Capacity and Site Readiness for Hypertension Control Program Implementation in the Federal Capital Territory of Nigeria: A Cross-sectional Study

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Baldridge, Kasarachi Omitiran, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-76952/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Apr, 2021 Read the published version in BMC Health Services Research → Version 1 posted 10 You are reading this latest preprint version Abstract Background : Nigeria faces an increase in the burden of non-communicable diseases (NCDs), including cardiovascular diseases (CVDs), leading to an estimated 29% of all deaths in the country. Nigeria has an estimated hypertension prevalence ranging from 25% to 40% of her adult population. Despite this high burden, awareness (14-30%), treatment (<20%), and control (9%) rates of hypertension are low in Nigeria. Against this backdrop, we sought to perform capacity and readiness assessments of public Primary Healthcare Centers (PHCs) to inform Nigeria's system-level hypertension control program's implementation and adaptation strategies. Methods : The study employed a multi-stage sampling to select 60 from the 243 PHCs in the Federal Capital Territory (FCT) of Nigeria. The World Health Organization (WHO) Service Availability and Readiness Assessment was adapted to focus on hypertension diagnosis and treatment and was administered to PHC staff from May 2019 – October 2019. Indicator scores for general and cardiovascular service readiness were calculated based on the proportion of sites with available amenities, equipment, diagnostic tests, and medications. Results : Median (interquartile range [IQR]) number of full-time staff was 5 (3-8), and were predominantly community health extension workers (median = 3 [IQR 2-5]). Few sites (n=8; 15%) received cardiovascular disease diagnosis and management training within the previous two years, though most had sufficient capacity for screening (n=58; 97%), diagnosis (n=56; 93%), and confirmation (n=50; 83%) of hypertension. Few PHCs had guidelines (n=7; 13%), treatment algorithms (n=3; 5%), or information materials (n=1; 2%) for hypertension. Most sites (n=55; 92%) had one or more functional blood pressure apparatus. All sites relied on paper records, and few had a functional computer (n=10; 17%) or access to internet (n=5; 8%). Despite inclusion on Nigeria’s essential medicines list, 35 (59%) PHCs had zero 30-day treatment regimens of any blood pressure-lowering medications in stock. Conclusions : This first systematic assessment of capacity and readiness for a system-level hypertension control program within the FCT of Nigeria demonstrated implementation feasibility based on the workforce, equipment, and paper-based information systems, but a critical need for essential medicine supply strengthening, health-worker training, and protocols for hypertension treatment and control in Nigeria. Health Economics & Outcomes Research Health Policy Hypertension Nigeria primary health care capacity readiness Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Nigeria faces an increase in the burden of non-communicable diseases (NCDs), causing an estimated 29% of all deaths in Nigeria, including 22% of premature deaths. 1 , 2 Moreover, more than one-third of all NCD-related deaths in Nigeria are due to cardiovascular diseases (CVDs). 1 Meanwhile, hypertension is the leading modifiable risk factor for CVD-related morbidity and mortality in Nigeria. 2 The estimated prevalence of hypertension among adults in Nigeria, defined as blood pressure (BP) of 140/90 mm Hg or higher or taking one or more BP-lowering drug(s), ranges from 25–40% of adults. 3 Despite this high burden, hypertension awareness (14%-30%), treatment (< 20%), and control (9%) rates are low. 2 Newer definitions of hypertension based on lower blood pressure thresholds raise these hypertension prevalence estimates even higher. 4 Following the United Nations' Sustainable Development Goals, Target 3.4, Nigeria set a national goal of reducing the risk of premature (30–69 years) mortality from NCDs, including CVDs, by one-third by 2030. The country will not achieve this target without substantially better BP control delivered through Nigeria’s primary health care system, where most Nigerians receive their care. 5 Primary Healthcare Centers (PHCs) in low- and middle-income countries (LMICs) frequently lack system capacity for hypertension screening, diagnosis, registration of diagnosed patients, follow-up, provision of essential drugs, and treatment protocols for hypertension management. 