Figure 1
Argentine endemic zones according to vectorial transmission risk.
*San Juan Province.
Adapted from Spillmann et al. (37).
Table 1
Educational components of the intervention.
| EDUCATIONAL COMPONENT ORDER | CHARACTERISTICS/RESOURCES | KEY CONCEPTS |
|---|---|---|
| I. Welcome video | Brief video of ~1.5 minutes. Available at: https://www.youtube.com/watch?v=CRhU7C8CJF8&list=PLtMRCLDmBFdV8goHaXTokmpZ3g2u4JeYe&index=2 | Initial invitation video including the description of the educational intervention components. |
| II. Adapted World Heart Federation Chagas Disease algorithm | Brief video of ~2.5 minutes. Available at: https://www.youtube.com/watch?v=2FHDALEbFEQ&list=PLtMRCLDmBFdV8goHaXTokmpZ3g2u4JeYe&index=3 | Animated video on the local adaptation of the World Heart Federation’s Chagas Disease flowchart for CCM evaluation, stratification, and follow-up. |
| III. Overview of Chagas disease | Brief video of ~5 minutes. Available at https://www.youtube.com/watch?v=Vu_i2IuEQpE&list=PLtMRCLDmBFdV8goHaXTokmpZ3g2u4JeYe&index=4 | Chagas disease epidemiology, disease progression, and chronic cardiac complications. |
| IV. Chagas Cardiomyopathy | Brief video of ~5 minutes. Available at https://www.youtube.com/watch?v=Lafo9KMuIXo&list=PLtMRCLDmBFdV8goHaXTokmpZ3g2u4JeYe&index=5 | Early identification of chronic cardiac complications. Clinical assessment of heart failure in CCM. |
| V. Provincial Tele-Chagas Program | Brief video of ~7 minutes. Available at https://www.youtube.com/watch?v=GF_XCI2SNgU&list=PLtMRCLDmBFdV8goHaXTokmpZ3g2u4JeYe&index=6 | Description of the local program and instructions for the correct use of this telemedicine tool. |
| VI. Electrocardiographic disorders associated with Chagas disease | Brief video of ~7 minutes. Available at https://www.youtube.com/watch?v=DLvJcP_4Nbo&list=PLtMRCLDmBFdV8goHaXTokmpZ3g2u4JeYe&index=7 | Presentation of the most common EKG disorders in Chagas disease and their classification according to severity. |
| VII. Clinical cases | Three interactive clinical cases. Available at https://view.genially.com/667b411b56c4260014e1bd6b | Presentation of three integrative and interactive clinical cases. This module allows users to navigate through responses, including explanations of the correct answer. |
| VIII. Webinar: ‘Antiparasitic Treatment in Chagas Disease: Current Experiences and Future Challenges’ | ~50-min duration webinar with the participation of local ministry of health authority in ChD and an expert from a scientific society (Argentine Federation of Cardiology) Link to recorded webinar: https://www.youtube.com/watch?v=c0mg3DxYjPs | Description of local provincial experience in the use of antiparasitic treatment. Analysis of current guidelines recommendations for the use of antiparasitic treatment in ChD and current lines of research in the field. |
[i] Abbreviations: ChD: Chagas disease; CCM: Chagas cardiomyopathy; EKG: electrocardiogram.
Table 2
Qualitative phase summary.
