Hypertension in Guatemala’s Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework

Abstract

Background Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. Methods We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. Results Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. Conclusions This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach.

Applying an equity lens to assess context and implementation in public health and health services research and practice using the PRISM framework

“…This project sought to improve hypertension control in Guatemala in intervention districts in rural and indigenous communities in 5 provinces ( 12 , 13 ). A needs assessment conducted at the outset showed that the health care system, part of the external environment , is like many in low- and middle-income countries: the public sub-system requires additional funding and system strengthening to ensure sufficient human resources and medications to adequately meet need across the country ( 14 ). Within Guatemala's Ministry of Health, actors at multiple levels take part in delivery of the intervention (national-level actors based in the capital, provincial-level Health Areas, and district-level providers), and patients, families, and community members are beneficiaries with important insight about implementation and access.…”

World Heart Federation Roadmap for Digital Health in Cardiology

“…This should translate to a broad needs and contextual assessment, considering the local (ICT) context, workflow, and sociopolitical barriers to accessing high-quality care. Health system assessment tools and frameworks can help structure the review of the current obstacles and facilitators surrounding CVD prevention and care [ 100 101 ], which often require a mixed-methods approach. User-centred and co-design principles are necessary to contextualise interventions and make them more effective [ 102 103 ].…”

Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: An application of the RE-AIM/PRISM extension for sustainability and health equity

“…This effort is being led by the Institute of Nutrition of Central America and Panama (INCAP) in partnership with Guatemala's Ministry of Health and Social Welfare (MoH) (8). The multilevel multicomponent hypertension intervention program (thereafter referred to as "program") consists of a core evidence-based intervention (EBI), protocol-based stepped-care hypertension treatment, and ve implementation strategies, which have been previously described (7,9,10). In March 2020, 9 months after launching the program, COVID-19 cases were growing in Guatemala and a national-level response with lockdowns and signi cant disruptions to rural communities and healthcare services occurred.…”