Effectiveness of community-based hypertension management on hypertension in the urban slums of Haiti: A mixed methods study.

Hypertension is a leading contributor to mortality in low-middle income countries including Haiti, yet only 13% achieve blood pressure (BP) control. We evaluated the effectiveness of a community-based hypertension management program delivered by community health workers (CHWs) and physicians among 100 adults with uncontrolled hypertension from the Haiti Cardiovascular Disease Cohort. The 12-month intervention included: community follow-up visits with CHWs (1 month if BP uncontrolled ≥140/90, 3 months otherwise) for BP measurement, lifestyle counseling, medication delivery, and dose adjustments. Primary outcome was mean change in systolic BP from enrollment to 12 months. Secondary outcomes were mean change in diastolic BP, BP control, acceptability, feasibility, and adverse events. We compared outcomes to 100 age, sex, and baseline BP matched controls with standard of care: clinic follow-up visits with physicians every 3 months. We also conducted qualitative interviews with participants and providers. Among 200 adults, median age was 59 years, 59% were female. Baseline mean BP was 154/89 mmHg intervention versus 153/88 mmHg control. At 12 months, the difference in SBP change between groups was -12.8 mmHg (95%CI -6.9, -18.7) and for DBP -7.1 mmHg (95%CI -3.3, -11.0). BP control increased from 0% to 58.1% in intervention, and 28.4% in control group. Four participants reported mild adverse events. In mixed methods analysis, we found community-based delivery addressed multiple participant barriers to care, and task-shifting with strong teamwork enhanced medication adherence. Community-based hypertension management using task-shifting with CHWs and community-based care was acceptable, and effective in reducing SBP, DBP, and increasing BP control.

Spectrum of prevalent cardiovascular diseases in urban Port-au-Prince, Haiti: a population-based cross-sectional study.

Background: Eighty percent of global cardiovascular disease (CVD) is projected to occur in low- and middle -income countries (LMICs), yet local epidemiological data are scarce. We provide the first population-based, adjudicated CVD prevalence estimates in Port-au-Prince, Haiti to describe the spectrum of heart disease and investigate associated risk factors. Methods: Demographic, medical history, clinical, imaging and laboratory data were collected among adults recruited using multistage random sampling from 2019 to 2021. Prevalent CVD (heart failure, stroke, ischemic disease) were adjudicated using epidemiological criteria similar to international cohorts. Multivariable Poisson regressions assessed relationships between risk factors and prevalent CVD. Findings: Among 3003 participants, median age was 40 years, 58.1% were female, 70.2% reported income <1 USD/day, and all identified as Black Haitian. CVD age-adjusted prevalence was 14.7% (95% CI 13.3%, 16.5%), including heart failure (11.9% [95% CI 10.5%, 13.5%]), stroke (2.4% [95% CI 1.9%, 3.3%]), angina (2.1% [95% CI 1.6%, 2.9%]), myocardial infarction (1.0% [95% CI 0.6%, 1.8%]), and transient ischemic attack (0.4% [95% CI 0.2%, 1.0%]). Among participants with heart failure, median age was 57 years and 68.5% of cases were among women. The most common subtype was heart failure with preserved ejection fraction (80.4%). Heart failure was associated with hypertension, obesity, chronic kidney disease, depression, and stress. Interpretation: Early-onset heart failure prevalence is alarmingly high in urban Haiti and challenge modelling assumptions that ischemic heart disease and stroke dominate CVDs in LMICs. These data underscore the importance of local population-based epidemiologic data within LMICs to expedite the selection and implementation of evidence-based cardiovascular health policies targeting each country's spectrum of heart disease. Funding: This study was funded by NIH grants R01HL143788, D43TW011972, and K24HL163393, clinicaltrials.govNCT03892265.

Population-Based Epidemiology of Heart Failure in a Low-Income Country: The Haiti Cardiovascular Disease Cohort.

