Qualitative assessment of a virtual cardiovascular medical education program in Haiti: local physicians in-training experiences

Abstract

Background

Haiti faces challenges in accessing equitable healthcare and medical education due to limited resources. Cardiovascular disease burden is high, necessitating a well-trained cardiovascular workforce. The International Cardiology Curriculum Accessible by Remote Distance Learning (ICARDs) program, launched in 2019, addresses this need by providing virtual cardiovascular education. This study aimed to explore the perceptions and experiences of internal medicine residents and physicians participating in the ICARDs program, focusing on their expectations, facilitators, barriers, and recommendations for improvement. A qualitative research approach was adopted, conducting three focus groups with participants in three different hospitals across Haiti.

Methods

The study utilized a Unified Theoretical Framework of Learning Theories as a structured framework to identify themes. A deductive content analysis was employed to identify barriers and facilitators and valuable information from participants’ responses.

Results

Participants expressed high expectations and reported positive experiences with the ICARDs program. They acknowledged its positive impact on patient care and the development of their medical skills. However, some concerns were raised regarding course content and irregularities in the program.

Conclusions

The ICARDs program fulfills participants’ expectations for cardiovascular education and fosters a supportive community. To enhance its effectiveness, addressing content concerns and infrastructure limitations is essential. The study’s findings provide valuable insights for program organizers to tailor the ICARDs program and better meet the participants’ needs.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-025-06763-1.

Background

Cardiovascular disease (CVD) remains a significant global health challenge, responsible for a substantial proportion of mortality and morbidity worldwide [1]. In low-resource settings like Haiti, where healthcare disparities are prevalent, the burden of CVD presents critical challenges for healthcare professionals [2]. Limited access to comprehensive training opportunities and a scarcity of specialized resources hinder the progress of medical education, leaving many internal medicine residents and physicians ill-equipped to address the complexities of cardiovascular medicine effectively [3, 4].

To address this pressing issue, the International Cardiology Curriculum Accessible by Remote Distance Learning (ICARDs) program was introduced in 2019. Developed by Global Medical Education Network Inc (GMEN), this innovative virtual learning platform (VLP) aimed to bridge the educational gap and provide essential training experiences for healthcare professionals in Port-au-Prince, Mirebalais and Cap-Haitian [5]. Initially launched as a pilot program in one public hospital, the ICARDs initiative was later expanded to the all four public hospitals targeting cardiovascular diseases across Haiti, allowing for broader implementation and a more comprehensive assessment of its impact on medical education. Through the integration of technological advancements like interactive webinars, online case discussions, and virtual simulations, the program strives to enhance the delivery of cardiology continuing medical education in a cost-effective and accessible manner [4]. Participant analysis showed an 80% increase in knowledge acquisition post-intervention. In the year-end evaluation, 94% found the curriculum relevant and educational for Haiti’s medical practice, with 100% rating it as good to excellent. Additionally, it effectively supported trainee education during the COVID-19 pandemic [5].

While the ICARDs program has demonstrated promising outcomes, little is known about the participants’ experiences and perceptions. Understanding the impact and effectiveness of the program was crucial for optimizing its content and delivery, ultimately leading to improved cardiovascular care in Haiti.

In this study, we explored the experiences of internal medicine residents and physicians participating in the ICARDs program. Through a comprehensive qualitative assessment, we explored their expectations, challenges, and recommendations, shedding light on the program’s efficacy and identifying areas for improvement. By capturing the voices of local internal medicine residents and physicians, we seek to contribute valuable insights to enhance the ICARDs program’s effectiveness and meet the specific needs of participants. The primary goal of the iCARDs program is to improve patient care by empowering local physician through enhancement of cardiology-related skills and medical training for residents who lacked sufficient cardiology training or faced limited access to cardiologists in their respective hospitals. We aimed to uncover participants’ initial expectations, positive experiences, and provider sentiments regarding the program. Additionally, we explored the facilitators and barriers to participation, which encompassed various elements like the online platform, accessibility challenges, and culturally relevant content. Furthermore, our study assessed the impact of the iCARDs program on participants’ confidence, clinical skills, and patient care in their specific settings. This research aspired to advance medical education in resource-constrained settings like Haiti and empower healthcare professionals to tackle CVD and other pressing health challenges effectively.