| CFIR DOMAIN | CODE | CONCEPT | SUMMARY | VERBATIM |
|---|---|---|---|---|
| Outer Setting (Patient needs & resources/External policies & incentives) | Detection of Chagas Disease (CD) in general | Detection, nominalization, serology, and confirmation methods. Barriers and facilitators for CD detection | Detection and nominalization have been strengthened since 2018 with the mandatory registration of cases in the SISA, supported by comprehensive detection strategies in the field and health centers. This is key to improving disease monitoring and control. Barriers such as the centralization of services and lack of access to specialized studies (such as ECKG and echocardiogram) persist, although facilitators like appointment management and free tests within the Provincial Chagas Program aim to improve timely detection and treatment. | “In an endemic province, I think any patient we have in front of us, we consider as potentially chagasic…” |
| Inner Setting (Available resources/Networks & communications | Detection and initial evaluation of CCM | Conduct for CCM detection, use of guidelines for CCM management | In some hospitals, there is effective coordination between biochemistry and infectious diseases, allowing for quick and efficient follow-up of Chagas patients. Smaller hospitals face infrastructure limitations, lacking equipment like echocardiograms, which forces the referral of suspected cases to better-equipped centers. In some centers, the initial evaluation includes chest X-ray, electrocardiogram, and clinical examination. | “We have chest X-ray and electro, plus our clinical examination, and from there we refer patients for more in-depth cardiological control, especially if there is any indication, if they have any arrhythmia on the electro, or the patient reports any suspicious symptom, for example, if they have had syncope.” |
| Inner Setting (Available resources) | Follow-up and referral | Follow-up and treatment of Heart Failure | Periodic reevaluation is carried out to detect changes or complications over time. Yearly follow-up is recommended for those without abnormal findings or with minor abnormalities. Patients with signs of cardiological abnormalities, such as chagas cardiomyopathy, are referred to a cardiologist for continuous follow-up in collaboration with their primary care physician. Regarding medication for heart failure, when it is not available in a health center, alternatives such as exchange between centers through a WhatsApp group or requests to the provincial program are used, thus ensuring adherence to treatment. | “At the primary level, we always do the follow-up visits, or the control. We send a message and look for the patients to book an appointment.” |
| Outer Setting (Patient needs & resources) | Antiparasitic treatment in general | Antiparasitic treatment and barriers to treatment with Benznidazole | Antiparasitic treatment for Chagas disease in San Juan follows the guidelines of the National Ministry of Health, offering treatment to all patients with Chagas in its vertical and acute phase, and to those in the chronic phase without evident cardiomyopathy, to prevent disease progression. Children tend to adhere better to treatment due to fewer side effects. In adults, adverse reactions such as nausea and dizziness can decrease adherence, sometimes leading to treatment suspension and follow-up delays. | “Those who already have evident cardiac involvement, diagnosed by the cardiologist, already have some alteration where antiparasitic treatment would no longer prevent the damage the parasite may cause.” |
| Outer Setting (Patient needs & resources) | Telemedicine | Telemedicine and Tele-Chagas | The implementation of telemedicine in San Juan has advanced with tele-assistance, tele-education, and tele-research programs, although barriers such as limited connectivity in some areas and digital literacy persist, hindering full adoption. The national telemedicine strategy aims to improve communication between levels of care and promote the integration of health professionals. Despite initial concerns, technology has proven to be a practical and effective tool, complementing personalized care and general education, with good uptake in programmatic areas. The need for specific audiovisual tools to facilitate its use is highlighted. | “And in relation to Tele-assistance, we are working at the national level with the Tele-Chagas Program, being part of the pilot provinces, along with Santa Fe and other northern provinces, working not only on synchronous tele-assistance but also asynchronous…” “…the platform would be the connection between the secondary, primary and tertiary level, where we have a large gap…” “…this research will reinforce the implementation of the Tele-Chagas strategy…” |
| Inner Setting (Access to knowledge & information) | Training | Barriers and facilitators regarding training modalities, training needs in MCC, internet access in the workplace | Every August, the Vector Control Program organizes a provincial symposium on Chagas aimed at the health team, focusing on disease detection and treatment, although with less emphasis on chagas cardiomyopathy. The pandemic boosted the use of digital tools for training, facilitating access in peripheral regions and overcoming transportation barriers. However, there remains a gap in knowledge about Chagas treatment in adults, highlighting the need to train both health professionals and the general population. Despite limited connectivity, technological flexibility has allowed effective use of these tools. | “And actually, when training has been considered, most have focused on disease detection and treatment, but not on cardiomyopathy, at least not in recent years.” |
Table 3
Characteristics of study participants.
| SOCIODEMOGRAPHIC CHARACTERISTICS | n = 23 |
|---|---|
| Female sex, % (n) | 82.6% (19) |
| Age, median years (IQR) | 50 (38–62) |
| Years of experience, median years (IQR) | 22 (6–38) |
| Medical specialty, % (n) | |
| Family/general medicine | 52.2% (12) |
| Internal medicine | 17.4% (4) |
| Other | 17.4% (4) |
| No specialty | 13.0% (3) |
| EKG availability, % (n) | 78.3% (18) |
| Health zone, % (n) | |
| 17.4% (4) |
| 13.1% (3) |
| 21.7% (5) |
| 26.1% (6) |
| 21.7% (5) |
[i] Abbreviation: EKG: electrocardiogram.
