Cupping therapy is defined as a therapeutic treatment using evacuated cups being placed to intact or scarified skin to withdraw blood and interstitial fluid filled with causative pathological substances. Clinical practice guideline is crucial to assist in decision making during patient care and promote standardized care which helps to increase quality and patient outcome. Adherence to cupping practice guideline was considered low at 5.3% in prior study (Mahat & Rahman, 2020). Hence, this study aimed to explore barriers of cupping practitioners’ adherence to Malaysian cupping practice guideline. This qualitative study involved three cupping practitioners who agreed to semi-structured interviews. Several barriers of practice guideline use were identified using thematic analysis. Among these are increased cost, lack of practice resources, lack of time, inadequate knowledge on the guideline, lack of agreement, and lack of feeling expectancy. Furthermore, being surrender or tawakkal is notified as a newly emerged barrier from the analysis. Specific measures addressing those should be disseminated and implemented, such as to streamline educational training in enhancing guideline familiarity. Besides, it is essential to have reminder systems such as notification pop-out, email, face-to face session and management chain to assist in guideline use

Cupping therapy or bekam, is among the most preferred traditional medicine among Malaysian population, as reported in the National Health & Morbidity Survey (NHMS) 2015. Even though adherence to practice guideline is crucial to improve the quality of care of patients, less data have been published to support the adherence (Chen, 2018). Hence, this study aimed to determine the level of adherence, knowledge, attitude towards cupping practice guideline among Malay cupping practitioners, factors associated with it, and to explore barriers of guideline use. This was an explanatory sequential mixed method research, involving two phases of quantitative and qualitative study. The first phase which involved 114 respondents selected via convenience sampling, found that adherence to cupping practice guideline was 76.3%. The highest adherence component was wearing gloves during treatment, at 86.0%. In terms of knowledge, 60.5% of respondents had adequate knowledge. Majority of the respondents agreed HIV, hepatitis B and hepatitis C can be transmitted through cupping if practitioner does not comply with infectious disease control measures, at 94.5%, 86.9% and 83.1% respectively. As for attitude, 99.1% of respondents agreed and strongly agreed that cupping guidelines were useful sources of advice, nonetheless, 26.9% had difficulty in changing their routine and habits to follow the guidelines. General linear model revealed that practitioners who had 10 patients treated per week had higher adherence score by 3 points (p=0.002). Females had significantly higher adherence score as compared to males by 5 points at p=0.010, and higher education (PhD, master, and degree) and diploma had significantly higher adherence score as compared to primary and secondary level of education at p=0.001 and p=0.005, respectively. The second phase involving three participants found the interpretation of the qualitative findings seen together with the quantitative data, showed the barriers to be increase cost, lack of agreement with the guideline, and lack of knowledge on the guideline. The findings of this study allude several implications, namely the provision of new data on the adherence to practice guideline and factors associated with it, and able to address ongoing education and competency. In conclusion, of all respondents, three quarter of them adhered to cupping practice guideline. In addition, more than half had adequate knowledge on cupping, and one quarter had difficulty in changing routine. Factors associated with adherence were number of patients treated per week, gender, and education levels. Barriers identified were cost increament, lack of agreement with the guideline, and lack of knowledge on the guideline.