Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease.

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

The case for precision medicine in the prevention, diagnosis, and treatment of cardiometabolic diseases in low-income and middle-income countries.

Cardiometabolic diseases are the leading preventable causes of death in most geographies. The causes, clinical presentations, and pathogenesis of cardiometabolic diseases vary greatly worldwide, as do the resources and strategies needed to prevent and treat them. Therefore, there is no single solution and health care should be optimised, if not to the individual (ie, personalised health care), then at least to population subgroups (ie, precision medicine). This optimisation should involve tailoring health care to individual disease characteristics according to ethnicity, biology, behaviour, environment, and subjective person-level characteristics. The capacity and availability of local resources and infrastructures should also be considered. Evidence needed for equitable precision medicine cannot be generated without adequate data from all target populations, and the idea that research done in high-income countries will transfer adequately to low-income and middle-income countries (LMICs) is problematic, as many migration studies and transethnic comparisons have shown. However, most data for precision medicine research are derived from people of European ancestry living in high-income countries. In this Series paper, we discuss the case for precision medicine for cardiometabolic diseases in LMICs, the barriers and enablers, and key considerations for implementation. We focus on three propositions: first, failure to explore and implement precision medicine for cardiometabolic disease in LMICs will enhance global health disparities. Second, some LMICs might already be placed to implement cardiometabolic precision medicine under appropriate circumstances, owing to progress made in treating infectious diseases. Third, improvements in population health from precision medicine are most probably asymptotic; the greatest gains are more likely to be obtained in countries where health-care systems are less developed. We outline key recommendations for implementation of precision medicine approaches in LMICs.

Effectiveness of Cardiac Rehabilitation Services in Low- and Middle-Income Countries: A Systematic Review.

Cardiac rehabilitation (CR) is a cost-effective intervention that can reduce cardiovascular disease (CVD) morbidity and mortality by 20%. Despite the clear benefits of CR, it remains unavailable and underutilized. This study aimed to assess the effectiveness of different CR models in reducing CVD-related morbidity and mortality in low-and middle-income countries. We conducted a systematic review of studies conducted in low- and middle-income countries that assessed at least one of the three phases of CR (inpatient rehabilitation, outpatient rehabilitation in a hospital, or community setting and maintenance). The primary outcomes of interest were mortality (all-cause and CVD-specific), CVD-related morbidity, functional capacity, risk factor reduction, and quality of life (QoL). The electronic search retrieved 1,102 studies, of which 22 were retrieved and included in the review. These studies were conducted between 2011 and 2022 and the majority (18) were conducted in Asia. All studies except one were randomized controlled trials (RCTs), and all except one were conducted at a single site. The target population in most studies (16) included patients with coronary artery disease (CAD). Seven studies have incorporated digital technology. Only one study has reported a significant reduction in all-cause mortality. Thirteen studies reported data on functional capacity, and 16 on quality of life (QoL), showing statistically significant improvements. Data on risk factors, anxiety, and depression have shown mixed results. CR is effective in low- and middle-income countries, and strategies to scale it up using locally available resources tailored to the patient population should be adopted.

The joint 15th Pan-African Society of Cardiology and Kenya Cardiac Society congress proceedings, 2021.

The 15th biennial Pan-African Society of Cardiology (PASCAR) congress held in Mombasa, Kenya, in November 2021, convened in its legacy of being the largest Pan-African conference on cardiovascular diseases (CVDs). The congress brough together members of cardiovascular societies from across the continent in the shared mission of advancing cardiovascular health in Africa. In partnership with the Kenyan Cardiac Society (KCS), the specific aims of the PASCAR conference were to (1) advance knowledge on CVDs in the region; (2) share local data, clinical cases, challenges and solutions and reinforce collaborative capacity initiatives in research and workforce training; (3) engage with policy makers to address health-system issues affecting access to CVD care in Africa; and (4) bring together local and international thought leaders in cardiovascular medicine to strengthen the partnerships between PASCAR, KCS, other African cardiac societies and key global stakeholders. Due to the COVID-19 pandemic, this congress demonstrated great success in providing both an in-person and a virtual platform of attendance, therefore making this an inaugural hybrid PASCAR congress, with inclusive and widespread participation from across the globe. We highlight the key areas of focus, various educational programmes and innovative initiatives that shaped the 15th PASCAR congress, including expert consensus on the future directions for advancing CVD care in Africa.

Adherence Clubs to Improve Hypertension Management in Nigeria: Clubmeds, a Feasibility Study.

