Cardiovascular Journal of Africa: Vol 29 No 3 (May/Junel 2018)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018 AFRICA 177
Facilitators, context of and barriers to acute coronary
syndrome care at Kenyatta National Hospital, Nairobi,
Kenya: a qualitative analysis
Ehete Bahiru, Tecla Temu, Julia Mwanga, Kevin Ndede, Sophie Vusha, Bernard Gitura, Carey Farquhar,
Frederick Bukachi, Mark D Huffman
Abstract
Background: The prevalence of ischaemic heart disease and
its acute manifestation, acute coronary syndrome (ACS), is
growing throughout sub-Saharan Africa, including Kenya. To
address this increasing problem, we sought to understand the
facilitators, context of and barriers to ACS care at Kenyatta
National Hospital, with the aim of improving the quality of
care of ACS.
Methods: We conducted in-depth interviews with healthcare
providers involved in the management of ACS patients from
January to February 2017 at Kenyatta National Hospital in
Nairobi, Kenya. We selected an initial sample of key partici-
pants for interviewing and used a snowballing technique to
identify additional participants until we achieved saturation.
After transcription of audio recordings of the interviews, two
authors conducted data coding and analysis using a frame-
work approach.
Results: We conducted 16 interviews with healthcare provid-
ers. Major themes included the need to improve the diag-
nostic and therapeutic capabilities of the hospital, including
increasing the number of ECG machines and access to
thrombolytics. Participants highlighted an overall wide avail-
ability of other guideline-directed medical therapies, includ-
ing antiplatelets, beta-blockers, statins, anticoagulants and
ACE inhibitors. All participants also stated the need for and
openness to accepting future interventions for improvement
of quality of care, including checklists and audits to improve
ACS care at Kenyatta National Hospital.
Conclusion: Major barriers to ACS care at Kenyatta National
Hospital include inadequate diagnostic and therapeutic capa-
bilities, lack of hospital-wide ACS guidelines, undertraining
of healthcare providers and delayed presentation of patients
seeking care. We also identified potential targets, including
checklists and audits for future improvements in quality of
care from the perspective of healthcare providers.
Keywords: acute coronary syndrome, sub-Saharan Africa, global
health, qualitative research
Submitted 20/6/17, accepted 15/2/18
Published online 17/4/18
Cardiovasc J Afr 2018; 29: 177–182
DOI: 10.5830/CVJA-2018-013
Sub-Saharan African countries, including Kenya, are
experiencing a rapid rise in the prevalence of ischaemic heart
disease and its risk factors, including aging, hypertension,
diabetes, obesity, physical inactivity and dyslipidaemia in the
context of urbanisation and globalisation. The need to strengthen
the health system in sub-Saharan Africa to adequately respond
to the growing trends of non-communicable chronic diseases
(NCDs), including ischaemic heart disease, is recognised by the
World Health Organisation (WHO). 1 Local cardiology societies
such as the Pan-African Society of Cardiology (PASCAR) and
the Kenyan Cardiac Society (KCS) advocate and support efforts
to increase understanding of the burden of ischaemic heart
disease and its acute manifestations such as acute coronary
syndrome (ACS) in this region, with the goal of building upon
and improving current management trends.2
To increase the understanding of ACS care in Kenya, our
team conducted a retrospective evaluation of the presentation,
management and outcomes of ACS patients managed at
Kenyatta National Hospital between 2013 and 2016.3 The
study has helped to describe current ACS management trends
to identify important areas for future improvement of quality
Northern Pacific Global Health Research Fellowship
Training Consortium, University of Washington, Seattle, WA;
and Division of Cardiology, Department of Medicine, David
Geffen School of Medicine, University of California, Los
Angeles, USA
Ehete Bahiru, MD,
Department of Preventive Medicine, Northwestern
University, Chicago, IL, USA
Mark D Huffman, MD, MPH
Department of Global Health, University of Washington,
Seattle, WA, USA
Tecla Temu, MD, PhD
Department of Medicine, University of Nairobi, Nairobi,
Kenya
Julia Mwanga, MB ChB
Kevin Ndede, MB ChB
Organization International Centre for Reproductive Health
Kenya (ICRHK), Kenya
Sophie Vusha
Division of Cardiology, Department of Medicine, Kenyatta
National Hospital, Nairobi, Kenya
Bernard Gitura, MB ChB
Departments of Global Health, Epidemiology and Medicine,
University of Washington, Seattle, WA, USA
Carey Farquhar, MD, MPH
Department of Medical Physiology, University of Nairobi,
Nairobi, Kenya
Frederick Bukachi, MB ChB, MMed, PhD