Overall, this study of cardiac care in Haiti demonstrates significant associations between ecological independent variables and clinical outcomes. The young median age in the patient database (5.87 years) supports existing evidence that cardiac diseases of childhood, including CHD and RHD, are a notable source of CVD burden in Haiti [5, 17]. However, because significant CHD and RHD are often symptomatic, they may rise to clinical attention earlier and more frequently than hypertensive and atherosclerotic forms of CVD. By natural course, hypertension and ASCVD often remain asymptomatic for decades; thus, for identification they require routine population-level screening that is largely unavailable in Haiti [18]. The lack of ASCVD patients in the HCA database is unsurprising given the limitations of the primary healthcare system in Haiti to detect these pathologies. Therefore, this study does not reflect upon the relative burden of hypertension and ASCVD in Haiti relative to CHD and RHD.
We also found that the West department was overrepresented in the HCA patient database relative to the population share of West in Haiti at large. Meanwhile, the more rural South, South-East, North, North-East, Grande-Anse, and Artibonite departments were relatively underrepresented. Beyond the fact that three of the five clinical sites are located in West, this patient distribution likely reflects differences in referral patterns due to a higher degree of urbanization in West [8], which contains the entire Port-au-Prince metropolitan area. Urbanization may increase HCA referrals because patients are closer to the referring facilities where their cases can be identified and closer to HCA clinics where referrals can be completed. Also, urban patients are more likely to have higher socioeconomic status, which may facilitate care access.
Indeed, the relative paucity of rural patients in the HCA database result aligns with existing literature on rural access barriers to specialty care in low- and middle- income countries. For instance, a 2021 study in rural Madagascar found that even in the presence of referral programs strengthened by the health system, geographic barriers leading to increased referral travel times were a primary driver of diminished access to specialty care in rural Madagascar [19]. Of note, a large portion of HCA patients present for cardiac complications of RHD, which begins with an infectious etiology and is less likely to be adequately treated and prevented in rural settings. Overall, these findings suggest that more decentralization of HCA referrals and evaluations is needed to bring cardiac care closer to the rural poor, as exemplified by the World Health Organization PEN-Plus strategy.
While most reflective of a similar rural-urban access disparity within Haiti, the urban-heavy distribution of HCA patients may also be compatible with other epidemiologic trends. In a 2018 review, Bickler et al. note that in Sub-Saharan Africa, rates of non-communicable diseases like CHD often rise faster in urban areas of a country than in lesser-developed parts of the same country; this may be partially attributable to documented genetic and epigenetic modifications that accompany urbanization [20], although no research to date explores similar biomolecular changes in a Haitian context.
Additionally, it is critical to note that the sociopolitical circumstances in Haiti during the timeframe of HCA data collection may have masked some intra-departmental disparities in access to care. Due to the COVID-19 pandemic and the Threat Level 4 travel advisory issued by the US State Department in response to kidnapping and uprising threats in Haiti, its national border was effectively closed for large parts of 2020 and 2021 [9]. While HCA continued to operate medically, this translated into a universal halt in surgical therapy (which, due to these security concerns, is now exclusively conducted at HCA’s international partner sites given the absence of cardiac surgical capability in Haiti) because eligible patients could not be transited abroad. This uniform reduction in treatment availability may have diminished some of the regional differences normally present in HCA care outcomes.
Our univariate logistic regression analysis showed a negative association between departmental childhood growth retardation and active care representation in HCA. Conversely, higher rates of childhood growth retardation were positively associated with loss to follow-up in HCA. Given the high prevalence of severe malnutrition in Haiti, childhood growth retardation has been identified as a key public health target [21]. In addition, the association between growth retardation and the percentage of patients receiving any form of healthcare is supported by existing literature. Analyses of Haitian national survey data in the aftermath of the 2010 earthquake suggested that rates of under-nutrition among children below five years declined in tandem with increased antenatal care attendance and associated “baby tents” designed to promote infant health [22].
