Table 2 Hypertension Treatment in Nigeria Program contextual factors and implementation strategies

 Assess for readiness and identify barriers and facilitators

Health facility

Formative work included quantitative evaluation of site-level readiness and capacity and qualitative evaluation of barriers and facilitators to implementation.

• Hypertension patient registry and empanelment

• Team-based care and community health extension worker provided hypertension management

 Audit and provide feedback

Health facility

Performance and quality reports are provided to each participating site on a monthly basis. Supportive supervision visits are performed quarterly (minimal semi-annually).

• Performance and quality reporting

 Conduct local needs assessment

Program

A service availability and readiness assessment was performed during the formative phase of the HTN Program alongside qualitative evaluation of stakeholder (healthcare workers, supervisors, and patients) needs. For the duration of the program, stakeholders have been engaged through an advisory board, including a patient representative.

• Hypertension patient registry and empanelment

• Team-based care and community health extension worker provided hypertension management

• Access to essential medicines and technology

 Develop and implement tools for quality monitoring

Health facility and Program

Simplified performance and quality reports were adapted from the WHO HEARTS reporting tools to focus on improving quality of care based on key indicators of hypertension treatment, control, and patient retention.

• Hypertension patient registry and empanelment

• Performance and quality reporting

• Fixed-dose combination

 Involve patients/consumers and family members

Program

Patients were engaged in focus group discussions during the formative phase and during the interim and end-of-study assessments. A local patient representative sits on the advisory committee.

• Hypertension patient registry and empanelment

 Provide local technical assistance

Program

Technical assistance is provided to sites for data entry and correction by the study team coordinators at University of Abuja Teaching Hospital.

• Hypertension patient registry and empanelment

• Performance and quality reporting

 Provide clinical supervision

Program

Local area council physicians conduct clinical consultations within PHCs in their catchment areas. They may be called upon by CHEWs to discuss specific hypertensive patient cases. CHEWs may also call the research unit at UATH directly for patient case consultation and direct referral.

• Performance and quality reporting

• Team-based care and community health extension worker provided hypertension management

 Tailor strategies

Health system

Strategies and implementation package component were locally adapted based on formative work. Emergent issues have driven adaptation to strategies and implementation package components, which are discussed by the operations team and enacted in a systematic way. A local context tracker is utilized to document emergent issues.

• Performance and quality reporting

• Team-based care and community health extension worker provided hypertension management

• Fixed-dose combination

 Inform local opinion leaders

Council Area and State

National and local area council public health leaders were included in the proposed program during the formative phase.

• Team-based care and community health extension worker provided hypertension management

 Use advisory boards and workgroups

Program

An advisory committee was formed and convenes on an annual basis to inform and review program progress and evaluation.

• Team-based care and community health extension worker provided hypertension management

• Access to essential medicines and technology

 Conduct ongoing training

Program

Training is routinely provided to participating health care workers on components of the intervention and retraining as needed to reinforce quality data collection and adherence to the protocol.

• Performance and quality reporting

• Simplified treatment guideline

• Team-based care and community health extension worker provided hypertension management

 Develop educational materials

Program

Contextually appropriate patient handouts and instructional materials were developed by the study team. Handouts depict the importance of health diets, regular physical exercise, smoking cessation, minimizing alcohol intake, weight loss, medication adherence and regular blood pressure checks.

Community awareness campaigns are conducted in each area council to increase awareness of and demand for hypertension services.

• Simplified treatment guideline

• Team-based care and community health extension worker provided hypertension management

 Distribute educational materials

Health facility

Patient handouts are distributed by health educators during community awareness programs and by CHEWs during blood pressure screening visits within the PHCs.

• Hypertension patient registry and empanelment

 Make training dynamic

Program

Demonstration-based learning techniques are used to reinforce information and methods for hypertension diagnosis, treatment, and management.

• Team-based care and community health extension worker provided hypertension management

 Provide ongoing consultation

Health facility

Supportive supervision visits are conducted at least semi-annually to each participating health facility. Initial and ongoing training is provided to participating healthcare centers and CHEWs on the implementation components.

• Performance and quality reporting

• Simplified treatment guideline

• Team-based care and community health extension worker provided hypertension management

 Create new clinical teams

Health facility

Team-based care (CHEWs, CHOs, Physicians, Medical Record Officers, Pharmacy Technicians, etc.) was provided at participating PHCs, focused on infectious diseases and maternal care. New teams specifically focused on hypertension care were formed or adapted for the HTN Program.

• Team-based care and community health extension worker provided hypertension management

 Revise professional roles

Program

Encourage implementation of team-based care and task sharing.

• Team-based care and community health extension worker provided hypertension management

 Increase demand

Health system

Conduct community outreach and mobilization activities to increase awareness and demand for hypertension services.

• Hypertension patient registry and Empanelment

• Community awareness and mobilization campaigns

 Intervene with patients/consumers to enhance uptake & adherence

Health system

Community awareness campaigns are conducted in each area council to increase awareness of and demand for hypertension services.

• Hypertension patient registry and empanelment

• Community awareness and mobilization campaigns

• Health coaching and home BP monitoring

 Alter incentive/allowance structures

Health worker

Frontline healthcare staff are compensated for registration of patients through monthly stipends of at least 10,000 naira each.

• Team-based care and community health extension worker provided hypertension management

 Alter patient/consumer fees

Health system

Free or low-cost medicines are made available to hypertensive patients registered in the Program.

• Simplified treatment guideline

• Fixed-dose combination

• Access to essential medicines and technology

 Change physical structure and equipment

Health facility

All sites were equipped with functional automated blood pressure monitors, paper case report forms, electronic tablet, and data connections.

• Hypertension patient registry and empanelment

 Change record system

Program

Create an electronic-based data capture system to supplement the paper-based system for rapid data collection and quality assurance.

• Performance and quality reporting

 Change service sites

Program

Patients who would typically seek care in a tertiary care center are able to find the same hypertension care in their local health clinic.

Home-based blood pressure monitoring and health coaching for individuals with persistently elevated blood pressure and social disadvantage

• Team-based care and community health extension worker provided hypertension management

• Health coaching and home BP monitoring

 Drug Revolving Fund

Health System

Addition of hypertension medications to the existing drug revolving fund.

• Simplified treatment guideline

• Fixed-dose combination

• Access to essential medicines and technology