Table 4
Results of the before-and-after KAP questionnaire.
| 1. Are you aware of the World Heart Federation’s recommendations for the identification, follow-up, and control of patients with Chagas cardiomyopathy | ||
| Before Intervention(n = 22) | After Intervention(n = 15) | |
| Yes | 4.5% (1) | 60.0% (9) |
| No | 86.4% (19) | 40.0% (6) |
| Don’t know/no answer | 9.1% (2) | – |
| 2. The most common presentations of Chagas cardiomyopathy are thromboembolic events and ventricular aneurysms | ||
| True | 31.8% (7) | 42.9% (6)* |
| False (correct answer) | 45.4% (10) | 57.1% (8)* |
| Don’t know/no answer | 22.8% (5) | – |
| 3. In a patient with positive Chagas serology, the presence of complete right bundle branch block (CRBBB) and left anterior fascicular block (LAFB) indicates a worse short-term prognosis | ||
| True | 68.1% (15) | 33.3% (5) |
| False (correct answer) | 27.3% (6) | 66.7% (10) |
| Don’t know/no answer | 4.6% (1) | – |
| 4. Pedro is 60 years old, under joint follow-up with a cardiologist for Chagas disease and heart failure diagnosis. He visits the health center to pick up medication and have his blood pressure checked. In the absence of contraindications, which of the following drug groups should not be missing from his treatment? | ||
| ACEI/ARB + amiodarone + aspirin | 45.4% (10) | 13.3% (2) |
| ACEI/ARB + beta-blockers + aspirin | 13.6% (3) | 6.7% (1) |
| ACEI/ARB + beta-blockers + aldosterone antagonists (correct answer) | 18.2% (4) | 66.1% (10) |
| ACEI/ARB + furosemide + amiodarone | 9.1% (2) | – |
| Don’t know/no answer | 13.6% (3) | 13.3% (2) |
| 5. In your opinion, do you believe that the identification and initial evaluation of people with Chagas disease can be done at the primary care level? | ||
| Strongly disagree | 9.1% (2) | 6.7% (1) |
| Somewhat disagree | 4.5% (1) | – |
| Neither agree nor disagree | – | – |
| Somewhat agree | 22.7% (5) | 13.3% (2) |
| Strongly agree | 63.6% (14) | 80.0% (12) |
| 6. In your opinion, do you consider that training activities on Chagas disease are necessary for the health team in your workplace? | ||
| Strongly disagree | 9.1% (2) | 6.7% (1) |
| Somewhat disagree | – | – |
| Neither agree nor disagree | – | – |
| Somewhat agree | 4.5% (1) | 6.7% (1) |
| Strongly agree | 86.4% (19) | 86.7% (13) |
| 7. In your opinion, do you think it is important to periodically monitor asymptomatic Chagas disease patients without demonstrated damage at the primary care level? | ||
| Strongly disagree | 9.1% (2) | 6.7% (1) |
| Somewhat disagree | – | – |
| Neither agree nor disagree | – | – |
| Somewhat agree | 31.8% (7) | – |
| Strongly agree | 59.1% (13) | 93.3% (14) |
| 8. For all individuals from Chagas-endemic areas, I ensure they have had at least one serological test for Chagas in their lifetime | ||
| Never | – | – |
| Rarely | – | 6.6% (1) |
| Sometimes | 13.6% (3) | – |
| Often | 22.7% (5) | 33.3% (5) |
| Always | 63.6% (14) | 60.0% (9) |
| 9. When I receive a patient with positive Chagas serology, I perform a complete physical exam and request an EKG and chest X-ray as complementary methods to assess possible referral to the second level of care | ||
| Never | – | – |
| Rarely | – | – |
| Sometimes | 4.5% (1) | – |
| Often | 13.6% (3) | 6.7% (1) |
| Always | 81.8% (18) | 93.3% (14) |
| 10. I use the Tele-Chagas platform as a tool to improve the follow-up of my patients with chronic Chagas in the clinic | ||
| Never | 86.4% (19) | 53.3% (8) |
| Rarely | 9.1% (2) | 26.7% (4) |
| Sometimes | 4.5% (1) | 6.7% (1) |
| Often | – | 13.3% (2) |
| Always | – | – |
[i] Values represent % (n).
Abbreviations: ACEI/ARB: ACE inhibitors/angiotensin receptor blockers.
