Exploring Barriers to Medication Adherence Using COM-B Model of Behaviour Among Patients with Cardiovascular Diseases in Low- and Middle-Income Countries: A Qualitative Study

Abstract

Pallavi Mishra,1 Ajay S Vamadevan,1,2 Ambuj Roy,3 Rohit Bhatia,4 Nitish Naik,3 Sandeep Singh,3 Gideon Senyo Amevinya,5 Ernest Amoah Ampah,5 Yolanda Fernandez,6 Caroline Free,7 Amos Laar,5 Dorairaj Prabhakaran,1,8,9 Pablo Perel,6 Helena Legido-Quigley10,11 1Health Systems Unit, Centre for Chronic Disease Control, New Delhi, India; 2Goa Institute of Management, Goa, India; 3Department of Cardiology, All India Institute of Medical Science, New Delhi, India; 4Department of Neurology, All India Institute of Medical Science, New Delhi, India; 5Department of Population, Family & Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana; 6Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK; 7Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK; 8Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; 9Research and Policy, Public Health Foundation of India, Gurugram, India; 10Saw Swee Hock School of Public Health, National University of Singapore, Singapore; 11Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UKCorrespondence: Pablo PerelCentre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UKTel +44 20 7636 8636Email Pablo.Perel@lshtm.ac.ukIntroduction: In 2016, cardiovascular diseases (CVDs) led to 17.9 million deaths worldwide, representing 31% of all global deaths. CVDs are the leading cause of mortality worldwide and significant barriers to achieving the sustainable development goals. Modern medicines have been significant in improving health outcomes. However, non-adherence to medication is one of the reasons behind adverse health-related outcomes among patients suffering from atherosclerotic cardiovascular disease in low- and middle-income countries.Patients and Methods: This qualitative study was conducted at two tertiary care hospitals in India and Ghana. A total of 35 in-depth interviews were conducted with atherosclerosis cardiovascular disease (ASCVD) patients. The data were analysed thematically using the Capability Opportunity and Motivation (COM-B) framework.Findings: The findings were summarised under three important broad themes of the COM-B framework: capability, opportunity and behaviour. Under capability, comprehension of disease, medication schedule, and unplanned travel affected adherence among patients. Cost of medication, insurance and access were the critical factors under opportunity, which negatively influenced medication adherence. Mood, beliefs about treatment and outcome expectations under motivation led to non-adherence among patients. Apart from these factors, some important health system factors such as health care experience and trust in the facilities and reliance on alternative medication also affected adherence in both countries.Conclusion: This study has highlighted that the health system factors have dominantly influenced adherence to medication in India and Ghana. In India, we found participants to be satisfied with their health care provided at the government hospitals. However, limited time for consultation, lack of well-stocked pharmacy and unclear prescription negatively influenced adherence among participants in India and Ghana. The study emphasises that the health system needs to be strengthened, and the patients' belief system needs to be explored to address the issue of medication adherence in LMICs.Keywords: non-communicable diseases, atherosclerotic cardiovascular disease, public health, qualitative research