6 In Nigeria, as of 2017, only 30% of PHCs reported availability of essential NCDs medicines, no PHCs had CVD management guidelines, and none offered CVD risk stratification services. 7 The World Health Organization (WHO) 2018 HEARTS Technical Package provides guidance for PHCs on hypertension training, diagnosis, treatment protocols, and monitoring systems to address these NCD gaps, based on the Kaiser Permanente Northern California model of hypertension care, which increased hypertension control from 44–90% in the United States. 8 , 9 In response to these needs and context, the Hypertension Treatment in Nigeria Program (NCT04158154) aims to develop implementation pathways and intervention packages for a system-level, large-scale hypertension program adapted from WHO's HEARTS and the Kaiser Permanente Northern California model to improve hypertension diagnosis, treatment, and control rates among patients attending public PHCs in the Federal Capital Territory of Nigeria. 8 , 9 During the formative phase of this Program, we performed facility-based capacity and readiness assessments among participating PHCs in the Federal Capital Territory of Nigeria to inform the implementation and adaptation strategies for a system-level hypertension control program. These activities were implemented in collaboration with key partners, including the Federal Ministry of Health in Nigeria, Federal Capital Territory Primary Health Care Board, WHO Nigeria office, and Resolve to Save Lives. Methods Survey Adaptation This formative study used an adaptation of the Service Availability and Readiness Assessment (SARA) tool to assess 60 PHCs across the six area councils of the Federal Capital Territory in Nigeria (the adapted tool is available at doi: 10.18131/g3-rknh-rr75 ). The WHO designed the SARA tool to assess health facilities’ availability and readiness to offer the services to inform the evidence-based decision to plan and manage the health systems. 10 , 11 It generates a set of core indicators on the health system's critical inputs and outputs to measure the health system strengthening over time. There are three main domains: 1) service availability, 2) general service readiness, and 3) service-specific readiness. 11 The research team adapted the SARA tool with input from the NCD divisions of the WHO Nigeria, Nigeria Federal Ministry of Health, and other relevant stakeholders, including the Federal Capital Territory Primary Health Care Board and Federal Capital Territory Public Health Department; to focus on non-communicable diseases diagnosis, treatment, and management, specifically hypertension and diabetes. The SARA tool has 13 sections: 1) service availability, 2) patient access, 3) staffing capacity, 4) infrastructure, 5) basic client amenities, 6) infection control, 7) healthcare waste management, 8) clinical mentoring, 9) basic equipment, 10) available services for non-communicable diseases and diagnostics, 11) supply chain, 12) medicines and vaccines, and 13) commodities. Site Selection We identified all (n = 243) public PHCs within the six council areas and 62 wards in the Federal Capital Territory of Nigeria. Health facility-level characteristics, including the number of staff, the cadre of staff, the mean number of hypertension cases per month, and the number of bed spaces (if applicable), were collected from each PHC. Facilities with a ward focal person (i.e., a community health extension worker with a supervisory role over other PHCs in the ward) and facilities receiving basic healthcare provision funds from the federal government were enumerated to account for these factors in the sample selection process. Consistent with the SARA methodology, a sub-nationally representative sample of PHCs were selected using a multi-stage sampling process (Fig. 1 ). 12 Some PHCs (n = 90) were excluded from the sample based on the feasibility of study implementation and evaluation. These include the PHCs that had fewer than two paid full-time staff (n = 77); and the ones associated with security concerns based on local knowledge (n = 6); also those with no or poor road access (n = 6), and the PHCs that were non-functional defined by lack of provision of patient services at the time of assessment (n = 1). The remaining eligible PHCs (n = 153) represented 51 wards within the Federal Capital Territory (Fig. 2 ). The research team performed the multi-stage sampling process using SAS proc survey select, with sampling weights for each of the 153 eligible PHCs proportional to the estimated mean number of patients with hypertension seen at each PHC