Abstract
Background
Uganda’s established HIV service platform could support integrated hypertension care, but organizational conditions required for implementation in resource-limited settings are poorly described. We characterized organizational readiness, implementation leadership, and implementation citizenship behaviour during implementation of integrated HIV–hypertension care in Kampala and Wakiso districts, Uganda.
Methods
We conducted a prospective cohort study nested within a stepped-wedge cluster-randomized trial at 16 public and private-not-for-profit HIV clinics implementing “hypertension BASIC- (basic training, supply of blood pressure devices and medications)” or “hypertension PLUS (BASIC components plus enhanced training, performance feedback and differentiated service delivery for hypertension)”. Healthcare providers completed the 12-item Organizational Readiness for Implementing Change scale at intervention rollout and trial completion, and the 12-item Implementation Leadership Scale and Implementation Citizenship Behavior Scale (six items) at six months and post intervention. Scores were standardized to 0–100. Changes were assessed using independent-samples tests, with facility-clustered linear regression as sensitivity analyses. Intraclass correlation coefficients (ICCs) assessed agreement between clinic-lead self-ratings and staff ratings.
Results
Forty-three healthcare providers participated at baseline, 42 at six months, and 41 at completion. The median age was 34 years (IQR: 30–42), and 24 (56%) were female Organizational readiness remained high (mean scores, 88.8–94.6% across arms and assessment periods), without significant changes over time. Leadership scores generally exceeded 75%, while citizenship behaviour scores exceeded 80%. In facility-clustered analyses, HTN PLUS clinic leads reported increases in overall leadership (10.7 percentage points; 95% CI 1.1–20.3, p=0.009) and proactive leadership (12.8; 95% CI 0.8–24.9, p=0.026); HTN BASIC clinic leads reported increased supportive leadership (19.2; 95% CI 6.0–32.4, p=0.012). Staff leadership ratings and citizenship behaviour did not change significantly.
Conclusion
Trial-supported HIV clinics demonstrated sustained readiness, strong leadership, and supportive citizenship behaviours for integrated care. However, declining leader–staff agreement highlights the value of multisource feedback. Future analyses should determine whether these organizational conditions translate into improved adoption, fidelity, and clinical outcomes.
Trial Registration #
NCT05609513. Registration date, November 8, 2022.
Key words: HIV, hypertension, integrated care, implementation climate, organization readiness, leadership capacity
Plain Language Summary
This paper provides empirical evidence that high organizational readiness and strong leadership are prevalent in Ugandan HIV clinics, facilitating integrated HIV-hypertension care.
The study uniquely assesses implementation climate using combined measures of leadership, organizational readiness, and citizenship behavior, filling a gap in low-resource settings.
The study highlights the importance of assessing leadership during multiple points during the implementation of integrated care models in sub Saharan Africa.
Introduction
Uganda, like many low and middle countries (LMICs) faces a dual burden of infectious and non-communicable diseases (NCD).1 Nearly a third of the 1.4 million adults living with HIV in Uganda have comorbid hypertension underscoring the extent to which these dual burdens overlap.2–5 Over the past two decades, Uganda’s largely vertical HIV program has achieved substantial success in HIV care delivery, establishing a strong service delivery platform that could be leveraged to improve care for comorbid conditions, including hypertension. However, despite hypertension being among the most prevalent comorbidities in people living with HIV (PLHIV) affecting approximately one in three and increasing cardiovascular disease risk, hypertension care remains suboptimal.2,3,6,7
The implementation of test and treat, adoption of tasking shifting, expanded access to HIV testing and antiretroviral therapy, and the scale up of differentiated service delivery (DSD) models have enhanced the health systems efficiency and have improved diagnosis, treatment initiation, retention in care and viral load suppression.8,9 Until recently, however, HIV programs have primarily focused on reducing HIV related morbidity and mortality with comparatively limited attention to the growing burden of non-HIV-associated comorbidities such as cardiovascular disease (CVD).10
In response to the increasing burden of CVD in resource constrained LMICs such as Uganda, the World Health Organization, national ministries of health and development partners have increasingly advocated for the integration of HIV and CVD prevention services at primary healthcare facilities as a strategy to optimize population-level health outcomes and maximize the efficient use of limited resources.11,12 Leveraging the mature HIV service delivery infrastructure therefore presents a critical opportunity to deliver integrated NCD services, including hypertension care, with quality and continuity comparable to that achieved for HIV.13,14
Evidence from Uganda and other LMICs has identified several barriers to integration of HIV and hypertension services. These include inadequate human resources, insufficient healthcare provider knowledge of hypertension care, limited access to anti-hypertensive medications and BP monitors, low prioritization of hypertension care, and weak monitoring and evaluation systems to effectively assess integration and quality of care.15–17 Collectively, these barriers may negatively influence the implementation climate for integrated HIV and hypertension services.
