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Myhre PL, Tromp J, Ouwerkerk W, Ting DSW, Docherty KF, Gibson CM, Lam CSP. Digital tools in heart failure: addressing unmet needs. Lancet Digit Health 2024; 6:e755-e766. [PMID: 39214764 DOI: 10.1016/s2589-7500(24)00158-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
This Series paper provides an overview of digital tools in heart failure care, encompassing screening, early diagnosis, treatment initiation and optimisation, and monitoring, and the implications these tools could have for research. The current medical environment favours the implementation of digital tools in heart failure due to rapid advancements in technology and computing power, unprecedented global connectivity, and the paradigm shift towards digitisation. Despite available effective therapies for heart failure, substantial inadequacies in managing the condition have hindered improvements in patient outcomes, particularly in low-income and middle-income countries. As digital health tools continue to evolve and exert a growing influence on both clinical care and research, establishing clinical frameworks and supportive ecosystems that enable their effective use on a global scale is crucial.
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Affiliation(s)
- Peder L Myhre
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway; KG Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Jasper Tromp
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | - Kieran F Docherty
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - C Michael Gibson
- Harvard Medical School, Boston, MA, USA; Baim Institute for Clinical Research, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore, Singapore; Baim Institute for Clinical Research, Boston, MA, USA.
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Kwan GF, Basow E, Isaac BD, Fenelon DL, Toussaint E, Calixte D, Ibrahim M, Hirschhorn LR, Drainoni ML, Adler A, Clisbee MA, Bukhman G. Heart Failure Care Facilitators and Barriers in Rural Haiti: A Qualitative Study. Ann Glob Health 2024; 90:60. [PMID: 39345843 PMCID: PMC11428663 DOI: 10.5334/aogh.4521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 09/01/2024] [Indexed: 10/01/2024] Open
Abstract
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.
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Affiliation(s)
- Gene F. Kwan
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center & Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Partners In Health, Boston, MA, USA
| | - Elizabeth Basow
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Darius L. Fenelon
- Zanmi Lasante, Haiti
- Boston University School of Public Health, Boston, MA, USA
| | | | | | - Michel Ibrahim
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Lisa R. Hirschhorn
- Ryan Family Center on Global Primary Care, Robert J Havey Institute for Global Health, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center & Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law Policy & Management, Boston University School of Public Health, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Alma Adler
- Center for Integration Science, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Gene Bukhman
- Partners In Health, Boston, MA, USA
- Center for Integration Science, Brigham and Women’s Hospital, Boston, MA, USA
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Wali S, Ssinabulya I, Muhangi CN, Kamarembo J, Atala J, Nabadda M, Odong F, Akiteng AR, Ross H, Mashford-Pringle A, Cafazzo JA, Schwartz JI. Bridging community and clinic through digital health: Community-based adaptation of a mobile phone-based heart failure program for remote communities in Uganda. BMC DIGITAL HEALTH 2023; 1:20. [PMID: 38800672 PMCID: PMC11116269 DOI: 10.1186/s44247-023-00020-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2024]
Abstract
Background In Uganda, limited healthcare access has created a significant burden for patients living with heart failure. With the increasing use of mobile phones, digital health tools could offer an accessible platform for individualized care support. In 2016, our multi-national team adapted a mobile phone-based program for heart failure self-care to the Ugandan context and found that patients using the system showed improvements in their symptoms and quality of life. With approximately 84% of Ugandans residing in rural communities, the Medly Uganda program can provide greater benefit for communities in rural areas with limited access to care. To support the implementation of this program within rural communities, this study worked in partnership with two remote clinics in Northern Uganda to identify the cultural and service level requirements for the program. Methods Using the principles from community-based research and user-centered design, we conducted a mixed-methods study composed of 4 participatory consensus cycles, 60 semi-structured interviews (SSI) and 8 iterative co-design meetings at two remote cardiac clinics. Patient surveys were also completed during each SSI to collect data related to cell phone access, community support, and geographic barriers. Qualitative data was analyzed using inductive thematic analysis. The Indigenous method of two-eyed seeing was also embedded within the analysis to help promote local perspectives regarding community care. Results Five themes were identified. The burden of travel was recognized as the largest barrier for care, as patients were travelling up to 19 km by motorbike for clinic visits. Despite mixed views on traditional medicine, patients often turned to healers due to the cost of medication and transport. With most patients owning a non-smartphone (n = 29), all participants valued the use of a digital tool to improve equitable access to care. However, to sustain program usage, integrating the role of village health teams (VHTs) to support in-community follow-ups and medication delivery was recognized as pivotal. Conclusion The use of a mobile phone-based digital health program can help to reduce the barrier of geography, while empowering remote HF self-care. By leveraging the trusted role of VHTs within the delivery of the program, this will help enable more culturally informed care closer to home. Supplementary Information The online version contains supplementary material available at 10.1186/s44247-023-00020-5.