per month. The sampling process included three steps: 1) Identification of sites (n = 37 PHCs) that housed a ward focal person (i.e., a healthcare worker with a supervisory responsibility across the ward), and one PHC with a ward focal person from each ward was randomly sampled (n = 36 PHCs in 36 wards); 2) within the remaining 15 wards (n = 38 PHCs) with no ward focal person in any PHC, one site per ward was randomly sampled (n = 15 PHCs, in 15 wards); and 3) within the remaining PHCs (n = 102 PHCs), the team randomly sampled sites from the Abuja Municipal (n = 6 PHCs), Gwagwalada (n = 2 PHCs), and Kuje (n = 1 PHCs) area councils to approximate geographic representation by population density. The researchers contacted selected sites to confirm their willingness to participate in the Hypertension Treatment in Nigeria Program, including a baseline SARA assessment and interview; all sites confirmed willingness to participate. They traveled to each selected PHC to invite and obtain written informed consent from the highest-level site staff or officer-in-charge and unit heads of nursing, pharmacy, and laboratory domains, to perform interviews and site assessment. The overall assessment included directly observing operations, equipment, medications, and supplies present at the site on the day of the interview. The research team completed all SARA interviews by speaking directly with the site staff to respond to survey questions. Statistical Analyses Graphical representations were used to assess the facility-based capacity and readiness for hypertension diagnosis and treatment. Continuous measures were summarized by mean and standard deviation, or median and interquartile range if non-parametrically distributed. Readiness and capacity were assessed based on domains of interest, including personnel, general service delivery, and cardiovascular service delivery in the hypertension treatment cascade, equipment and supplies, information systems, and blood pressure-lowering medications. Indicator scores for general and cardiovascular service readiness were calculated based on the proportion of sites with available amenities, equipment, diagnostic tests, or medicines within the SARA defined question bank. For statistical analysis, the study team used SAS version 9.4 (SAS, Cary, NC, USA) and R version 3.5.1 (R Foundation, Vienna, Austria) Results Participants The team completed SARA assessments at all (n = 60) PHCs between May 2019 – October 2019. Among 60 participating PHCs, 36 had a ward focal person, and 34 were sites of interest to the Federal Capital Territory Primary Health Care Board as target facilities for investments to achieve universal health coverage. Staff and Service Delivery Staffing levels, based on full or part-time status, and service delivery were tabulated based on interviews with the officer in charge. Most PHCs (n = 54; 90%) had sufficient human resource capacity according to the self-report of two or more full-time staff (Table 1 ). The median (interquartile range [IQR]) number of full-time staff was 5 (3–8), and predominantly comprised community health extension workers (CHEWs; median = 3; IQR 2–5) and nurses (median = 1; IQR 0–2). Few (n = 8; 15%) sites received any training to diagnose and manage cardiovascular diseases within the previous two years. Nearly all PHCs (n = 58, 97%) had sufficient capacity for screening, and most had capacity for diagnosis (n = 56; 93%) and confirmation (n = 50; 83%) of hypertension. Over half had capacity for dispensing initial (n = 34; 57%) or follow-up (n = 34; 57%) blood pressure-lowering medications and for providing long-term continued care (n = 36; 60%) for patients with hypertension. Figure 3 demonstrates the hypertension treatment cascade components across the Federal Capital Territory's six area councils, from screening and diagnosis to monitoring and long-term care. Among the components, the highest rates were related to screening and diagnosis across all area councils and were highest in Bwari. The lowest rates were related to dispensing initial treatment regimen, follow-up treatment, and long-term care overall, with the lowest rates in Bwari. General and Cardiovascular Service Readiness Across the six area councils within the FCT, variability in general service readiness indicator scores for basic amenities, equipment, infection prevention, diagnostic capacity, and essential medicines were found (Table 2 ). Cardiovascular service availability was consistently high within the six area councils of the Federal Capital Territory (i.e., Abaji, Abuja Municipal Area Council [AMAC], Bwari, and Gwagwalada wards); all the PHCs reported offering cardiovascular disease diagnosis and management services. However, the study demonstrated wide variability in cardiovascular service readiness indicator scores for the presence of guidelines, equipment, and medicines. The Bwari area council consistently had the highest indicator score across general and cardiovascular domains, ranging from 29.2% for general essential medicines to 100% for equipment and cardiovascular service availability. Essential cardiovascular medicines scores, based on the availability of calcium channel blockers, aspirin, beta-blockers, ACE-I, statins, or thiazides, were low in comparison to other domains and were very low for hypertension medicines. Equipment, Supplies, & Information Systems Equipment, supplies, and information systems were assessed in consultation with the officer-in-charge and staff in charge of medical records and data and based on direct observation to determine the availability and function of equipment on the day of assessment. Few PHCs had guidelines (n = 7; 13%), treatment algorithms (n = 3; 5%), or information materials (n = 1; 2%) for hypertension diagnosis or management within the clinic on the day of assessment. Most sites (n = 55; 92%) had at least one functional BP apparatus present. All sites relied on paper-based longitudinal records, and relatively few had a functional computer (n = 10; 17%) or access to the internet or email (n = 5; 8%). Medications Hypertension medications were tabulated based on direct observation of the pharmaceutical inventory against record logs, where available. The adapted SARA tool classified medications into broad classes. Figure 4 reported the number of 30-day treatment regimens available on the day of assessment by class. At one site, the pharmaceutical inventory was not accessible on the day of the visit. The most commonly stocked medications were calcium channel blockers (n = 19; 32%), followed by diuretics (n = 15; 25%), central acting agents (n = 11; 19%), and angiotensin-converting enzyme inhibitors (ACE-I; n = 10; 17%). Despite their inclusion on the WHO and Nigeria essential medicines lists, few PHCs (n = 4; 7%) had fixed-dose combinations for hypertension treatment. The median (IQR) number of 30-day treatment regimens of all blood pressure-lowering medications in stock on the day of assessment was 0 (0–20) regimens, and 35 (59%) PHCs had zero 30-day treatment regimens of BP-lowering medication in stock. Discussion While Nigeria has set a national goal of reducing the risk of premature (30–69 years) mortality from NCDs, including CVDs, by one-third by 2030, the country has not fully translated into action within the PHCs, necessary components to implement a system-level hypertension service. Although cardiovascular service availability is high in the Federal Capital Territory, there is wide variability in readiness to provide these services identified, including the presence of guidelines, equipment, and medicines. We demonstrated the feasibility of implementing the Hypertension Treatment in Nigeria Program based on the workforce, equipment, and paper-based information systems, but identified critical needs for health worker training, protocol implementation, and essential medicine supply strengthening for hypertension treatment and control. Staff and Service Delivery Our study shows that full-time staff members were primarily CHEWs and nurses, who comprise the cadre of non-physician health workers needed to provide service delivery in community-based care. PHCs need qualified, trained staff to implement an effective task-shifting strategy for improved NCDs management, including hypertension. 13 Our benchmark of including PHCs with at least two full-time staff as sufficient human resource capacity for implementing the Hypertension Treatment in Nigeria Program aligns closely with the minimum number of CHEWs required to operate a PHC. 14 The relatively large number of non-physician health workers in PHCs in this study, including CHEWs, may be partially attributed to the cumulative density of schools of health technology, which are training institutions for CHEWs in Nasarawa, Kogi, Kaduna, and Niger states, that share boundary with the Federal Capital Territory. 