Adherence to Secondary Prevention Medications and Factors Influencing Adherence, After Acute Coronary Syndrome in Patient Attending a Tertiary Care Centre Of Nepal: A Descriptive Cross-sectional Study
Conditions: Acute Coronary Syndromes (ACS), Adherence
Sponsor: Institute of medicine, Maharagjung medical campus

 
 
COVER PAGE 
Official Study Title: 
Adherence to Secondary Prevention Medications and Factors influencing Adherence, After 
Acute Coronary Syndrome (ACS) in Patient Attending a Tertiary Care Centre Of Nepal: A 
Descriptive Cross-sectional Study 
NCT Number: 
Unavailable 
Unique Protocol ID: 
290 (6-11) E2 081/ 082 
Sponsor: 
Institute of Medicine, Maharajgunj Medical Campus 
Principal Investigator: 
Abhishek Kumar Shah 
Principal Investigator 
Institute of Medicine, Maharajgunj Medical Campus 
Document Type: 
Study Protocol, Statistical Analysis Plan, and Informed Consent Form 
Document Date: 
December 3, 2025 
Version: 
Version 1.0 
 
 
 
 
 
 
 
 
 
 

 
 
Submitted by 
  
Name                   
:  
Mr. Abhishek Kumar Shah 
Full Qualification       :  
MBBS Student 
Designation         
:  
Student 
Department          
:  
MBBS 
College                
:  
Maharajgunj Medical Campus 
Address                
:  
Maharajgunj, Kathmandu 
Contact no.          
:  
9845061279 
Email                   
:  
shahabhi61@gmail.com   
Detail information of investigators 
  
Principal Investigator 
  
S.N. 
Full name 
Details 
1. 
ABHISHEK KUMAR 
SHAH 
Designation: Student 
Full qualification: MBBS student 
Department: MBBS 
Campus: Maharajgunj Medical Campus 
Mobile no.: 9845061279 
Email: shahabhi61@gmail.com 
  
Co-investigators 
(Please also indicate as Guides and Co-guides under the full names for thesis proposal) 
S.N. 
Full name 
Details 

 
 
1. 
 RAJA KHANAL 
Designation : Assistant professor 
Full qualification : DM cardiology 
Department : Cardiology 
Campus/Institute/Org. : Manmohan 
Cardiothoracic Vascular and Transplant Centre 
Mobile no. : +9779851082406 
2. 
 NARAYAN NEUPANE 
Designation : MEDICAL OFFICER 
Full qualification : MBBS 
Department : MBBS 
Campus/Institute/Org. : MAHARAJGUNJ 
MEDICAL CAMPUS 
Mobile no. : 9867503999 
Email : narayanrm1796@gmail.com 
3. 
 DINESH OD 
Designation: Student 
Full qualification: MBBS student 
Department: MBBS 
Campus: Maharajgunj Medical Campus 
Mobile no.:9842606485 
Email: dineshod2001@gmail.com 
4. 
 AASHIK JHA 
Designation: Student 
Full qualification: MBBS student 
Department: MBBS 
Campus: Maharajgunj Medical Campus 
Mobile no.:9803348704 
Email: Aashik.jha2060@gmail.com 
(Please add rows if needed) 

 
 
  
General information 
●       Name and title of Supervisor (For graduate and post graduate students) 
●       Names and titles of Guide and Co-guides (For thesis) 
●       Address and telephone number(s) of the research site(s) 
●       Name(s) and address(es) of the clinical laboratory(ies) and other medical and/or technical 
department(s) and/or institution(s) involved in the research 
●      Name and address of the sponsor/funder if any. 
  
 
1.   Research title 
ADHERENCE TO SECONDARY PREVENTION MEDICATIONS AND FACTORS 
INFLUENCING ADHERENCE, AFTER ACUTE CORONARY SYNDROME (ACS) IN 
PATIENTS ATTENDING A TERTIARY CARE CENTRE OF NEPAL: A DESCRIPTIVE 
CROSS SECTIONAL STUDY  
 
2.  Project summary (~250 words) 
This study aims to assess adherence to secondary prevention medications among patients in Nepal 
following an Acute Coronary Syndrome (ACS) event and identify factors affecting adherence. ACS, a 
major cause of morbidity and mortality globally and in Nepal, requires effective secondary prevention 
to minimize recurrent cardiovascular events. However, adherence to prescribed medications remains 
low, especially in low- and middle-income countries like Nepal. Poor adherence can lead to increased 
healthcare burden, worsened patient outcomes, and higher mortality rates. To address this, the study 
will evaluate patients’ medication adherence through the MYMEDS questionnaire, a self-reported tool, 
which has been positively received for its simplicity and clarity. 
 