BACKGROUND: Cardiovascular disease disproportionately affects persons living in low- and middle-income countries and heart failure (HF) is thought to be a leading cause. Population-based studies characterizing the epidemiology of HF in these settings are lacking. We describe the age-standardized prevalence, survival, subtypes, risk factors, and 1-year mortality of HF in the population-based Haiti Cardiovascular Disease Cohort. METHODS: Participants were recruited using multistage cluster-area random sampling in Port-au-Prince, Haiti. A total of 2981 completed standardized history and exam, laboratory measures, and cardiac imaging. Clinical HF was defined by Framingham criteria. Kaplan-Meier and Cox proportional hazard regression assessed mortality among participants with and without HF; logistic regression identified associated factors. RESULTS: Among all participants, the median age was 40 years (interquartile range, 27-55), and 58.2% were female. Median follow-up was 15.4 months (interquartile range, 9-22). The age-standardized HF prevalence was 3.2% (93/2981 [95% CI, 2.6-3.9]). The average age of participants with HF was 57 years (interquartile range, 45-65), and 67.7% were female. The first significant increase in HF prevalence occurred between 30 to 39 and 40 to 49 years (1.1% versus 3.7%, P=0.003). HF with preserved ejection fraction was the most common HF subtype (71.0%). Age (adjusted odds ratio, 1.36 [1.12-1.66] per 10-year increase), hypertension (2.14 [1.26-3.66]), obesity (3.35 [95% CI, 1.99-5.62]), poverty (2.10 [1.18-3.72]), and renal dysfunction (5.42 [2.94-9.98]) were associated with HF. One-year HF mortality was 6.6% versus 0.8% (hazard ratio, 7.7 [95% CI, 2.9-20.6]; P<0.0001). CONCLUSIONS: The age-standardized prevalence of HF in this low-income setting was alarmingly high at 3.2%-5-fold higher than modeling estimates for low- and middle-income countries. Adults with HF were two decades younger and 7.7× more likely to die at 1 year compared with those in the community without HF. Further research characterizing the population burden of HF in low- and middle-income countries can guide resource allocation and development of pragmatic HF prevention and treatment interventions, ultimately reducing global cardiovascular disease health disparities. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03892265.

Diabetes Epidemiology Among Adults in Port-au-Prince, Haiti: A Cross-Sectional Study.

Introduction: Diabetes mellitus is a chronic noncommunicable disease associated with death and major disability, with increasing prevalence in low- and middle-income countries. There is limited population-based data about diabetes in Haiti. The objective of this study was to assess the prevalence of diabetes and associated factors among adults in Port-au-Prince, Haiti using a population-based cohort. Methods: This study analyzes cross-sectional enrollment data from the population-based Haiti Cardiovascular Disease Cohort Study, conducted using multistage sampling with global positioning system waypoints in census blocks in the metropolitan area of Port-au-Prince, Haiti. A total of 3,005 adults ≥18 years old were enrolled from March 2019 to August 2021. We collected socio-demographic data, health-related behaviors, and clinical data using standardized questionnaires. Diabetes was defined as any of the following criteria: enrollment fasting glucose value ≥ 126 mg/dL or non-fasting glucose ≥ 200 mg/dL, patient self-report of taking diabetes medications, or study physician diagnosis of diabetes based on clinical evaluation. Results: Among 2985 (99.3%) with complete diabetes data, median age was 40 years, 58.1% were female, and 17.2% were obese. The prevalence of diabetes was 5.4% crude, and 5.2% age standardized. In unadjusted analysis, older age, higher body mass index (BMI), low physical activity, low education were associated with a higher odds of diabetes. After multivariable logistic regression, older age [60+ vs 18-29, Odds Ratio (OR)17.7, 95% CI 6.6 to 47.9] and higher BMI (obese vs normal/underweight, OR 2.7, 95% CI 1.7 to 4.4) remained statistically significantly associated with higher odds of diabetes. Conclusion: The prevalence of diabetes was relatively low among adults in Port-au-Prince, but much higher among certain groups (participants who were older and obese). The Haitian health system should be strengthened to prevent, diagnose, and treat diabetes among high-risk groups.

Hypertension continuum of care: Blood pressure screening, diagnosis, treatment, and control in a population-based cohort in Haiti.

