Development,Testing, and Implementation of a Training Curriculum for Nonphysician Health Workers to Reduce Cardiovascular Disease

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide. The need to address CVD is greatest in low- and middle-income countries where there is a shortage of trained health workers in CVD detection, prevention, and control.

Effect of a Community Health Worker-Based Approach to Integrated Cardiovascular Risk Factor Control in India: A Cluster Randomized Controlled Trial

BackgroundEighty percent of premature mortality from cardiovascular disease occurs in low- and middle-income countries. Hypertension, diabetes, and smoking are the top risk factors causing this disease burden.ObjectivesThe study aimed to test the hypothesis that utilizing community health workers (CHWs) to manage hypertension, diabetes and smoking in an integrated manner would lead to improved control of these conditions.MethodsThis was a 2-year cluster (n = 12) randomized controlled trial of 3,556 adults (35 to 70 years of age) in a single town in India, who were screened at home for hypertension, diabetes, and smoking. Of these adults, 1,242 (35%) had at least 1 risk factor (hypertension = 650, diabetes = 317, smoking = 500) and were enrolled in the study. The intervention group had behavioral change communication through regular home visits from community health workers. The control group received usual care in the community. The primary outcomes were changes in systolic blood pressure, fasting blood glucose, and average number of cigarettes/bidis smoked daily among individuals with respective risk factors.ResultsThe mean ± SD change in systolic blood pressure at 2 years was ?12.2 ± 19.5 mm Hg in the intervention group as compared with ?6.4 ± 26.1 mm Hg in the control group, resulting in an adjusted difference of –8.9 mm Hg (95% confidence interval [CI]: –3.5 to –14.4 mm Hg; p = 0.001). The change in fasting blood glucose was ?43.0 ± 83.5 mg/dl in the intervention group and ?16.3 ± 77.2 mg/dl in the control group, leading to an adjusted difference of –21.3 mg/dl (95% CI: 18.4 to –61 mg/dl; p = 0.29). The change in mean number of cigarettes/bidis smoked was nonsignificant at +0.2 cigarettes/bidis (95% CI: 5.6 to –5.2 cigarettes/bidis; p = 0.93).ConclusionsA population-based strategy of integrated risk factor management through community health workers led to improved systolic blood pressure in hypertension, an inconclusive effect on fasting blood glucose in diabetes, and no demonstrable effect on smoking. (Study of a Community-Based Approach to Control Cardiovascular Risk Factors in India [SEHAT]; NCT02115711).     

Worsening of the Cardiovascular Profile in a Developing Country: The Greater Beirut Area Cardiovascular Cohort

Background

Lebanon has no established governmental noncommunicable diseases surveillance and monitoring system to permit reporting on noncommunicable diseases rates. The last World Health Organization-supported surveillance report showed worrying trends in cardiovascular disease (CVD) risk factors.

A Human-Centered Approach to CV Care: Infrastructure Development in Uganda

In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease.     

Survival After MI in a Community Cohort Study: Contribution of Comorbidities in NSTEMI

Background

Non–ST-segment elevation myocardial infarction (NSTEMI) comprises the majority of MI worldwide, yet mortality remains high. Management of NSTEMI is relatively delayed and heterogeneous compared with the “time is muscle” approach to ST-segment elevation MI, though it is unknown to what extent comorbid conditions drive NSTEMI mortality.

Stakeholder Engagement in the Translation of a Hypertension Control Program to Guatemala's Public Primary Health Care System: Lessons Learned,Challenges, and Opportunities

BackgroundThere is an urgent need to define appropriate intervention strategies to control blood pressure in low- and middle-income countries. In 2018, a program proven effective in Argentina was translated to Guatemala's public primary health care system in rural and primarily indigenous communities.ObjectivesThis paper describes the stakeholder engagement process used to adapt the program to the Guatemalan rural context prior to implementing a type II hybrid effectiveness-implementation trial and shares lessons learned.MethodsWe identified key differences in the 2 contexts that are relevant to translating the intervention to the Guatemalan context. Alongside interviews and focus group discussions, we conducted consultation workshops in July and August 2018, applying a participatory translation process involving patients, family members, community members, health care providers, and Ministry of Health officials. The process consisted of multiple meetings in Guatemala City, as well as meetings in each of the 5 departments where the study will be implemented, and 1 district per department. During the workshops, we presented the evidence-based experience from Argentina and then focused on the challenges and recommended solutions that the participants identified for each of the intervention's 6 components. The process concluded with a meeting in which the research team and Ministry of Health officials defined specific details of the intervention.ResultsThe outcome of the process is an adapted approach appropriate to integrate into Guatemala's public primary health care system in the trial phase. The approach considers the challenges and recommended strategies for each of the 6 intervention components.ConclusionsWe identified lessons learned, challenges, and opportunities during the adaptation process. Findings will inform ongoing stakeholder engagement during the study implementation and future scale-up and efforts to translate evidence-based hypertension control strategies to low- and middle-income countries globally.     

Cardiovascular Disease Prognostic Models in Latin America and the Caribbean: A Systematic Review

Background

Cardiovascular prognostic models guide treatment allocation and support clinical decisions. Whether there are valid models for Latin American and Caribbean (LAC) populations is unknown.

Stakeholder Engagement in Planning the Design of a National Needs Assessment for Cardiovascular Disease Prevention and Management in Nepal

BackgroundThere is growing support for stakeholder engagement in health research, but the actual impact of such engagement has not been well established.ObjectivesThis paper describes the stakeholder engagement process and evaluation during the planning of the national needs assessment for cardiovascular disease in Nepal.MethodsWe used personal and professional networks to identify relevant stakeholders within the 7Ps framework (Patients and the Public, Providers, Purchasers, Payers, Public Policy Makers and Policy Advocates, Product Makers and the Principal Investigators) to develop a plan for assessing cardiovascular health needs in Nepal. We consulted 40 stakeholders through 2 meetings in small groups and a workshop in a large group to develop the study methods, conceptual framework, and stakeholder engagement process. We interviewed 33 stakeholders to receive feedback on the stakeholder engagement process.ResultsWe engaged 80% of the targeted stakeholders through small group discussions and a workshop. Three of 5 recommendations from the small group discussion were aimed at improving the stakeholder engagement process and 2 were aimed to improve the research methods. Eleven of 27 recommendations from the workshop aimed to improve the research methods, 4 aimed to improve stakeholder engagement, and 2 helped to expand the scope of dissemination. Ten were irrelevant or could not be incorporated due to resource limitation. Most stakeholders noted that the workshop provided an open platform for a multisectoral group to colearn from one another and share ideas. Others highlighted that the discussion generated insights to enhance research by incorporating expertise and ideas from different perspectives. The major challenges discussed were about committing the time for engagement.ConclusionsThe stakeholder engagement process positively affected the design of our research. This study provides important insights for future researchers that aim to engage stakeholders in national-level assessment programs in the health care system in the context of Nepal.