Conducted at the Manmohan Cardiothoracic Vascular and Transplant Centre in Nepal, the study will 
involve a sample of adult patients readmitted or attending follow-ups post-ACS. Convenience sampling 
will be used, targeting approximately 117 patients to account for non-responses. The research will 
gather data on patient demographics, socioeconomic factors, clinical characteristics, and self-reported 
adherence barriers, analyzing these with SPSS to assess correlations with clinical outcomes. 
 
The expected 12-month project will consist of phases for ethical approvals, data collection, analysis, 
and report dissemination. By identifying key barriers to adherence, the study aims to inform targeted 
interventions that could enhance medication adherence, improve long-term cardiovascular outcomes, 
and reduce healthcare burdens in Nepal and other similar settings. 
 
3.      Introduction 
Patients experiencing myocardial infarctions (MI) are at risk of subsequent cardiovascular 
events  and prevention of recurrent events is a major clinical and public health priority (1). 

 
 
Pharmacological therapy plays a key role in the secondary prevention of CVD  and improve 
long term outcomes particularly in patients who have not undergone revascularization via 
percutaneous coronary intervention (PCI) (2–4). Large evidence supports drugs conferring 
mortality benefit from several different classes: antiplatelet agents, angiotensin-converting 
enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta blockers and lipid-
lowering drugs (5–7).  
Adherence to secondary prevention medications following acute coronary syndromes (ACS) 
is a predictor of future major adverse cardiovascular events. Medication usage (and its 
success) requires the coordination of the behaviours of both treating physicians and patients, 
particularly with regards to adherence. Underutilisation of these medications is associated 
with higher risk of major adverse cardiovascular events globally (8). Patients’ poor adherence 
to their medication is a complex problem for health care services, especially in the care of  
heart diseases, for which the correct and effective treatment is essential for a patient’s quality 
of life and survival rate(9). A study had shown that patients who recently experienced a 
myocardial infarction (MI) and did not adhere closely to their prescribed regimen were 2.6 
times more likely to die within a year following the MI compared with those who followed 
their regimen more closely (10). 
Medication adherence has been studied extensively over the past decades. Numerous reports 
in the literature had estimated that by 12 months, adherence to cardioprotective therapy had 
dropped to less than 50% across several classes of drugs including statins and ACE-
Inhibitors(11). Some of the predictors of non-adherence most often cited include 
polypharmacy, frequency of medication changes, socioeconomic status, cost, household 
composition, comorbidity, and accessibility to medical care (12). Gaining an understanding 
of the key factors that inﬂuence adherence among patients post-ACS may allow treating 
physicians to tailor their treatment approach and implement eﬀective hospital interventions to 
improve patient adherence and, subsequently, CV outcomes(13). 
Various kinds of tools have been used to assess patients’s adherence to medication, of these, 
one of the most convenient and easiest way is self-reporting. The ‘My Experience of Taking 
Medicines’ (MYMEDS) questionnaire is a recently developed self reporting tool for 
identifying modifiable adherence barriers among individuals prescribed post-myocardial 
infarctions secondary prevention medicines (SPM). The MYMEDS questionnaire received 
positive feedback from 131 patients, with 96.9% stating it helped them consider their 
medications, 97.7% finding it simple and clear, and 99.2% agreeing the length was 
acceptable. Patients felt it improved understanding of their therapies and facilitated 
meaningful consultations (14). 
 
4.   Rationale and Justification of study 
Acute Coronary Syndrome (ACS) is a leading cause of morbidity and mortality globally, and Nepal is 
no exception (15). Despite advancements in medical treatments, secondary prevention remains a critical 
aspect of managing patients post-ACS to reduce the risk of recurrent cardiovascular events. However, 
adherence to these medications remains suboptimal, especially in low- and middle-income countries 
like Nepal, leading to a higher incidence of recurrent cardiovascular events and increased healthcare 
burden(16).Several factors contribute to poor adherence to secondary prevention medications in Nepal. 
In Nepal, where healthcare infrastructure is still developing, adherence to long-term medications is 

 
 
particularly challenging for patients, especially in rural and underserved regions (16). 
This research is critically needed to address the growing burden of cardiovascular disease in Nepal by 
exploring the current state of adherence to secondary prevention medications after ACS. Understanding 
the extent and factors contributing to poor adherence will help in identifying key barriers and 
implementing targeted interventions. Given the paucity of data on this topic in Nepal, this research will 
not only fill a crucial gap in the literature but also help guide clinicians and healthcare administrators 
in developing effective strategies for enhancing secondary prevention efforts. The findings could have 
broader implications for improving long-term cardiovascular outcomes in low- and middle-income 
countries with similar healthcare challenges. 
In summary, this study is essential for understanding why patients in Nepal fail to adhere to life-saving 
medications post-ACS and what can be done to mitigate this problem, ultimately improving patient care 
and reducing the burden on the healthcare system. 
 