Methods

To gain comprehensive insights into the impact and effectiveness of the ICARDs program, we adopted a qualitative research approach. Focus group (FG) discussions were conducted with a purposive sample of internal medicine residents and physicians enrolled in the program, allowing us to delve into their perceptions and experiences. The ICARDs curriculum included comprehensive cardiology modules covering both fundamental and advanced topics, delivered through lectures, quizzes, and practical assessments. A detailed list of the topics covered in the training is available in supplementary Table 4.

This study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline to ensure comprehensive and transparent reporting, supplementary Table 1 [6]. To design the interview guide about internal medicine residents and physicians perceptions of the ICARDs program, we used a unified theoretical framework of learning (UTF-L) for public health continuing medical education [7]. This framework integrates cognitive, social, and effective learning theories, guiding the design, delivery, and evaluation of continuing medical education programs. Moreover, it emphasizes the significance of context and the role of the learner in the learning process, which in turn informed the effectiveness of the ICARDs-Haiti program. Deductive content analysis was employed to identify recurring categories and subcategories in the participants’ responses, helping us to uncover participants’ diverse experiences.

Drawing from researchers’ prior experiences and leveraging the framework, they shaped the interview guides, and data interpretation. We critically reflected on our diverse disciplinary backgrounds, which included expertise in family medicine, cardiology, psychology, and public health, recognizing that these perspectives could influence our approach to the study. From the outset, we acknowledged potential biases, such as assumptions about the effectiveness of virtual education programs like ICARDs. While committed to objectively assessing the program’s impact, we were mindful that our shared dedication to addressing gaps in cardiovascular training might shape the framing of our research questions and interpretation of findings. To mitigate these influences, we held regular discussions to critically evaluate our biases and ensure a balanced and rigorous analysis.

Setting and study participants

At the time of this study, four university hospitals in Haiti contributed to the training of internal medicine residents. Two hospitals are located in the capital, Port-au-Prince: Hôpital de l’Université d’État d’Haïti (HUEH), the largest public hospital, trains 23 internal medicine residents with 54 post-emergency beds, but its central location makes it vulnerable to strikes and political disruptions, often restricting access. Hôpital Universitaire La Paix (HUP), situated in the suburb of Delmas, 9 km from the city center, trains 17 residents with 20 post-emergency beds, offering a stable environment for resident participation. In the central region, Hôpital Universitaire de Mirebalais (HUM), 54 km from Port-au-Prince, operates under a hybrid public-private model, housing 17 residents and 38 post-emergency beds, with modern facilities that facilitate strong communication and consistent engagement. Finally, in the northern city of Cap-Haïtian, Hôpital Universitaire Justinien (HUJ) trains 8 residents with 32 post-emergency beds, though its geographic distance and unreliable internet access have limited full participation in the project.

Three semi-structured FGs were conducted with internal medicine residents (n = 11) and attending physicians (n = 4) from four hospitals across Haiti: HUP–La Paix, Port-au-Prince (n = 4), HUM–Mirebalais (n = 4), HUJ–Justinien, Cap-Haïtien (n = 3), and HUEH–General Hospital, Port-au-Prince (n = 4). Two FGs were conducted with residents: the first on July 20, 2022, (n = 5) and the second on July 21, 2022 (n = 6). The third FG was held with attending physicians on July 27, 2022 (n = 4). The FGs were conducted virtually in French via Zoom [8]. To ensure inclusivity and open dialogue, participants were grouped by role, allowing them to freely express their thoughts and concerns. Engaging participants from various hospital settings enabled us to capture a diverse range of perspectives on the ICARDs program’s impact and effectiveness. Participants were recruited using a combination of text messages, emails, and in-person communication, ensuring accessibility and broad outreach across various hospital settings. Participants were recruited through purposeful sampling resulting in a total of 15 enrolled participants. All invited participants agreed to participate, and no dropouts occurred during the study. To ensure inclusivity and open dialogue, we arranged two separate FG, each with 5–6 residents. We also held an exclusive FG for attending physicians, empowering all participants to freely express their thoughts and concerns. Each participant took part in a single focus group session, and no repeat interviews were conducted.

