Table 2.

Hypertension Treatment in Nigeria Program contextual factors and implementation strategies

Strategy for Implementing HTN Program	Level of implementation	Description	Implementation package component supported
Use evaluative and iterative 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 interactive assistance
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
Adapt and tailor context
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
Develop stakeholder interrelationships
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
Train and educate stakeholders
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
Support clinicians
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
Engage consumers
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
Utilize financial strategies
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 infrastructure
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

Abbreviations: BP Blood pressure, CHEW Community health extension worker, CHO Community health officer, HTN Hypertension Treatment in Nigeria, PHC Primary healthcare center, WHO World Health Organization