Background: Hypertension control remains a significant challenge in reducing the cardiovascular disease burden worldwide. Community peer-support groups have been identified as a promising strategy to improve medication adherence and blood pressure (BP) control. Objectives: The study aimed to evaluate the feasibility and impact of adherence clubs to improve BP control in Southeast Nigeria. Methods: This was a mixed-methods research involving a formative (pre-implementation) research, pilot study and process evaluation. Hypertensive patients in two communities were recruited into peer-support adherence clubs under the leadership of role-model patients to motivate and facilitate medication adherence, BP monitoring, and monthly medication delivery for six months. The primary outcome was medication adherence measured using visual analogue scale (VAS), with BP level at six months as a key secondary outcome. Results: We recruited a total of 104 participants. The mean age was 56.8 (SD-10.7) years, 72 (69.2%) were women, mean BP was 146.7 (SD-20.1)/86.9 (SD-11.2) mmHg, and the mean percentage of medication adherence on the VAS was 41.4% (SD-11.9%). At six months, 67 patients were assessed; self-reported adherence on the VAS increased to 57.3% (SD-25.3%) (mean difference between baseline and follow-up of 15.5%, p < 0.0001), while the mean BP decreased to 132.3 (SD-22.0)/82.9 (SD-12.2) mmHg (mean difference of 13.0 mmHg in systolic BP, p < 0.0001 and of 3.6 mmHg in diastolic BP, p = 0.02). Five in-depth interviews and four focus groups discussions were conducted as part of the qualitative analyses of the study. The participants saw hypertension as a big issue, with many unaware of the diagnosis, and they accepted the CLUBMEDS differential service delivery (DSD) model concept in hypertension. Conclusions: The study demonstrates that the implementation of adherence clubs for hypertension control is feasible and led to a statistically significant and clinically meaningful improvement in self-reported medication adherence, resulting in BP reduction. Upscaling the intervention may be needed to confirm these findings.

PASCAR and WHF Cardiovascular Diseases Scorecard project.

Data collected for the World Heart Federation's Scorecard project regarding the current state of cardiovascular disease prevention, control and management, along with related non-communicable diseases in Kenya are presented. Furthermore, the strengths, threats, weaknesses and priorities identified from these data are highlighted in concurrence with related sections in the accompanying infographic. Information was collected using open-source data sets from the World Bank, the World Health Organization, the Institute for Health Metrics and Evaluation, the International Diabetes Federation and relevant government publications.

May Measurement Month 2019: an analysis of blood pressure screening results from Kenya.

Elevated blood pressure (BP) is the leading cause of global mortality, but control rates remain poor because most patients, especially in Africa, are unaware. May Measurement Month (MMM) is an annual global BP screening campaign that was initiated by the International Society of Hypertension (ISH) in 2017 to raise awareness of raised BP. Following participation in 2017 and 2018, Kenya participated again in 2019 and the results are reported here. Screening was carried out in 30 sites by volunteers coordinated by the Kenya Cardiac Society. Participants had three BP readings by standard methods with the last two being averaged and recorded. Heart rate, weight, height, socio-demographic parameters, and co-morbidities were documented. Hypertension was defined as a systolic BP (SBP) ≥140 mmHg and/or a diastolic BP (DBP) ≥90 mmHg or being on treatment with at least one antihypertensive medication. A total of 33 992 participants were screened, mean age was 42.5 (SD 16.8) years and 58.7% of participants were female. Only 27.3% had their BPs checked within the preceding 12 months. After multiple imputation, 26.1% were hypertensive, of whom 34.5% were aware of their hypertension and 31.5% were on treatment. Of those on treatment, 59.7% were controlled translating to 18.8% of all hypertensives. Being on treatment for hypertension, overweight, obese or having had hypertension in previous pregnancy were associated with increased SBP and DBP, while diabetes was associated with raised SBP. Two-thirds of hypertensives were unaware. Only a third of those aware were on treatment, with about 60% of these controlled. Lack of awareness remains a significant barrier to BP control. Programmes to raise awareness such as MMM are significant in raising population awareness.

Adapting a club-based medication delivery strategy to a hypertension context: the CLUBMEDS Study in Nigeria.

INTRODUCTION: The prevalence of hypertension in sub-Saharan Africa is among the world's highest; however, awareness, treatment and control of hypertension in this region are suboptimal. Among other barriers, the overburdened healthcare system poses a great challenge for hypertension control. Community peer-support groups are an alternative and promising strategy to improve adherence and blood pressure (BP) control. The CLUBMEDS study aims to evaluate the feasibility and impact of adherence clubs to improve hypertension control in Nigeria. METHODS AND ANALYSIS: The CLUBMEDS study will include a formative (pre-implementation) qualitative evaluation, a pilot study and a process (postimplementation) qualitative evaluation. At the formative stages, focus group discussions with patient groups and in-depth interviews with healthcare providers, managers and key decision makers will be conducted to understand the feasibility, barriers and facilitators, opportunities and challenges for the successful implementation of the CLUBMEDS strategy. The CLUBMEDS pilot study will be implemented in two primary healthcare facilities, one urban and one rural, in Southeast Nigeria. Each adherence club, which consists of a group of 10-15 patients with hypertension under the leadership of a role-model patient, serves as a support group to encourage and facilitate adherence, BP self-monitoring and medication delivery on a monthly basis. A process evaluation will be conducted at the end of the pilot study to evaluate the acceptability and engagement with the CLUBMEDS strategy. To date, 104 patients were recruited and grouped into nine clubs, in which patients will be followed-up for 6 months. ETHICS AND DISSEMINATION: The study was approved by the University of Abuja Teaching Hospital and the Federal Teaching Hospital Abakaliki Human Research Ethics Committees and all patients provided informed consent. Our findings will provide preliminary data on the potential effectiveness and acceptance of this strategy in a hypertension context. Study findings will be disseminated via scientific forums.