15 This contrasts with the 2018 report from Garcia de Quevedo et al., who identified limited NCDs workforce as a challenge in Mozambique, Colombia, and the Dominican Republic based on the high rate of temporary contract workers for NCD-related care. 16 Moucheraud reported low staff and training readiness scores for NCD diagnosis and management using Service Provision Assessment surveys across PHCs in Bangladesh (24%), Haiti (29%), Malawi (18%), Nepal (4%), and Tanzania (12%), 17 signifying that low staff and service delivery readiness is common throughout LMICs. These differences between the current study and data reported by Garcia de Quevedo et al. and Moucheraud are due, at least in part, to the current study's inclusion criterion of PHCs with at least two full-time health workers for Hypertension Treatment in Nigeria Program implementation. While staff in the current study were integrated into the broader PHC delivery system in Nigeria, they also had responsibilities beyond hypertension and NCDs. We identified substantial gaps in training for diagnosing and managing CVDs, including gaps in standing orders for CHEW-based CVD- and hypertension-related care, unlike other chronic conditions such as human immunodeficiency virus (HIV). Lack of adequate staff training is a recurring challenge in health program implementation in LMICs. 16 – 18 These results inform initial training and longitudinal re-training activities before and during the Hypertension Treatment implementation in Nigeria Program, given the fundamental need for training and supportive supervision. Further investments in staff and staff training and development and implementation of standing orders for managing CVD and hypertension may be needed to keep pace with these conditions' growing burden. Service Readiness In terms of general service readiness, the domains of basic equipment, infection prevention, and diagnostic capacity reported across all area councils revealed that more than half of facilities met general readiness criteria. Meeting these criteria may have been influenced by federal and local government support and commitments for other disease control programs in these PHCs, including maternal and child health. In terms of basic amenities (e.g., portable water, toilet facility, power supply), only two out of six area councils had more than half of their PHCs meeting the criteria. Further, essential medicine provision indices were low across all the area councils, demonstrating the heterogeneous investments in capital-intensive infrastructure. According to Oyekale et al., 19 the effective delivery of healthcare services at the PHC system requires adequate infrastructure, diagnostic medical equipment, essential medicines, and well-trained health workers. Therefore, there is a need to strengthen service readiness for effective Hypertension Treatment in Nigeria Program service delivery. Equipment, Supplies, & Information Systems We found low availability of guidelines, treatment algorithms, and information materials for hypertension, similar to previous reports in other sub-Saharan African countries, including Tanzania. 18 , 20 We found that while most sites had at least one functional BP apparatus, only a few PHCs had hypertension guidelines, treatment algorithms, information, education, and communication materials. These results also underscore the importance of Nigeria’s Federal Ministry of Health's recent steps to integrate the WHO-recommended Package of Essential NCD interventions (PEN) into PHCs in collaboration with crucial stakeholders, 21 to address this gap. Although few PHCs had computers or internet access available onsite with no sites reporting electronic patient records, Nigeria’s PHCs generally have a well-developed paper-based information management system for programs like HIV infection, antenatal care, and family planning, which can be leveraged for the treatment of hypertension and other NCDs. Substantial investments in infrastructure, hardware, software, secure internet access, and training will be needed to upgrade to an electronic data management system to achieve the WHO's four functions of health information systems: 1) data generation, 2) compilation, 3) analysis and synthesis, and 4) communication and use within care teams and patients. 11 Our results are similar to reports of lower availability of CVDs guidelines and higher availability of equipment for CVDs among health facilities in LMICs, 17 but differ from other findings which describe lack of essential equipment as a critical barrier to providing quality NCDs services at the primary care level. 