Journal Article > ResearchFull Text
BMC Health Serv Res. 4 June 2022; Volume 22 (Issue 1); 744.; DOI:10.1186/s12913-022-08040-z
Murphy A, Willis R, Ansbro É, Masri S, Kabbara N, et al.
BMC Health Serv Res. 4 June 2022; Volume 22 (Issue 1); 744.; DOI:10.1186/s12913-022-08040-z
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.
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.
Conference Material > Slide Presentation
Ansbro E, Masri S, Prieto-Merino D, Bahous SA, Molfino L, et al.
MSF Scientific Days International 2022. 11 May 2022; DOI:10.57740/mzsh-8t29
Conference Material > Abstract
Ansbro E, Masri S, Prieto-Merino D, Bahous SA, Molfino L, et al.
MSF Scientific Days International 2022. 11 May 2022; DOI:10.57740/8697-vn33
INTRODUCTION
Cardiovascular disease (CVD) is the leading cause of death and disability globally, including in humanitarian contexts. Fixed-dose combination (FDC) drugs are cost-effective for primary and secondary prevention of CVD. From 2012 until the end of 2020, MSF provided care for CVD patients from Syrian refugee and host populations in primary care clinics in Tripoli, north Lebanon. In this implementation study, we assessed whether FDC use is linked with adherence to CVD medications and treatment simplification in a humanitarian setting.
METHODS
Our prospective, before-and-after cohort study followed CVD patients in MSF clinics in Lebanon during two consecutive six month periods. Eligible patients, enrolled February-May 2019, were switched to Trinomia® FDC (atorvastatin 20mg, aspirin 100 mg, ramipril 2.5/5/10/mg) after six months’ usual care. During the study, the Covid-19 pandemic, an economic crisis, and clinic closures occurred. Descriptive and regression analyses compared key outcomes: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) levels, and systolic blood pressure (SBP) control, at six and twelve months. We performed intention-to-treat analyses and secondary analyses of non-switchers.
ETHICS
This study was approved by the MSF Ethics Review Board, the LSHTM Research Ethics Committee, and the Lebanese American University’s Institutional Review Board.
RESULTS
Of 521 enrolled patients, 460 (88.3%) were retained at six months and 418 (80.3%) switched to FDC. By month 12, 84% of switched patients remained on FDC (n=351), 8.1% (n=34) discontinued, and 7.9% (n=33) were lost to follow-up. Among the 385 who initially switched and remained in the study at 12 months, total adherence improved by 23% from 63% (95% confidence intervals (CI) 0.58-0.68) at month six to 86% (95% CI 0.82-0.90) at month 12. Mean non-HDL-C levels dropped 0.28 millimoles/litre (mmol/L; 95% CI -0.38 to -0.1; p=0.000) from 2.39 (95% CI 2.26 - 2.51) to 2.11 mmol/L (95% CI 2.00 - 2.22); mean SBP dropped 3.07 mmHg (95% CI -4.76 to -1.38; p= 0004) from 132.7 (95% CI 130.8 - 134.6) to 129.7 mmHg (95% CI 127.9 - 131.5). Among non-switchers, total adherence was lower and improvements in clinical outcomes were less pronounced.
CONCLUSION
Implementing a CVD secondary prevention FDC was associated with better adherence and intermediate clinical outcomes inan MSF primary care clinic in Lebanon. Further operational experience is needed to ascertain how best to integrate and sustain CVD FDC’s in humanitarian operations. MSF could advocate for their broader use with other humanitarian actors and within public health systems of crisis-affected countries.
CONFLICTS OF INTEREST
None declared.
Cardiovascular disease (CVD) is the leading cause of death and disability globally, including in humanitarian contexts. Fixed-dose combination (FDC) drugs are cost-effective for primary and secondary prevention of CVD. From 2012 until the end of 2020, MSF provided care for CVD patients from Syrian refugee and host populations in primary care clinics in Tripoli, north Lebanon. In this implementation study, we assessed whether FDC use is linked with adherence to CVD medications and treatment simplification in a humanitarian setting.
METHODS
Our prospective, before-and-after cohort study followed CVD patients in MSF clinics in Lebanon during two consecutive six month periods. Eligible patients, enrolled February-May 2019, were switched to Trinomia® FDC (atorvastatin 20mg, aspirin 100 mg, ramipril 2.5/5/10/mg) after six months’ usual care. During the study, the Covid-19 pandemic, an economic crisis, and clinic closures occurred. Descriptive and regression analyses compared key outcomes: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) levels, and systolic blood pressure (SBP) control, at six and twelve months. We performed intention-to-treat analyses and secondary analyses of non-switchers.
ETHICS
This study was approved by the MSF Ethics Review Board, the LSHTM Research Ethics Committee, and the Lebanese American University’s Institutional Review Board.
