Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping.

BACKGROUND: Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa. METHODS: Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies. RESULTS: Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials. CONCLUSIONS: Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.

Knowledge, attitudes, and preventive practices regarding ischemic heart disease among HIV-positive individuals in northern Tanzania.

OBJECTIVES: To describe knowledge, attitudes, and practices (KAP) regarding ischemic heart disease (IHD) among adults with HIV in Tanzania. METHODS: Adults presenting for routine HIV care at a clinic in northern Tanzania were consecutively enrolled and were administered a standardised KAP survey. For each participant, an IHD knowledge score was calculated by tallying correct answers to the IHD knowledge questions, with maximum score 10. Individual 5-year risk of cardiovascular event was calculated using the Harvard NHANES model. Associations between participant characteristics and IHD knowledge scores were assessed via Welch's t-test. RESULTS: Among the 500 participants, the mean (SD) age was 45.3 (11.4) years and 139 (27.8%) were males. Most participants recognised high blood pressure (n = 313, 62.6%) as a risk factor for IHD, but fewer identified diabetes as a risk factor (n = 241, 48.2%), or knew that aspirin reduces the risk of a secondary cardiovascular event (n = 73, 14.6%). Higher IHD knowledge score was associated with post-primary education (mean 6.27 vs. 5.35, p = 0.001) and with >10% 5-year risk of cardiovascular event (mean 5.97 vs. 5.41, p = 0.045). Most participants believed there were things they could do to reduce their chances of having a heart attack (n = 361, 72.2%). While participants indicated that they adhered to their prescribed medications (n = 488, 97.6%), only 106 (21.2%) attended regular health check-ups. CONCLUSION: Efforts are needed to improve gaps in IHD knowledge, and increase uptake of cardiovascular preventative practices among Tanzanian adults with HIV.

Acute myocardial infarction under-diagnosis and mortality in a Tanzanian emergency department: A prospective observational study.

BACKGROUND: Growing evidence suggests that under-diagnosis of acute myocardial infarction (AMI) may be common in sub-Saharan Africa. Prospective studies of routine AMI screening among patients presenting to emergency departments in sub-Saharan Africa are lacking. Our objective was to determine the prevalence of AMI among patients in a Tanzanian emergency department. METHODS: In a prospective observational study, consecutive adult patients presenting with chest pain or shortness of breath to a referral hospital emergency department in northern Tanzania were enrolled. Electrocardiogram (ECG) and troponin testing were performed for all participants to diagnose AMI types according to the Fourth Universal Definition. All ECGs were interpreted by two independent physician judges. ECGs suggesting ST-elevation myocardial infarction (STEMI) were further reviewed by additional judges. Mortality was assessed 30 days following enrollment. RESULTS: Of 681 enrolled participants, 152 (22.3%) had AMI, including 61 STEMIs and 91 non-STEMIS (NSTEMIs). Of AMI patients, 91 (59.9%) were male, mean (SD) age was 61.2 (18.5) years, and mean (SD) duration of symptoms prior to presentation was 6.6 (12.2) days. In the emergency department, 35 (23.0%) AMI patients received aspirin and none received thrombolytics. Of 150 (98.7%) AMI patients completing 30-day follow-up, 65 (43.3%) had died. CONCLUSIONS: In a northern Tanzanian emergency department, AMI is common, rarely treated with evidence-based therapies, and associated with high mortality. Interventions are needed to improve AMI diagnosis, care, and outcomes.

Multicountry Distribution and Characterization of Extended-spectrum ß-Lactamase-associated Gram-negative Bacteria From Bloodstream Infections in Sub-Saharan Africa.