18 Medications We found that while most PHCs had sufficient capacity for screening, diagnosis, and confirmation of hypertension, more than half of them did not have any 30-day treatment regimens of blood pressure-lowering medicines with significant variability across area councils. This finding is similar to that of Moucheraud et al., 17 who reported that most facilities in LMICs studied had limited essential cardiovascular medicines. Low availability of cardiovascular medicines at PHCs has also been reported in other LMICs such as Tanzania (25–40%), Bangladesh (30%), Nepal (28%), and higher rates have been reported in Malawi (67%) and Haiti (93%). 17,22 Provision of essential medicines for hypertension is generally a challenge within PHC systems in sub-Saharan Africa. The scarcity of medications may be explained by a lack of government-supported programs for NCDs within PHC systems. There are opportunities for support, mainly through strengthening drug revolving funds, which rely upon initial investments and recurring reduced out-of-pocket costs to sustain the funds and subsequent medicine supplies. Drug revolving funds may improve the availability of BP-lowering drugs in the PHCs until community insurance programs are fully funded and established. 23 Strengths And Limitations Key strengths of the current study include 1) sampling frame to maximize generalizability in the Federal Capital Territory, 2) adaptation of the SARA instrument to hypertensive services and local context and topic, and 3) engagement with PHCs, and other stakeholders, including the Federal Ministry of Health. This study also has significant limitations. First, the study excluded facilities with fewer than two full-time staff and, therefore, is not representative of all PHCs in the Federal Capital Territory or all of Nigeria, limiting generalizability. Nevertheless, the Hypertension Treatment in Nigeria Program aims to improve hypertension treatment and control rates, and the presence of full-time staff is necessary for it to be effective. Besides, the SARA instrument collects cross-sectional data, and therefore temporal changes in service availability and readiness among the included PHCs were not captured. However, our team will perform annual repeated cross-sectional assessments using the adapted SARA instrument throughout the Hypertension Treatment in Nigeria Program to address this limitation. The SARA instrument is also susceptible to recall and reporting biases by deriving responses from the highest-level site staff or officer-in-charge. The research team mitigated this risk by direct observation of supplies and equipment where possible. Also, the BP-lowering drug availability estimates do not include the availability of essential medicines through private pharmacies, where out-of-pocket costs are often higher than public pharmacies. 24 Finally, measures of service availability and readiness may not capture the quality and experience of service provision, which have generally become a larger contributor to health loss in LMICs compared with service availability alone. 25 Conclusions This study is the first systematic assessment of capacity and readiness for a system-level hypertension control program within the Federal Capital Territory of Nigeria. We demonstrated the feasibility of implementing hypertension treatment and control based on the workforce, equipment, and existing information systems. Nevertheless, we identified critical needs for capital intensive infrastructure investments, health worker training, hypertension treatment protocol implementation, and essential medicine supply strengthening in Nigeria. These data highlight the need for upfront and longitudinal investments across health system building blocks to deliver high-quality hypertension care at PHCs in Nigeria. These investments will be critical for Nigeria’s health system to not only respond to the current and projected burden of hypertension-related diseases but also to improve its resilience in the face of other emerging health threats. 26 Abbreviations AMAC : Abuja Municipal Area Council ACE-I : Angiotensin Converting Enzyme Inhibitors CVD s : Cardiovascular Diseases CHEW : Community Health Extension Worker FCT : Federal Capital Territory HEARTS : H ealthy-lifestyle counselling ; E vidence-based treatment protocols ; A ccess to essential medicines and technology ; R isk-based CVD management; T eam-based care ; S ystems for monitoring HIV : Human Immunodeficiency Virus IQR : Inter-Quartile Range LMICs : Low-and Middle-Income Countries NCDs : Non-Communicable Diseases PEN : Package of Essential NCD interventions PHC : Primary Healthcare Center SARA : Service Availability and Readiness Assessment WHO : World Health Organization Declarations Ethics approval and consent to participate : Written informed consent was obtained from all participants in this study. The study was reviewed by