Cardiovascular disease (CVD) is the number one cause of death in low-income countries including Haiti, with hypertension (HTN) being the leading risk factor. This study aims to identify gaps in the HTN continuum of screening, diagnosis, treatment, and blood pressure (BP) control. Sociodemographic and clinical data were collected from a population-based sample of adults ≥18 years in Port-au-Prince (PAP) from March 2019 to April 2021. HTN was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or use of antihypertensive medication. Screening was defined as ever having had a BP measurement; diagnosis as previously being informed of a HTN diagnosis; treatment as having taken antihypertensives in the past 2 weeks; and controlled as taking antihypertensives and having BP < 140/90 mmHg. Factors associated with attaining each step in the continuum were assessed using Poisson multivariable regressions. Among 2737 participants, 810 (29% age-standardized) had HTN, of whom 97% had been screened, 72% diagnosed, 45% treated, and 13% controlled. There were no significant differences across age groups or sex. Obesity (BMI ≥ 30) was a significant factor associated with receiving treatment compared to normal weight (BMI < 25), with a prevalence ratio (PR) of 1.5 (95% CI 1.1-2.0). Having secondary or higher education was associated with higher likelihood of controlled BP (PR 1.9 [95% CI 1.1-3.3]). In this urban Haitian population, the greatest gaps in HTN care are treatment and control. Targeted interventions are needed to improve these steps, including broader access to affordable treatment, timely distribution of medications, and patient adherence to HTN medication.

Neighborhood cohesion and violence in Port-au-Prince, Haiti, and their relationship to stress, depression, and hypertension: Findings from the Haiti cardiovascular disease cohort study.

Neighborhood factors have been associated with health outcomes, but this relationship is underexplored in low-income countries like Haiti. We describe perceived neighborhood cohesion and perceived violence using the Neighborhood Collective Efficacy and the City Stress Inventory scores. We hypothesized lower cohesion and higher violence were associated with higher stress, depression, and hypertension. We collected data from a population-based cohort of adults in Port-au-Prince, Haiti between March 2019 to August 2021, including stress (Perceived Stress Scale), depression (PHQ-9), and blood pressure (BP). Hypertension was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or on antihypertensive medications. Covariates that were adjusted for included age, sex, body mass index, smoking, alcohol, physical activity, diet, income, and education, multivariable linear and Poisson regressions assessed the relationship between exposures and outcomes. Among 2,961 adults, 58.0% were female and median age was 40 years (IQR:28-55). Participants reported high cohesion (median 15/25, IQR:14-17) and moderate violence (9/20, IQR:7-11). Stress was moderate (8/16) and 12.6% had at least moderate depression (PHQ-9 ≥ 11). Median systolic BP was 118 mmHg, median diastolic BP 72 mmHg, and 29.2% had hypertension. In regressions, higher violence was associated with higher prevalence ratios of moderate-to-severe depression (Tertile3 vs Tertile1: PR 1.12, 95%CI:1.09 to 1.16) and stress (+0.3 score, 95%CI:0.01 to 0.6) but not hypertension. Cohesion was associated with lower stress (Tertile3 vs Tertile1: -0.4 score, 95%CI: -0.7 to -0.2) but not depression or hypertension. In summary, urban Haitians reported high perceived cohesion and moderate violence, with higher violence associated with higher stress and depression.

High Lead Exposure Associated With Higher Blood Pressure in Haiti: a Warning Sign for Low-Income Countries.

Cardiovascular disease is the leading cause of death in lower-income countries including Haiti. Environmental lead exposure is associated with high blood pressure and cardiovascular mortality in high-income countries but has not been systematically measured and evaluated as a potential modifiable cardiovascular risk factor in lower-income countries where 6.5 billion people reside. We hypothesized lead exposure is high in urban Haiti and associated with higher blood pressure levels. Blood lead levels were measured in 2504 participants ≥18 years enrolled in a longitudinal population-based cohort study in Port-au-Prince. Lead screening was conducted using LeadCare II (detection limit ≥3.3 µg/dL). Levels below detection were imputed by dividing the level of detection by √2. Associations between lead (quartiles) and systolic blood pressure and diastolic blood pressure were assessed, adjusting for age, sex, obesity, smoking, alcohol, physical activity, income, and antihypertensive medication use. The median age of participants was 40 years and 60.1% were female. The geometric mean blood lead level was 4.73µg/dL, 71.1% had a detectable lead level and 42.3% had a blood lead level ≥5 µg/dL. After multivariable adjustment, lead levels in quartile four (≥6.5 µg/dL) compared with quartile 1 (<3.4 µg/dL) were associated with 2.42 mm Hg (95% CI, 0.36-4.49) higher systolic blood pressure and 1.96 mm Hg (95% CI, 0.56-3.37) higher diastolic blood pressure. In conclusion, widespread environmental lead exposure is evident in urban Haiti, with higher lead levels associated with higher systolic and diastolic blood pressure. Lead is a current and potentially modifiable pollutant in lower-income countries that warrants urgent public health remediation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03892265.

