Julian T. Hertz

Background: Acute myocardial infarction (AMI) is an increasing cause of morbidity and mortality in Sub-Saharan Africa (SSA) but is often underdiagnosed and undertreated. To address this gap, the Multicomponent Intervention to Improve Myocardial Infarction Care (MIMIC) was developed and implemented to improve evidence-based AMI care. The aim of this study was to explore stakeholder perceptions of the acceptability of MIMIC following its implementation. Methods: This qualitative study involved in-depth interviews with 20 key stakeholders (physicians, nurses, administrators, and patients diagnosed with AMI) who participated in MIMIC during the first year of implementation in the emergency department (ED) of a regional referral center in northern Tanzania. Purposive sampling was used to recruit diverse participants. Interviews were guided by a semi-structured interview guide informed by the Theoretical Framework of Acceptability (TFA). Interview transcripts were thematically analyzed by a team of coders using an inductive, grounded theory approach guided by the seven TFA domains. Results: Nineteen major themes emerged across all TFA domains. Overall, participants described MIMIC as acceptable, minimally burdensome, and well-aligned with professional and ethical values. Perceived effectiveness was most emphasized, with staff citing improvements in AMI recognition, electrocardiogram (ECG) and troponin testing, and use of evidence-based therapies. Most components were described as effective and easily integrated into existing workflows. Patients valued the educational pamphlet for improving knowledge and self-efficacy, though staff expressed concerns about distributing it during acute care, contributing to inconsistent delivery. Champions were viewed as key in promoting adherence and sustaining implementation. Conclusion: MIMIC was found to be acceptable in all seven TFA domains among ED providers and patients, with perceived effectiveness driving positive attitudes across stakeholder groups. MIMIC’s co-design approach likely contributed to high intervention acceptability. Patient education strategies may require adaptation to improve fidelity. These findings support continued implementation and targeted adaptation of MIMIC.

This Research Topic set out to advance implementation research in emergency care, with four aims: rigorous work on uptake of evidence-based practice in the emergency department (ED) and in prehospital and emergency medical services (EMS); new methods for implementation research in acute settings; deimplementation of low-value emergency testing and treatment; and attention to disaster preparedness and to resource-constrained settings, particularly low-and middle-income countries (LMICs), where disparities in access to evidence-based emergency care are widest. This Editorial reads the 13 contributions against those aims.Implementation science studies the strategies, contexts, and behaviors that determine whether an evidence-based practice is adopted, delivered with fidelity, and sustained. Triage algorithms, evacuation plans, and outbreak responses all demand precise execution under pressure and across systems that vary enormously. Yet emergency and disaster medicine remain thinly represented in the formal implementation literature, which has concentrated on mental health, HIV, primary care, and chronic disease. A systematic scoping review of implementation research in emergency medicine found that most papers stopped at documenting evidence-practice gaps; only two used an explicit theoretical framework, and only five of 77 effectiveness studies used a randomized design (1,2). Independent reviews of the West African Ebola epidemic and of COVID-19 both located the decisive failures in operations rather than science: delayed detection and alerting, fragmented coordination, and slow translation of existing guidance into field practice (3,4).Four questions run through the collection: how hazards are communicated and managed across systems; how routine emergency and prehospital care builds the capabilities preparedness draws on; how the ED works as a platform for population health and continuity of care; and how equity shapes critical emergency outcomes. Table 1 gives each contribution with its country and income group, article type and design, and the preparedness capability it speaks to.The largest group treats hazards broadly and converges on one point: communication and information flow are themselves implementation problems. A policy and practice review from Sweden offers the most explicit toolkit: how to distinguish interventions from implementation strategies, adapt to context, iterate in structured cycles, and coordinate across agencies. It draws on the author's account of Stockholm's COVID-19 response rather than on new data (5). A study protocol from North Carolina aims to build a durable statewide coalition after Hurricane Helene, using surveys and focus groups across 15 affected counties; no results yet (6). A perspective argues that email-based heat alerts and incomplete rural surveillance leave both the warning and the counting incomplete (7). An original research article from Aomori, Japan develops a compound hazard risk index, applies it across 108 medical institutions, and overlays projected earthquake damage to identify facilities needing evacuation support; the prefecturewide support model is proposed, not yet operating (8). A cross-sectional survey of 517 residents of typhoon-prone Hainan, China found disaster knowledge and official trust positively associated with public risk perception, with the influence of warning sources fully mediated through them; the outcome was risk perception, not protective action (9).A second group reports on emergency and prehospital care. These are not disaster studies, and we do not read them as such. Their relevance is indirect but concrete: the capabilities a disaster consumes, ensuring an appropriately trained workforce, standing workflows and order sets, coordination across services, usable data, and continuity after the visit, are built in everyday operations and drawn down under surge. One academic ED took ultrasound-guided nerve blocks from zero to more than 50 procedures per quarter over four years by hiring a champion, building order panels with dosing safeguards, and embedding the technique in four clinical pathways; 93 residents and 34 faculty performed or supervised blocks, by building workforce capacity and standing workflows (10). A survey of 517 Nepali prehospital providers evaluating the knowledge to practice gap found good knowledge in 62% but good practice in only 25%, locating the gap in workflow and supervision rather than training content (11). A survey of 137 Polish soldiers found a similar knowledge to practice gap as roughly a quarter failed a first-aid test, with prior certification unrelated to score (12). An economic sub-analysis of stepped-wedge data from seven EMS agencies estimated $6.9 million in averted pediatric asthma hospitalization costs nationally, rising to $26.4 million if targeted to mild exacerbations and long transports; hospitalizations averted in routine practice are also beds free for a surge (13).Three contributions position the ED as a hub for population health and continuity of care. A review of Deja Tu Huella, an HIV screening program, reports 223,659 HIV serologies requested across 187 Spanish EDs in four years, yielding 2,357 new diagnoses and 87% linkage to care: a standing multi-site testing and reporting structure of the kind outbreak response requires (14). A trial protocol proposes adapting an ED-initiated fall-prevention intervention to telehealth for smaller EDs, with implementation feasibility as the primary outcome; no results yet (15). And furthermore, pre-post study in Moshi, Tanzania found higher 30-day use of antiplatelets (57% vs. 16%), beta-blockers (40% vs. 4%), and statins (42% vs. 8%) after an ED-based educational intervention following myocardial infarction, with no overall difference in disease understanding visit (16).A systematic review and meta-analysis addresses equity. Pooling predominantly retrospective studies, it found White patients had higher survival to...