NH and VS-J had pre-existing relationships with the hospitals participating in the study, which helped streamline access and coordination for the focus groups. Additionally, throughout the research process, we worked closely with residents and attending physicians in Haiti, including GLP, CAM, TP-H, ED, and CD. This collaboration ensured continuous engagement and a shared understanding of the study’s goals, fostering trust and a cooperative dynamic.

Data collection

Each FG lasted approximately 60 min, with a research assistant facilitating conversations using open-ended semi-structured questions and diligently taking notes to ensure accuracy and comprehensiveness of the collected data. We utilized structured questions tailored to each participant group. Supplementary Table 2 outlines the questions used for the resident focus groups, while Supplementary Table 3 lists the questions for the supervising physicians and attendings focus group. These tables are included as supplementary material.

MI, the research assistant responsible for facilitating the focus groups was thoroughly trained in qualitative research methodologies, with specific expertise in focus group facilitation and content analysis. Her skill set included the ability to foster open-ended discussions while striving to maintain an environment that was as neutral and inclusive as possible.

At the beginning of each focus group, the facilitator introduced herself, outlined her role in guiding the discussion, and encouraged participants to share their experiences openly. Although she aimed to maintain neutrality throughout the process, we recognized the possibility that her own perspectives could inadvertently shape the discussion. To mitigate this, we adhered to a structured guide and focused on actively listening to participants’ contributions. The focus group discussions were conducted in a confidential and focused setting, with only the participants and the facilitator present. Transcripts were not returned to participants for comment or feedback. However, authors affiliated with hospitals in Haiti reviewed the interpretations to ensure they were relevant and aligned with the Haitian healthcare context.

The study protocol underwent thorough review and received approval, with IRB exemptions from Zanmi Lasante/HUM and UPenn IRB committees. Participants received comprehensive information about the study’s purpose and provided informed consent. Strict confidentiality measures were implemented to protect their identities and data.

Data analysis

Audio tape data were transcribed using a non-verbatim method. This involved editing out pauses, interjections, and non-essential audio not affecting participants’ intended messages. Speaker identification relied on numbered video references, maintaining strict confidentiality. The mixed methods research lab (MMRL) at UPenn managed English translation, which was subsequently reviewed by the facilitator using FG notes to ensure precision and completeness. During the analysis phase, we carefully evaluated data saturation and discussed it with the authors affiliated with the participating hospitals. We collectively determined that no new themes emerged after the third focus group, indicating that the topics had been explored with sufficient depth and comprehensiveness.

This study employed a deductive content analysis approach for FG analysis, informing data examination and guiding interpretation. This approach facilitates exploring how varied learning theories impact cardiology medical education in Haiti. Its application enabled a systematic analysis of FG data, identifying the codes, with pre-defined categories such as barriers and facilitators. Data were systematically sorted into these categories, and any additional subcategories that emerged from the data were noted and incorporated into the framework. Two independent reviewers meticulously assessed transcripts, resolving disparities with NVivo software [9].

Results

To provide an overview of the study participants, Table 1 summarizes the general characteristics of the internal medicine residents and attending physicians involved in the focus groups. It includes demographic details, professional roles, and hospital affiliations, highlighting the diverse backgrounds represented in the study.