BACKGROUND: Antimicrobial resistance (AMR) is a major global health concern, yet, there are noticeable gaps in AMR surveillance data in regions such as sub-Saharan Africa. We aimed to measure the prevalence of extended-spectrum ß-lactamase (ESBL) producing Gram-negative bacteria in bloodstream infections from 12 sentinel sites in sub-Saharan Africa. METHODS: Data were generated during the Typhoid Fever Surveillance in Africa Program (TSAP), in which standardized blood cultures were performed on febrile patients attending 12 health facilities in 9 sub-Saharan African countries between 2010 and 2014. Pathogenic bloodstream isolates were identified at the sites and then subsequently confirmed at a central reference laboratory. Antimicrobial susceptibility testing, detection of ESBL production, and conventional multiplex polymerase chain reaction (PCR) testing for genes encoding for ß-lactamase were performed on all pathogens. RESULTS: Five hundred and five pathogenic Gram-negative bloodstream isolates were isolated during the study period and available for further characterization. This included 423 Enterobacteriaceae. Phenotypically, 61 (12.1%) isolates exhibited ESBL activity, and genotypically, 47 (9.3%) yielded a PCR amplicon for at least one of the screened ESBL genes. Among specific Gram-negative isolates, 40 (45.5%) of 88 Klebsiella spp., 7 (5.7%) of 122 Escherichia coli, 6 (16.2%) of 37 Acinetobacter spp., and 2 (1.3%) of 159 of nontyphoidal Salmonella (NTS) showed phenotypic ESBL activity. CONCLUSIONS: Our findings confirm the presence of ESBL production among pathogens causing bloodstream infections in sub-Saharan Africa. With few alternatives for managing ESBL-producing pathogens in the African setting, measures to control the development and proliferation of AMR organisms are urgently needed.

Knowledge of myocardial infarction symptoms and perceptions of self-risk in Tanzania.

BACKGROUND: Little is known about community knowledge of myocardial infarction symptoms and perceptions of self-risk in sub-Saharan Africa. METHODS: A community survey was conducted in northern Tanzania, where the prevalence of cardiovascular risk factors is high. Households were selected randomly in a population-weighted fashion and surveys were administered to self-identified household healthcare decision-makers. Respondents were asked to list all symptoms of a heart attack and asked whether they thought they had a chance of suffering a heart attack. Associations between participant sociodemographic features and responses to these questions were assessed with Pearson's chi-squared and the Student t test. RESULTS: There were 718 survey participants, with median (IQR) age 48 (32, 62) years. Of these, 115 (16.0%) were able to identify any conventional symptom of a heart attack, including 24 (3.3%) respondents who cited chest pain as a possible symptom. There was no association between ability to identify a conventional symptom and gender, level of education, socioeconomic status, urban residence, or age. Of respondents, 198 (27.6%) thought they had a chance of suffering a heart attack. Older respondents were more likely to perceive themselves to be at risk (P < .001), but there was no association between perception of self-risk and gender, level of education, socioeconomic status, or urban residence. CONCLUSIONS: In northern Tanzania, knowledge of myocardial infarction symptoms is poor among all segments of the population and only a minority of residents perceive themselves to be at risk of this disease. Educational interventions regarding ischemic heart disease are urgently needed.

Perceptions of Stroke and Associated Health-Care-Seeking Behavior in Northern Tanzania: A Community-Based Study.

BACKGROUND: Little is known about knowledge of stroke symptoms, perceptions of self-risk, and health-care-seeking behavior for stroke in East Africa. METHODS: A 2-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household health-care decision makers were asked to list all symptoms of a stroke. They were further asked if they thought they had a chance of having a stroke and where they would present for care for stroke-like symptoms. A socioeconomic status score was derived via principal component analysis from 9 variables related to wealth. RESULTS: Of 670 respondents, 184 (27.4%) knew a conventional stroke symptom and 51 (7.6%) thought they had a chance of having a stroke. Females were less likely to perceive themselves to be at risk than males (OR 0.49, 95% CI 0.28-0.89, p = 0.014). Of respondents, 558 (88.3%) stated they would present to a hospital for stroke-like symptoms. Preference for a hospital was not associated with knowledge of stroke symptoms or perception of self-risk but was associated with a higher socioeconomic status score (p < 0.001). CONCLUSIONS: Knowledge of stroke symptoms and perception of self-risk are low in northern Tanzania, but most residents would present to a hospital for stroke-like symptoms.