The implementation climate, as first defined by Klein and Sorra,18 refers to the shared perception among staff that implementation of a specific innovation is expected, supported, and rewarded within the organization. Studies conducted primarily in high income countries demonstrate that a favourable implementation climate is associated with increased adoption, fidelity and sustainment of evidence-based interventions.19,20 One determinant of a strong implementation climate is effective implementation leadership.20 Aarons et al describe implementation leadership as the specific, proactive, knowledgeable, supportive, and perseverant behaviours that leaders demonstrate to facilitate the adoption and delivery of evidence-based practices, such as integrated HIV and hypertension services.21 Implementation leaders, especially mid-level supervisors, play catalytic roles in shaping the implementation climate by removing obstacles to implementation and supporting strategic actions such as training and feedback loops. These actions may also influence the effectiveness of an evidence-based practice.22 Implementation citizenship behavior captures the discretionary, extra-role actions undertaken by organizational staff to support the implementation of evidence-based practices.23 The Implementation Citizenship Behaviour Scale (ICBS), which comprises the domains of helping others and keeping others informed, mediates the relationship between implementation leadership and implementation climate.23
In addition to leadership, implementation climate is also influenced by organizational readiness for change (ORIC). Organizational readiness refers to the collective perceived motivation and capacity of an organization to implement a new practice.24 High organizational readiness is associated with stronger implementation climate and ultimately more successful implementation outcomes.25 In the context of integrated care, implementation leadership, organizational readiness, and contextual factors such as staffing, infrastructure, and supply chain reliability jointly shape the extent to which providers are willing and able to adopt integrated HIV and hypertension care.
To our knowledge, no published studies have described the implementation climate for integrated HIV and hypertension services using the combined lenses of implementation leadership, citizenship behaviour and organizational readiness. As part of the Strengthening the Blood Pressure Care and Treatment Cascade for Ugandans Living with HIV -Implementation Strategies to Save Lives (PULESA Uganda) trial,26 we describe the implementation climate for integrated HIV-hypertension services across public and private-not-for-profit HIV clinics in the Kampala and Wakiso districts, Uganda.
Conceptual Framework
Adoption of integrated HIV and hypertension care may be influenced by the interaction between organizational implementation determinants and broader contextual conditions. Implementation leadership, characterized by proactive, knowledgeable, supportive and perseverant leadership behaviours, is positioned as an upstream determinant of organizational readiness and implementation climate.22,27,28 Strong implementation leadership is expected to reinforce healthcare providers’ shared commitment and confidence to deliver integrated HIV-hypertension care, fostering an environment where such care is expected, supported and valued. Organizational readiness and implementation climate are subsequently anticipated to promote implementation citizenship behaviours, including helping colleagues and remaining informed about implementation.29 These behaviours represent proximal mechanisms through which organizational conditions influence adoption. Contextual factors operating at the intervention, individual, facility and health-system levels may directly influence adoption or modify the strength of the hypothesized relationships. Adoption may subsequently contribute to greater reach, fidelity and improved hypertension-care outcomes.
Methods
Parent Clinical Trial Design
This study was nested within a stepped wedge cluster-randomized trial [(NCT05609513), Registration date, November 8, 2022] of HIV and hypertension care integration conducted at 16 HIV clinics in the Wakiso and Kampala districts.26 The total duration of the trial was 30 months (February 2023 to August 2025), with eight steps occurring every two months. We purposively selected these clinics from a pool of 120 total HIV clinics across the two districts, then randomly assigned them to one of the two intervention arms. We stratified the randomization by clinic size (large vs small), clinic type (public vs private not-for-profit), and district (Kampala vs Wakiso). A local implementing partner, funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR), supports all participating clinics to provide HIV care and treatment services.
At each step, two clinics were randomized to implement one of two models of integrated hypertension care, referred to subsequently as “HTN BASIC” or “HTN PLUS”. Eight clinics assigned to the HTN BASIC arm received evidence-based antihypertensive medication provided to patients at no cost, an adequate supply of BP monitoring devices and 2- half day training sessions focusing on hypertension screening, diagnosis and treatment. Providers also received standardised training materials including a guideline-based hypertension treatment algorithm. Eight clinics assigned to HTN PLUS received all components of HTN BASIC package in additional to enhanced implementation support. This included ongoing coaching, in-person clinic-based training sessions, ad hoc online training sessions, quarterly audit and feedback reports on hypertension cascade metrics, and structured support to integrate hypertension services within existing HIV DSD models. Additional details of the stepped wedge trial have been described in detail elsewhere.26
Nested Prospective Single Arm Cohort Study
For this nested prospective cohort study of implementation climate, we enrolled healthcare providers working at all 16 participating clinics to assess implementation leadership, organizational readiness, and implementation citizenship behaviour. Given the limited number of healthcare providers working in the HIV clinics participating in the PULESA trial, a formal sample size calculation was not performed. Instead, we sought to enrol at least 48 (n=3 per clinic) healthcare providers involved in hypertension service delivery, together with their respective clinic team leads. A total of 44 healthcare workers were enrolled to participate in baseline surveys.
Eligible participants included medical doctors, nurses, clinical officers, and pharmacy technicians/pharmacists who provided integrated HIV and hypertension care and who planned to remain at their respective study clinics for the foreseeable future. We excluded providers who were engaged in exclusively non-medical activities.
Survey Tools and Scoring
Organization Readiness Implementation (ORIC)
Organizational readiness was assessed using the 12-item ORIC scale, which captures two domains: change commitment and change efficacy.30 The ORIC questionnaire is scored using a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree).30 The minimum score was 12, while the maximum possible score was 60. For our analysis, each item was transformed to a 0–100% metric. Composite indices were constructed as the mean of the standardized items: overall ORIC, commitment, and efficacy.
