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.