Table 1.

Characteristics of participants

Characteristic	Count (%)
Total Participants	15
Gender
Male	8 (53%)
Female	5 (33%)
Role
Resident	11 (73%)
Attending Physician	4 (27%)
Hospital Affiliation
Hospital 1 (La Paix)	4 (27%)
Hospital 2 (Mirebalais)	4 (27%
Hospital 3 (Justinien)	3 (19%)
Hospital 4 (General)	4 (27%)

Our study delved into multiple aspects of the iCARDs program, focusing on participants’ experiences and the factors influencing their training.

Experiences and expectations

Before starting the iCARDs program, participants had certain expectations. Most expected to enhance their cardiology-related skills and medical training. They also aimed to improve patient care using knowledge gained from iCARDs. Additionally, they looked forward to learning American and European approaches to CVD management and being exposed to an international community of cardiologists. Another expectation was to gain a basic understanding of echocardiography.

[…] I wanted to know at least how to take care of my patients in outpatient and independent clinics. I wanted to start taking care of them before referring to a cardiologist.

(Interviewee 01, FG 2)

Participants had positive experiences with the iCARDs program, highlighting the sense of community and support among peers. They appreciated the opportunity to exchange ideas with other healthcare providers, even internationally. Improved patient care and cardiology-related knowledge were also mentioned as positive outcomes. However, some negative experiences included challenges with completing pre- and post-tests on the platform and a desire for more practical and applicable course topics, such as long-term care, ECGs, and echocardiography.

Participants in the FG expressed positive sentiments about their experience with iCARDs (Table 2). They felt that the program met their expectations, resulting in an overall positive experience. Compared to the previous year, this year’s iCARDs coursework and material were deemed better, particularly because of the more relevant, diverse, and engaging topics for Haitian providers. Courses related to electrocardiogram were especially important and interesting to the majority of participants, as they found the knowledge applicable in their clinical settings and lacked resources outside of the iCARDs platform to learn this information. Additionally, the availability of iCARDs lecturers was viewed positively, providing support for residents with questions or concerns.

Table 2.

Experiences with ICARDs Program

Positive Experiences with ICARDs	Negative Experiences with ICARDs
Feeling of Community	Challenges with Pre- and Post-Tests
Improved Patient Care	Non-Applicable Program Content
Access to Diverse and Applicable Topics	Platform Navigation Issues
Availability of iCARDs Lecturers	Irregularities in Program Delivery
Increased Medical Skills and Knowledge	Lack of Practical Topics (e.g. Echocardiography or ECG interpretation)
Opportunities for Knowledge Exchange	Limited Access to Echocardiography

Nearly all the negative sentiments pertained to insufficient echocardiography content (Table 2) They felt that their understanding and practical skills in this area did not improve as expected. Additionally, they pointed out irregularities in this year’s program, such as having a redundancy of some topics and some lecturers being unavailable for live sessions on short notice. The absence of more practical topics further contributed to their negative experience with the program. For instance, participants would have greatly appreciated additional training on echocardiography and ECG, enhancing their learning experience. Furthermore, participants encountered challenges with platform progression and faced difficulties in completing the pre-tests and post-tests.

We had progression issues on the platform and participants had a challenge to complete the pre-tests and the post-tests. […] We had the same course with different lecturers. And we missed practical topics, and the sessions were mostly theoretical. For instance, echography and ECG were not really part of the program of this year.

(Interviewee 02, FG 2)

Participation and accessibility

iCARDs program facilitators were associated with aspects of the iCARDs program that made participants continually engage in the program or return for the new term (Table 2). They encouraged continuous participation by fostering competitiveness through the inclusion of more Haitian hospitals. However, some participants suggested that promoting collaboration among hospitals could be more beneficial. Additionally, the accessible scheduling allowed participants to attend without difficulty.