5.   Objectives 
a. General objectives: 
To assess the level of adherence to prescribed secondary prevention medications and identify 
the factors influencing adherence among patients with Acute Coronary Syndrome (ACS) in 
Nepal. 
 
b. Specific objectives: 
 
● To assess the level of adherence to secondary prevention medications (SPMs) among 
patients discharged after an Acute Coronary Syndrome (ACS) event, including antiplatelets, 
statins, beta-blockers, and ACE inhibitors/ARBs. 
● To explore the influence of patient demographic factors (such as age, gender, education 
level, occupation, and place of residence) and clinical characteristics (type of ACS, 
comorbidities) on medication adherence. 
● To identify patient-reported barriers to medication adherence, including concerns 
about medication side effects, pill burden, practical issues with medication administration, 
and difficulties in integrating medications into daily routines. 
● To evaluate the relationship between medication adherence and clinical outcomes, such 
as recurrent cardiac events, rehospitalization. 
 6.   
Research questions/hypothesis 
● What is the level of adherence to secondary prevention medications among Acute Coronary 
Syndrome (ACS) patients in Nepal, and what demographic, clinical, and patient-reported 
factors influence this adherence and its associated clinical outcomes? 
 
7.   Research design and Methodology 
 
7.1. Research method 

 
 
 Quantitative Survey: The adherence to secondary prevention medications among re-
hospitalized patients after cardiac complications following Acute Coronary Syndrome (ACS) 
will be evaluated using a structured questionnaire. This survey will assess patient 
demographics, socioeconomic status, and barriers to adherence such as medication cost, side 
effects, and treatment complexity. Administered either in person or via an online platform, the 
survey will collect key data on adherence patterns and influencing factors in high-risk patients. 
This method aims to ensure efficient data collection while maintaining confidentiality and ease 
of access for participants. 
7.2 Types of study 
Observational Cross Sectional Study 
7.3 Study population/Sampling frame 
A sample of adult patients (age ≥18 years) who have either come to OPD for follow-up or have been 
readmitted for having cardiac complications months after surviving ACS (including STEMI, NSTEMI, 
and unstable angina) in Manmohan Cardiothoracic Vascular and Transplant Centre, Nepal will be 
selected via convenience sampling. The total population under study is around 1000. 
 
7.4 Study site and its justification 
This descriptive cross-sectional study will be conducted at Manmohan Cardiothoracic Vascular and 
Transplant Centre, a premier tertiary care institution in Nepal, specializing in cardiovascular care. As 
one of the nation's leading centres for heart disease management, it offers advanced diagnostic, 
therapeutic, and surgical services to patients with a wide spectrum of cardiovascular conditions, 
including Acute Coronary Syndrome (ACS). The centre’s reputation for excellence in cardiology and 
its strategic location make it an ideal setting for research into adherence to secondary prevention 
medications after ACS. 
 
The patient population at this centre is diverse, including individuals from both urban and rural areas of 
Nepal, which provides a comprehensive understanding of medication adherence patterns across various 
demographic and socioeconomic groups. The centre regularly follows up with ACS survivors, both 
through outpatient visits and during readmissions for cardiac complications. This makes it a prime 
location to study patients who have either come for follow-up visits or been readmitted within 12 
months of their initial ACS event, including STEMI, NSTEMI, and unstable angina. 
 
By focusing on this centre, the research will leverage the expertise of its specialized staff and access to 
detailed patient records, providing valuable insights into medication adherence in real-world clinical 
practice. These insights can then be used to inform targeted interventions to improve long-term 
outcomes for ACS survivors across Nepal. 
 
 
7.5 Sampling method 
In our research study, we will employ convenience sampling. Convenience sampling is a non-
probability method where units are selected for inclusion in the sample because they are the easiest for 
the researcher to access.The target population consists of adult patients (age ≥18 years) who have  either 
come to OPD for follow-up or have been readmitted in hospital for having cardiac complications months 
after surviving ACS (including STEMI, NSTEMI, and unstable angina). Rather than applying specific 

 
 
stratification based on cancer type, we will approach patients who are readily available within the 
hospital setting. We will use the MYMEDS questionnaire. The researcher will personally ask all the 
questions and fill out the questionnaire for each eligible patient. To assess the socioeconomic status of 
participants, we will utilize the Modified Kuppuswamy's Socioeconomic Status Scale, adapted to the 
context of Nepal (18). Alongside demographic information such as gender, age at diagnosis, and marital 
status, we will collect data on education level, occupation, and family income, as per the scale's 
criteria(18).  
Once we collect the responses, we will use MS Excel for data entry and analyze the data using SPSS 
version 29.  
   