Implementation Leadership Scale (ILS)
We used the original tool developed by Aarons (2014) to assess four dimensions of leadership: proactive (items 1–3), knowledgeable (items 4–6), supportive (items 7–9), and perseverant (items 10–12).21 This 12-item scale includes two components—one completed by clinic staff and the other by supervisors or clinic team leads. Clinic staff rated the leadership of their clinic team leads (subordinate ratings), while clinic team leads assessed their own leadership approach to integrating HIV and hypertension care (self-ratings). We emphasized confidentiality and privacy, ensuring that providers’ responses were not shared with their team leads. Domain and overall composite scores were generated as the mean of constituent items.
Implementation Citizenship Behaviour Scale (ICBS)
We administered the 6-item ICBS survey to team leaders at HIV clinics to evaluate their subordinates’ behaviour in “keeping informed” and “helping others” during the delivery of integrated hypertension care.23 Each item was transformed onto a 0–100 scale. Composite scores were created for overall ICBS and each of the two subdomains. Each team leader assessed up to two subordinates.
Each survey was administered twice. The ORIC was administered during initial rollout of integrated care and again at the end of the trial period. This aimed to assess the clinics’ readiness to implement integrated care models. The ILS and ICBS survey tools were administered six months after rollout and again at the end. For all three surveys, a research assistant was present while participants completed the questionnaires to provide clarification whenever needed. Both the ILS and ICBS were administered six months after intervention rollout to ensure that participants had sufficient exposure to the intervention. The questionnaires were administered in English, and the data were entered and managed using a REDCap database hosted at the Infectious Diseases Research Collaboration.31,32
Data Analysis
Data were exported from REDCap to STATA version 18.5 (StataCorp, Texas, USA) for analysis. All data were cleaned, labelled, and merged using unique facility and role identifiers.
Descriptive summaries of the participant characteristics were conducted stratified by the PULESA intervention arm. Categorical variables were summarized using frequencies and proportions and numerical variables with medians and interquartile ranges. Comparison of categorical variables were performed using chi-squared tests or appropriate alternative tests, and continuous variables were compared using the Wilcoxon rank-sum test. The Wilcoxon rank-sum test was preferred due to the non-normal distribution of the data.
For each construct (ORIC, ICBS, ILS), composite indices were computed only for respondents with complete item sets. To facilitate comparison across constructs, all final indices (except factor scores) were standardized to a 0–100 range. Internal consistency was assessed using Cronbach’s alpha at baseline and post-intervention. Changes between the initial survey and post-intervention were compared using independent samples t-tests, stratified by study arm and respondent role. The independent-samples approach was used because staff turnover and replacement recruitment meant that respondents at the two assessments were not fully identical. Normality and equality of variances were assessed using Shapiro–Wilk and variance-ratio tests, respectively. Where assumptions were not satisfied, Welch unequal-variance t-tests and Wilcoxon rank-sum tests were used as sensitivity analyses. Because participants were nested within 16 facilities, linear regression with facility-clustered standard errors was additionally used to assess the robustness of the comparisons. These models were sensitivity analyses of the descriptive cohort findings and were not intended to estimate the intervention effect of the parent stepped-wedge trial.
To evaluate the extent of agreement between supervisors’ self-assessed ILS leadership and staff perceptions, we estimated two-way mixed-effects absolute agreement Intraclass Correlation Coefficients (ICC), which treat clinics as fixed rater and individuals as random targets. ICCs were computed separately at six months and post-intervention for each leadership domain and the overall ILS score. Interpretation followed standard thresholds for agreement (poor <0.5; moderate 0.5–0.75; good 0.75–0.9; excellent >0.9).33 Linear regression and ICC addressed different questions: regression examined associations with implementation scores and the robustness of changes over time, whereas ICC assessed absolute agreement between clinic-lead self-ratings and facility-level mean staff ratings.
Ethics Approval and Consent to Participate
The Makerere University School of Medicine Research and Ethics Committee (Mak-SOMREC-2022-40) and the Uganda National Council for Science and Technology (HS2398ES) approved the study. We obtained administrative clearance from the Uganda Ministry of Health and from the district leadership in Kampala and Wakiso. All participants provided informed consent before taking part in the study. To ensure confidentiality, data collected from clinic staff and their respective clinic team leads were entered into a secure REDCap database that was accessible only to authorized research staff. In addition, all interviews were conducted in the private offices of the healthcare providers.
Results
Eligibility Criteria
Overall, 44 healthcare providers participated in the baseline survey, 43 at six months, and 41 at study completion. Of the participants enrolled at baseline, 11 (26%) were lost to follow up by the end of the study due to staff transfers (n=10), and retirement (n=1). Another nine participants were recruited to make a sample of 41 during the post intervention surveys. Figure 1.
Figure 1.
Eligibility assessment.
Participants Characteristics
Among those who participated in baseline surveys, 24 (57%) were female, with a median age of 34 years (IQR: 30–42). We observed no significant differences between participants in the two intervention arms. Table 1.
Table 1.
