Identifying facilitators and barriers to heart failure care in Haiti to adapt a community-based intervention

PROJEC T总结Y 该提案旨在评估心力衰竭（HF）患者与 他们的卫生系统，以指导循证干预措施，以改善病人的福祉，在低-和中等- 收入国家（LMIC）。心血管疾病（CVD）导致海地所有死亡人数的30%;近4倍以上 人类免疫缺陷病毒（HIV）。我们已发表的工作表明，心力衰竭（HF）是 占成人内科住院的37%。然而，从住院病人到 门诊治疗没有得到很好的发展，因为三分之二的HF患者没有成功地与门诊治疗联系起来， 其中关联被定义为在出院后30天内进行门诊访视。 我的长期职业目标是发展成为一名实施科学家，并测试改善联系的策略 在低收入国家治疗心血管疾病。本申请的目的是首先确定贫困的障碍， 在海地农村地区的HF住院患者的联系，然后适应和试点循证CHW 在艾滋病毒模型的基础上，采取干预措施消除障碍。我的总体假设是如此复杂 可识别和可改变的生物社会和卫生系统障碍的组合如何影响海地农村HF 患者获得护理，经过调整的CHW干预措施将加强与慢性病护理的联系。拟议 研究将在海地农村与卫生合作伙伴和Zanmi Lasante合作进行。 目的1：确定住院HF患者门诊护理联系的促进因素和障碍。通过 从多个角度评估已建立的和新的促进因素和HF护理联系的障碍的显著性， aim将调查哪些因素会影响患者返回接受后续护理的决定和能力。我将进行一次 与24-30名患者进行的一系列焦点小组讨论（按相关和非相关患者分层）; 12-15名CHW; 8-12名医生和护士。我将确定综合框架所分类的核心概念， 实施研究，并产生和完善有关促进者和联系障碍的假设。 目的2：调整CHW干预措施，以改善HF患者的护理联系。通过应用这些发现， 从目标1使用ADAPT-ITT框架，已成功地用于调整护理联系战略 对于HIV患者，我将修改现有的用于HIV患者护理的循证CHW干预措施 根据目标1中确定的促进因素和障碍，在HF入院后出院。 目标3：试点CHW干预措施，以评估可行性和可接受性。我将驾驶改装的CHW 对HF患者样本（n=30）进行链接支持干预（目标2），以改善与护理的链接。我会 对患者、社区卫生工作者、医生、护士和卫生系统进行定性访谈和调查 管理人员评估试点干预的可接受性、适当性、可行性和保真度 在所有利益相关者中。我将探讨次要有效性结果，包括 干预组与参比组30例HF患者进行比较。

PROJEC T SUMMAR Y This proposal seeks to evaluate the biosocially complex interaction between heart failure (HF) patients and their health system to guide evidence-based interventions to improve wellbeing for patients in low- and middle- income countries (LMIC). Cardiovascular disease (CVD) causes 30% of all deaths in Haiti; nearly 4-times more deaths than human immunodeficiency virus (HIV). Our published work has shown that heart failure (HF) is the leading cause – 37% – of adult internal medicine hospitalizations. However, the crucial link from inpatient to outpatient care is not well developed as two-thirds of HF patients are not successfully linked to outpatient care, where linkage is defined as having a clinic visit within 30 days after discharge. My long-term career goal is to develop as an implementation scientist and test strategies to improve linkage to care for CVD in low-income countries. The objective of this application is to first identify barriers to poor linkage for patients hospitalized with HF in rural Haiti, and then to adapt and pilot an evidence-based CHW intervention to address the barriers based on models for HIV. My overarching hypotheses are that complex combinations of identifiable and modifiable biosocial and health system barriers influence how rural Haitian HF patients access care and that an adapted CHW intervention will enhance linkage to chronic care. The proposed research will be conducted in rural Haiti in collaboration with Partners In Health and Zanmi Lasante. Aim 1: Identify facilitators and barriers to outpatient care linkage for hospitalized HF patients. By assessing the salience of established and novel facilitators and barriers to HF care linkage from multiple perspectives, this aim will investigate what factors influence patients' decision and capacity to return for follow-up care. I will conduct a series of focus group discussions with 24-30 patients (stratified by those linked and not linked); 12-15 CHWs; and 8-12 doctors and nurses. I will identify central concepts categorized by the Consolidated Framework for Implementation Research, and also generate and refine hypotheses about facilitators and barriers to linkage. Aim 2: Adapt a CHW intervention to improve linkage to care for HF patients. By applying the findings from Aim 1 using the ADAPT-ITT framework, which has been successfully used to adapt care linkage strategies for HIV patients, I will modify an existing evidence-based CHW intervention used in HIV care for patients discharged after a HF admission based on the facilitators and barriers identified in Aim 1. Aim 3: Pilot the CHW intervention to assess feasibility and acceptability. I will pilot the adapted CHW linkage support intervention (Aim 2) with a sample of patients with HF (n=30) to improve linkage to care. I will use qualitative interviews and surveys among the patients, CHWs, doctors, nurses, and health system administrators to assess the acceptability, appropriateness, feasibility, and fidelity of the pilot intervention among all stakeholders. I will explore secondary effectiveness outcomes including linkage among the intervention group compared with a reference group of 30 HF patients.