A Multicountry Molecular Analysis of Salmonella enterica Serovar Typhi With Reduced Susceptibility to Ciprofloxacin in Sub-Saharan Africa.

BACKGROUND: Salmonella enterica serovar Typhi is a predominant cause of bloodstream infections in sub-Saharan Africa (SSA). Increasing numbers of S. Typhi with resistance to ciprofloxacin have been reported from different parts of the world. However, data from SSA are limited. In this study, we aimed to measure the ciprofloxacin susceptibility of S. Typhi isolated from patients with febrile illness in SSA. METHODS: Febrile patients from 9 sites within 6 countries in SSA with a body temperature of ≥38.0°C were enrolled in this study. Blood samples were obtained for bacterial culture, and Salmonella isolates were identified biochemically and confirmed by multiplex polymerase chain reaction (PCR). Antimicrobial susceptibility of all Salmonella isolates was performed by disk diffusion test, and minimum inhibitory concentrations (MICs) against ciprofloxacin were measured by Etest. All Salmonella isolates with reduced susceptibility to ciprofloxacin (MIC > 0.06 µg/mL) were screened for mutations in quinolone resistance-determining regions in target genes, and the presence of plasmid-mediated quinolone resistance (PMQR) genes was assessed by PCR. RESULTS: A total of 8161 blood cultures were performed, and 100 (1.2%) S. Typhi, 2 (<0.1%) Salmonella enterica serovar Paratyphi A, and 27 (0.3%) nontyphoid Salmonella (NTS) were isolated. Multidrug-resistant S. Typhi were isolated in Kenya (79% [n = 38]) and Tanzania (89% [n = 8]) only. Reduced ciprofloxacin-susceptible (22% [n = 11]) S. Typhi were isolated only in Kenya. Among those 11 isolates, all had a Glu133Gly mutation in the gyrA gene combined with either a gyrA (Ser83Phe) or gyrB mutation (Ser464Phe). One Salmonella Paratyphi A isolate with reduced susceptibility to ciprofloxacin was found in Senegal, with 1 mutation in gyrA (Ser83Phe) and a second mutation in parC (Ser57Phe). Mutations in the parE gene and PMQR genes were not detected in any isolate. CONCLUSIONS: Salmonella Typhi with reduced susceptibility to ciprofloxacin was not distributed homogenously throughout SSA. Its prevalence was very high in Kenya, and was not observed in other study countries. Continuous monitoring of antimicrobial susceptibility is required to follow the potential spread of antimicrobial-resistant isolates throughout SSA.

Utilization of Healthcare in the Typhoid Fever Surveillance in Africa Program.

BACKGROUND: Assessing healthcare utilization is important to identify weaknesses of healthcare systems, to outline action points for preventive measures and interventions, and to more accurately estimate the disease burden in a population. METHODS: A healthcare utilization survey was developed for the Typhoid Fever Surveillance in Africa Program (TSAP) to adjust incidences of salmonellosis determined through passive, healthcare facility-based surveillance. This cross-sectional survey was conducted at 11 sites in 9 sub-Saharan African countries. Demographic data and healthcare-seeking behavior were assessed at selected households. Overall and age-stratified percentages of each study population that sought healthcare at a TSAP healthcare facility and elsewhere were determined. RESULTS: Overall, 88% (1007/1145) and 81% (1811/2238) of the population in Polesgo and Nioko 2, Burkina Faso, respectively, and 63% (1636/2590) in Butajira, Ethiopia, sought healthcare for fever at any TSAP healthcare facility. A far smaller proportion-namely, 20%-45% of the population in Bissau, Guinea-Bissau (1743/3885), Pikine, Senegal (1473/4659), Wad-Medani, Sudan (861/3169), and Pietermaritzburg, South Africa (667/2819); 18% (483/2622) and 9% (197/2293) in Imerintsiatosika and Isotry, Madagascar, respectively; and 4% (127/3089) in Moshi, Tanzania-sought healthcare at a TSAP healthcare facility. Patients with fever preferred to visit pharmacies in Imerintsiatosika and Isotry, and favored self-management of fever in Moshi. Age-dependent differences in healthcare utilization were also observed within and across sites. CONCLUSIONS: Healthcare utilization for fever varied greatly across sites, and revealed that not all studied populations were under optimal surveillance. This demonstrates the importance of assessing healthcare utilization. Survey data were pivotal for the adjustment of the program's estimates of salmonellosis and other conditions associated with fever.