Participants Demographics Stratified by PULESA Intervention Arms
| Variable | Clinic Leads | Clinic Staff | Combined | |||
|---|---|---|---|---|---|---|
| HTN-BASIC N=7 |
HTN-PLUS N=9 |
HTN-BASIC N=13 |
HTN-PLUS N=14 |
HTN-BASIC N=20 | HTN-PLUS N=23 | |
| Age (years) | 32 (30, 36) | 37 (29, 53) | 33 (30–39) | 38.5 (30–42) | 33(28.5–38.5) | 38(30–48) |
| Sex | ||||||
| Female | 3 (42.9) | 5 (55.7) | 7 (53.9) | 10 (71.4) | 10(50.0) | 15(65.2) |
| Male | 4 (57.1) | 4 (44.4) | 6 (46.1) | 4 (28.6) | 10(50.0) | 8(34.8) |
| Years of practice | 7 (6–12) | 13 (6–27) | 6 (6–10) | 12.5 (6–18) | 7(6–11) | 13(6–27) |
| Professional Practice | ||||||
| Less than 10 years | 5 (71.4) | 4 (44.4) | 8 (61.5) | 5 (35.7) | 13(65.0) | 9(39.1) |
| 10 years or more | 2 (28.6) | 5 (55.6) | 5 (38.5) | 9 (64.3) | 7(35.0) | 14(60.9) |
| Professional cadre | ||||||
| Doctors | 3 (42.9) | 5 (55.6) | 1 (7.7) | 1 (7.1) | 4(20.0) | 6(26.1) |
| Nurses | 1 (13.3) | 1 (11.1) | 4 (30.8) | 6 (42.9) | 5(25.0) | 7(30.4) |
| Pharmacy technician | 0 | 0 | 1 (7.7) | 1 (7.1) | 1(5.0) | 1(0.4) |
| Clinical officer | 3 (42.9) | 3 (33.3) | 7 (53.8) | 6 (42.9) | 10(50.0) | 9(36.6) |
| Clinic type | ||||||
| Public | 5 (71.4) | 7 (77.8) | 10 (76.9) | 10 (71.4) | 15(75.0) | 17(73.9) |
| PNFP | 2 (28.6) | 2 (22.2) | 3 (23.1) | 4 (28.6) | 5(25.0) | 6(26.1) |
| District | ||||||
| Wakiso | 4 (57.1) | 5 (55.6) | 4 (30.8) | 7 (50.0) | 8(40.0) | 12(52.2) |
| Kampala | 3 (42.9) | 4 (44.4) | 9 (69.2) | 7 (50.0) | 12(60.0) | 11(48.8) |
Validity of ORIC, ILS and ICBS
Internal consistency was acceptable to strong for the overall scales. Cronbach’s alpha was 0.78 at baseline and 0.83 post-intervention for ORIC; 0.90 and 0.92 for staff-rated ILS; 0.89 and 0.83 for clinic-lead self-rated ILS; and 0.87 and 0.86 for ICBS, respectively (Supplementary Table S1). ORIC subscale reliability was lower at baseline and is therefore interpreted cautiously.
Organization Readiness to Implement Integrated HIV and Hypertension Care
Overall readiness to implement integrated HIV-hypertension care was high across both intervention arms, with mean ORIC scores exceeding 90% at both baseline and post-intervention. There were no statistically significant differences in the baseline mean scores for the overall ORIC measure or for the two readiness domains (change efficacy and change commitment) between study arms. At both study points, healthcare providers in clinics assigned to the HTN PLUS strategy demonstrated higher mean readiness scores compared with those in the HTN BASIC clinics. Table 2.
Table 2.
Organizational Readiness to Implement Change
| Variable | Clinic Leads | Clinic Staff | Combined Sample | |||
|---|---|---|---|---|---|---|
| HTN-BASIC N=7 |
HTN-PLUS N=8 |
HTN-BASIC N=13 |
HTN-PLUS N=14 |
HTN-BASIC N=20 |
HTN-PLUS N=22 |
|
| Total ORIC score (Mean± SD) | ||||||
| Baseline | 87.8 ±12.3 | 97.4 4.6 | 92.1 ±6.4 | 93.0 ±7.9 | 90.6 ±8.8 | 94.6 ±7.1 |
| Post intervention | 91.9 ±6.7 | 93.5 ±6.6 | 86.6 ±15.2 | 95.3 ±4.5 | 88.8 ±12.6 | 94.6 ±5.4 |
| Difference | −4.1 | 3.9 | 5.5 | −2.3 | 1.9 | 0 |
| p | 0.424 | 0.186 | 0.243 | 0.358 | 0.588 | |
| Change commitment (Mean± SD) | ||||||
| Baseline | 89.8 ±12.1 | 99.1 ±2.5 | 94.0 ±5.9 | 94.9 ±5.9 | 92.5 ±8.5 | 96.4 ±5.3 |
| Post intervention | 93.8 ±6.5 | 96.0 ±4.9 | 91.1 ±16.3 | 97.3 ±2.6 | 92.1 ±13 | 96.7 ±3.6 |
| Difference | −4.0 | 3.1 | 2.9 | −2.4 | 0.4 | −0.3 |
| p | 0.437 | 0.130 | 0.557 | 0.197 | 0.919 | 0.814 |
| Change efficacy (Mean± SD) | ||||||
| Baseline | 85 ±12.9 | 95 ±8.0 | 89.6 ±9.0 | 90.4 ±11.3 | 88 ±10.4 | 92.0 ±10.3 |
| Post intervention | 89.4 ±7.8 | 90 ±10.6 | 80.4 ±17.8 | 92.7 ±9.5 | 84 ±15.0 | 91.6 ±9.8 |
| Difference | −4.3 | 5 | 9.2 | −2.3 | 4 | 0.5 |
| p | 0.434 | 0.295 | 0.112 | 0.569 | 0.334 | 0.882 |
Notes: Difference is the earlier assessment minus the later assessment; a negative value therefore indicates an increase over time. P-values are from independent-samples t-tests. Sensitivity analyses are presented in Supplementary Table S2.
