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Background: Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates remain very low. An expanding literature supports the strategy of task redistribution of hypertension care to nurses. Objective: We aimed to evaluate the effect of a nurse-based hypertension management program in Kenya. Methods: We conducted a retrospective data analysis of patients with hypertension who initiated nurse-based hypertension management care between January 1, 2011, and October 31, 2013. The primary outcome measure was change in systolic blood pressure (SBP) over one year, analyzed using piecewise linear mixed-effect models with a cut point at 3 months. The primary comparison of interest was care provided by nurses versus clinical officers. Secondary outcomes were change in diastolic blood pressure (DBP) over one year, and blood pressure control analyzed using a zero-inflated Poisson model. Results: The cohort consisted of 1051 adult patients (mean age 61 years; 65% women). SBP decreased significantly from baseline to three months (nurse-managed patients: slope-4.95 mmHg/month; clinical officer-managed patients: slope-5.28), with no significant difference between groups. DBP also significantly decreased from baseline to three months with no difference between provider groups. Retention in care at 12 months was 42%. Conclusions: Nurse-managed hypertension care can significantly improve blood pressure. However, retention in care remains a challenge. If these results are reproduced in prospective trial settings with improvements in retention in care, this could be an effective strategy for hypertension care worldwide.

Background Globalization has increased the demand for international experiences in medical education. International experiences improve medical knowledge, clinical skills, self-development, influence career objectives, and provide insights on ethical and societal issues. However, global health rotations can end up being no more than tourism if not structured to foster personal transformation and global citizenship. Objective We conducted a qualitative assessment of trainee-reported critical incidents to more deeply understand the impact of our global health experience on trainees. Method A cross-sectional survey was administered to trainees who had participated in a two-month elective in Kenya from January 1989 to May 2013. We report the results of a qualitative assessment of the critical incident reflections participants (n=137) entered in response to the prompt: “Write about one of their most memorable experiences and explain why you chose to describe this particular one.” Approach Qualitative analyses were conducted using thematic analysis and crystallization immersion analytic methods based on the principles of grounded theory, employing a constructivists’ research paradigm. Results Four major themes emerged. These themes included: Opening Oneself to a Broader World View; Impact of Suffering and Death; and Life Changing Experiences; and Commitment to Care for the Medically Underserved. Conclusions Circumstances that learners encounter in the resource-scarce environment in Kenya are eye-opening and life-changing. When exposed to these frame-shifting circumstances, students elaborate upon or transform existing points of view. These emotionally disruptive experiences in an international health setting allowed students to enter a transformational learning process with a global mind. Students can see the world as an interdependent society and develop the capacity to advance both their enlightened self-interest and the interest of people elsewhere in the world as they mature as global citizens. Medical schools are encouraged to foster these experiences by finding ways to integrate them into curriculum.

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In the Funding section of the article cited above, the sentence "The authors thank the Abbott Fund for providing glucose testing supplies and funding to support this effort" should have read, "The authors thank Abbott for providing glucose testing supplies and Abbott Fund for providing funding to support this effort." The online version reflects these changes.

Background: Heart failure (HF), is a leading cause of cardiovascular morbidity and mortality in Sub-Saharan Africa. Cardiac rehabilitation (CR) is known to improve functional capacity and reduce morbidity associated with HF. Although CR is a low-cost intervention, global access and adherence rates to CR remain poor. In regions such as Western Kenya, CR programs do not exist. We sought to establish the feasibility CR for HF in this region by testing adherence to institution and home-based models of CR. Methods: One hundred participants with New York Heart Association (NYHA) class II and III HF symptoms were prospectively enrolled from a tertiary health facility in Western Kenya. Participants were non-randomly assigned to participate in one of two CR models based on their preference. Institution based cardiac rehabilitation (IBCR) comprised 36 facility-based exercise sessions over a period of 12 weeks. Home based cardiac rehabilitation (HBCR) comprised weekly pedometer guided exercise targets over a period of 12 weeks. An observational arm (OA) receiving usual care was also enrolled. The primary endpoint of CR feasibility was assessed based on study participants to adherence to at least 25% of exercise sessions. Secondary outcomes of change in NYHA symptom class, and six-minute walk time distance (6MWTD) were also evaluated. Data were summarized and analyzed as means (SD) and frequencies. Paired t-tests, Chi Square, Fisher’s, and ANOVA tests were used for comparisons. Findings: Mean protocol adherence was greater than 25% in both CR models; 46% ± 18 and 29% ± 11 (P < 0.05) among IBCR and HBCR participants respectively. Improvements by at least one NYHA class were observed among 71%, 41%, and 54%, of IBCR, HBCR and OA participants respectively. 6MWTD increased significantly by a mean of 31 ± 65 m, 40 ± 55 m and 38 ± 71 m in the IBCR, HBCR and OA respectively (P < 0.05). Conclusions: IBCR and HBCR, are feasible rehabilitation models for HF in Western Kenya. Whereas improvement in functional capacity was observed, effectiveness of CR in this population remains unknown. Future randomized studies evaluating effect size, long term efficacy, and safety of cardiac rehabilitation in low resource settings such as Kenya are recommended.

Background: Heart failure (HF) is a growing driver of morbidity and mortality worldwide. Cardiac rehabilitation in HF improves functional status, quality of life, and depression. Global access to cardiac rehabilitation remains poor, and adherence rates are low. Methods: We implemented and assessed adherence rates associated with two models of cardiac rehabilitation in Western Kenya. One hundred participants with HF were prospectively enrolled. Choice of rehabilitation model was based on participant preference. Twenty-five participants opted to participate in 36 institution-based sessions (IBCR). Thirty-one participants enrolled into home-based sessions (HBCR). HBCR comprised 12 weekly pedometer step targets. Forty-four participants were later enrolled into an observational arm (OA). We hypothesized that participants would adhere to at least 25% of prescribed sessions. We secondarily compared changes in 6-minute walk time distance (6MWTD), depression screening (PHQ9) and quality of life (SF36) scores using a paired t-test. Results: The mean age of participants was 51 years, of whom 73 were female. Rehabilitation participants preferred institution based rehabilitation. Both study arms were adherent to the prescribed protocol as shown in figure 1. All study arms demonstrated significant improvement in 6MWTD, PHQ9 and SF36 scores. Conclusions: IBCR and HBCR, are feasible rehabilitation models for HF in this setting. Adherence rates attained in both models are higher than those seen in many developed countries. Although our results demonstrate feasibility, future research should focus on methods to further improve adherence as well evaluate efficacy of cardiac rehabilitation in this setting.