At the department level, multivariate regression models showed positive associations of active care representation with adult employment rate. This association is also well established in LMICs given the increased ability of employed individuals to afford out-of-pocket expenses in areas without widespread health insurance [13]. Travel time to the nearest healthcare facility was also negatively associated with the proportion of patients in active care. Because increased travel time is often interlinked with other social determinants of health such as financial barriers and acceptability of seeking professional medical help, multivariable analysis here was necessary to parse the individualized contribution of travel time [23]. Travel time has also been identified as a driver of healthcare disparities between urban and rural areas in LMICs [24]. In this study, however, it is worth considering that referral biases may cause overrepresentation of patients with shorter travel times to HCA clinics from within the broader departmental population.
Counterintuitively, active care representation was negatively associated with access to qualified prenatal care when controlling for other covariates. While a precise mechanism for this finding is unclear, departments with greater availability of qualified prenatal care are also more likely to have other established providers. It is plausible that patients in these areas may view HCA as a pathway to cardiac surgery rather than a long-term cardiac care provider; they may prefer to receive postoperative follow-up and medical management from locally established providers instead of HCA.
Strengths
This study has numerous strengths. It is the first analysis of Haiti’s largest known cardiac patient database, which has significant statistical power owing to a large sample size. This rare source of patient-based data from Haiti allows us to offer one of the first academic approaches to characterizing regional health disparities within Haiti, as defined by clinical outcomes. Because the study uses data derived from zero-cost cardiac consultations in public and aid-based clinics, it is broadly inclusive and likely to represent the general Haitian population. Drawing from multiple clinic sites across Haiti, the study includes data from all 10 administrative departments and provides a national-level picture of cardiac care.
As opposed to current literature that primarily describes healthcare access in specific settings of Haiti [12, 17], this study is also among the first to identify factors associated with current disparities in cardiac care access using readily available department-level sociodemographic data. Using the objective data in EMMUS-VI, the study proposes a starting point to triangulate “access to care,” a concept that is difficult to measure directly, particularly in Haiti where experiences of poverty and resource scarcity are quite distinct in rural versus urban settings. In these ways, our study draws from department-level data on both HCA clinical outcomes and sociodemographic indices to advance the literature on social determinants of health in Haiti.
Limitations & Future Directions
This study is not without limitations, which were often imposed by data availability. First, defining clinical outcomes in three broad categories (active care, deceased preoperatively, or lost to follow-up) does not account for the full spectrum of clinical experiences over time. For instance, departments in which a high proportion of patients have been in consistent active care for years may differ from those where most patients have been in active care for weeks to months, yet our classification system does not reflect these differences. It also does not differentiate patients with sustained active care from those who were lost to follow-up for some time and subsequently returned to care (possibly after interim disease progression).
Second, we were unable to analyze patients by type or severity of cardiac pathology (even broadly as surgical versus non-surgical), which may substantially impact clinical outcomes. For example, medically treated patients for whom surgery is recommended are especially vulnerable because they die at higher rates without surgical intervention [25, 26], despite optimal medical management; our study merges this group with patients who lack operative indications. On the other hand, many patients with surgical cardiac pathologies present to HCA so far into the disease course that surgery is prohibitively high-risk; our data does not distinguish these patients from those who died preoperatively due to structural unavailability of surgery.
Third, the HCA database includes only patients for whom information about treatment outcome and departmental location was available; excluded patients (ie. those with no address or geographic location on file) might have altered aggregate outcomes in meaningful ways. It is also not possible to be certain that department-level survey data on sociodemographic covariates is representative of the HCA patient base in that particular department. Finally, given the lack of available sociodemographic data at finer administrative levels like the commune or section, our analysis cannot address cardiac care access barriers within a given department.
As a result of these limitations, all findings of this study should be interpreted as hypothesis-generating. Future studies should aim to model cardiac care disparities in Haiti with greater precision by using patient-level data (home address, income or other indicators of economic status, travel time to cardiac clinic, employment status, surgical vs non-surgical cardiac pathology, and comorbidities) to predict clinical patient outcomes. To increase internal validity and better inform policymaking, regional-level studies of HCA data should be conducted at the neighborhood level. In this way, precise estimates of on-the-ground travel time and travel distance to the nearest cardiac clinic may be incorporated.