Validation and Identification of Invasive Salmonella Serotypes in Sub-Saharan Africa by Multiplex Polymerase Chain Reaction.

Salmonella enterica serovar Typhi and nontyphoidal Salmonella (NTS) cause the majority of bloodstream infections in sub-Saharan Africa; however, serotyping is rarely performed. We validated a multiplex polymerase chain reaction (PCR) assay with the White-Kauffmann-Le Minor (WKLM) scheme of serotyping using 110 Salmonella isolates from blood cultures of febrile children in Ghana and applied the method in other Typhoid Fever Surveillance in Africa Program study sites. In Ghana, 47 (43%) S. Typhi, 36 (33%) Salmonella enterica serovar Typhimurium, 14 (13%) Salmonella enterica serovar Dublin, and 13 (12%) Salmonella enterica serovar Enteritidis were identified by both multiplex PCR and the WKLM scheme separately. Using the validated multiplex PCR assay, we identified 42 (66%) S. Typhi, 14 (22%) S. Typhimurium, 2 (3%) S. Dublin, 2 (3%) S. Enteritidis, and 4 (6%) other Salmonella species from the febrile patients in Burkina Faso, Guinea-Bissau, Madagascar, Senegal, and Tanzania. Application of this multiplex PCR assay in sub-Saharan Africa could advance the knowledge of serotype distribution of Salmonella.

The Relationship Between Invasive Nontyphoidal Salmonella Disease, Other Bacterial Bloodstream Infections, and Malaria in Sub-Saharan Africa.

BACKGROUND: Country-specific studies in Africa have indicated that Plasmodium falciparum is associated with invasive nontyphoidal Salmonella (iNTS) disease. We conducted a multicenter study in 13 sites in Burkina Faso, Ethiopia, Ghana, Guinea-Bissau, Kenya, Madagascar, Senegal, South Africa, Sudan, and Tanzania to investigate the relationship between the occurrence of iNTS disease, other systemic bacterial infections, and malaria. METHODS: Febrile patients received a blood culture and a malaria test. Isolated bacteria underwent antimicrobial susceptibility testing, and the association between iNTS disease and malaria was assessed. RESULTS: A positive correlation between frequency proportions of malaria and iNTS was observed (P = .01; r = 0.70). Areas with higher burden of malaria exhibited higher odds of iNTS disease compared to other bacterial infections (odds ratio [OR], 4.89; 95% CI, 1.61-14.90; P = .005) than areas with lower malaria burden. Malaria parasite positivity was associated with iNTS disease (OR, 2.44; P = .031) and gram-positive bacteremias, particularly Staphylococcus aureus, exhibited a high proportion of coinfection with Plasmodium malaria. Salmonella Typhimurium and Salmonella Enteritidis were the predominant NTS serovars (53/73; 73%). Both moderate (OR, 6.05; P = .0001) and severe (OR, 14.62; P < .0001) anemia were associated with iNTS disease. CONCLUSIONS: A positive correlation between iNTS disease and malaria endemicity, and the association between Plasmodium parasite positivity and iNTS disease across sub-Saharan Africa, indicates the necessity to consider iNTS as a major cause of febrile illness in malaria-holoendemic areas. Prevention of iNTS disease through iNTS vaccines for areas of high malaria endemicity, targeting high-risk groups for Plasmodium parasitic infection, should be considered.

