Heart Failure Care Facilitators and Barriers in Rural Haiti: A Qualitative Study.

Background: Heart failure (HF) is a leading cause of hospitalizations in Haiti. However, few patients return for outpatient care. The factors contributing to chronic HF care access are poorly understood. Objective: The purpose of this study is to investigate the facilitators and barriers to accessing care for chronic HF from the patients' perspectives. Methods: We conducted a qualitative descriptive study of 13 patients with HF participating in three group interviews and one individual interview. We recruited patients after discharge from a nongovernmental organization-supported academic hospital in rural Haiti. We employed thematic analysis using emergent coding and categorized themes using the socioecological model. Findings: Facilitators of chronic care included participants' knowledge about the importance of treatment for HF and engagement with health systems to manage symptoms. Social support networks helped participants access clinics. Participants reported low cost of care at this subsidized hospital, good medication accessibility, and trust in the healthcare system. Participants expressedstrong spiritual beliefs, with the view that the healthcare system is an extension of God's influence. Barriers to chronic care included misconceptions about the importance of adherence to medications when symptoms improve and remembering follow-up appointments. Unexpectedly, participants believed they should take their HF medications with food and that food insecurity resulted in missed doses. Lack of social support networks limited clinic access. The nonhealthcare costs associated with clinic visits were prohibitive for many participants. Participants expressed low satisfaction regarding the clinic experience. A barrier to healthcare was the belief that heart disease caused by mystical and supernatural spirits is incurable. Conclusions: We identified several facilitators and barriers to chronic HF care with meaningful implications for HF management in rural Haiti. Future interventions to improve chronic HF care should emphasize addressing misconceptions about HF management and fostering patient support systems for visit and medication adherence. Leveraging local spiritual beliefs may also promote care engagement.

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries.

INTRODUCTION: The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up. METHODS AND ANALYSIS: Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews. ETHICS AND DISSEMINATION: This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

Online team-based electrocardiogram training in Haiti: evidence from the field.

BACKGROUND: The electrocardiogram (ECG) is the most relied upon tool for cardiovascular diagnosis, especially in low-resource settings because of its low cost and straightforward usability. It is imperative that internal medicine (IM) and emergency medicine (EM) specialists are competent in ECG interpretation. Our study was designed to improve proficiency in ECG interpretation through a competition among IM and EM residents at a teaching hospital in rural central Haiti in which over 40% of all admissions are due to CVD. METHODOLOGY: The 33 participants included 17 EM residents and 16 IM residents from each residency year at the Hôpital Universitaire de Mirebalais (HUM). Residents were divided into 11 groups of 3 participants with a representative from each residency year and were given team-based online ECG quizzes to complete weekly. The format included 56 ECG cases distributed over 11 weeks, and each case had a pre-specified number of points based on abnormal findings and complexity. All ECG cases represented cardiovascular pathology in Haiti adapted from the Association of Program Directors in Internal Medicine evaluation list. The main intervention was sharing group performance and ECG solutions to all participants each week to promote competition and self-study without specific feedback or discussion by experts. To assess impact, pre- and post-intervention assessments measuring content knowledge and comfort for each participant were performed. RESULTS: Overall group participation was heterogeneous with groups participating a median of 54.5% of the weeks (range 0-100%). 22 residents completed the pre- and post-test assessments. The mean pre- and post-intervention assessment knowledge scores improved from 27.3% to 41.7% (p = 0.004). 70% of participants improved their test scores. The proportion of participants who reported comfort with ECG interpretation increased from 57.6% to 66.7% (p = 0.015). CONCLUSION: This study demonstrates improvement in ECG interpretation through a team-based, asynchronous ECG competition approach. This method is easily scalable and could help to fill gaps in ECG learning. This approach can be delivered to other hospitals both in and outside Haiti. Further adaptations are needed to improve weekly group participation.