Factors influencing the integration of evidence-based task-strengthening strategies for hypertension control within HIV clinics in Nigeria

Abstract

Background Evidence-based task-strengthening strategies for hypertension (HTN) control (TASSH) are not readily available for patients living with HIV in sub-Saharan Africa where the dual burden of HTN and HIV remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of practice facilitation versus a self-directed control (i.e., receipt of TASSH with no practice facilitation) in reducing blood pressure and increasing the adoption of task-strengthening strategies for HTN control within HIV clinics in Nigeria. Prior to implementing the trial, we conducted formative research to identify factors that may influence the integration of TASSH within HIV clinics in Nigeria. Methods This mixed-methods study was conducted with purposively selected healthcare providers at 29 HIV clinics, followed by a 1-day stakeholder meeting with 19 representatives of HIV clinics. We collected quantitative practice assessment data using two instruments: (a) an adapted Service Availability and Readiness Assessment (SARA) tool to assess the capacity of the clinic to manage NCDs and (b) Implementation Climate Scale to assess the degree to which there is a strategic organizational climate supportive of the evidence-based practice implementation. The quantitative data were analyzed using descriptive statistics and measures of scale reliability. We also used the Consolidated Framework for Implementation Research (CFIR), to thematically analyze qualitative data generated and relevant to the aims of this study. Results Across the 29 clinics surveyed, the focus on TASSH (mean=1.77 (SD=0.59)) and educational support (mean=1.32 (SD=0.68)) subscales demonstrated the highest mean score, with good–excellent internal consistency reliability (Cronbach’s alphas ranging from 0.84 to 0.96). Within the five CFIR domains explored, the major facilitators of the intervention included relative advantage of TASSH compared to current practice, compatibility with clinic organizational structures, support of patients’ needs, and intervention alignment with national guidelines. Barriers included the perceived complexity of TASSH, weak referral network and patient tracking mechanism within the clinics, and limited resources and diagnostic equipment for HTN. Conclusion Optimizing healthcare workers’ implementation of evidence-based TASSH within HIV clinics requires attention to both the implementation climate and contextual factors likely to influence adoption and long-term sustainability. These findings have implications for the development of effective practice facilitation strategies to further improve the delivery and integration of TASSH within HIV clinics in Nigeria. Trial registration ClinicalTrials.gov, NCT04704336

A mixed methods approach identifying facilitators and barriers to guide adaptations to InterCARE strategies: an integrated HIV and hypertension care model in Botswana

“…In a mixed-methods study of the implementation of a task-strengthening strategy for hypertension and HIV control, clinic HCPs from 29 HIV clinics in Lagos, Nigeria noted that a sub-optimal number of clinics (52%) reported access to hypertension training materials. Training was desired as long as it did not overburden health care HCPs [ 36 ]. This study had consistent findings highlighting the need for dedicated provider training in HIV/hypertension integration interventions [ 18 , 38 – 40 ], which is a key component of the InterCARE intervention.…”

“…A strength of this study design was the use of the updated CFIR to identify determinants of implementation and guide adaptations of implementation strategies. This is one of the few studies to use the updated CFIR to assess factors that influence hypertension and HIV care integration [ 29 , 36 ]. This study demonstrates the utility of the updated CFIR as a guiding framework for systematic implementation of integrated care in settings outside of Botswana [ 20 , 44 ].…”

Assets for integrating task-sharing strategies for hypertension within HIV clinics: Stakeholder’s perspectives using the PEN-3 cultural model

“…We developed an interview topic guide that focused on factors likely to influence the integration and adoption of TASSH within HIV clinics in Akwa Ibom, Nigeria such as the relative advantage of TASSH, alignment with existing clinic structures, patient support, and alignment with national guidelines, the perceived complexity of TASSH, and limited resources [ 1 ]. We piloted the draft interview guide for comprehensibility, flow, and meaning, with two individuals who met all inclusion criteria and were not participating in the study.…”

“…Not only are they key decision-makers with implementation, but their opinions may influence whether evidence-based task-sharing strategies for hypertension care are implemented or adopted within HIV services [ 27 ]. Prior studies suggest that stakeholder engagement during the implementation process may help to identify factors that may influence implementation, optimize care delivery strategies, and uncover readiness and/or apprehension around change, while providing training, and performance feedback to change recipients of the interventions [ 1 ]. Stakeholders can expedite the implementation process, by highlighting relevant and innovative perspectives that are most efficient and may effectively move research to practice in their own settings [ 28 ].…”

Bridging language barriers in developing valid health policy research tools: insights from the translation and validation process of the SHEMESH questionnaire

“…The Organizational Readiness for Change Assessment (ORCA) questionnaire was developed to assess PARIHS constructs in the context of implementation studies and programs [29]. It was developed in the context of the Veterans Health Administration in the United States, but since then has been used in different settings and contexts [30][31][32]. The purpose of ORCA is to help apply the PARIHS framework by providing actionable measures of the key components of the framework.…”