Compliance with follow-up and adherence to medication in hypertensive patients in an urban informal settlement in Kenya: comparison of three models of care.

OBJECTIVE: To determine and compare, among three models of care, compliance with scheduled clinic appointments and adherence to antihypertensive medication of patients in an informal settlement of Kibera, Kenya. METHODS: Routinely collected patient data were used from three health facilities, six walkway clinics and one weekend/church clinic. Patients were eligible if they had received hypertension care for more than 6 months. Compliance with clinic appointments and self-reported adherence to medication were determined from clinic records and compared using the chi-square test. Univariate and multivariate logistic regression models estimated the odds of overall adherence to medication. RESULTS: A total of 785 patients received hypertension treatment eligible for analysis, of whom two-thirds were women. Between them, there were 5879 clinic visits with an overall compliance with appointments of 63%. Compliance was high in the health facilities and walkway clinics, but men were more likely to attend the weekend/church clinics. Self-reported adherence to medication by those complying with scheduled clinic visits was 94%. Patients in the walkway clinics were two times more likely to adhere to antihypertensive medication than patients at the health facility (OR 1.97, 95% CI 1.25-3.10). CONCLUSION: Walkway clinics outperformed health facilities and weekend clinics. The use of multiple sites for the management of hypertensive patients led to good compliance with scheduled clinic visits and very good self-reported adherence to medication in a low-resource setting.

Using lean manufacturing principles to evaluate wait times for HIV-positive patients in an urban clinic in Kenya.

As human immunodeficiency virus (HIV) treatment programs expand in Africa, delivery systems must be strengthened to support patient retention. Clinic characteristics may affect retention, but a relationship between clinic flow and attrition is not established. This project characterized HIV patient experience and flow in an urban Kenyan clinic to understand how these may affect retention. We used Toyota's lean manufacturing principles to guide data collection and analysis. Clinic flow was evaluated using value stream mapping and time and motion techniques. Clinic register data were analyzed. Two focus group discussions were held to characterize HIV patient experience. Results were shared with clinic staff. Wait times in the clinic were highly variable. We identified four main barriers to patient flow: inconsistent patient arrivals, inconsistent staffing, filing system defects, and serving patients out of order. Focus group participants explained how clinic operations affected their ability to engage in care. Clinic staff were eager to discuss the problems identified and identified numerous low-cost potential solutions. Lean manufacturing methodologies can guide efficiency interventions in low-resource healthcare settings. Using lean techniques, we identified bottlenecks to clinic flow and low-cost solutions to improve wait times. Improving flow may result in increased patient satisfaction and retention.

Uptake and linkage into care over one year of providing HIV testing and counselling through community and health facility testing modalities in urban informal settlement of Kibera, Nairobi Kenya.

BACKGROUND: We examine the uptake of HIV Testing and Counselling (HTC) and linkage into care over one year of providing HTC through community and health facility testing modalities among people living in Kibera informal urban settlement in Nairobi Kenya. METHODS: We analyzed program data on health facility-based HIV testing and counselling and community- based testing and counselling approaches for the period starting October 2013 to September 2014. Univariate and bivariate analysis methods were used to compare the two approaches with regard to uptake of HTC and subsequent linkage to care. The exact Confidence Intervals (CI) to the proportions were approximated using simple normal approximation to binomial distribution method. RESULTS: Majority of the 18,591 clients were tested through health facility-based testing approaches 72.5 % (n = 13485) vs those tested through community-based testing comprised 27.5 % (n = 5106). More clients tested at health facilities were reached through Provider Initiated Testing and Counselling PITC 81.7 % (n = 11015) while 18.3 % were reached through Voluntary Counselling and Testing (VCT)/Client Initiated Testing and Counselling (CITC) services. All clients who tested positive during health facility-based testing were successfully linked to care either at the project sites or sites of client choice while not all who tested positive during community based testing were linked to care. The HIV prevalence among all those who were tested for HIV in the program was 5.2 % (n = 52, 95 % CI: 3.9 %-6.8 %). Key study limitation included use of aggregate data to report uptake of HTC through the two testing approaches and not being able to estimate the population in the catchment area likely to test for HIV. CONCLUSION: Health facility-based HTC approach achieved more clients tested for HIV, and this method also resulted in identifying greater numbers of people who were HIV positive in Kibera slum within one year period of testing for HIV compared to community-based HTC approach. Linking HIV positive clients to care proved much easier during health facility- based HTC compared to community- based HTC.