7.6 Sample size 
Based on the assumptions that the margin of error is 5%, the confidence level is 95%, the response 
distribution is 50%, and the prevalence of adherence to medication is 92.5%, the sample size for our 
study is 117. These assumptions are used to determine the sample size required to estimate a population 
parameter with a certain level of precision. The prevalence of adherence to medication (92.5%) was 
taken from a study conducted at Shahid Gangalal National Heart Centre in 2018, which reported that 
92.5% of respondents were highly adherent to medication, as measured by the Morisky, Green, and 
Levine (MGL) scale 4-item questionnaire. 
The sample size (n) is calculated according to Cochran’s formula: n = [z2 * p * q / d2] 
Where: z = 1.96 for a confidence level (α) of 95%, p = proportion (expressed as a decimal), d = 
margin of error and adding a 10% non-response rate by using the following formula: 
z = 1.96, p = 0.925, d = 0.05 
n = [1.962 * 0.924 * (1 - 0.817) / (0.05)2] = 106.39 
n ≈ 106 
The sample size needed for the study is 106 participants. By adding 10% non-response, the sample 
size is increased to 117 participants. 
 
  
7.7 Inclusion and Exclusion criteria 
● Inclusion Criteria: 
1. Patients diagnosed with ACS, including ST-Elevation Myocardial Infarction 
(STEMI), Non-ST-Elevation Myocardial Infarction (NSTEMI), or Unstable Angina 
within the last 12 months. 
2. Patients aged 18 years and older. 
3. Patients willing to participate and provide informed consent for the study. 
● Exclusion Criteria: 
1. Individuals who have not been diagnosed with ACS or those with other acute or 
chronic conditions that might influence medication adherence unrelated to ACS. 
2. Patients with cognitive impairments or mental health issues that prevent them from 
understanding or responding accurately to the study questionnaires. 
3. Patients with severe chronic conditions (e.g., terminal illness, advanced dementia) 
that may affect their ability to adhere to medication regimens. 
7.8 Study variables 

 
 
Dependent Variable: 
● Adherence to Secondary Prevention Medications (SPMs): This includes adherence levels 
to specific medications such as antiplatelets, statins, beta-blockers, and ACE inhibitors/ARBs, 
measured through MYMEDS questionnaire. 
Independent Variables: 
1. Demographic Factors: 
○ Age 
○ Gender 
○ Education Level 
○ Occupation 
○ Place of Residence (Rural vs. Urban) 
○ Monthly Income 
2. Clinical Characteristics: 
○ Type of Acute Coronary Syndrome (e.g., STEMI, NSTEMI, Unstable Angina) 
○ Comorbidities (e.g., Hypertension, Diabetes Mellitus, Dyslipidemia, Chronic Kidney 
Disease) 
3. Patient-Reported Factors: 
○ Concerns about medication side effects 
○ Pill burden (number of medications) 
○ Practical issues with medication administration (e.g., difficulties opening bottles) 
○ Difficulty integrating medications into daily routines 
  
7.9 Expected time and duration of the study 
The study is expected to be completed in 12 months, divided as follows: 
● Months 1-2: Ethical approval, recruitment of research assistants 
● Months 3-8: Data collection (patient interviews, medical record review). 
● 
 Months 9-10: Data entry and analysis. 
● 
 Months 11-12: Report writing, dissemination of results, and publication 
  
7.10 Tools and techniques for data collection 
 •  Tools: 
Questionnaire 
The questionnaire is composed of six simple-to-complete sections. 
Section 1: 
 
● Patients provide essential contextual information about the medicines they are taking, 
when they are administered each day, and their understanding of why they are taking 
them. 
● This helps clinicians compare a patient's actual medication usage with documented 
clinical records and uncover any medication changes since discharge. 

 
 
Subsequent sections (Section 2-6): 
● These sections use Likert scales instead of binary yes/no responses, which improves 
the quality of information gathered. 
● For example, it allows the assessment of the frequency of non-adherence behaviors 
rather than just detecting non-adherence. 
Section 2: 
● Explores overall understanding and satisfaction with medicines. 
● Patients respond to four statements regarding their understanding of why their 
medicines were prescribed and how well they think they are working, using a four-
point Likert scale (strongly agree, agree, disagree, strongly disagree). 
Sections 3–5: 
● Assess specific modifiable barriers to adherence, using the same four-point Likert 
scale as section 2. 
● A free-text box allows patients to specify which medicines their concerns involve. 
Section 3: 
● Explores three areas of anxiety about medicines (e.g., concerns about medicines 
causing more harm than good or feeling there are too many medicines). 
Section 4: 
● Examines four practical concerns associated with medicine-taking (e.g., difficulties 
with swallowing pills or obtaining repeat prescriptions). 
Section 5: 
● Assesses three issues related to fitting medicines into the patient's daily routine (e.g., 
forgetfulness or inconvenience). 
● These issues are linked to non-adherence and can potentially be addressed in clinical 
practice. 
Section 6: 
● Focuses on adherence to each individual secondary prevention medication (SPM) 
over the past month. 
● It uses a modified version of the SQ tool and a five-point Likert scale. 
● Patients are considered non-adherent if they select any answer other than ‘all of the 
time’ for any SPM. 
 