Bloodstream Infections and Frequency of Pretreatment Associated With Age and Hospitalization Status in Sub-Saharan Africa.

BACKGROUND: The clinical diagnosis of bacterial bloodstream infections (BSIs) in sub-Saharan Africa is routinely confused with malaria due to overlapping symptoms. The Typhoid Surveillance in Africa Program (TSAP) recruited febrile inpatients and outpatients of all ages using identical study procedures and enrollment criteria, thus providing an opportunity to assess disease etiology and pretreatment patterns among children and adults. METHODS: Inpatients and outpatients of all ages with tympanic or axillary temperatures of ≥38.0 or ≥37.5°C, respectively, and inpatients only reporting fever within the previous 72 hours were eligible for recruitment. All recruited patients had one blood sample drawn and cultured for microorganisms. Data from 11 TSAP surveillance sites in nine different countries were used in the analysis. Bivariate analysis was used to compare frequencies of pretreatment and BSIs in febrile children (<15 years old) and adults (≥15 years old) in each country. Pooled Cochran Mantel-Haenszel odds ratios (ORs) were calculated for overall trends. RESULTS: There was no significant difference in the odds of a culture-proven BSI between children and adults among inpatients or outpatients. Among both inpatients and outpatients, children had significantly higher odds of having a contaminated blood culture compared with adults. Using country-pooled data, child outpatients had 66% higher odds of having Salmonella Typhi in their bloodstream than adults (OR, 1.66; 95% confidence interval [CI], 1.01-2.73). Overall, inpatient children had 59% higher odds of pretreatment with analgesics in comparison to inpatient adults (OR, 1.59; 95% CI, 1.28-1.97). CONCLUSIONS: The proportion of patients with culture-proven BSIs in children compared with adults was similar across the TSAP study population; however, outpatient children were more likely to have Salmonella Typhi infections than outpatient adults. This finding points to the importance of including outpatient facilities in surveillance efforts, particularly for the surveillance of typhoid fever. Strategies to reduce contamination among pediatric blood cultures are needed across the continent to prevent the misdiagnosis of BSI cases in children.

Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study.

INTRODUCTION: People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. METHODS: In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. RESULTS: 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. CONCLUSIONS: PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.

Characteristics and outcomes of patients with symptomatic chronic myocardial injury in a Tanzanian emergency department: A prospective observational study.

BACKGROUND: Chronic myocardial injury is a condition defined by stably elevated cardiac biomarkers without acute myocardial ischemia. Although studies from high-income countries have reported that chronic myocardial injury predicts adverse prognosis, there are no published data about the condition in sub-Saharan Africa. METHODS: Between November 2020 and January 2023, adult patients with chest pain or shortness of breath were recruited from an emergency department in Moshi, Tanzania. Medical history and point-of-care troponin T (cTnT) assays were obtained from participants; those whose initial and three-hour repeat cTnT values were abnormally elevated but within 11% of each other were defined as having chronic myocardial injury. Mortality was assessed thirty days following enrollment. RESULTS: Of 568 enrolled participants, 81 (14.3%) had chronic myocardial injury, 73 (12.9%) had acute myocardial injury, and 412 (72.5%) had undetectable cTnT values. Of participants with chronic myocardial injury, the mean (± sd) age was 61.5 (± 17.2) years, and the most common comorbidities were CKD (n = 65, 80%) and hypertension (n = 60, 74%). After adjusting for CKD, thirty-day mortality rates (38% vs. 36%, aOR 1.03, 95% CI: 0.52-2.03, p = 0.931) were similar between participants with chronic myocardial injury and those with acute myocardial injury, but significantly greater (38% vs. 13.6%, aOR 3.63, 95% CI: 1.98-6.65, p<0.001) among participants with chronic myocardial injury than those with undetectable cTnT values. CONCLUSION: In Tanzania, chronic myocardial injury is a poor prognostic indicator associated with high risk of short-term mortality. Clinicians practicing in this region should triage patients with stably elevated cTn levels in light of their increased risk.