Implementation Leadership
Overall, the clinic leads reported high leadership scores, with mean ratings exceeding 75% at six months and 86% post intervention. Clinic staff also rated their supervisor’s leadership towards integrating hypertension and HIV care highly. In the HTN PLUS arm, but not in HTN BASIC, clinic leads demonstrated significant improvements in overall leadership scores from six-months to post-intervention, with a mean difference of –9.4 percentage points. In contrast, clinic staff ratings of clinic lead leadership did not change significantly in either arm. Furthermore, clinic leads in the HTN PLUS arm reported notable improvements in proactiveness and knowledge, whereas those in the HTN BASIC arm demonstrated significant improvement in supportive leadership. Despite these changes, clinical staff perceptions of leadership style did not significantly differ between the six-month and post-intervention assessments. Table 3 and Figure 2. Sensitivity analyses generally supported the primary findings (Supplementary Table S2). After accounting for facility clustering, the increases among HTN-PLUS clinic leads remained significant for overall ILS (10.7 percentage points; 95% CI 1.1 to 20.3; p=0.034) and proactive leadership (12.8 percentage points; 95% CI 0.8 to 24.9; p=0.039). The increase in knowledgeable leadership was attenuated (11.1 percentage points; 95% CI −1.1 to 23.3; p=0.069). The improvement in supportive leadership among HTN-BASIC clinic leads remained significant (19.2 percentage points; 95% CI 6.0 to 32.4; p=0.011). Other sensitivity analyses did not materially change the interpretation of the results.
Table 3.
Implementation Leadership Domain Scores by Clinic Staff and Clinic Team Leads Across Intervention
| Variable | Clinic Leads | Clinic Staff | ||
|---|---|---|---|---|
| HTN-BASIC | HTN-PLUS | HTN-BASIC | HTN-PLUS | |
| N=7 | N=9 | N=13 | N=14 | |
| Overall, (Mean± SD) | ||||
| Six months | 76.5 ±14.6) | 83.6 ±8.9 | 75.8 ±18.2 | 85.0 ±9.3 |
| Post intervention | 86.0 ±8.8) | 94.3 ±5.2 | 81.9 ±13.4 | 78.4 ±17.0 |
| Difference | −9.4 | −10.7 | −6.1 | 6.6 |
| p | 0.148 | 0.009 | 0.35 | 0.218 |
| Proactive, (Mean± SD) | ||||
| Six months | 69.0 ±21.4 | 77.8 ±10.2 | 64.1 ±26.7 | 75 ±13.5 |
| Post intervention | 76.0 ±15.1 | 90.6 ±11.3 | 77.8 ±17.5 | 67.3 ±24.9 |
| Difference | −7 | −12.8 | −13.7 | 7.7 |
| p | 0.472 | 0.0263 | 0.147 | 0.322 |
| Knowledgeable, (Mean± SD) | ||||
| Six months | 92.9 ±15.5 | 88.9 ±13.2 | 89.1 ±13.8 | 91.7 ±14.6 |
| Post intervention | 95.8 ±8.9 | 100 | 90.3 ±16.9 | 88.5 ±17.2 |
| Difference | −3 | −11.1 | −1.2 | 3.2 |
| p | 0.651 | 0.0312 | 0.85 | 0.606 |
| Supportive, (Mean± SD) | ||||
| Six months | 71.4 ±15.9 | 85.2 ±14.3 | 75.6 ±19.7 | 89.3 ±11.9 |
| Post intervention | 90.6 ±9.4 | 95.8 ±11.8 | 80.6 ±13.9 | 84.6 ±17.9 |
| Difference | −19.2 | −10.6 | −4.9 | 4.7 |
| p | 0.012 | 0.117 | 0.482 | 0.431 |
| Perseverant (Mean± SD) | ||||
| Six months | 72.6 ±11.5 | 82.4 ±9.7 | 74.4 ±21.1 | 83.9 ±12.4 |
| Post intervention | 81.3 ±13.9 | 90.6 ±6.9 | 79.2 ±15.3 | 73.1 ±20.5 |
| Difference | −8.6 | −8.2 | −4.8 | 10.851 |
| p | 0.217 | 0.066 | 0.534 | 0.105 |
Notes: Difference is the earlier assessment minus the later assessment; a negative value therefore indicates an increase over time. P-values are from independent-samples t-tests.
Figure 2.
Heatmap showing the distribution of ICBS, ILS and ORIC scores across each of the 16 facilities.
Concordance Between Clinic Leads and Clinic Implementation Leadership Scores
At six months, there was a strong correlation between clinic staff ratings of their team leads and the team leads’ self-ratings for overall implementation leadership; however, this correlation was not observed at post intervention assessment. Moderate to good agreement was observed for proactive leadership ratings at six months, as well as for implementation knowledge scores at six months. Table 4. Clinic-lead self-ratings and facility-level staff ratings are provided in Supplementary Table S3.