Technique: 
● A relevant questionnaire will be developed and distributed to our research team. They will visit 
cardiology outpatient department (OPD) as well as in the cardiology ward in Manmohan 

 
 
Cardiothoracic Vascular and Transplant Centre to administer and fill the questionnaire, asking 
patients who meet the research criteria the necessary questions. 
● Prior to participation, participants will receive comprehensive information regarding the study's 
objectives, procedures, and potential risks and benefits. They will be assured that their personal 
information will remain confidential and solely utilized for research purposes. 
● Participants are expected to provide truthful and accurate responses to all study inquiries and 
protocols. 
● The questionnaire will be individually distributed to each participant. 
  
  
 
7.13 A graphic outline of the study design and procedures using a flow diagram including the timing 
of assessments. 
 
  
8.   Plan for data management and statistical analysis 
●       Information on how the data will be managed (data handling and coding for computer 
analysis, monitoring and verification). 
●       Procedures for accounting for any missing or spurious data etc. 
●       The statistical methods and tests proposed to be used for the analysis of data. 
●       For projects involving qualitative approaches, specify in sufficient detail how the data will 
be analyzed. 
  
9.   Biases 
• 
Selection Bias: The adherence behaviors of OPD patients may differ significantly from 
those of re-hospitalized patients. Re-hospitalized patients might have more severe 
conditions, leading to differences in adherence patterns. This could introduce bias in 
comparing adherence rates across both groups. 
• 
Survivor Bias: Re-hospitalized patients represent those who have survived a second cardiac 
event. This excludes patients who may have suffered more severe outcomes or death, 
potentially skewing the findings. 

 
 
• 
Self-Reported Data: The reliance on patient self-reports for adherence may introduce recall 
bias or social desirability bias, where patients overestimate their adherence to appear 
compliant. 
 
10.   Limitations of the study 
·Heterogeneity of Patient Conditions: Re-hospitalized patients might have more complex medical 
histories or complications, while OPD patients might represent a more stable cohort. This could lead 
to difficulties in interpreting results uniformly across both groups. 
· Single-Centre Study: Conducting the study in one tertiary care hospital limits the generalizability of 
the findings to other settings, such as rural or private healthcare facilities. 
· Cross-Sectional Design: The study captures adherence at a single point in time, making it difficult to 
assess changes in adherence over time or the long-term effects of non-adherence. 
· Incomplete Records: Excluding patients with incomplete medical records may result in the loss of 
potentially valuable data, especially if those patients differ systematically from others. 
· Confounding Factors: Factors like access to healthcare, comorbidities, or socio-economic conditions 
may influence both adherence and re-hospitalization but might be difficult to fully account for in the 
analysis. 
  
11.   Safety considerations 
This study on medication adherence post-acute coronary syndrome (ACS) prioritizes participant safety 
by ensuring confidentiality, obtaining informed consent, and designing the questionnaire to minimize 
discomfort. Participants can skip any questions that may cause unease, and those facing adherence 
challenges will receive information on local support resources. Though risks are minimal, any adverse 
events will be recorded, with participants advised to seek medical help if necessary. The study follows 
ethical guidelines approved by our institution’s ethics board to safeguard participant well-being 
throughout the research. 
  
12.   Plan for supervision and monitoring 
●  Developing the Plan: We will outline responsibilities of the research team and external 
supervisors, including key activities and milestones for data collection, follow-ups, and quality 
checks. 
● Communication Channels: We will establish regular meetings, email, and phone updates to 
maintain clear communication and address study progress or challenges in real time. 
● Regular Meetings: We will schedule weekly and monthly meetings with the research team and 
supervisors to review progress, resolve issues, and ensure adherence to the timeline. 
● Data Quality Monitoring: We will conduct regular checks on data accuracy and consistency, 
addressing errors immediately to maintain the integrity of the data. 
● Progress Review: We will continuously track recruitment, data collection, and adherence to 
timelines, ensuring the study remains on schedule and goals are met. 

 
 
● Issue Resolution: We will address any arising issues promptly by adjusting protocols or 
consulting external supervisors, ensuring the study remains on track. 
 
13.   Expected outcome of the research 
● Adherence Rates: We will determine the level of adherence to secondary prevention 
medications among patients re-hospitalized after ACS in Nepal. 
● Factors Influencing Non-Adherence: We will identify key factors contributing to non-
adherence, such as socio-economic barriers, patient knowledge, and healthcare system 
challenges. 
● Targeted Interventions: The findings will inform targeted interventions to improve 
medication adherence and reduce re-hospitalization rates. 
● Policy Insights: We will provide valuable insights for healthcare policy improvements in post-
ACS care, helping enhance long-term cardiac outcomes in Nepal. 
● Patient Education: The study will highlight the need for increased patient education on the 
importance of medication adherence. 
 
