Faculty Bibliography

Shared decision making (SDM) has increasingly become appreciated as a method to enhance patient involvement in health care decisions, patient-provider communication, and patient-centered care. Compared with cancer, the literature on SDM for hypertension is more limited. This is notable because hypertension is the leading risk factor for cardiovascular disease and both conditions disproportionately affect certain subgroups of patients. However, SDM holds promise for improving health equity by better engaging patients in their health care. For example, many reasonable options exist for treating uncomplicated stage-1 hypertension. These options include medication and/or lifestyle changes such as healthy eating, physical activity, and weight management. Deciding on "the best" plan of action for hypertension management can be challenging because patients have different goals and preferences for treatment. As hypertension management may be considered a preference-sensitive decision, adherence to treatment plans may be greater if those plans are concordant with patient preferences. SDM can be implemented in a broad array of care contexts, from patient-provider dyads to interprofessional collaborations. In this article, we argue that SDM has the potential to advance health equity and improve clinical care. We also propose a process to evaluate whether SDM has occurred and suggest future directions for research.

BACKGROUND:Given the growing burden of cardiovascular diseases in sub-Saharan Africa, global donors and governments are exploring strategies for integrating evidence-based cardiovascular diseases prevention into HIV clinics. We assessed the capabilities, motivations and opportunities that exist for HIV clinics to apply evidence-based strategies for hypertension control among people living with HIV (PLHIV) in Nigeria. METHODS:We used a concurrent Quan-Qual- study approach (a quantitative first step using structured questionnaires followed by a qualitative approach using stakeholder meetings).We invited key stakeholders and representatives of HIV and non-communicable disease organizations in Lagos, Nigeria to 1) assess the capacity of HIV clinics (n = 29) to, and; 2) explore their attitudes and perceptions towards implementing evidence-based strategies for hypertension management in Lagos, Nigeria (n = 19)The quantitative data were analyzed using SPSS whereas responses from the stakeholders meeting were coded and analyzed using thematic approach and an implementation science framework, the COM-B (Capabilities, Opportunities, Motivations and Behavior) model, guided the mapping and interpretation of the data. RESULTS:Out of the 29 HIV clinics that participated in the study, 28 clinics were public, government-owned facilities with 394 HIV patients per month with varying capabilities, opportunities and motivations for integrating evidence-based hypertension interventions within their services for PLHIV. Majority of the clinics (n = 26) rated medium-to-low on the psychological capability domains, while most of the clinics (n = 25) rated low on the physical capabilities of integrating evidence-based hypertension interventions within HIV clinics. There was high variability in the ratings for the opportunity domains, with physical opportunities rated high in only eight HIV clinics, two clinics with a medium rating and nineteen clinics with a low rating. Social opportunity domain tended to be rated low in majority of the HIV clinics (n = 21). Lastly, almost all the HIV clinics (n = 23) rated high on the reflective motivation domain although automatic motivations tended to be rated low across the HIV clinics. CONCLUSION/CONCLUSIONS:In this study, we found that with the exception of motivations, the relative capabilities whether physical or psychological and the relative opportunities for integrating evidence-based hypertension intervention within HIV clinics in Nigeria were minimal. Thus, there is need to strengthen the HIV clinics in Lagos for the implementation of evidence-based hypertension interventions within HIV clinics to improve patient outcomes and service delivery in Southwest Nigeria.