Table 4.
Agreement Between Supervisor and Staff Leadership Ratings Using ICC
| Domain | Period | ICC (LCI–UCI) | Interpretation |
|---|---|---|---|
| Proactive | Six months | 0.70 (0.30–0.89) | Good agreement |
| Post-intervention | –0.21 (–0.58–0.29) | No agreement / disagreement | |
| Knowledge | Six months | 0.66 (0.21–0.88) | Moderate–good agreement |
| Post-intervention | 0.36 (–0.08–0.71) | Poor agreement | |
| Supportive | Six months | 0.41 (–0.15–0.77) | Poor–fair agreement |
| Post-intervention | 0.35 (–0.11–0.72) | Poor agreement | |
| Perseverant | Six months | 0.31 (–0.28–0.72) | Poor agreement |
| Post-intervention | –0.18 (–0.50–0.29) | No agreement / disagreement | |
| Overall ILS | Six months | 0.70 (0.28–0.90) | Good agreement |
| Post-intervention | 0.04 (–0.24–0.43) | No agreement |
Implementation Citizenship Behaviour for Integrated HIV-Hypertension Care
Clinic team leads rated their subordinates’ implementation behaviours related to integrated HIV-hypertension care highly, with mean scores exceeding 80% across both study arms. The overall ICBS score, and the two domain-specific scores showed modest improvement over course of implementing the integrated HIV and hypertension care; however, these changes did not reach statistical significance. Additionally, no notable differences were observed between the two approaches of integrated HIV and hypertension care. Table 5 and Figure 2.
Table 5.
Implementation Citizenship Behaviour Scores
| Variable | HTN-BASIC N=10 six months, 13 post implementations |
HTN-PLUS N=16 six months, 15 post implementations |
|---|---|---|
| Total ICBS | ||
| Six months | 80.8 ±24.5 | 83.1 ±16.7 |
| Post intervention | 86.9 ±14.5 | 86.9 ±12.5 |
| Difference | −6.0 | −5.2 |
| p | 0.450 | 0.369 |
| Helping Others | ||
| Six months | 85.8 ±19.7 | 84.4 ±16.4 |
| Post intervention | 89.7 ±16.0 | 91.1 ±15.3 |
| Difference | −3.9 | −6.7 |
| p | 0.604 | 0.246 |
| Keeping Informed | ||
| Six months | 75.8 ±31.0 | 81.8 ±19.1 |
| Post intervention | 84.0 ±13.4 | 85.5 ±17.4 |
| Difference | −8.1 | −3.8 |
| p | 0.404 | 0.569 |
Notes: Difference is the earlier assessment minus the later assessment; a negative value therefore indicates an increase over time. P-values are from independent-samples t-tests.
Clinic Level Scores for ORIC, ILS and IBCS
Figure 2 shows substantial variation across clinics and implementation measures, although scores were generally high. Clinic-level ORIC scores were high at baseline and remained high after the intervention, despite modest declines in some clinics. All clinics reported mean ORIC scores above 75% at both baseline and post-intervention. ILS and ICBS scores showed greater variability across clinics. Three clinics at six months and two clinics at post-intervention reported mean ILS scores below 75%. Nevertheless, the overall mean ILS score increased modestly between the two assessment periods. Most clinics also demonstrated improvements in implementation citizenship behaviour, although substantial declines were observed in some clinics. Among the 14 clinics with paired ICBS observations, eight showed improvement.
Discussion
In this prospective study nested within the PULESA trial, we describe the implementation climate using the lenses of organizational readiness, implementation leadership, and implementation citizenship behaviour during the integration of hypertension care into HIV clinics in Kampala and Wakiso districts. Across the 16 participating clinics, health care providers reported high organizational readiness at the start of implementation and at the post-intervention assessment. Clinic leads and staff also reported high implementation leadership scores, while clinic leads rated staff citizenship behaviours highly in both intervention groups. Readiness and citizenship scores did not change significantly over time. In exploratory analyses, HTN PLUS clinic leads reported increases in overall ILS and proactive leadership domain from six months to post-intervention after accounting for facility clustering, while HTN BASIC clinic leads reported increased supportive leadership. Taken together, the findings indicate favourable organizational conditions and behaviours for integrated HIV-hypertension care in these trial-supported clinics.
Organizational readiness was high and remained stable across the implementation period. This suggests that participating clinics developed substantial commitment and confidence in their collective ability to integrate hypertension care when implementation began. The persistently high scores throughout the study may also reflect limited potential for measurable improvement because ORIC scores were clustered near the upper end of the scale. Healthcare providers reported slightly higher change commitment than change efficacy across all strata by role and by intervention arm at both time points. This is consistent with reports from other resource-limited settings.34 This finding suggests that health care providers were strongly motivated to deliver integrated HIV-hypertension care but were somewhat less confident in their collective capability to do so. In clinics where hypertension care was not routinely provided, sustaining commitment may require reliable access to blood pressure monitoring devices, anti-hypertensive medicines and regular performance assessment and feedback while improving change efficacy may require ongoing implementation support and additional training to strengthen healthcare providers confidence in delivering integrated HIV-hypertension care. The domain difference should nevertheless be interpreted cautiously because baseline reliability was lower for the ORIC subscales.