14.   Plan for dissemination of research results 
• 
Writing a research report: We plan to create a detailed research report outlining the 
study’s objectives, methodology, results, and conclusions, with an emphasis on 
findings related to medication adherence following acute coronary syndrome (ACS). 
• 
Publishing the research report: We intend to submit the research report for 
publication in a reputable peer-reviewed journal focusing on cardiology or public 
health to ensure it reaches a scientific audience interested in ACS management and 
adherence studies. 
• 
Sharing the research report with the research team: We will distribute the report 
to all members of the research team, including collaborators and supervisors, to keep 
everyone informed of the outcomes and enable them to incorporate findings into their 
ongoing work. 
• 
Sharing the research report with relevant stakeholders: We plan to disseminate 
the report to key stakeholders such as cardiology departments to support 
improvements in patient care and policy development. 
• 
Presenting the research findings: We will present our findings at national and 
international cardiology or public health conferences, allowing us to share insights 
with a broader audience of healthcare professionals and researchers. 
15.   Plan for utilization of the research finding 
• 
Reviewing the research findings: We will review the research findings thoroughly 
to understand the implications for patient care and the management of secondary 
prevention adherence following acute coronary syndrome (ACS). 
• 
Sharing the research findings with relevant stakeholders: We plan to share our 
findings with relevant stakeholders, such as cardiologists, healthcare providers, 
hospital administrators, policymakers, and patient advocacy groups, to promote 
awareness and encourage support for improved adherence strategies. 

 
 
• 
Developing recommendations for practice and policy: Based on the research 
results, we will develop targeted recommendations for clinical practice and policy 
aimed at enhancing medication adherence and follow-up care among ACS patients, 
with a focus on feasible strategies for Nepal’s healthcare context. 
• 
Communicating the recommendations: We will communicate these 
recommendations to relevant stakeholders through presentations, workshops, and 
written materials such as policy briefs and practice guidelines, helping translate our 
findings into actionable steps. 
• 
Implementing the recommendations: We plan to collaborate with healthcare 
providers and institutions to incorporate our recommendations into clinical settings, 
ensuring that ACS patients receive comprehensive adherence support and education. 
• 
Monitoring the implementation of the recommendations: We will monitor the 
adoption and effectiveness of the recommendations by gathering feedback from 
healthcare providers and assessing adherence improvement among ACS patients over 
time. 
• 
Evaluating the impact of the recommendations: We will evaluate the impact of our 
recommendations on adherence outcomes, healthcare utilization, and patient health, 
using this evaluation to inform future research and to optimize secondary prevention 
efforts in ACS care. 
16.   Work plan 
 
Total duration of study: 12 months 
Timeline: Gantt chart 
·     August 2024 
o   Planning and discussion of the research title 
·     October 2024 to November 2024 
o   Literature Review and Questionnaire Development 
·     December 2024 to June 2025 
o   Contacting participants and data collection 
o  All participants will complete a questionnaire. 
·     August 2025 
o  Data analysis-The data collected from the assessment questionnaire will be 
analyzed. 
 
17.   Ethical issues and considerations regarding human participants 
●       Are human participants required in this research? If yes, offer justification. 
Yes, human participants are required in this research. The study aims to assess adherence to 
secondary prevention medications among patients who have experienced Acute Coronary 
Syndrome (ACS). This research requires direct data collection from individuals who have been 
prescribed such medications to understand their adherence patterns, factors influencing 
adherence, and potential barriers. The insights gained from these participants will contribute to 
improving post-ACS care in Nepal and reducing the risk of recurrent cardiac events. 
 
●       Clearly indicate the participant’s responsibilities in the research. What is expected of the 
research participants during the research? 
o   Providing informed consent: Participants will be fully informed about the purpose, 
procedures, and potential risks and benefits of the study before deciding whether or not 
to participate. 

 
 
o   Completing study procedures: Participants should be willing to fill out the 
questionnaire. 
    oProtecting their own privacy: Participants should be aware that their personal 
information will be kept confidential and only used for the purposes of the study 
o   Protecting the confidentiality of others: Participants should not disclose any 
information about other participants or the study to anyone outside of the research team. 
o   Providing honest and accurate responses: Participants should provide honest and 
accurate responses to all study questions and procedures. 
 
●       Are vulnerable members of the population required for this research? If yes, offer 
justification. 
No 
 
●       Are there any risks to the involved participants? If yes, identify clearly what are the expected 
risks for the human participants in the research and provide a justification for these risks. 
No 
 
●       Are there any benefits to participants? If yes, identify clearly what are the expected benefits 
for the participants. 
Indirect Benefits to Healthcare: Participants contribute to research that aims to improve post-
ACS care and enhance medication adherence strategies, potentially benefiting future patients. 
Personal Satisfaction: Patients may feel a sense of fulfillment by contributing to research that 
could improve public health and the care of other ACS patients. 
Awareness and Self-reflection: By participating, patients may gain a better understanding of 
the importance of medication adherence, which could positively influence their own adherence 
behaviors. 
18.   Informed consent 
● Who is responsible for obtaining informed consent from the participants? 
○ 
 Researchers 
● How is informed consent obtained from the participants? 
○ Informed consent will be obtained from all the students participating in this 
study before they answer our research questionnaire. Participants will be 
presented with our research consent. 
● Is there anything withheld from the research participants (deception) at the time of 
getting informed consent? State the reason for deception. 
○ No information will be withheld from the research participants at the time of 
getting informed consent. 
  