RESULTS
Of 521 enrolled patients, 460 (88.3%) were retained at six months and 418 (80.3%) switched to FDC. By month 12, 84% of switched patients remained on FDC (n=351), 8.1% (n=34) discontinued, and 7.9% (n=33) were lost to follow-up. Among the 385 who initially switched and remained in the study at 12 months, total adherence improved by 23% from 63% (95% confidence intervals (CI) 0.58-0.68) at month six to 86% (95% CI 0.82-0.90) at month 12. Mean non-HDL-C levels dropped 0.28 millimoles/litre (mmol/L; 95% CI -0.38 to -0.1; p=0.000) from 2.39 (95% CI 2.26 - 2.51) to 2.11 mmol/L (95% CI 2.00 - 2.22); mean SBP dropped 3.07 mmHg (95% CI -4.76 to -1.38; p= 0004) from 132.7 (95% CI 130.8 - 134.6) to 129.7 mmHg (95% CI 127.9 - 131.5). Among non-switchers, total adherence was lower and improvements in clinical outcomes were less pronounced.
CONCLUSION
Implementing a CVD secondary prevention FDC was associated with better adherence and intermediate clinical outcomes inan MSF primary care clinic in Lebanon. Further operational experience is needed to ascertain how best to integrate and sustain CVD FDC’s in humanitarian operations. MSF could advocate for their broader use with other humanitarian actors and within public health systems of crisis-affected countries.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
PLOS One. 10 May 2021; Volume 16 (Issue 5); e0251316.; DOI:10.1371/journal.pone.0251316
Mohamad M, Moussally K, Lakis C, El-Hajj M, Bahous SA, et al.
PLOS One. 10 May 2021; Volume 16 (Issue 5); e0251316.; DOI:10.1371/journal.pone.0251316
INTRODUCTION
Low adherence to medications, specifically in patients with Diabetes (DM) and Hypertension (HTN), and more so in refugee settings, remains a major challenge to achieving optimum clinical control in these patients. We aimed at determining the self-reported medication adherence prevalence and its predictors and exploring reasons for low adherence among these patients.
METHODS
A mixed-methods study was conducted at Médecins Sans Frontières non-communicable diseases primary care center in the Shatila refugee camp in Beirut, Lebanon in October 2018. Data were collected using the validated Arabic version of the 8-items Morisky Medication Adherence Scale (MMAS-8) concurrently followed by in-depth interviews to explore barriers to adherence in patients with DM and/or HTN. Predictors of adherence were separately assessed using logistic regression with SPSS© version 20. Manual thematic content analysis was used to analyze the qualitative data.
RESULTS
Of the 361 patients included completing the MMAS, 70% (n = 251) were moderately to highly adherent (MMAS-8 score = 6 to 8), while 30% (n = 110) were low-adherent (MMAS-8 score<6). Patients with DM-1 were the most likely to be moderately to highly adherent (85%; n = 29). Logistic regression analysis showed that patients with a lower HbA1C were 75% more likely to be moderately to highly adherent [(OR = 0.75 (95%CI 0.63-0.89), p-value 0.001]. Factors influencing self-reported moderate and high adherence were related to the burden of the disease and its treatment, specifically insulin, the self-perception of the disease outcomes and the level of patient's knowledge about the disease and other factors like supportive family and healthcare team.
CONCLUSION
Adherence to DM and HTN was good, likely due to a patient-centered approach along with educational interventions. Future studies identifying additional factors and means addressing the barriers to adherence specific to the refugee population are needed to allow reaching optimal levels of adherence and design well-informed intervention programs.
Low adherence to medications, specifically in patients with Diabetes (DM) and Hypertension (HTN), and more so in refugee settings, remains a major challenge to achieving optimum clinical control in these patients. We aimed at determining the self-reported medication adherence prevalence and its predictors and exploring reasons for low adherence among these patients.
METHODS
A mixed-methods study was conducted at Médecins Sans Frontières non-communicable diseases primary care center in the Shatila refugee camp in Beirut, Lebanon in October 2018. Data were collected using the validated Arabic version of the 8-items Morisky Medication Adherence Scale (MMAS-8) concurrently followed by in-depth interviews to explore barriers to adherence in patients with DM and/or HTN. Predictors of adherence were separately assessed using logistic regression with SPSS© version 20. Manual thematic content analysis was used to analyze the qualitative data.
RESULTS
Of the 361 patients included completing the MMAS, 70% (n = 251) were moderately to highly adherent (MMAS-8 score = 6 to 8), while 30% (n = 110) were low-adherent (MMAS-8 score<6). Patients with DM-1 were the most likely to be moderately to highly adherent (85%; n = 29). Logistic regression analysis showed that patients with a lower HbA1C were 75% more likely to be moderately to highly adherent [(OR = 0.75 (95%CI 0.63-0.89), p-value 0.001]. Factors influencing self-reported moderate and high adherence were related to the burden of the disease and its treatment, specifically insulin, the self-perception of the disease outcomes and the level of patient's knowledge about the disease and other factors like supportive family and healthcare team.
CONCLUSION
Adherence to DM and HTN was good, likely due to a patient-centered approach along with educational interventions. Future studies identifying additional factors and means addressing the barriers to adherence specific to the refugee population are needed to allow reaching optimal levels of adherence and design well-informed intervention programs.