Implementation leadership scores were also high throughout the study. In HTN PLUS clinics, the observed increases in clinic leads rating of overall and proactive leadership could have been due to the additional packages provided in HTN PLUS such as enhanced training, audit and feedback and support to integrate hypertension care within existing differentiated service delivery models. These activities could plausibly help leaders anticipate barriers, communicate priorities, and organize implementation. However, this interpretation remains exploratory. ILS was first administered six months after implementation began, the number of clinic leads was small, respondents changed over time, and staff ratings did not show corresponding improvement. In addition, the increase in knowledgeable leadership in HTN PLUS was attenuated after facility clustering was considered. The improvement in supportive leadership reported by HTN BASIC clinic leads may reflect the influence of the standard training and resource package, maturation during implementation, or imprecision from multiple subgroup comparisons. These findings therefore identify potentially important leadership patterns rather than comparative intervention effects. Consistent with previous studies in similar settings,35 strong implementation leadership may foster and sustain a supportive environment in which leaders actively promote the delivery of integrated services. Although this study did not examine the relationship between implementation leadership and implementation outcomes such as fidelity, adoption or patient-level outcomes, future secondary analyses of the PULESA trial could explore these associations. The divergence between clinic-lead self-ratings and staff ratings is an important finding. At six months, ICC point estimates suggested moderate agreement for overall, proactive, and knowledgeable leadership. At the post-intervention assessment, agreement was poor across the overall score and most domains. This may mean that leaders perceived changes in their own behaviour that were not visible or experienced similarly by staff. Alternative explanations include a response shift among leaders after greater exposure to implementation activities, staff turnover, and self-serving bias. Prior research suggests that discrepancies between leader and follower ratings can be relevant to organizational climate,26 but the present study did not assess humble leadership or determine why perceptions diverged. Routine multi-source feedback, structured staff check-ins, and joint review of implementation barriers may help leaders align intended support with staff experience.
During the early implementation period at 6 months, there seemed to be good agreement between clinic staff ratings of their team leaders’ leadership styles and the team leaders’ self-assessment. However, by the end of the study, the team leaders’ self-assessment improved, while the clinic staff assessment stayed the same or went down slightly. This resulted in poor agreement between the two measures at the end of the study. Although Aarons et al36 reported discrepancies between supervisor and staff ratings in the proactive and supportive leadership domains, our study identified discrepancies across all domains during the post-intervention phase. This finding may indicate that leaders perceived changes in their own behaviour that were not equally visible to or experienced by staff. Alternative explanations include a response shift among leaders following greater exposure to implementation activities, staff turnover, and reduced precision due to the small number of participating facilities. Nevertheless, previous research suggests that large discrepancies, particularly where supervisors rate themselves more favourably than their staff, may signal communication or relationship gaps and may be associated with less favourable organizational and implementation climates.37
Implementation citizenship behaviour was rated highly in both groups, with mean overall scores exceeding 80 at six months and post-intervention. The modest increases in helping others and keeping informed were not statistically significant, and no clear differences were observed between HTN BASIC and HTN PLUS. These scores suggest that extra-role behaviours supportive of integration were perceived to be present, which may help teams adapt tasks and share practical knowledge during service redesign.18 However, scores may have been affected by ceiling effects and by the assessment approach: clinic leads rated up to two subordinates, potentially introducing selection or halo bias. Although the conceptual framework positions citizenship behaviour as a proximal mechanism through which organizational conditions may influence adoption, the present analysis did not test mediation or link ICBS scores to implementation outcomes.
These findings have several implications for implementation and scale-up. First, health systems should preserve the high commitment observed among health providers while strengthening collective efficacy through reliable supplies, practical training, integrated workflows, job aids, and accessible performance data. Second, leadership development should combine coaching and audit-and-feedback with mechanisms that capture both leader and staff perspectives; high leader self-ratings alone may not reflect staff experience. Third, future analyses should examine whether ORIC, ILS, and ICBS scores are associated with adoption, reach, fidelity, and patient level outcomes like blood pressure screening, treatment initiation, and blood-pressure control in the PULESA trial. Such analyses are necessary to determine whether favourable perceived organizational conditions translate into implementation and clinical benefit.
The setting is also important when interpreting transferability. Participating sites were largely standalone HIV clinics supported by an implementing partner and by trial-provided medicines, blood-pressure devices, training, and implementation support. Leadership structures, staffing, and readiness may differ in facilities that provide fully integrated chronic care within the same clinical space or in less-supported rural settings. The findings therefore show that established HIV platforms can offer a promising organizational foundation for integrated hypertension care, but they do not establish that all HIV clinics in Uganda are equally ready or that the observed conditions will be sustained after external support is withdrawn.
Strength and Limitations
Our study collected data from clinic settings of varying size and context, including large and small clinics, public and private not profit clinics, and urban and peri-urban settings. This enhanced the applicability of the findings across multiple healthcare contexts. In addition, the use of multiple implementation measures (ILS, ORIC and ICBS) ensured a comprehensive assessment of implementation climate from the perspectives of both clinic staff and their leaders.