19.   Budget 
(Should include financial provision necessary for carrying out the research up to dissemination of 
research findings.) 
 
Element/s 
Price (NRs.) 
1.  Questionnaire printing (for offline 
survey) 
Rs. 5000 
2.  Article Publication 
Rs. 5000 

 
 
Total 
Rs. 10000 
  
•        
Source of budget: Researchers 
•        
Sponsor, if any: Not any 
 
 
 
 
 
 
 
 
 
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Available from: http://dx.doi.org/10.1007/s40119-019-00147-5 
2. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 
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the Management of Blood Cholesterol: A Report of the American College of 
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll 
Cardiol [Internet]. 2019 Jun 25;73(24):e285–350. Available from: 
http://dx.doi.org/10.1016/j.jacc.2018.11.003 
3. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC 
Guidelines for the management of acute coronary syndromes in patients presenting without 
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20.   Annexes 
1. Pro forma sheet 
 
 
 
 
 

 
 
Research Proforma 
Section 1: Patient Demographic Information 
1. Patient ID: ____________________________ 
2. Name: _________________________________ 
3. Age: _________________________________ 
4. Gender: 
○ [ ] Male 
○ [ ] Female 
○ [ ] Other 
5. Ethnicity: 
● Brahmin 
● Chhetri 
● Madhesi and Tharu 
● Newar 
● Muslims 
● Dalit 
● Janjati 
● Others 
6. Marital Status: 
○ [ ] Single 
○ [ ] Married 
○ [ ] Divorced 
○ [ ] Widowed 
7. Education Level: 
○ Professional or Honors/Ph.D 
○ Graduate or Postgraduate (Bachelors/Masters) 
○ Intermediate or Post-high school diploma (Class 11–12) 
○ High school certificate (Class 9–10, SLC/SEE passed) 
○ Middle school certificate (Class 6–8) 
○ Primary school or literate (Class 1–5) 
○ Illiterate (cannot read or write) 
8. Occupation: 
1. Profession or Honors 
○ Doctors, senior administrative officers, senior lecturers, college principals, 
advocates, planters owning large estates, expert musicians, newspaper editors, 
auditors, architects, managing directors of firms, bank managers 
2. Semi-profession 
○ Mechanical and electrical engineers, high school teachers, lecturers, junior 
administrators, junior doctors, insurance inspectors, commission agents, musicians, 
research assistants 
3. Clerical, shop owner, farmer, skilled worker 
4. Semi-skilled worker 
○ Factory or workshop laborer, laboratory or library attendant, car cleaner 

 
 
5. Unskilled worker 
○ Watchman, peon, domestic servant, rickshaw puller 
6. Unemployed 
9. Family Monthly Income (NPR): ___________________ 
● ≥ 97,451 
● 48,751–97,450 
● 36,551–48,750 
● 24,351–36,550 
● 14,551–24,350 
● 4,851–14,550 
● ≤ 4,850 
10. Place of Residence: 
○ [ ] Rural 
○ [ ] Urban 
11. Distance from Healthcare Facility: ____________ (km) 
Section 2: Clinical Information 
1. Type of ACS: 
○ [ ] ST-Elevation Myocardial Infarction (STEMI) 
○ [ ] Non-ST-Elevation Myocardial Infarction (NSTEMI) 
○ [ ] Unstable Angina 
2. Date of ACS Diagnosis: _______________________ 
3. Treatment Received: 
○ [ ] Percutaneous Coronary Intervention (PCI) 
○ [ ] Coronary Artery Bypass Grafting (CABG) 
○ [ ] Medical Management Only 
4. Comorbidities: 
○ [ ] Hypertension 
○ [ ] Diabetes Mellitus 
○ [ ] Dyslipidemia 
○ [ ] Chronic Kidney Disease 
○ [ ] Stroke 
○ [ ] Peripheral Arterial Disease 
○ [ ] Others (Specify): ___________________________ 
 
 
Section 3: Assessment of Adherence 
MYMEDS Questionnaire 
Section 1: Current Medicines 

 
 
Serial 
Number 
Name of 
Medicines 
Administration Time 
(Morning/Afternoon/Evening/
Night) 
Reason for Taking Medicine 
1 
Antiplatelets 
_________________________ 
_________________________ 
2 
Statins 
_________________________ 
_________________________ 
3 
Beta-blockers 
_________________________ 
_________________________ 
4 
ACE 
inhibitors/ARBs 
_________________________ 
_________________________ 
5 
Others (Loop 
diuretics,Nitrate
s,specify) 
_________________________ 
_________________________ 
 
  
Section Number 
Statement 
Strongly 
agree 
Agree 
Disagree Strongly 
disagree 
Section 2: 
Understanding and 
satisfaction with 
medicines 
a. I fully understand 
my heart medicines 
and why they were 
prescribed. 
 
