PROJECT SUMMARY Myocardial infarction (MI) is a leading cause of death worldwide. There is a critical need to improve uptake of evidence-based care for MI in resource-limited settings. This proposal presents a research career development program to 1) identify barriers to evidence-based MI care in Tanzania, 2) develop a multicomponent intervention to improve care by adapting proven strategies from other settings, and 3) assess the feasibility, acceptability, and potential effectiveness of the intervention. The candidate, an Assistant Professor of Surgery at Duke University and emergency medicine physician, has experience conducting research regarding MI in Tanzania. The high MI-associated mortality he identified as an NIH Fogarty Global Health Fellow led him to seek additional training in implementation science, intervention development, and clinical trial design. Working with a diverse mentoring committee of experts in implementation research, clinical trials, and global cardiovascular disease, as well as Tanzanian colleagues with whom he has collaborated for the past ten years, he will build upon his prior study of MI in northern Tanzania. The proposed activities will equip the candidate with a combination of skills in global emergency implementation research and position him to become a successful independent investigator operating at the intersection of global health, emergency medicine, and implementation science. Growing evidence suggests that in sub-Saharan Africa (SSA), MI is common, frequently misdiagnosed, rarely treated with evidence-based therapies, and associated with high mortality. Preliminary research conducted by the candidate in Tanzania found that 22% of patients presenting to the emergency department (ED) with typical symptoms have an acute MI, but 90% of acute MI cases are missed by ED physicians. The candidate’s research found a 30-day mortality rate following acute MI of 43%--more than sixfold higher than the mortality rate in the United States. Such poor MI outcomes are likely related to low uptake of evidence-based MI care; for example, the candidate’s preliminary data found that only 23% of patients with acute MI were treated with aspirin—a WHO “best buy” for reducing noncommunicable disease mortality. Despite these alarming data, the barriers to evidence-based MI care in SSA remain largely unexplored and locally-tailored interventions to improve MI care in resource limited settings are sorely lacking. There is an urgent need to identify barriers to MI care and to develop locally-appropriate interventions that will improve MI outcomes in low-income settings like Tanzania. This proposal will bridge this knowledge gap by using an approach rooted in implementation science. Specifically, this study will 1) identify barriers to evidence-based diagnosis and treatment of MI in northern Tanzania, 2) develop a multicomponent tailored intervention to improve MI care, and 3) determine feasibility, acceptability, and potential effect of a tailored intervention on MI care. This study will be an important first step towards reducing excess MI-associated morbidity and mortality in resource-limited settings.

PUBLIC HEALTH RELEVANCE STATEMENT Evidence suggests that in sub-Saharan Africa myocardial infarction (MI) is associated with very high mortality, but locally-appropriate interventions to improve uptake of evidence-based care are lacking. This study will identify barriers to MI care, develop a tailored multicomponent intervention to improve care, and assess the feasibility, acceptability, and preliminary effectiveness of this tailored intervention. The results from this study will lead directly to clinical trials to test interventions to reduce mortality from myocardial infarction in resource-limited domestic and global settings.