Implementation of fixed-dose combination therapy for secondary prevention of atherosclerotic cardiovascular disease among Syrian refugees in Lebanon: a qualitative evaluation

Abstract

Background We report findings of a qualitative evaluation of fixed-dose combination therapy for patients with established atherosclerotic cardiovascular disease (ASCVD) attending Médecins Sans Frontières (MSF) clinics in Lebanon. Cardiovascular disease is a leading cause of death and disability worldwide, and humanitarian actors are increasingly faced with the challenge of providing care for chronic diseases such as ASCVD in settings where health systems are disrupted. Secondary prevention strategies, involving 3–5 medications, are known to be effective for patients at risk of heart attack or stroke, but supply and adherence are challenging in humanitarian settings. Fixed dose combination therapy, combining two or more medications in one tablet, may be a strategy to address this. Methods The evaluation was nested within a prospective mixed-methods study in which eligible ASCVD patients were followed for 1 year during (i) 6 months of usual care then (ii) 6 months of fixed dose combination (FDC) therapy. After 1 year, we conducted in-depth interviews with a purposive sample of patients, MSF staff and external stakeholders. Interviews focused on acceptability and sustainability of the fixed dose therapy intervention. Interview data were analysed thematically, informed by thea Theoretical Framework of Acceptability. Additional attention was paid to non-typical cases in order to test and strengthen analysis. Results Patients and health care providers were positive about the FDC intervention. For patients, acceptability was related to ease of treatment and trust in MSF staff, while, for staff, it was related to perceived improvements in adherence, having a good understanding of the medication and its use, and fitting well with their priorities for patient’s wellbeing. External stakeholders were less familiar with FDC therapy. While external clinicals expressed concerns about treatment inflexibility, non-clinician stakeholder interviews suggested that cost-effectiveness would have a major influence on FDC therapy acceptability. Sustainability was tied to the future role of MSF care provision and coherence with the local health system. Conclusions For patients and clinic staff, FDC was an acceptable treatment approach for secondary prevention of ASCVD disease in two MSF clinics in Lebanon. Sustainability is more complex and calls for better alignment of care with public systems.

Fixed dose combination drugs for cardiovascular disease in a prolonged humanitarian crisis in Lebanon: an implementation study

“…Our qualitative analysis, reported separately, also supports our main findings, with the majority of patients reporting that it was easier to adhere to taking the FDC than to taking the three component drugs separately 35. We note that medication was also provided free-of-charge to patients by MSF, which would have facilitated retention in care and adherence.…”

“…Our qualitative analysis, reported separately, also supports our main findings, with the majority of patients reporting that it was easier to adhere to taking the FDC than to taking the three component drugs separately. 35 We note that medication was also provided free-of-charge to patients by MSF, which would have facilitated retention in care and adherence. There is ample evidence showing that NCD patients in Lebanon and Jordan prioritise a regular medication supply over other elements of care, and that access to consistent, affordable NCD medications remains challenging.…”

“…The implementation outcomes, acceptability and sustainability, are reported in our related qualitative paper, and costs will be reported separately. 35 …”

“…Here, we report on adherence measures, including self-reported medication adherence, changes in CVD risk factor levels (systolic blood pressure (SBP) and non-high density lipoprotein (HDL) cholesterol) and adverse events. The implementation outcomes, acceptability and sustainability, are reported in our related qualitative paper, and costs will be reported separately 35…”

Acceptability of fixed-dose combination treatments for hypertension in Kenya: a qualitative study using the Theoretical Framework of Acceptability

“…To conceptualize acceptability of FDC treatments for hypertension, we used the Theoretical Framework of Acceptability (TFA) (19). TFA has been applied in implementation research across a range of settings and health domains, including for a hypertension and CVD management in LMIC settings (20, 21). TFA identifies seven component constructs contributing to acceptability of healthcare interventions.…”