 
 
 
b. My heart medicines 
seem to be working for 
me. 
 
 
 
 
c. I feel convinced of 
the importance of all 
my heart medicines. 
 
 
 
 
d. At least 
occasionally, I need to 
alter my medicines on 
my own to make them 
work or meet my 
expectations. 
 
 
 
 

 
 
Section 3: Concerns 
about medicines 
a. I worry that one or 
more of my medicines 
will do me more harm 
than good. 
 
 
 
 
b. I feel concerned 
about being prescribed 
too many medicines. 
 
 
 
 
c. I sometimes alter 
my medicines by 
cutting back or 
stopping taking them.( 
(e.g. due 
to feeling worse, 
getting worried or for 
any other reason) 
 
 
 
 
Section 4: Practical 
issues that may be a 
barrier to adherence 
a. I have difficulties or 
problems opening the 
medicine bottles or 
blister packs and 
would like a solution 
or an alternative. 
 
 
 
 
b. I have difficulties or 
problems swallowing 
my medicine(s) and 
would like a solution 
or an alternative. 
 
 
 
 
c. I have difficulties or 
problems getting my 
repeat prescriptions 
and would like help 
ordering them from 
my GP or pharmacy. 
 
 
 
 
d. I have difficulties or 
problems reading the 
label on the medicines 
bottle or box and 
would like a solution 
or alternative. 
 
 
 
 

 
 
Section 5: Fitting 
medicines into daily 
routine 
a. I sometimes forget 
to take my heart 
medicines. 
 
 
 
 
b. I am finding it 
difficult to fit one or 
more of my heart 
medicines into my 
daily routine. 
 
 
 
 
c. I feel 
inconvenienced/bother
ed about sticking to all 
my heart medicines. 
 
 
 
 
 
Section 6: Adherence to Individual SPMs 
For each of your prescribed medicines (SPMs), please indicate how often you have taken 
them as prescribed in the PAST MONTH: 
Medication 
All of 
the 
Time 
Nearly All of 
the Time 
Most of the 
Time 
About Half 
the Time 
Less than Half 
the Time 
Aspirin 
 
 
 
 
 
ACE 
Inhibitor 
(e.g. 
Ramipril, 
Lisinopril,) 
 
 
 
 
 
Beta Blocker 
(e.g.Acebutal
ol) 
 
 
 
 
 
Medication 4 
Statin 
(e.g. 
Simvastatin) 
 
 
 
 
 
ARIIA 
(e.g. 
Candesartan) 
 
 
 
 
 

 
 
 
 
Section 4: Clinical Outcomes 
1. Have you experienced any of the following since discharge? (Check all that apply) 
○ [ ] Recurrent chest pain 
○ [ ] Rehospitalization for cardiac issues 
○ [ ] Stroke 
○ [ ] Heart failure symptoms 
○ [ ] No major events 
2. Follow-up with healthcare provider since discharge: 
○ [ ] Yes 
○ [ ] No 
○ If Yes, how many visits: ________ 
 
 
 
 
                                              INFORMED CONSENT FORM  
Adherence to Secondary Prevention Medications After 
Acute Coronary Syndrome (ACS) in Nepal:A Descriptive 
Cross-sectional Study 
  
Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Institute of Medicine 
Maharajgunj, Kathmandu, Nepal 
I, ............................................................. , a male/female of ............ years of age, have received 
information regarding this research to be conducted by ............................................................. 
by reading and/or listening to the attached 'Information Sheet/Booklet' and through a question-
and-answer session. 
• 
I understand that my participation in this research work depends entirely on my personal 
will, and that I can withdraw from this research process at any time if I wish. I have 
been made to understand that I do not need to provide any reason for this, and it will 
not affect the services I receive or my legal rights. 
• 
I understand that no personal identifying information about me will be published in the 
report of this research or in any related publications. 
• 
Knowing and understanding all these points, I voluntarily agree to participate in this 
study-research and hereby provide my signature on this Informed Consent Form. 
 

 
 
[Participant's] 
Signature : ........................... 
Full Name : ....................................... 
Date : ......./....../...... (YYYY/MM/DD) 
 
Participant's Thumbprint 
 
 
Right 
Left 
 
[Witness's] 
Signature : ........................... 
Full Name : ....................................... 
Date : ......./....../....... (YYYY/MM/DD) 
 
[Researcher's] 
Signature : ........................... 
Full Name : ....................................... 
Date : ......./....../....... (YYYY/MM/DD)