The study has several limitations. First, its descriptive design limited the analysis to characterizing implementation climate scores rather than examining their effects on key indicators of successful implementation of integrated HIV and hypertension care. Nevertheless, prior studies have demonstrated that a strong implementation climate is associated with greater adoption and improved effectiveness of evidence-based practices. Future secondary analyses from the PULESA Uganda trial may examine the relationship between implementation climate scores and the effectiveness of implementation strategies. This study included a relatively small sample of healthcare providers. However, this sample size reflects the staffing levels typical of HIV clinics where integrated HIV and hypertension services are delivered and thus remains representative of the implementation context.
An additional limitation relates to the organizational context in which this study was conducted. Data were collected primarily from largely standalone HIV clinics, whereas recent shifts in funding streams and national policy in Uganda have promoted more fully integrated chronic care models, in which patients with HIV and other non-communicable diseases are managed within the same clinical space by the same cadre of health care providers. Implementation dynamics, leadership structures, and provider readiness may differ in such fully integrated settings, and the observed implementation climate scores may therefore not be directly transferable. However, this contextual distinction does not diminish the value of our findings. Standalone HIV clinics remain a dominant platform for HIV service delivery in many LMICs, and they represent the foundational infrastructure from which integrated chronic care models are evolving. Moreover, the implementation constructs assessed in this study, organizational readiness, leadership, and behaviour change, are core determinants of successful implementation across care delivery models. As such, our findings provide important insights into the readiness of existing HIV platforms to absorb and scale integrated NCD services and offer empirically grounded lessons that are likely to remain relevant as health systems transition toward more fully integrated models of chronic disease care.
The small number of providers and facilities limited precision for subgroup and change analyses. Participants were clustered within facilities, and some score distributions showed ceiling effects, non-normality, or unequal variances. However, Welch t-tests, Wilcoxon rank-sum tests, and facility-clustered regression generally supported the primary conclusions. The study was descriptive and was not powered to detect small subgroup differences; non-significant estimates should therefore be interpreted in light of their confidence intervals and the possibility of type II error.
Conclusion
This study characterized the implementation climate for integrated HIV and hypertension care in HIV clinics in Kampala and Wakiso districts, Uganda. Although some variability was observed across the trial clinics, the overall implementation environment was consistently strong, as reflected by high levels of organizational readiness for implementing change, implementation leadership, and implementation citizenship behaviour. Healthcare providers and their supervisors demonstrated substantial motivation and commitment to delivering integrated HIV and hypertension services. These findings suggest that, in settings where contextual barriers to integrated service delivery have been addressed, organizations may be well positioned to implement integrated care models, with strong commitment and motivation among both supervisors and healthcare providers. Future research, including secondary analyses of data from the PULESA Uganda trial, could further clarify the relationships between these implementation measures and successful implementation outcomes.
Acknowledgments
We would like to express our appreciation to the research participants and the managers of health facilities and clinics who agreed to take part in this study. We also acknowledge the support of the Uganda Ministry of Health, the Wakiso District Local Government Health Directorate, and the Kampala Capital City Authority Directorate of Public Health and Environment officials, as well as the HIV comprehensive partners in the two districts. Finally, we thank the National Heart, Lung, and Blood Institute and the Fogarty International Center of the US National Institutes of Health (https://www.nih.gov/about-nih/contact-us) for funding this trial and supporting our work. We also extend our gratitude to the Makerere University School of Medicine Implementation Science Training Program for providing the first author with foundational training in implementation science.
Funding Statement
The research reported in this publication was funded by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (USA) under Award number 1UG3HL154501. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the US Department of Health and Human Services.
Data Sharing Statement
The datasets used during this study are available from the corresponding author upon reasonable request.
Ethics Approval and Consent to Participate
The Makerere University School of Medicine Research and Ethics Committee (Mak-SOMREC-2022-40) and the Uganda National Council for Science and Technology (HS2398ES) approved the study. We obtained administrative clearance from the Uganda Ministry of Health and from the district leadership in Kampala and Wakiso. All participants provided informed consent before taking part in the study.
Author Contributions
FCS, and CTL secured funding for the study and supervised trial implementation. JBK, FCS, CTL, ARK, and AF conceptualized the manuscript. JBK drafted the initial manuscript. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
Dr Donna Spiegelman reports this publication was funded by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (USA) under Award number 1UG3HL154501. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the US Department of Health and Human Services., during the conduct of the study; Grants or contracts from NIH 1R01HL167936-01A1, NIH R01CA279175, NIH 1R01HL169421, NIH T32HL155000, NIH DP1DA058988, NIH 1R24MH134305-01, NIH R01MD018750, MR/X004171/1, NIH/NIMH 1R21 AI169643, R3EDI 1R24AI194905-01, PCORI ME-2023C1-31350, NIH 2P30MH062294, NIH 1R01MH134715-01, NIH R01 MH134721-01, NIH 1R01HL166585-01A1, PCORI, NIH 1R01MD017526, HPTN 096 CRISP UM1AI068619 (PO23000491), outside the submitted work.
Dr Jeremy Schwartz reports support for the manuscript from NIH, during the conduct of the study; Grants or contracts from American Heart Association; Meeting/travel support from Yale School of Medicine; Leadership or fiduciary roles from Coalition for access to NCD medicines and products, outside the submitted work. Dr Chris Longenecker reports grants or contracts from Coefficient Giving, American Heart Association, National Institutes of Health; Consulting fees from Gilead Sciences, American Heart Association, outside the submitted work. No other competing interests to declare.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used during this study are available from the corresponding author upon reasonable request.