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Original Research

Exploring the Barriers to and Facilitators of Using Evidence-Based Drugs in the Secondary Prevention of Cardiovascular Diseases: Findings From a Multistakeholder, Qualitative Analysis

Authors:

Victoria Miller,

Population Health Research Institute, McMaster University, Hamilton, Ontario, CA
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Lavanya Nambiar,

Public Health Foundation of India, New Delhi, IN
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Malvika Saxena,

Public Health Foundation of India, New Delhi, IN
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Darryl Leong,

Population Health Research Institute, McMaster University, Hamilton, Ontario, CA
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Amitava Banerjee,

Farr Institute of Health Informatics Research, University College of London, London, GB
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José Pablo Werba,

Istituto Di Ricovero e Cura a Carattere Scientifico, Milan, IT
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Jose Rocha Faria Neto,

Pontificia Universidade Católica do Paraná, Curitiba, BR
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Katherine Curi Quinto,

Instituto de Nutrición y Tecnologia de los Alimentos, Asociación Kausasunchis, Lima, PE
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Mohammed Moniruzzaman,

World Health Organization, Dhaka, BD
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Shweta Khandelwal

Public Health Foundation of India, New Delhi, IN
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Abstract

Background: Health-system barriers and facilitators associated with cardiovascular medication adherence have seldom been studied, particularly in low- and middle-income countries where uptake rates are poorest.

Objectives: This study sought to explore the major obstacles and facilitators to the use of evidence-supported medications for secondary prevention of cardiovascular disease using qualitative analysis in 2 diverse countries across multiple levels of their health care systems.

Methods: A qualitative descriptive study approach was implemented in Hamilton, Ontario, Canada, and Delhi, India. A purposeful sample (n = 69) of 23 patients, 10 physicians, 2 nurse practitioners, 5 Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy physicians, 11 pharmacists, 3 nurses, 4 hospital administrators, 1 social worker, 3 nongovernmental organization workers, 2 pharmaceutical company representatives, and 5 policy makers participated in interviews in Hamilton, Ontario, Canada (n = 21), and Delhi, India (n = 48). All interviews were digitally recorded and transcribed followed by directed content analysis to summarize and categorize the interviews.

Results: Themes that emerged across the stakeholder groups included: medication counseling; monitoring adherence; medication availability; medication affordability and drug coverage; time restrictions; and task shifting. The depth of verbal medication counseling provided varied substantially between countries, with prescribers in India unable to convey relevant information about drug treatments due to time constraint and high patient load. Canadian patients reported drug affordability as a common issue and very few patients were familiar with government subsidized drug programs. In India, patients purchased medications out-of-pocket from private, community pharmacies to avoid long commutes, lost wages, and unavailability of medications from hospitals formularies. Task shifting medication-refilling and titration to nonphysician health workers was accepted and supported by physicians in Canada but not in India, where many of the physicians considered a high level of clinical expertise a precondition to carry out these tasks skillfully.

Conclusions: Our findings reveal context-specific, health system factors that affect the patient’s choice or ability to initiate and/or continue cardiovascular medication. Strategies to optimize cardiovascular drug use should be targeted and relevant to the health care system.

Highlights

  • Health care workers in India did not give adequate medication counseling to patients.
  • Drug affordability was a common issue among patients in Canada and India.
  • Many Canadian patients were unfamiliar with government-subsidized drug programs.
  • Many Indian patients purchased medications out of pocket to ensure consistent access.
  • Shifting many drug-management tasks to nonphysicians was only supported in Canada.
How to Cite: Miller V, Nambiar L, Saxena M, Leong D, Banerjee A, Werba JP, et al.. Exploring the Barriers to and Facilitators of Using Evidence-Based Drugs in the Secondary Prevention of Cardiovascular Diseases: Findings From a Multistakeholder, Qualitative Analysis. Global Heart. 2018;13(1):27–34. DOI: http://doi.org/10.1016/j.gheart.2017.08.001
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Published on 01 Mar 2018.
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