Barriers and facilitators of benzathine penicillin G adherence among rheumatic heart disease patients: a mixed methods systematic review using the COM-B (capability, opportunity, and motivation for behavior) model

Abstract

Background: Benzathine penicillin G (BPG) is a proven preventive agent for preventing the progression of rheumatic heart disease (RHD) and is recognized as a standard of care. However, ensuring adherence to BPG remains a global challenge. The objective of this review was to synthesize the available evidence on the barriers to and facilitators of BPG adherence among RHD patients.

Methods: This systematic review included both qualitative and quantitative studies on RHD patients published in the English language. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search strategy involved PubMed, Embase, CINAHL, Global Health, Scopus, and Web of Sciences databases to identify keywords and terms contained in the title and abstract and the index terms used to describe articles. The review included papers published from January 1, 2000, to March 30, 2024. Two independent reviewers screened, appraised, and extracted the data. The data analysis was carried out deductively to fit onto the components of the COM-B (Capability, Opportunity, Motivation-Behaviour) model.

Results: In this review, 1067 records were screened, and 22 studies with 7338 participants were included. Thirty-five barriers and twenty facilitators were identified and mapped onto COM-B components. Physical capability (e.g., felt healthy), psychological capability (e.g., lack of knowledge), reflective motivation (e.g., poor patient handling), automatic motivation (e.g., BPG injection pain), physical opportunity (e.g., BPG unavailability) and social opportunity (e.g., inadequate counseling) were identified as barriers. The most discussed barrier was automatic motivation, followed by psychological capability and physical opportunity.

Conclusions: Our review revealed variable levels of BPG adherence across studies and identified significant barriers and facilitators. Further research is recommended to identify contextual interventions to address barriers and capitalize on facilitators.

Systematic review registration: PROSPERO CRD42024535398.

Keywords: Adherence; Barriers; Benzathine Penicillin G; Facilitators; Rheumatic heart disease.

Fig. 1

COM-B model [24]

Fig. 2

Behavioral change wheel [16]

Fig. 3

PRISMA flow diagram of the search and study selection process [28]