicians participated. Overall, 57% demonstrated good knowledge of asthma management guidelines and 78% reported positive attitudes toward guideline use, while 54.4% reported good adherence to guideline-based asthma management. The most frequently reported barriers included poor patient adherence to treatment (83.0%), lack of diagnostic tools such as spirometry (78.3%), limited access to asthma educators (76.8%), and limited availability of inhaler devices (73.5%). Key facilitators included regular asthma guideline training (85.7%), sufficient consultation time (85.7%), and improved availability of inhaler devices (83.7%). Conclusion Adherence to asthma management guidelines in Somaliland is influenced by determinants including provider knowledge, health system resources, and patient-related factors. Implementation strategies addressing training, diagnostic capacity, medication access, and patient education are needed to improve guideline uptake and strengthen asthma care delivery.