A Review of Hypertension and Diabetes Protocols for Medical Service Trips (MSTs) in Latin America and the Caribbean

Background: Hypertension and diabetes are among the most common chronic conditions that may be managed on short-term, primary care medical service trips (MSTs) in Latin America and the Caribbean (LAC), but the quality of patient care delivered remains unclear. Objective: This study summarizes protocols that Western volunteer clinicians use in managing these patients, and highlights their commonalities, differences, and potential limitations. Methods: A systematic web search was used to identify organizations operating MSTs in LAC. Organizations were contacted by email or through their websites to obtain clinical protocols intended for use on their brigades. These protocols were qualitatively analyzed, and recommendations were categorized into clinical assessment, non-pharmacologic recommendations, and pharmacologic recommendations. Findings: Two hundred twenty-five organizations were identified and contacted, and protocols were obtained for 20 of these. Eleven (55%) of these protocols discussed hypertension, and 10 (50%) discussed diabetes. Only one protocol provided any literature support for its recommendations. Conclusions: The analyzed protocols may give insight into context-specific realities of practice on MSTs, but they often neglected key aspects of clinical management that are emphasized in international guidelines. This study is an initial step in clinical guidelines development for MSTs operating in LAC.

NGOs currently operating short-term, primary care MSTs in Latin America or the Caribbean were sampled and identified in three ways. First, several online databases were used (www.missionfinder.org, www.medicalmissions.org, www.mmex.org, www.globalhealth.arizona.edu, www. internationalhealthvolunteers.org) to identify NGOs. Second, a systematic Google web search was conducted using combinations of the terms: "medical missions", "short term missions", and "medical mission organizations", combined with each country in Latin America and the Caribbean [5]. Based on a similar search for short-term MSTs conducted by Lasker [6], the Google search was extended to include different combinations of the terms: "international health volunteering", "Christian health volunteering", "religious health volunteering", "corporate global health volunteering", "international health fellowships", "international health educational opportunities", "global health director", "international service learning", "global health elective", "medical school international internships", "intercultural learning", "global health volunteer projects university", and "international volunteer organizations". Third, organizations were also located through social media, using the Twitter hashtags "medical mission" and "global health". These searches were performed every two months between April 17, 2014 and July 20, 2015 to find and include as many organizations as possible due to the diversity of web presence and constantly changing NGO landscape.
Organizations were contacted by the research team if they: facilitated North American clinicians (physician, physician assistant, osteopath, or nurse practitioner) traveling to Latin America or the Caribbean, and had operated at least one short-term (i.e. less than one month) primary care MST in the previous year. Exclusion criteria were organizations that exclusively performed specialty or surgical trips, as well as trips that did not involve direct patient care by North American clinicians. Organizations with multiple chapters (i.e. university MST organizations) were treated as a single unified parent organization and only one chapter was contacted.

Procedures
We obtained the following data from the website of each eligible organization and entered it into an Excel spreadsheet: its base of operations, countries served, frequency of MSTs to Latin America, clinical setting of the MST (rural, urban), number and type of providers, diagnostic resources available during the MST, and whether the organization was faith-based or secular.
We searched each NGO website and downloaded any medical provider handbook, clinical protocols document, or description of clinical management on an MST. If no such documents could be found, an attempt was made to contact the NGO directly by the email address posted on the website. If NGOs were contacted by email, a prepared email explained the study purpose and then asked: "Do you have any specific clinical protocols or training documents for clinicians working in low resource mission settings?" We documented the number of NGOs contacted, and any reasons provided for the absence of protocols or for declining to share protocols. All clinical protocols received were saved on a secure cloud drive.

Analysis
An Excel spreadsheet was used to systematically classify and code data from the received protocols into categories related to clinical assessment, non-pharmacologic management suggestions, and pharmacologic management suggestions. The most common protocol statements in each category were identified, organized thematically, and checked for the inclusion of supporting references. Figure 1 indicates the number of protocols retrieved and the responses of NGOs to information requests. The search strategy generated 225 unique NGOs. Of these NGOs, 113 (50.2%) did not respond to our attempts to contact them. Sixty-eight (30.2%) responded that they did not use any clinical protocols, while 13 (5.8%) responded that they had recommended pre-departure readings but no specific protocols. Although structured analysis of the reasons for lacking protocols was outside the scope of this study, organizations without protocols responded that treatment offered was "the same as in the US", "on the spot medicine", "mostly basic healthcare issues", "mostly basic family medicine", and described the presence of "very few diagnostic syndromes, and they are all treated the same out of necessity".

Results
Thirty-one NGOs (13.8%) used clinical protocols and 20 (64%) of these were obtained and included in this analysis ( Table 1). Of the 20 organizations for whom protocols were obtained, only two served in South America, and all remaining groups served in Central America and the Caribbean. The most common locations were Haiti (35%, n = 7), Honduras (25%, n = 5), Guatemala (25%, n = 5), and Nicaragua (20%, n = 4). Six organizations served in more than one country. All organizations except one operated mobile or standing clinics in rural locations, and the remaining organization operated in an urban setting. Six organizations were faith based, while the other fourteen were secular. The number of MSTs that each organization operated annually was highly variable, ranging from one to hundreds.