Evaluating the performance of the HEART score in a Tanzanian emergency department.

OBJECTIVE: The HEART score successfully risk stratifies emergency department (ED) patients with chest pain in high-income settings. However, this tool has not been validated in low-income countries. METHODS: This is a secondary analysis of a prospective observational study that was conducted in a Tanzanian ED from January 2019 through January 2023. Adult patients with chest pain were consecutively enrolled, and their presenting symptoms and medical history were recorded. Electrocardiograms and point-of-care troponin assays were obtained for all participants. Thirty-day follow-up was conducted, assessing for major adverse cardiac events (MACEs), defined as death, myocardial infarction, or coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention). HEART scores were calculated for all participants. Likelihood ratios, sensitivity, specificity, and negative predictive values (NPVs) were calculated for each HEART cutoff score to predict 30-day MACEs, and area under the curve (AUC) was calculated from the receiver operating characteristic curve. RESULTS: Of 927 participants with chest pain, the median (IQR) age was 61 (45.5-74.0) years. Of participants, 216 (23.3%) patients experienced 30-day MACEs, including 163 (17.6%) who died, 48 (5.2%) with myocardial infarction, and 23 (2.5%) with coronary revascularization. The positive likelihood ratio for each cutoff score ranged from 1.023 (95% CI 1.004-1.042; cutoff ≥ 1) to 3.556 (95% CI 1.929-6.555; cutoff ≥ 7). The recommended cutoff of ≥4 to identify patients at high risk of MACEs yielded a sensitivity of 59.4%, specificity of 52.8%, and NPV of 74.7%. The AUC was 0.61. CONCLUSIONS: Among patients with chest pain in a Tanzanian ED, the HEART score did not perform as well as in high-income settings. Locally validated risk stratification tools are needed for ED patients with chest pain in low-income countries.

Provider attitudes towards quality improvement for myocardial infarction care in northern Tanzania.

INTRODUCTION: Myocardial Infarction (MI) is a leading cause of death worldwide. In high income countries, quality improvement strategies have played an important role in increasing uptake of evidence-based MI care and improving MI outcomes. The incidence of MI in sub-Saharan Africa is rising, but uptake of evidence-based care in northern Tanzania is low. There are currently no published quality improvement interventions from the region. The objective of this study was to determine provider attitudes towards a planned quality improvement intervention for MI care in northern Tanzania. METHODS: This study was conducted at a zonal referral hospital in northern Tanzania. A 41-question survey, informed by the Theoretical Framework for Acceptability, was developed by an interdisciplinary team from Tanzania and the United States. The survey, which explored provider attitudes towards MI care improvement, was administered to key provider stakeholders (physicians, nurses, and hospital administrators) using convenience sampling. RESULTS: A total of 140 providers were enrolled, including 82 (58.6%) nurses, 56 (40.0%) physicians, and 2 (1.4%) hospital administrators. Most participants worked in the Emergency Department or inpatient medical ward. Providers were interested in participating in a quality improvement project to improve MI care at their facility, with 139 (99.3%) strongly agreeing or agreeing with this statement. All participants agreed or strongly agreed that improvements were needed to MI care pathways at their facility. Though their facility has an MI care protocol, only 88 (62.9%) providers were aware of it. When asked which intervention would be the single-most effective strategy to improve MI care, the two most common responses were provider training (n = 66, 47.1%) and patient education (n = 41, 29.3%). CONCLUSION: Providers in northern Tanzania reported strongly positive attitudes towards quality improvement interventions for MI care. Locally-tailored interventions to improve MI should include provider training and patient education strategies.

Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention.

Background: Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Objectives: Co-design a quality improvement intervention for AMI care tailored to local contextual factors. Methods: An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. Findings: The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. Conclusion: MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.

Comparing actual and perceived causes of fever among community members in a low malaria transmission setting in northern Tanzania.

OBJECTIVE: To compare actual and perceived causes of fever in northern Tanzania. METHODS: In a standardised survey, heads of households in 30 wards in Moshi, Tanzania, were asked to identify the most common cause of fever for children and for adults. Responses were compared to data from a local hospital-based fever aetiology study that used standard diagnostic techniques. RESULTS: Of 810 interviewees, the median (range) age was 48 (16, 102) years and 509 (62.8%) were women. Malaria was the most frequently identified cause of fever, cited by 353 (43.6%) and 459 (56.7%) as the most common cause of fever for children and adults, respectively. In contrast, malaria accounted for 8 (2.0%) of adult and 6 (1.3%) of paediatric febrile admissions in the fever aetiology study. Weather was the second most frequently cited cause of fever. Participants who identified a non-biomedical explanation such as weather as the most common cause of fever were more likely to prefer a traditional healer for treatment of febrile adults (OR 2.7, P < 0.001). Bacterial zoonoses were the most common cause of fever among inpatients, but no interviewees identified infections from animal contact as the most common cause of fever for adults; two (0.2%) identified these infections as the most common cause of fever for children. CONCLUSIONS: Malaria is perceived to be a much more common cause of fever than hospital studies indicate, whereas other important diseases are under-appreciated in northern Tanzania. Belief in non-biomedical explanations of fever is common locally and has important public health consequences.

Hypertension in an Emergency Department Population in Moshi, Tanzania; A Qualitative Study of Barriers to Hypertension Control.

BACKGROUND: Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control. METHODS: In northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method. RESULTS: We enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time. CONCLUSION: Patients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.

Use of Virtual Interactive Patient Encounters to Prepare First-Year Medical Students for Clinical Practice.

PROBLEM: With the dissolution of the Step 2 Clinical Skills exam, medical programs have a greater responsibility to teach and assess clinical skills in the preclerkship years. Clinical teaching this early has traditionally been avoided because of insufficient integration with biomedical sciences, curricular time constraints, and concerns about overwhelming novice learners with clinical learning objectives. To overcome these barriers, the authors created a clinical framework for the biomedical science curriculum by integrating a series of virtual interactive patient (VIP) videos. APPROACH: Matriculating first-year medical students were enrolled in a clinically integrated biomedical science course that used VIP videos to teach and assess clinical skills. The VIP videos were enhanced with interactive pop-in windows, and at the conclusion of each video, students performed a clinical documentation task and received immediate feedback. The authors implemented 7 VIP cases during fall 2021 in which first-year medical students wrote the patient care plan, problem representation statement, or clinical reasoning assessment. Student responses were independently evaluated by course faculty using a 4-level scoring scale. The authors calculated the pooled mean scores for each documentation task and examined student feedback. OUTCOMES: Seven VIP encounters were assigned to 124 students (mean response rate, 98.5%). Pooled mean scores on the clinical documentation tasks showed that most students were able to achieve levels 3 or 4 when writing the patient care plan (97 [82%] to 113 [94%]), addressing social determinants of health (80 [67%]), writing an accurate problem representation statement (113 [91%] to 117 [94%]), and performing clinical reasoning skills (48 [40%] to 95 [82%]). NEXT STEPS: VIP encounters were feasible to produce, effective at integrating course content, successful at assessing student clinical documentation skills, and well received. The authors will continue to produce, implement, and study the VIP as an integrating learning tool in undergraduate medical education.

Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study.

Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.