Healthcare provider and patient perspectives on access to and management of atrial fibrillation in the Northern Province, Sri Lanka: a rapid evaluation of barriers and facilitators to care
Authors: Sheron Vethanayagam Antony , Shanmugathas Shivany , Gooden Tiffany E. , Guruparan Mahesan , Kumarendran Balachandran , Lip Gregory Y. H. , Manaseki-Holland Semira , Nirantharakumar Krishnarajah , Shribavan Kaneshamoorthy , Subaschandren Kumaran , Haniffa Rashan , Surenthirakumaran Rajendra , Thomas G. Neil , Uruthirakumar Powsiga , Greenfield Sheila , Lane Deirdre A. , Beane Abi ,   NIHR Global Health Research Group on Atrial Fibrillation Management, Sheron Vethanayagam Antony , Shanmugathas Shivany , Gooden Tiffany E. , Guruparan Mahesan , Kumarendran Balachandran , Lip Gregory Y. H. , Manaseki-Holland Semira , Nirantharakumar Krishnarajah , Shribavan Kaneshamoorthy , Subaschandren Kumaran , Haniffa Rashan , Surenthirakumaran Rajendra , Thomas G. Neil , Uruthirakumar Powsiga , Greenfield Sheila , Lane Deirdre A. , Beane Abi , Arasalingam Ajini , Bensenor Isabela M. , Brocklehurst Peter , Cheng Kar Keung , El-Bouri Wahbi , Feng Mei , Goulart Alessandra C. , Guo Yutao , Gusso Gustavo , Humphreys Lindsey , Jolly Kate , Jowett Sue , Kodippily Chamira , Lancashire Emma , Li Xuewen , Li Yan-guang , Lobban Trudie , Lotufo Paulo A. , Moore David , Olmos Rodrigo D. , Paschoal Elisabete , Pirasanth Paskaran , Powsiga Uruthirakumar , Romagnolli Carla , Santos Itamar S. , Shantsila Alena , Szmigin Isabelle , Tai Meihui , Toippa Timo , Varella Ana C. , Wang Hao , Wang Jingya , Zhang Hui , Zhong Jiaoyue 
Published: August 2022

Abstract
Background
Atrial fibrillation (AF) is the most common cardiac arrhythmia that affects 60 million people worldwide. Limited evidence on AF management exists from low- and middle-income countries and none from Sri Lanka. We aimed to investigate the existing AF care pathway and patients’ perception on AF management to identify barriers and enablers for optimal AF care in Northern Province, Sri Lanka.

Methods
A rapid evaluation was undertaken with use of qualitative methods. Local healthcare providers (HCPs) mapped the intended pathway of care for AF patients which was then explored and annotated through 12 iterative sessions with additional HCPs. Topics of inefficiencies identified from the finalised map were used to guide focus group discussions (FGDs) with AF patients. AF patients who were attending the anticoagulation clinic at the only tertiary hospital in Northern Province were recruited and invited to participate using purposive sampling. The topic guide was developed in collaboration with local clinicians and qualitative experts. FGDs were conducted in the native Tamil language and all sessions were recorded, transcribed verbatim and thematically analysed using a deductive approach.

Results
The mapped pathway revealed inefficiencies in referral, diagnosis and ongoing management. These were explored through three FGDs conducted with 25 AF patients aged 25 to 70 years. Two key themes that contributed to and resulted in delays in accessing care and ongoing management were health seeking behaviours and atomistic healthcare structures. Four cross-cutting sub-themes identified were decision making, paternalistic approach to care, cost impacts and lifestyle impacts. These are discussed across 10 unique categories with consideration of the local context.

Conclusions
Strengthening primary healthcare services, improving public health literacy regarding AF and building patient autonomy whilst understanding the importance of their daily life and family involvement may be advantageous in tackling the inefficiencies in the current AF care pathway in Sri Lanka.