Acute myocardial infarction (AMI) is an increasing cause of morbidity and mortality in Sub-Saharan Africa (SSA) but is often underdiagnosed and undertreated. To address this gap, the Multicomponent Intervention to Improve Myocardial Infarction Care (MIMIC) was developed and implemented in the emergency department (ED) of a regional referral center in northern Tanzania. We conducted in-depth interviews with 20 key stakeholders (physicians, nurses, administrators, and patients) who participated in MIMIC during the first year of implementation. Purposive sampling was used to recruit a broad range of participants. Interviews were guided by a semi-structured interview guide informed by the Theoretical Framework of Acceptability (TFA). Interview transcripts were thematically analyzed by a team of coders using an inductive, grounded theory approach guided by the seven TFA domains. Nineteen major themes emerged across all TFA domains. Overall, participants described MIMIC as highly acceptable, minimally burdensome, and well-aligned with professional and ethical values. Perceived effectiveness was most emphasized, with staff citing improvements in AMI recognition, ECG and troponin testing, and use of evidence-based therapies. All components were highlighted as effective and easily integrated into existing workflows. Patients valued the educational pamphlet for improving knowledge and self-efficacy, though staff expressed concerns about distributing it during acute care, contributing to inconsistent delivery. Champions were viewed as key in promoting adherence and sustaining implementation of the intervention. MIMIC was widely acceptable in all seven TFA domains among ED providers and patients, with perceived effectiveness driving positive attitudes across stakeholder groups. Use of a co-design approach in MIMIC development likely contributed to high intervention acceptability. Patient education strategies may require adaptation to improve fidelity. These findings suggest that continued implementation and future adaptation of MIMIC may be feasible.

Background: In Tanzania, many people living with HIV (PLWH) have uncontrolled hypertension, yet integration of hypertension management into HIV care remains limited. The Community Health Worker Optimization of Antihypertensive Care in HIV (COACH) intervention was developed to integrate standardized hypertension management into HIV clinic workflows. Setting: A single-arm pilot trial was conducted from December 2024 to September 2025 at two public HIV clinics in Moshi, Tanzania. Methods: COACH included six monthly community health worker (CHW)-delivered hypertension education sessions within HIV clinic visits, monthly blood pressure (BP) checks, care coordination, subsidized antihypertensive medications, a standardized treatment algorithm, and provider training. The primary effectiveness outcome was BP control at six months (2 (p=0.019), and the proportion with ≥20% five-year cardiovascular risk declined from 33% to 7% (p<0.001). Conclusions: COACH resulted in substantial improvements in BP control, hypertension knowledge, medication adherence, and cardiovascular risk among PLWH in Tanzania.

The Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC) was developed to address gaps in AMI diagnosis and treatment in norther

Background: In Tanzania, acute myocardial infarction (AMI) is underdiagnosed, and uptake of evidence‑based care remains limited. The Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC) increased evidence‑based AMI care in a pilot trial conducted in a Tanzanian emergency department (ED). Whether MIMIC was sustained as implemented and its gains persisted after the pilot is unknown. Objectives: To evaluate the long‑term fidelity, penetration, and effectiveness of MIMIC one year after the pilot trial. Methods: We conducted a sequential cohort study in a Tanzanian ED, enrolling adults with chest pain or dyspnea during the pilot period (September 2023–August 2024) and post‑pilot period (September 2024–August 2025). Pre‑intervention data (February–August 2023) served as supplemental baseline. Outcomes included fidelity and penetration of MIMIC components and 11 AMI care metrics. Proportions were compared using Pearson’s χ² tests and odds ratios (ORs) with 95% confidence intervals (CIs). Findings: Of 260 post‑pilot participants, 29 had AMI. Fidelity and penetration of MIMIC components were similar to pilot levels. Electrocardiogram (ECG) uptake remained high (~90% in both periods). Cardiac biomarker testing was lower post‑pilot (64.0% [n = 203, excluding stock‑out periods] vs 78.0%, OR 0.50, 95% CI 0.35–0.72; P < 0.001), coinciding with reagent stock‑outs, but exceeding pre‑intervention baseline (41.4%). Among AMI participants, treatment with aspirin, clopidogrel, heparin, and statins in the ED was comparable between pilot and post‑pilot periods. Compared with the pre‑intervention baseline, uptake of diagnostic testing and evidence‑based therapies was substantially higher, including a >5‑fold increase in 30‑day antiplatelet use (10% vs 52%; OR 9.54, 95% CI 2.49–46.46; P < 0.001). Conclusions: One year after implementation, MIMIC demonstrated sustained fidelity, penetration, and clinical effectiveness. AMI care remained substantially improved compared with pre‑intervention baseline, suggesting that a pragmatic, workflow‑integrated intervention can achieve durable gains in AMI care in a resource‑limited ED.

Persons living with HIV (PLWH) face double the risk of cardiovascular disease (CVD) compared to others. We assessed HIV prevalence among patients presenting to a Tanzanian emergency department (ED) with acute myocardial infarction (AMI) or heart failure (HF). In this prospective observational study (Nov 2020-Jan 2023), adults with chest pain or dyspnea were enrolled. Patients without known HIV underwent HIV 1/2 assay and confirmatory testing. AMI was defined per the Fourth Universal Definition; HF by physician diagnosis at discharge. Thirty-day follow-up was via phone or home visit. Of 836 enrolled participants, 344 (41.1%) met criteria for AMI or HF. Among these, 16 (4.7%) had HIV (15 known, 1 new). In participants without AMI or HF, 17 (3.5%) had known HIV. Follow-up was achieved for 99.8% (n = 834). HIV-positive participants with AMI or HF had higher unadjusted 30-day mortality than HIV-negative participants (37.5% vs 24.5%, OR 1.93, 95% CI: 1.05-3.60, p < 0.05). Targeted HIV testing for patients with cardiovascular complaints in a Tanzanian ED setting may not be a high-yield method for identifying new HIV cases. Future studies should be tailored to populations underrepresented in current programs. Thirty-day mortality following AMI or HF diagnosis is significantly higher for PLWH in Tanzania, emphasizing the need for interventions to address poor clinical outcomes of CVD among this population.

Introduction: There is a large burden of uncontrolled hypertension among people with HIV (PWH) in sub-Saharan Africa (SSA), including in Tanzania. Yet, few evidence-based interventions to improve hypertension control have been adapted for use in PWH in this region. This study describes the adaptation process of an evidence-based hypertension intervention to develop the Community Health Worker Optimization of Antihypertensive Care in HIV ( COACH ) intervention, a multi-component strategy designed to improve blood pressure control among Tanzanians with HIV and hypertension. Methods: A 27 member interdisciplinary intervention design team consisting of HIV and hypertension clinicians, nurses, community health workers (CHWs), pharmacists, social workers and patients with HIV and hypertension from Tanzania met biweekly from May 2024 to October 2024. The design team used the Assessment-Decision-Adaptation-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) framework supported by participatory co-design principles to iteratively adapt the intervention to the local context. Results: To address the unique needs of PWH and hypertension in Tanzania, we iteratively adapted an evidence-based CHW intervention for hypertension care originally developed in Asia ( Control of Blood Pressure and Risk Attenuation—COBRA ), resulting in development of the COACH intervention for the HIV clinical setting in Tanzania. COACH , includes five key components: 1) CHW-delivered hypertension counselling integrated into HIV clinic visits, 2) Integration of routine blood pressure monitoring and referrals for antihypertensive medication management in the HIV clinic, 3) Hypertension management training for HIV providers and creation of an antihypertensive treatment algorithm, 4) CHW care navigation and coordination of hypertension care in the HIV clinic, and 5) Subsidization of antihypertensive medications. Conclusions: COACH is one of the first contextually-tailored interventions developed to address hypertension care among PWH in Tanzania. A pilot feasibility study of the intervention is in process and future studies will evaluate the implementation and clinical effectiveness outcomes of the COACH intervention. The rigorous, systematic application of the ADAPT-ITT framework to iteratively develop COACH supports reproducibility of the adaptation process, and strengthens the potential for COACH core components to be highly relevant for PWH with hypertension in other resource limited settings worldwide.