An investigation of patients’ adherence to secondary preventive medications for stroke, and an exploration of the role of hospital pharmacists in the secondary prevention of stroke in the Kingdom of Saudi Arabia (KSA): a mixed method study

Alqahtani, Saeed ORCID: 0000-0003-2954-854X (2023). An investigation of patients’ adherence to secondary preventive medications for stroke, and an exploration of the role of hospital pharmacists in the secondary prevention of stroke in the Kingdom of Saudi Arabia (KSA): a mixed method study. University of Birmingham. Ph.D.

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Abstract

Background: A range of pharmacological treatments are supported by scientific data to lower the risk of stroke recurrence. However, it is known that non-adherence to secondary preventative medications is common amongst stroke patients, which negatively impacts patient outcomes. Understanding the factors that influence adherence and non-adherence can allow the development of interventions to promote adherence. In addition, evidence indicates that a variety of pharmacist interventions, particularly their role in increasing medication adherence among stroke patients, is able to enhance patient outcomes. This study aimed to investigate stroke patients’ adherence to secondary preventive medications and explore the role of the hospital pharmacists in secondary prevention and the management of stroke in the Kingdom of Saudi Arabia (KSA).

Methods: A pragmatic, mixed-methods sequential exploratory study was conducted. Firstly, a systematic review and meta-analysis were performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to explore the role and outcomes of pharmacists’ interventions in relation to pharmaceutical care for the primary and secondary prevention of stroke. Secondly, a cross-sectional study was conducted with a convenient sample of Saudi stroke patients to measure patients’ adherence to medications prescribed for secondary prevention using a validated Arabic version of the Hill-Bone Medication Adherence Scale (HB-MAS) and multivariate linear regression. Following that, semi-structured interviews were conducted with a purposive sample of stroke patients who had been recruited in the previous cross-sectional study with the sub-optimal/optimal adherence groups. This qualitative study used the theoretical domains framework (TDF) and directed content analysis to explore the facilitators and barriers to medication adherence for the secondary prevention of stroke from the perspective of stroke patients. Finally, semi-structured interviews were performed with a purposive sample of Saudi hospital pharmacists to assess their experience and practice in the secondary prevention of stroke, with thematic analysis used to analyse the data.

Results: The systematic review and meta-analysis included 31 studies; seven studies addressed the role of pharmacists in primary prevention and 24 in secondary prevention of stroke. The pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported statistically significant improvements in outcomes associated with medicines optimisation, risk factor modification, medicines adherence, and health-related quality of life (HRQoL) because of pharmacists’ input into patient care. Where measured, clinical outcomes in the secondary prevention of stroke (such as hospital readmission, thromboembolic events, and bleeding rates) were also improved. Importantly, meta-analysis of seven studies showed pharmacist intervention in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 minutes, odds ratio: 2.69 [95% confidence interval [CI]: 1.95-3.72]; p<0.001.

The cross-sectional study showed that the level of stroke secondary preventive medications (SSPM) adherence was 72.3%, with a suboptimal adherence to SSPM. Males (224) showed suboptimal adherence (n= 170, 75.9%); more than females (119) (n=78, 65.5%), which was statistically significant (chi-square=4.15, p-value=.042). The average age was significantly higher in the group with suboptimal adherence (69.65 years) compared to the group with optimal adherence (64.33 years) and Mann–Whitney U (n optimal adherence=95, n suboptimal adherence=248) =2.165, p-value=0.03. Binary regression analysis revealed that per participant, the number of strokes (OR=1.779, 95% CI: 2.03 - 17.30, p-value=.001), and number of other medications used (OR=1.61, 95% CI: 1.26 - 2.05, p-value<.001) were significantly associated with suboptimal adherence.

Numerous facilitators and barriers that influenced SSPM adherence were identified in the patient interview study. Fear of suffering another stroke, knowledge of SSPM, realisation of SSPM benefits in life expectancy and improving quality of life, family support, and establishing SSPM as a habit were identified as facilitators. On the contrary, SSPM barriers related to a lack of understanding regarding stroke and SSPM, forgetting to take medications, the ability for self-care and social influence, as well as certain religious beliefs.

The pharmacist interview study found that most hospital pharmacists expressed good knowledge in regards to secondary stroke prevention. Additionally, most of the pharmacists recruited in the study were aware of the guidelines, such as the American Stroke Association (ASA) for the prevention and treatment of stroke. Some study participants stressed the need for adequate training and specialised stroke clinics within hospitals to effectively deal with stroke patients. Similarly, most of the participants outlined the lack of collaboration between the physicians. Many pharmacists were aware of their responsibility to improve patient medication adherence.

Conclusion: This research study reveals certain factors that influence stroke patients’ adherence; and suggests possible solutions to increase stroke patients’ awareness of the importance of adhering to SSPM. Subsequently, the findings will provide future researchers and decision-makers with an extensive range of factors that might be considered when setting targets for interventions to improve adherence in the stroke population. Furthermore, this research can provide important recommendations regarding pharmacists and healthcare system roles in promoting medication adherence and seamless care of stroke patients.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):