Clinical and echocardiographic characteristics and outcomes in congestive heart failure at the Hospital of The State University of Haiti.

BACKGROUND: This study aimed to evaluate the clinical and epidemiologic profile of congestive heart failure at the principal free-care hospital in Haiti. Cardiovascular disease represents the most prevalent cause of admissions to the medical service of the University Hospital of the State of Haiti. No previous study has examined the demographics of congestive heart failure in urban Haiti. METHODS: Two hundred forty-seven patients presented to the inpatient service between May 2011 and May 2013. Evaluation included history and physical, CBC, renal/metabolic profile, serum glucose, anti-HIV antibody, ECG, chest radiograph and echocardiogram. Treatment included angiotensin converting enzyme inhibitors, furosemide and spironolactone, carvedilol, digoxin and anticoagulation. RESULTS: Women (62.4%) outnumbered men; patients were relatively young (mean age 50.1) and from the lowest socio-economic levels of the population. Nearly all (98.8%) presented with NYHA III-IV status, with correspondingly high mortality (23.3%). Echocardiography showed 73% dilated cardiomyopathy; 83% showed moderate to severe LV systolic dysfunction (mean EF 36.5 +/- 15%) and 17% preserved LV systolic function. The three principal etiologies were dilated cardiomyopathy (29%) hypertensive cardiomyopathy (27%) and peripartum cardiomyopathy (20%). Ischemic cardiomyopathy was rare (3.4%). At 27 months follow-up, 76.7% of the patients were alive and well. Among those who died, mean survival time was 113 days. Readmission carried a poor prognosis. CONCLUSIONS: This congestive heart failure study from Haiti shows an unusually high proportion of young women, primarily due to peripartum cardiomyopathy. Ischemic cardiomyopathy is rare, as in Africa. Further study is warranted to address the particular problem of the high frequency of peripartum cardiomyopathy in this population.

A 19-Year Record of Training Haitian Residents in Otorhinolaryngology and Cervicofacial Surgery.

OBJECTIVES: Since 1996, 1 to 4 annual training missions have been carried out to train Haitian otorhinolaryngology (ENT) and cervicofacial surgery residents by the association Liens Otorhinolaryngology Ayti (LOA). Until 1996, ENT was practiced and taught by ophthalmologists. The aim of this article is to describe the contributions and limitations of LOA in training of Haitian resident physicians and the creation of the ENT specialty in Haiti. DESIGN: Retrospective analysis of clinical consultation and surgical interventions records and didactics carried out during missions from 1996 through 2014. PARTICIPANTS: A total of 37 missions were made during the 19-year period in which 29 senior ENT specialists participated, with an average of 3.37 missions per physician. RESULTS: A total of 10,300 consultations and 173 surgical procedures were made jointly by a senior LOA physician and a Haitian resident physician. Totally 16 Haitian ENT residents were trained, 81% of whom are still practicing in Haiti. ENT became a surgical specialty in 2001 after the nomination of a Haitian ENT specialist as Assistant Director of the ENT-Ophthalmology service. The latter benefitted from dual training by LOA in Haiti and abroad. CONCLUSION: The Haitian population experiences significant difficulties with access to medical care owing to very low number of resident medical personnel. LOA's work has contributed over 19 years to the training of ENT physicians now practicing in Haiti and to the creation of a local ENT specialty.