Does distance from a clinic and poverty impact visit adherence for noncommunicable diseases? A retrospective cohort study using electronic medical records in rural Haiti.

BACKGROUND: Adherence to regular outpatient visits is vital to managing noncommunicable diseases (NCDs), a growing burden in low and middle-income countries. We characterized visit adherence among patients with NCDs in rural Haiti, hypothesizing higher poverty and distance from the clinic were associated with lower adherence. METHODS: We analyzed electronic medical records from a cohort of adults in an NCD clinic in Mirebalais, Haiti (April 2013 to June 2016). Visit adherence was: 1) visit constancy (≥1 visit every 3 months), 2) no gaps in care (> 60 days between visits), 3) ≥1 visit in the last quarter, and 4) ≥6 visits per year. We incorporated an adapted measure of intensity of multidimensional poverty. We calculated distance from clinic as Euclidean distance or self-reported transit time. We used multivariable logistic regressions to assess the association between poverty, distance, and visit adherence. RESULTS: We included 463 adult patients, mean age 57.8 years (SE 2.2), and 72.4% women. Over half of patients had at least one visit per quarter (58.1%), but a minority (19.6%) had no gaps between visits. Seventy percent of patients had a visit in the last quarter, and 73.9% made at least 6 visits per year. Only 9.9% of patients met all adherence criteria. In regression models, poverty was not associated with any adherence measures, and distance was only associated with visit in the last quarter (OR 0.87, 95% CI [0.78 to 0.98], p = 0.03) after adjusting for age, sex, and hardship financing. CONCLUSIONS: Visit adherence was low in this sample of adult patients presenting to a NCD Clinic in Haiti. Multidimensional poverty and distance from clinic were not associated with visit adherence measures among patients seen in the clinic, except for visit in the last quarter. Future research should focus on identifying and addressing barriers to visit adherence.

High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti.

Background: Poverty is a major barrier to healthcare access in low-income countries. The degree of equitable access for noncommunicable disease (NCD) patients is not known in rural Haiti. Objectives: We evaluated the poverty distribution among patients receiving care in an NCD clinic in rural Haiti compared with the community and assessed associations of poverty with sex and distance from the health facility. Methods: We performed a cross-sectional study of patients with NCDs attending a public-sector health center in rural Haiti 2013-2016, and compared poverty among patients with poverty among a weighted community sample from the Haiti 2012 Demographic and Health Survey. We adapted the multidimensional poverty index: people deprived ≥44% of indicators are among the poorest billion people worldwide. We assessed hardship financing: borrowing money or selling belongings to pay for healthcare. We examined the association between facility distance and poverty adjusted for age and sex using linear regression. Results: Of 379 adults, 72% were women and the mean age was 52.5 years. 17.7% had hypertension, 19.3% had diabetes, 3.1% had heart failure, and 33.8% had multiple conditions. Among patients with available data, 197/296 (66.6%) experienced hardship financing. The proportions of people who are among the poorest billion people for women and men were similar (23.3% vs. 20.3%, p > 0.05). Fewer of the clinic patients were among the poorest billion people compared with the community (22.4% vs. 63.1%, p < 0.001). Patients who were most poor were more likely to live closer to the clinic (p = 0.002). Conclusion: Among patients with NCD conditions in rural Haiti, poverty and hardship financing are highly prevalent. However, clinic patients were less poor compared with the community population. These data suggest barriers to care access particularly affect the poorest. Socioeconomic data must be collected at health facilities and during community-level surveillance studies to monitor equitable healthcare access. Highlights: Poverty and hardship financing are highly prevalent among NCD patients in rural Haiti.Patients attending clinic are less poor than expected from the community.People travelling farther to clinic are less poor.Socioeconomic data should be collected to monitor healthcare access equity.

Descriptive epidemiology and short-term outcomes of heart failure hospitalisation in rural Haiti.

OBJECTIVE: There is increasing attention to cardiovascular diseases in low-income countries. However, little is known about heart failure (HF) in rural areas, where most of the populations in low-income countries live. We studied HF epidemiology, care delivery and outcomes in rural Haiti. METHODS: Among adults admitted with HF to a rural Haitian tertiary care hospital during a 12-month period (2013-2014), we studied the clinical characteristics and short-term outcomes including length of stay, inhospital death and outpatient follow-up rates. RESULTS: HF accounted for 392/1049 (37%) admissions involving 311 individuals; over half (60%) were women. Mean age was 58.8 (SD 16.2) years for men and 48.3 (SD 18.8) years for women; 76 (41%) women were <40 years of age. Median length of stay was 10 days (first and second quartiles 7, 17), and inhospital mortality was 12% (n=37). Ninety nine (36%) of the 274 who survived their primary hospitalisation followed-up at the hospital's outpatient clinic, and 18 (6.6%) were readmitted to the same hospital within 30 days postdischarge. Decreased known follow-up (p<0.01) and readmissions (p=0.03) were associated with increased distance between patient residence and hospital. Among the one-quarter (81) patients with echocardiograms, causes of HF included: non-ischaemic cardiomyopathy (64%), right HF (12%), hypertensive heart disease (7%) and rheumatic heart disease (5%). One-half of the women with cardiomyopathy by echocardiogram had peripartum cardiomyopathy. CONCLUSIONS: HF is a common cause of hospitalisation in rural Haiti. Among diagnosed patients, HF is overwhelming due to non-atherosclerotic heart disease and particularly affects young adults. Implementing effective systems to improve HF diagnosis and linkage to essential outpatient care is needed to reduce long-term morbidity and mortality.