BACKGROUND:Integrated cardiovascular disease (CVD) and HIV (CVD-HIV) care interventions are being adopted to tackle the growing burden of noncommunicable diseases (NCDs) in low-and middle-income countries (LMICs) but there is a paucity of studies on the feasibility of these interventions in LMICs. This scoping review aims to present evidence of the feasibility of integrated CVD-HIV care in LMICs, and the alignment of feasibility reporting in LMICs with the existing implementation science methodology. METHODS:A systematic search of published articles including systematic and narrative reviews that reported on integrated CVD-HIV care was conducted, using multiple search engines including PubMed/Medline, Global Health, and Web of Science. We examined the articles for evidence of feasibility reporting. Adopting the definition of Proctor and colleagues (2011), feasibility was defined as the extent to which an intervention was plausible in a given agency or setting. Evidence from the articles was synthesized by level of integration, the chronic care continuum, and stages of intervention development. RESULTS:Twenty studies, reported in 18 articles and 3 conferences abstracts, reported on feasibility of integrated CVD-HIV care interventions. These studies were conducted in Sub-Saharan Africa, Southeast Asia and South America. Four of these studies were conducted as feasibility studies. Eighty percent of the studies reported feasibility, using descriptive sentences that included words synonymous with feasibility terminologies in existing definition recommended by Proctor and colleagues. There was also an overlap in the use of descriptive phrases for feasibility amongst the selected studies. CONCLUSIONS:Integrating CVD and HIV care is feasible in LMICs, although methodology for reporting feasibility is inconsistent. Assessing feasibility based on settings and integration goals will provide a unique perspective of the implementation landscape in LMICs. There is a need for consistency in measures in order to accurately assess the feasibility of integrated CVD-HIV care in LMICs.

Introduction: Blunted heart rate dip has been shown to increase the risk of cardiovascular and non-cardiovascular morbidity and mortality among people with chronic kidney disease (CKD). Despite increased access to 24 hour ambulatory blood pressure monitoring, relatively few studies on sleep heart rate exist especially among native black Africans. Objectives: The purpose of the study was to assess the prevalence and clinical correlates of non-dipping heart rate in CKD patients using data from CRECKID study. Methods: All the participants had a 24-hour ambulatory blood pressure monitoring done using SpaceLabs ABPM (SpaceLabs Healthcare, Issaquah, WA). Blood samples were analyzed for fasting plasma glucose, lipid profile, electrolytes, urea and creatinine. Hear rate dipping was estimated as (1 - night time heart rate/daytime heart rate) x100. Normal dipping of heart rate was defined as >10% decrease in heart rate. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI Creatinine Equation and CKD was defined as eGFR<60ml/min/1.73m². Results: Four hundred and seven consented participants comprising of 225 (55.3%) women, 242 (59.5%) hypertensive without CKD, 90 (22.1%) normotensive and 75 (18.4%) CKD patients with mean age 55.3+/-14.7 years with complete data were analyzed. A total of 172 (42.3%) participants were non-dippers. Compared to heart rate dippers, non-dippers had higher mean clinic and ambulatory blood pressure parameters, creatinine, and triglyceride with lower eGFR, HDLc, and heart rate dipping (3.15+/-5.2 vs 19.28+/-13.9, p<0.0001). Non-dippers were more common among men (47.9% vs 37.8%; p=0.042). Four out of every five CKD patients were non-dippers compared with a third and one-fifth among hypertensives and normotensives, respectively (p< 0.0001). eGFR was an independent predictor of heart rate non-dipping (OR 1.03, CI 1.003-1064, p=0.033). Conclusion: This study highlights high prevalence of heart rate non-dipping worse in CKD patients. Non-dippers had more constellations of cardiovascular risk factors and eGFR was an independent correlates of heart rate non-dipping. A larger prospective study is required for determination of prognostic relevance of these findings. Disclosure of Interest: None declared

Poor outcomes for breast cancer in Ghana have been attributed to late presentation of symptoms at biomedical facilities. This study explored factors accounting for delays in initiation of breast cancer treatment at the Korle-Bu Teaching Hospital in Accra. Focus group discussions were conducted with 20 women with breast cancer. A theory-driven thematic analysis identified three multilevel factors influencing treatment seeking delays: (1) patient (e.g. misinterpretation of symptoms, fear), (2) healthcare provider (e.g. negative attitudes) and (3) health systems (e.g. shortage of medicines). Addressing treatment delays will require multilevel interventions, including culturally congruent education, psychosocial counselling/support and strengthening health systems.