Participants faced barriers during their iCARDs program (Table 2). Busy clinical schedules often made it challenging to find time for coursework and to attend sessions. Limited access to specific treatments and medications added to the difficulties, requiring them to adapt their learning with available resources. Pharmacological challenges in managing CVD were also common due to resource constraints. Internet problems hindered access to pre- and post-tests, while general electricity and internet issues in hospitals and other settings further compounded the challenges. Accessibility barriers were primarily related to internet connection and Wi-Fi issues experienced by participants using iCARDs program. Many reported that the Wi-Fi in their hospitals lacked the necessary strength to ensure seamless participation. Some resorted to using personal data, but its reliability was not always guaranteed, with the possibility of running out.

Regarding the medication, I want to talk about dyslipidemia. We [have] statins, and we don’t have a lot of other things. […] That’s the first thing. The second thing is that we follow studies that are published internationally on the inhibitor of SGLT2 and have noticed that has an impact on heart failure. However, these medicines are rare and very expensive. Therefore, patients cannot have a long-term follow-up with these medications.

(Interviewee 05, FG 1)

Sometimes, I don’t get the ICARDs platform because I am in external rotation in isolated areas and where internet access is rare.

(Interviewee 01, FG 1)

Table 3.

Facilitators and barriers to participation in the ICARDs Program

Facilitators to Participation	Barriers to Participation
Friendly Competitiveness among Haitian hospitals	Lack of access to certain treatments and medications
Fostering motivation and competitiveness	Busy clinical schedules
Interactive learning environment	Need to adapt learned knowledge to available resources
Scheduling and timing of coursework	Internet issues and platform access challenges
Availability of iCARDs lecturers	General electricity and internet problems

Applicable and non-applicable content

Participants found applicable content in iCARDs program, which they could apply in their clinical settings. Topics like electrocardiogram, pre-op assessment, hypercholesterolemia, preventative medicine, cardiovascular risk assessment, infections, valvopathy, cardiac imaging, and pathophysiology were particularly relevant to them. This knowledge from iCARDs positively impacted their clinical work and patient care, resulting in improved quality of care at their respective hospitals.

“[…] Courses are pertinent based on our Haitian reality. Most patients […] have complications or cardiovascular pathologies. [In hospital 1], we don’t have cardiologists. […] it is important to have a protocol for taking care of the patients. When we read about it and then have more practical and concrete courses, we feel more comfortable with taking care of the patients. […] when we started the course with ICARDS, we have noticed the difference with the patients in optimal way. And, I can say this program has a greater impact more than you can even imagine. I feel comfortable taking care of my patients with high blood pressure and cardiomyopathy. I feel comfortable taking care of them thanks to ICARDS program. And, I can say that ICARDS will be competent in the future with more materials and resources. I think you should continue with it as residents at the university. There are many residents in iCARDs, and we discuss cases together. When you are alone, then you really feel the impact of ICARDS…”.

(Interviewee 01, FG 2)

Non-applicable content refers to material participants found irrelevant to their practice for various reasons. They stressed the importance of focusing on clinical cases more prevalent in Haiti and emphasized the need for more emphasis on preventative medicine, considering the limited access to certain treatments and medications they were learning about.

Confidence and positive implications

The iCARDs program significantly improved participants’ skills, knowledge, and confidence. Nearly all of them stated that the program enhanced their medical expertise and boosted their confidence, especially in managing critical or life-threatening clinical situations.

[…] The class on pre-op assessment has helped me to better assess the cardiovascular risks of the patients. That has also helped me change my approaches, particularly with patients having surgery and who are highly risk or may have cardiovascular complications.

(Interviewee 006, FG 1)

Participants also highlighted the positive impact of the iCARDs program on their patient care in clinical settings. They expressed how the platform equipped them with the necessary knowledge and skills to handle patients from diverse specialties, even in cases where they lacked prior experience or sufficient knowledge. As a result of iCARDs, many participants observed significant improvements in patient care at their respective hospitals.

