Factors influencing community pharmacists' provision of health promotion and disease prevention services in Jordan: Qualitative thematic analysis and deductive mapping to the COM-B model.

Valvular heart disease (VHD) is a leading global cause of cardiovascular symptoms and functional disability, contributing to an estimated 1.4 million deaths and over 10 million disability-adjusted life years annually [–]. While degenerative and functional VHD dominate in high-income countries, rheumatic heart disease (RHD) caused by rheumatic fever remains the primary form in low- and middle-income countries []. In 2019, the global prevalence of RHD was estimated at 40.5 million, with the highest burden among marginalized populations in sub-Saharan Africa (SSA) [,]. Rheumatic heart disease complicating to VHD remains highly prevalent in Tanzania, with pooled estimates around 9% and echocardiographic studies reporting subclinical valvular diseases in approximately 2–3% of school-aged children, highlighting a substantial disease burden [,,]. Valvular heart diseases are generally progressive, and surgical treatment is required in cases of severe insufficiency or stenosis [,]. Patients need to cope with further difficulties despite successful surgery. One of these difficulties in care post-surgery is the patients’ lifelong use of anticoagulant medication [,,]. Anticoagulation is crucial in preventing valve-related thromboembolic complications. It is assessed using the international normalized ratio (INR) test []. The target therapeutic INR value varies according to the valve type, ranging between 2.5–3.5 in the mitral valve, and 2.0–3.0 in the aortic valve []. A high INR value is associated with anticoagulant toxicity and poses the risk of bleeding, while a low INR value increases the risk of thrombosis to the patient []. In SSA, suboptimal anticoagulation control among patients on warfarin has been widely reported, further increasing the risk of both thromboembolic and bleeding complications in this population []. Although direct oral anticoagulants (DOACs) are increasingly used in other cardiovascular conditions, their use in patients with mechanical prosthetic heart valves remains limited due to insufficient evidence on safety and effectiveness in this population. As a result, warfarin remains the standard anticoagulant therapy for these patients. Moreover, the availability and affordability of newer anticoagulants such as DOACs remain major challenges in low-resource settings [,]. Warfarin is used as a long-term oral anticoagulant in patients with prosthetic heart valves in Tanzania []. For an effective therapeutic outcome, warfarin adherence is mandatory [,]. Patients are usually discharged with health information given regarding consistent medication use with the recommended dose, dietary and lifestyle modification, and regular blood tests for INR monitoring [,,–]. The health information given at discharge aims to promote warfarin compliance, prevent complications, and improve patients’ quality of life [,,].