*(n = 14, 1 missing).
Table 5
Feasibility, utility, and acceptability indicators of the educational intervention.
| Number of modules received (n = 17) | ||||||
| None | – | |||||
| 1 or 2 | – | |||||
| 3 or 4 | 11.8% (2) | |||||
| 5 or more | 88.2% (15) | |||||
| Videos viewed (n = 17) | ||||||
| Watched all | 70.6% (12) | |||||
| Watched some | 29.4% (5) | |||||
| Did not watch any | – | |||||
| Level of satisfaction (n = 17) | ||||||
| (1 is poor, 5 is excellent) | 1 | 2 | 3 | 4 | 5 | Don’t know/no response |
| Video with adapted animated flowchart from the World Heart Foundation | – | – | – | 29.4% (5) | 70.6% (12) | – |
| Class on ‘Epidemiology of Chagas Disease and its Complications’ | – | – | – | 17.6% (3) | 82.4% (14) | – |
| Class on ‘Comprehensive Approach to Chagas Cardiomyopathy’ | – | – | – | 11.8% (2) | 82.4% (14) | 5.9% (1) |
| Class on ‘Tele-Chagas Program’ | – | – | 11.8% (2) | 23.5% (4) | 58.9% (10) | 5.9% (1) |
| Class on ‘Electrocardiographic Disorders’ | – | – | 11.8% (2) | 5.9% (1) | 64.7% (11) | 17.6% (3) |
| Webinar on Antiparasitic Treatment in Chagas Disease | – | – | 5.9% (1) | 11.8% (2) | 64.7% (11) | 17.6% (3) |
| Interactive clinical cases | – | – | – | 11.8% (2) | 70.6% (12) | 17.6% (3) |
| Training modules characteristics evaluation (n = 17) | ||||||
| (1 is bad and 5 is excellent) | 1 | 2 | 3 | 4 | 5 | Don’t know/no response |
| Clarity of the content | – | – | 5.9% (1) | 11.8% (2) | 82.4% (14) | – |
| Weekly delivery of materials | – | – | – | 23.5% (4) | 76.5% (13) | – |
| Use of WhatsApp platform for material delivery | – | – | – | 11.8% (2) | 88.2% (15) | – |
| Duration of the videos | – | – | – | 11.8% (2) | 88.2% (15) | – |
| Audiovisual quality of the videos (animation, image clarity, audio quality) | – | – | 5.9% (1) | 5.9% (1) | 88.2% (15) | – |
| Topic covered in the webinar | – | – | – | 41.2% (7) | 41.2% (7) | 17.6% (3) |
| Navigation through the clinical cases | – | – | – | 5.9% (1) | 76.5% (13) | 17.6% (3) |
| Potential utility for decision-making (n = 17) | ||||||
| Very useful | 70.6% (12) | |||||
| Quite useful | 23.5% (4) | |||||
| Will not change my decisions or behaviors | 5.9% (1) | |||||
| Not very useful | – | |||||
| Not useful at all | – | |||||
| Regarding the short videos, was there any video that you couldn’t watch? (n = 17) | ||||||
| Yes | 17.6% (3) | |||||
| No | 82.4% (14) | |||||
| What were the reasons you couldn’t watch certain videos? (n = 3) | ||||||
| Lack of time | 66.7% (2) | |||||
| I was not interested in watching the videos | – | |||||
| I did not enjoy watching the videos | – | |||||
| Lack of memory on my mobile phone | – | |||||
| Lack of internet connectivity | 33.3% (1) | |||||
| Have you shared the videos with other colleagues? (n = 14, 3 missing values) | ||||||
| Yes | 64.3% (9) | |||||
| No | 35.7% (5) | |||||
| Were you able to register for the webinar on antiparasitic treatment organized in collaboration with the Argentine Federation of Cardiology and the government of the province of San Juan? (n = 17) | ||||||
| Yes | 64.7% (11) | |||||
| No | 35.3% (6) | |||||
| Were you able to connect live to the webinar? (n = 11) | ||||||
| Yes | 63.6% (7) | |||||
| No | 36.4% (4) | |||||
| What was the reason you didn’t register? (n = 6) | ||||||
| I didn’t find the chosen topic important | – | |||||
| I was not available on that day and time | 83.3% (5) | |||||
| I don’t like webinars | – | |||||
| Others | 16.7% (1) | |||||