Table 3.

Roadblocks and solutions.

	Dimension	Barriers	Solutions
Pre/Diagnosis	Demographic and socio-economic factors (individual level)	Lack of access to testing centres	Facilitate access to health centres where individuals can be diagnosed.
	Knowledge and beliefs (individual level)	People are not aware that they are at risk of hypertension/have hypertension. Individuals have a poor understanding of the importance of detecting hypertension.	Implement community awareness campaigns. Roll out opportunistic screening (see case study 2). Implement community- and worksite-based screening and education. Identify and engage local/national champions, including community health workers and volunteers and other non-traditional means to raise awareness [144] (e.g., barber shops[145]). Encourage out-of-office BP measurement (see case study 3). Encourage involvement in and expansion of May Measurement Month.
	Health systems resources and processes	Lack of health care professionals to screen/prescribe priority interventions and to provide counselling	Promote task sharing/enhanced scope of practice for non-physician health workers for opportunistic screening and early diagnosis of HT (see case study 5). Provide clinical decision support systems and incentives for health care providers.
	Social relations, norms, traditions
	Demographic and socio-economic factors (individual level)	Financial constraints Forgetfulness and poor motivation Competing family and work responsibilities	Support universal health care (UHC) for all and ensure hypertension is adequately covered in UHC coverage plans. Facilitate access to health centres where patients can be followed up free of charge. Provide financial and social support for patients (eliminate user fees and out-of-pocket medication costs). Choose low-cost alternatives in settings where there is idiosyncratic pricing.
Start of treatment	Knowledge and beliefs (individual level)	Poor understanding of hypertension Doubt that medicine can alleviate symptoms, fear of taking medication Lack of willingness to seek treatment for an asymptomatic condition	Involve families, social networks, local vendors accounting for the fact that many people self-manage using advice from such sources. Support e-health and education of both health care recipients and carers to enable linkage between diagnosis and treatment.
	Health systems resources and processes	Health care professionals are not aware of guidelines Health care professionals are aware but do not follow guidelines Lack of understanding of guidelines by healthcare professionals	Educate health care professionals on hypertension risk and guidelines. Implement practical guidelines targeted to LMICs: (ISH guidelines). Promote the HEARTS approach and the ISH 2020 guidelines for use of simple of diagnostic and treatment algorithms (see case study 7). Encourage healthcare workers to share knowledge. Regulate and develop policies to increase the uptake of accuracy validated automated BP devices for routine screening and clinical care (see case study 6).
		Lack of linkage between the diagnosis of hypertension and treatment Lack of staff, medication, and equipment, long queues, long distances Priority interventions are not available Priority interventions are not affordable	Include affordable high-quality long-acting evidence-based and preferably single pill combination generic antihypertensive drugs in the national list of essential medicines. Promote task sharing/enhanced scope of practice for non-physician health workers with prescription rights to trained nurses and pharmacists for first line anti-hypertensive drugs. Ensure that priority interventions are available at the community level (including pharmacies) (see case study 9). Promote local quality-controlled manufacturing, bulk purchasing and/or efficient system to streamline medication supply (see case study 9). Ensure the availability of low-price, good-quality, and resistant sphygmomanometers.
	Social relations, norms, traditions	Patient lack of partner and social support Poor relations between health workers and patients Fear of being reprimanded by health workers Poor relationships with family and friends ‘Unhealthy’ social norms and traditions Traditional hierarchical relationships between providers and patients	Involve families, social networks, local vendors. Develop and promote ‘healthy lifestyle’ campaigns (see case study 5). Educate providers and health workers re the need for enhanced communication with patients.
	Demographic and socio-economic factors (individual level)	Need to prioritise family, work, domestic commitments	Allow for multi-month medication prescriptions and community medication delivery so that patients with stably controlled BP require less frequent office visits.
Follow-up and retention	Knowledge and beliefs (individual level)	Patients are not aware of the need for long term treatment and do not understand the care pathway Patients do not adhere to treatment Patients have issues with complex medication regimen, polypharmacy, side effects of medications Beliefs that long-term medication can cause damage to the body	Strengthen patient and carer education. Develop a whole-society approach, including families, media personalities and social networks. Deliver people centred care to include community-based hypertension management and easily accessible and affordable primary health care. Deliver education and campaigns for health care recipients to promote understanding of the importance of long-term treatment. Use information and communication technology to remind and reassure patients about recommendations. Use patient-nominated, non-professional treatment supporters (e.g., spouse, friends, family, peer groups). Strengthen the role of community health workers who often operate across sectors locally. Improve patient experience (e.g., foster interaction with HCWs when dealing with long queues). Utilise interventions with active involvement of patients and patient support groups.
	Health systems resources and processes	Same as for ‘start of treatment/drug therapy’
	Social relations, norms, traditions	Same as for ‘start of treatment/drug therapy’