Of course, yes. Last week, I saw a patient who had palpitations […] thought to be due to asthma. So, when I saw her, she told me […] palpitation, and pain, and I thought of a heart issue. And it was the case. I started taking care of her with a high blood pressure 220/120 mmHg, the cardiac frequency with nearly 230. […] the respiratory rhythm was about 30. When I start taking care of her, I put her […] on furosemide […] She had criteria for admission, but due the difficult political situation in the country, I had to take an ambulatory approach, and I saw her in 48 h. And, she said that she started to progress well and then she felt good at night. I visited her after echocardiography. After one week, the patient was doing much better, and she sleeps well at night. It is something very positive. I imagine that if people have this basic training [ICARDs], then they can better take care of the patients.

(Interviewee 01, FG 2)

Positive implications arose from participants’ experiences with iCARDs, highlighting its beneficial impact on their practice and patient care. One significant implication was the exposure to clinical cases that expanded their experience. Communication among residents from different programs facilitated knowledge exchange. iCARDs also motivated participants to conduct further research, leading to an expansion of their medical knowledge. Notably, participants mentioned specific clinical situations where applying knowledge from iCARDs resulted in positive outcomes.

Cultural and socio-political factors

The cultural dimension captured barriers related to participants’ cultural context in the iCARDs program. One noted barrier was the absence of medical approaches available due to resource limitations. Another significant cultural barrier involved the lack of translations for materials provided in English to French, making some terms and information less accessible. The socio-political dimension captured references to social or political situations that could have influenced participation in the iCARDs program or had an impact on Haitian medical providers. The assassination of the Haitian president was the most notable situation discussed. While some participants stated that this event had little impact on them, a few mentioned experiencing some effects.

Suggestions

Participants shared valuable suggestions to enhance the iCARDs content for a more practical and beneficial experience. They emphasized organizing Haitian clinical cases in a more interactive manner, focusing on practical aspects of topics, and tailoring teaching materials to account for the lack of medical resources in Haiti and the prevalence of specific pathologies. Preventative medicine was highlighted as a crucial area to concentrate on given its relevance to their environment. Having Haitian cardiologists abroad as guest lecturers and incorporating mentors to assist with publication of clinical cases were also recommended.

Regularly scheduled sessions were proposed, where providers from different Haitian hospitals and universities could convene to discuss challenging clinical cases. Ensuring material caters to the varying training levels of residents and providers was underscored to avoid redundancy and cater to more experienced professionals. Regarding the online platform, participants suggested addressing internet connectivity issues to prevent losing coursework progress. Providing documents in French for ease of use was also recommended. Other suggestions included fostering collaboration with other Haitian residents and programs, notifying participants of upcoming course topics for better preparation, and incorporating clinical case presentations. Adjusting learning times to mornings/early afternoons and facilitating in-person lectures and classes were additional proposals to enrich the learning experience.

Discussion

Key insights from the study shed light on participants’ experiences with iCARDs. High expectations were largely met, leading to positive experiences and a supportive community. The program positively impacted patient care and cardiology-related skills. Although participants appreciated the program, some negatives emerged, like insufficient echocardiography content and course irregularities. Facilitators to participation included competitiveness among Haitian hospitals and favorable scheduling, while barriers encompassed busy clinical schedules, limited access to treatments, internet connectivity issues, and weak hospital Wi-Fi. The program’s accessibility raised concerns, stressing the importance of reliable internet connections. Content was mostly applicable, especially specific pertinent topics.

Cultural and socio-political factors were also identified. Participants highlighted the importance of culturally tailored content and accessible language, aligning with recommendations from global reviews of medical education in low-income settings [10]. To contextualize these findings, the experiences of ICARDs participants reflect challenges commonly reported in other low-resource virtual training programs, such as internet connectivity issues. For example, studies on telemedicine education in sub-Saharan Africa emphasize the importance of strong digital infrastructure and integrating practical skills [11]. Similarly, the sense of community and peer knowledge-sharing emphasized by ICARDs participants aligns with findings from global health education initiatives, which highlight the value of collaboration and shared learning in strengthening professional networks and enhancing training outcomes [12].

