Table 5 Summary of qualitative findings with example quotations

Provider-Centred Themes

Use of risk charts by doctors

Although some doctors used the charts correctly, there was generally confusion about when to use the charts, and an inability to calculate a risk score during the first consultation without cholesterol information

“Yes, they are 90 years old. When I look at them”, “Okay, we will not do the risk assessment for this patient”. Because I don’t know how.” – Doctor D

“So if it’s the first time the patient is coming I need to wait for the labs to calculate what the percentage is.” – Doctor A

“I think I’m using it with most of patients because the score gives you a clear idea about the risk and how to react so I depend on it a lot.”– Doctor B

Choosing risk factor measurements for calculation of risk score

Diverse and incorrect methods used when recording and choosing risk factor measurements for the calculation of a risk score

“most of the time I use the highest [reading] to be in the safe side.” – Doctor B

“The lower reading I take it.” – Nurse A

“Some patients when we measure blood pressure it is 210. At that visit they are 210/120 something like that, so I can’t do it. I postpone the risk assessment to the next visit when we have better reading.”– Doctor D

Tendency to favour lifestyle interventions as first line therapy

Doctors tended to favour lifestyle intervention over drug intervention even in patients where drug intervention was indicated

“[if] the cardiovascular risk is 20–30 [%], we can decrease it by normalization of blood pressure that’s high and the cholesterol level if it’s high, we can give him 3 months to 4 months diet and then recheck it. If it’s still high we can start statin to reduce it.” – Doctor C

“Yes, so do the first line and then pharmacological treatment.” – Doctor E

“The patient in the first maybe refuse to take the statin. We give him a chance for 3 month to change the lifestyle, to change about diet, about their physical activity.” – Nurse D

Doctors’ understanding and use of drug treatment

Doctors had a good understanding of the use of lipid-lowering treatment in secondary prevention but some weren’t certain about the role of treatment in primary prevention

“Nowadays, up till now, the studies said that there’s no role for statin as primary prevention that’s what I know. So no, I don’t start statin, if the cholesterol level is normal, as a primary prevention.”– Doctor B

“Yes, if the patient having for example a high risk and previously they’re having ischaemic heart disease or for example peripheral arterial disease, we should prescribe statin even if [cholesterol] is normal.”– Doctor E

Risk Communication

Risk charts were used by doctors to help communicate with patients and make decisions; nurses did not use CVD risk charts, but felt they could be helpful during counselling sessions.

“So we are just, I mean showing indication that you are in the green area, [...] so you don’t need to take aspirin because you might have side effects more than the benefits from aspirin and actually a lot of them they are convinced [...]. So it is very helpful and it is convincing.”– Doctor E

“From my experience the colours are best for our patient from numbers.”

– Nurse E

“When we simplify this [CVD risk chart] for them, they will do just the same. They will drop it and they will start saying”, “Okay. I am 50. I was in the dark red here because my blood pressure was 180 or more so I was in the dark red zone. Now because I quit smoking, I’m here in the orange zone, for example, in the yellow zone. And after that, okay, my blood cholesterol dropped from eight to five.” “So they can just put their own thoughts and as you know, the colour is really useful.”

– Nurse C

Patient-Centred Themes

Patient reaction and adherence to drug intervention

Patients were reluctant to start, stop, or change medication and were often not adherent

“We tell them that I like to add statin a new medication that’s called statin, it’s for cholesterol. And they usually react”, “I don’t have any cholesterol and no I don’t have any problems with my cholesterol,” or “something like that.” – Doctor A

“Many patients when you give a new medication they just”, “No” – Doctor C

“Most of them they don’t have problem with it. A small percentage they don’t want to change their medication…and they are not convinced.”– Doctor E

“Why didn’t you use it? “I didn’t like it, I didn’t feel well,” or, “I felt my blood pressure was down, I didn’t [have] headache, so I didn’t take my drugs.” – Person C

Antagonistic role of health myths

Many health myths existed amongst the Syrian community and these myths can antagonise the advice of clinicians

““If I drink a cup of water plus one tablespoon of vinegar, it’s bad on the cholesterol?” This is a common question.” // “It’s something usually in Facebook.”– Person A

“They are taking an aspirin because they are told that every patient above 40 must take aspirin as prophylactic, yes. They are told not by doctor by neighbours by relatives, yes.” – Doctor C

“Sometimes they accept the neighbours’ opinion more than us.” – Nurse A

“Yes. Many of our women didn’t want to follow diet regimen or DM diet… they want medication to lose weight and they ask about medication.” // “I told them that it’s not useful…but many of them search about them and bring and use.” – Nurse E

Patients’ ability to modify risk factors

Security concerns, socio-economic deprivation, shame, and stress can reduce the ability of patients to adhere to modify their risk factors

“they have a fear of walking outside because they didn’t have an ID or an UNHCR paper so they refuse walking.” – Nurse E

“Some patients gradually decrease their cigarettes, but suddenly when they come” “I increased my consumption.” “Why?” “Because my brother left away in Syria, because my son died, because I need more money.” – Nurse B

“Sometimes our patients are shamed to tell you about that. Just you hear” “you must take vegetables, fruit just one time a week.” “They are still silent, because sometimes they do not have anything. That is the problem. It is better, I think, in the home visit to give a good picture or clear picture” – Nurse F

Health education

Individual health education sessions were often co-opted by more immediate needs of patients; education in a group was seen as more effective

“They’re just continually thinking about that their son was killed and that’s all they can think about…. And then so then the health education portion gets pushed aside because they need to sit and just listen to the patient.” – Person B

“They just keep telling us about what happened in Syria and after they finish, we start our health coaching sessions.” – Nurse C

““I think the refugees become more relax when they talk together, see same cases like”, “I’m not the only one. I have cardio or I have DM there’s a lot of person like me.” It’s more unique. I think it’s more effective than the individual session.”– Person A