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Affiliation(s)
- Sahr Wali
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, R. Fraser Elliott Building, 4th floor, 190 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Isaac Ssinabulya
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, MulagoNational Referral Hospital, Kampala, Uganda
| | | | | | | | - Martha Nabadda
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | | | - Ann R. Akiteng
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, MulagoNational Referral Hospital, Kampala, Uganda
| | - Heather Ross
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON Canada
- Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON Canada
| | - Angela Mashford-Pringle
- Dalla Lana School of Public Health, Waakebiness-Bryce Institute for Indigenous Health, University of Toronto, Toronto, ON Canada
| | - Joseph A. Cafazzo
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, R. Fraser Elliott Building, 4th floor, 190 Elizabeth St, Toronto, ON M5G 2C4 Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON Canada
- Department of Computer Science, University of Toronto, Toronto, ON Canada
| | - Jeremy I. Schwartz
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, USA
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Hearn J, Wali S, Birungi P, Cafazzo JA, Ssinabulya I, Akiteng AR, Ross HJ, Seto E, Schwartz JI. A digital self-care intervention for Ugandan patients with heart failure and their clinicians: User-centred design and usability study. Digit Health 2022; 8:20552076221129064. [PMID: 36185389 PMCID: PMC9520172 DOI: 10.1177/20552076221129064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of heart failure (HF) is increasing in Uganda. Ugandan patients with HF report receiving limited information about their illness and associated self-care behaviours. Interventions targeted at improving HF self-care have been shown to improve patient quality of life and reduce hospitalizations in high-income countries. However, such interventions remain underutilized in resource-limited settings like Uganda. This study aimed to develop a digital health intervention that enables improved self-care amongst HF patients in Uganda. Methods We implemented a user-centred design (UCD) process to develop a self-care intervention entitled Medly Uganda. The ideation phase comprised a scoping review and preliminary data collection amongst HF patients and clinicians in Uganda. An iterative design process was then used to advance an initial prototype into a functional digital health intervention. The evaluation phase involved usability testing of the intervention amongst Ugandan patients with HF and their clinicians. Results Medly Uganda is a digital health intervention that allows patients to report daily HF symptoms, receive tailored treatment advice and connect with a clinician when showing signs of decompensation. The system harnesses Unstructured Supplementary Service Data (USSD) technology that is already widely used in Uganda for mobile phone-based financial transactions. Usability testing showed Medly Uganda to be both acceptable and feasible amongst clinicians, patients and caregivers. Conclusions Medly Uganda is a functional digital health intervention with demonstrated acceptability and feasibility in enabling Ugandan HF patients to better care for themselves. We are hopeful that the system will improve self-care efficacy amongst HF patients in Uganda.
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Affiliation(s)
- Jason Hearn
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada
| | - Sahr Wali
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Patience Birungi
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Joseph A Cafazzo
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Isaac Ssinabulya
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Emily Seto
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda.,Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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