Future research could explore longitudinal studies to evaluate the long-term effects of the ICARDs program on participants’ clinical practices and patient outcomes. To improve the program, incorporating practical training components, such as echocardiography and advanced ECG interpretation, is recommended, consistent with findings from studies on virtual training programs in similar settings [13]. Additionally, comparative studies in other resource-limited settings could offer valuable insights into adapting and scaling similar virtual education initiatives, helping to refine their implementation and address global disparities in medical training.

Limitations

While the iCARDs program positively impacted participants’ confidence, skills, and knowledge, we must address the study’s limitations. Focusing on specific hospitals in Haiti may limit diverse experiences, and the findings might not fully apply to other healthcare settings or regions. Generalizing the results should be approached cautiously. Furthermore, improvements in practical topics and platform accessibility are needed to enhance program effectiveness and provide a more comprehensive learning experience. Acknowledging these limitations and actively working to address them will better cater to a broader range of participants and foster professional development in cardiology.

Conclusion

Our study provides valuable insights into the experiences of internal medicine residents and physicians participating in the ICARDs program. The findings underscore the program’s positive influence on participants’ skills, patient care, and sense of community. However, addressing content concerns and infrastructure limitations is vital to ensure participant satisfaction and program effectiveness. Recognizing ICARDs’ limitations, including lack of control over Wi-Fi connectivity, is also important to minimize technological issues and therefore ensuring program success and participant satisfaction. By implementing the study’s recommendations, program organizers can tailor the ICARDs program to better meet the specific needs of participants, thereby enhancing the delivery of cardiology education in Haiti. Through continuous improvement, we can foster a more impactful and beneficial learning experience for healthcare professionals in the region.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

CVD

Cardiovascular disease

ICARDs

International Cardiology Curriculum Accessible by Remote Distance Learning

GMEN

Global Medical Education Network Inc

FGs

Focus groups

ECG

Electrocardiogram

Author contributions

Marwa Ilali, Norrisa Haynes, Veauthyelau Saint-Joy, Abdul Cadri, Virginie Clavel, and David Etienne conceived and planned the study. Marwa Ilali, Norrisa Haynes, Veauthyelau Saint-Joy, and Virginie Clavel carried out the study. Marwa Ilali performed data collection. Mlka Mengesha, Marwa Ilali, Norrisa Haynes, and Veauthyelau Saint-Joy performed data analysis and interpretation. Marwa Ilali drafted the manuscript. Norrisa Haynes, Veauthyelau Saint-Joy, Abdul Cadri, David Etienne, Calixte Dawson, and Veronika Panagiotou critically reviewed the article. Marwa Ilali, Virginie Clavel, Veronika Panagiotou, Mlka Mengesha, Giovanni Léon Policard, Carmene Altagracia Moïse, Tamara Petit-Homme, David Etienne, Abdul Cadri, Eliezer Dade, Calixte Dawson, Michel Ibrahim, Veauthyelau Saint-Joy, and Norrisa Haynes approved the final version of the manuscript for publication.

Funding

The authors declare that they have received no funding.

Data availability

Authors confirm that all experimental protocols conducted in this study were approved by the Zanmi Lasante/HUM and UPenn IRB committees. Informed consent was diligently obtained from all subjects participating in the research. All authors and participants consented for publication. The raw datasets generated and/or analyzed during the current study are not publicly available due to the ease of identifying individual participants from the data. However, they can be obtained from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

IRB exemptions were obtained from the Zanmi Lasante/HUM and UPenn IRB committees.

Consent for publication

All authors and participants consented for publication.

Competing interests

The authors declare no competing interests.