Hypertension clinical protocols
Of the 20 protocols obtained, 11 discussed hypertension (55%; Organizations 1-11), and the most common recommendations are summarized in Figure 2. Only one guideline (Organization 7) provided literature support for its management suggestions, citing the 2003 WHO/ISH Hypertension Guidelines [7].
Seven protocols defined hypertension as a blood pressure measurement >140/90 (Organizations 2-8) while the others did not provide any parameters. With respect to clinical assessment, four organizations (1-4) mentioned that patients with hypertension may be asymptomatic or may present with non-specific symptoms such as headache, dizziness, blurred vision, and nausea. The most commonly recommended non-pharmacological intervention was lifestyle modification (Organization 2-8), which included limiting salt, alcohol, and tobacco, increasing exercise, and eating a healthy diet. Nine of the 11 organizations (Organizations 1, 2, 4, 5, 6, 8-11) suggested diuretics or an ACE inhibitor as first-line therapy and a calcium channel blocker (CCB) as second-line therapy. One NGO (Organization 2) recommended that pharmacologic therapy be reserved for patients with elevated blood pressure readings on two separate clinic visits. Only four protocols (Organization 1-3, 5) explicitly discussed clinical followup within two to four weeks. Four protocols (Organization 2, 4, 7, 8) included additional recommendations for severe hypertension or hypertensive emergencies, which included the addition of another antihypertensive drug and referral to a medical center.
No protocols specifically discussed diagnosis and management of Type I diabetes.

Discussion
This review is the first to consolidate unpublished protocols for commonly treated chronic conditions on MSTs operating in Latin America. Eleven of the 20 organizations that had protocols included recommendations for managing either hypertension or diabetes, suggesting that these conditions are recognized as relevant to such groups. None of the protocols, however, were the product of rigorous literature searches, and most were not backed by any literature citations. Therefore, it is unclear whether such protocols are based on robust evidence, availability of scarce resources, or simply expert opinion. This review gives an indication of the current landscape of medical management on MSTs in austere settings, but limited insight into whether treatments are efficient, effective, sustainable, or cost-effective. In the following paragraphs, we discuss the hypertension and diabetes protocols in the context of international practice guidelines to identify the strengths and weaknesses of current MST practice recommendations.

Hypertension
The six protocols with objective definitions for hypertension were in substantial concordance with International Society of Hypertension (ISH) recommendations that stratify the diagnosis as either mild, moderate, or severe  [7]. However, while most international recommendations also draw attention to concerning signs and symptoms of hypertensive emergency that warrant a higher level of care, only five protocols discussed such features. A clear case definition for those requiring tertiary care referral would be particularly valuable for MST clinicians working in remote settings, where the financial and logistic cost of emergency transport presents a barrier to both patients and NGOs. Lifestyle changes were recommended by the MST protocols with varying degrees of comprehensiveness, but generally mirrored World Health Organization (WHO) and ISH guidelines [7]. In terms of pharmacologic therapy, both the protocols and international guidelines agree that a thiazide diuretic is most cost effective for initial therapy; however, clinicians should also separately consider whether more expensive drugs are indicated for unique patient populations or specific conditions. While diagnosis and monitoring require only a blood pressure cuff, the treatment of hypertension in MST settings carries additional ethical implications. While some protocols addressed accessible follow-up care as vital in ensuring appropriate dose titration and medication adherence, none discussed the prohibitive costs of renewing medication for many patients in impoverished rural areas, as well as cultural influences and health literacy. Given these concerns, protocols should make clinicians aware of potential discontinuation syndromes (i.e. rebound hypertension or retention of sodium and water), or consequences of misuse and overdose (i.e. hypotension and electrolyte abnormalities) [8,9,10]. Furthermore, NGOs should consider patient education initiatives that emphasize safe medication use, and encourage clinicians to confirm that a patient starting pharmacologic therapy has the financial and logistic means to continue that therapy.

Diabetes mellitus
Protocols were in agreement with international guidelines for the diagnosis of diabetes, which support the use of point of care glucometers in resource limited settings [11,12], based on a fasting glucose >126 mg/dL (7 mmol/L), >200 mg/dL (11.1 mmol/L) two-hour glucose tolerance, or >200 mg/dL random blood sugar with symptoms [11,12]. No protocol considered diagnosis based on glycosuria with classic diabetes symptoms (sensitivity 21-64%, specificity 98%) [12], which would be a valuable adjunct, considering that urine dipsticks are readily available on most MSTs (Dainton et al., unpublished data).
Although one protocol mentions emergent treatment for hyperglycemia, most do not mention this or other serious indications for urgent referral. These would include biannual review of high-risk patients with previous ulcers, difficulty with foot care, peripheral arterial disease, foot deformities, evidence of neuropathy, with urgent foot care team referral if necessary [12]. Referral is also suggested in the presence of proteinuria with refractory hypertension (greater than 130/80) despite dual pharmacologic therapy [11], or for any blood pressure greater than 160/95 [13]. This lack of such recommendations might result from resource limitations making such referrals unfeasible, or more concerning, due to limited integration of MSTs within the local referral network.
Lifestyle recommendations for weight loss and daily physical activity were largely in line with international guidelines [11, 12,14], as were pharmacologic recommendations for metformin and sulfonylurea as firstand second-line therapy respectively [11,12]. Similarly, no protocols mentioned insulin therapy, which is commonly considered either unfeasible [11] or third-line treatment [12 ]in resource-poor settings. While no protocols specifically mentioned statin therapy, there is also controversy in the literature on its benefit: some suggest treatment for all patients over 40 [11,13], or in high cardiac risk patients like diabetics, even when a lipid profile cannot be measured [12]. For implementation, the protocols we reviewed would require blood glucose strips, a glucose monitor, and urine dipsticks, all of which are readily available on MST brigades (Dainton et al., unpublished data), but which may