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Original research article
Health system barriers and facilitators to medication adherence for the secondary prevention of cardiovascular disease: a systematic review
  1. Amitava Banerjee1,
  2. Shweta Khandelwal2,
  3. Lavanya Nambiar2,
  4. Malvika Saxena2,
  5. Victoria Peck3,
  6. Mohammed Moniruzzaman4,
  7. Jose Rocha Faria Neto5,
  8. Katherine Curi Quinto6,
  9. Andrew Smyth3,
  10. Darryl Leong3 and
  11. José Pablo Werba7
  1. 1Farr Institute of Health Informatics Research, University College London, London, UK
  2. 2Public Health Foundation of India, New Delhi, India
  3. 3Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
  4. 4WHO Bangladesh, Dhaka, Bangladesh
  5. 5Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
  6. 6Instituto de Nutrición y Tecnología de los Alimentos, Asociación Kausasunchis—ADEK Perú, Lima, Peru
  7. 7Centro Cardiologico Monzino, IRCCS, Milan, Italy
  1. Correspondence to Dr Amitava Banerjee; ami.banerjee{at}


Background Secondary prevention is cost-effective for cardiovascular disease (CVD), but uptake is suboptimal. Understanding barriers and facilitators to adherence to secondary prevention for CVD at multiple health system levels may inform policy.

Objectives To conduct a systematic review of barriers and facilitators to adherence/persistence to secondary CVD prevention medications at health system level.

Methods Included studies reported effects of health system level factors on adherence/persistence to secondary prevention medications for CVD (coronary artery or cerebrovascular disease). Studies considered at least one of β blockers, statins, angiotensin–renin system blockers and aspirin. Relevant databases were searched from 1 January 1966 until 1 October 2015. Full texts were screened for inclusion by 2 independent reviewers.

Results Of 2246 screened articles, 25 studies were included (12 trials, 11 cohort studies, 1 cross-sectional study and 1 case–control study) with 132 140 individuals overall (smallest n=30, largest n=63 301). 3 studies included upper middle-income countries, 1 included a low middle-income country and 21 (84%) included high-income countries (9 in the USA). Studies concerned established CVD (n=4), cerebrovascular disease (n=7) and coronary heart disease (n=14). Three studies considered persistence and adherence. Quantity and quality of evidence was limited for adherence, persistence and across drug classes. Studies were concerned with governance and delivery (n=19, including 4 trials of fixed-dose combination therapy, FDC), intellectual resources (n=1), human resources (n=1) and health system financing (n=4). Full prescription coverage, reduced copayments, FDC and counselling were facilitators associated with higher adherence.

Conclusions High-quality evidence on health system barriers and facilitators to adherence to secondary prevention medications for CVD is lacking, especially for low-income settings. Full prescription coverage, reduced copayments, FDC and counselling may be effective in improving adherence and are priorities for further research.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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