the Northwestern University Institutional Review Board and Health Research Ethics Committees of University of Abuja Teaching Hospital and Federal Capital Territory (FHREC/2019/01/03/16-01-19). All procedures followed were in accordance with the ethical standards of the ethics committees and institutional review board and the Helsinki Declaration of 1975, as revised in 2000. Consent for publication : Not Applicable. Availability of data and materials : The datasets supporting the conclusions of this article are included within the article. Competing interests : Dr. Huffman reports grants from American Heart Association, Verily, AstraZeneca, personal fees from American Medical Association, outside the submitted work. The George Institute for Global Health has a patent, license, and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. All other authors declare that they have no competing interests. Funding: This study was funded by National Heart Lung and Blood Institutes grant #R01HL144708. The funding body had no direct role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Authors' contributions: Design and concept of study: MDH, DO; Acquisition of data: SA, AB, MG, LH, MH, NK, DO, TO, KO, IO, GS; Data analysis and interpretation: AB, MG, IO; Manuscript draft: AB, LH, MH, NK, DO, TO, KO, IO, GS; Statistical expertise: AB; Acquisition of funding: MH, DO; Administrative: AB, MG; Supervision: MDH, DO. All the authors have read and approved this manuscript. Acknowledgements: This study was supported by National Heart Lung and Blood Institutes grant #R01HL144708. We are very appreciative to Regina Asuku, Charity Akor, Confidence Joseph-Alo, Elizabeth Nggada Bosede and Dr. Helen Eze for assistance with data collection and management. 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Health Aff (Millwood). 2018 Aug;37(8):1321-1330. doi: 10.1377/hlthaff.2018.0151. Bintabara D, Mpondo BCT. Preparedness of lower-level health facilities and the associated factors for the outpatient primary care of hypertension: Evidence from Tanzanian national survey. PLoS One. 2018 Feb 15;13(2):e0192942. doi: 10.1371/journal.pone.0192942. Oyekale AS. Assessment of primary health care facilities' service readiness in Nigeria. BMC Health Serv Res. 2017;17(1):172. https://doi.org/10.1186/s12913-017-2112-8. Leung C, Aris E, Mhalu A, Siril H, Christian B, Koda H, et al. Preparedness of HIV care and treatment clinics for the management of concomitant non-communicable diseases: a cross-sectional survey. BMC Public Health. 2016;16(1):1002. https://doi.org/10.1186/s12889-016-3661-1 World Health Organization. WHO and Nigerian government move to curb cardiovascular diseases. 2019, October 7. https://www.afro.who.int/news/who-and-nigerian-government-move-curb-cardiovascular-diseases (c2020). Accessed 16 Apr 2020. Peck R, Mghamba J, Vanobberghen F, Kavishe B, Rugarabamu V, Smeeth L, et al. Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey. Lancet Glob Health. 2014 May;2(5):e285-292. doi: 10.1016/S2214-109X(14)70033-6 Uzochukwu BS, Onwujekwe OE, Akpala CO. Effect of the Bamako-Initiative drug revolving fund 23 on availability and rational use of essential drugs in primary health care facilities in south-east Nigeria. Health Policy Plan. 2002;17(4):378-383. Wirtz VJ, Hogerzeil HV, Gray AL, Bigdeli M, de Joncheere CP, Ewen MA, et al. Essential medicines for universal health coverage. Lancet. 2017 Jan 28;389(10067):403-476. DOI: 10.1016/S0140-6736(16)31599-9 Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High- quality health systems in Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018 Nov;6(11): e1196-e1252. DOI: 10.1016/S2214-109X(18)30386-3 26. Kruk ME, Ling EJ, Bitton A, Cammett M, Cavanaugh K, Chopra M, et al. Building resilient health systems: a proposal for a resilience index. BMJ. 2017 May 23;357:j2323. doi: 10.1136/bmj.j2323. Tables Table 1. Capacity and Readiness in Federal Capital Territory, Nigeria, for Implementing System-Level Hypertension Control Program within 60 Primary Healthcare Centers. Site Characteristics No. Sites Responded Result Personnel and Training Sites with two or more full-time staff, a n (%) 54 54 (90) Number of full-time healthcare professionals, median (IQR) 60 5 (3-8) Full-time community health extension workers, median (IQR) 60 3 (2-5) Full-time nurses, median (IQR) 60 1 (0-2) Full-time doctors (generalists and specialists), median (IQR) 60 0 (0-0) Received CVD training within the past two years, n (%) 55 8 (15) Hypertension Service Delivery Screen for hypertension status, n (%) 60 58 (97) Diagnose hypertension, n (%) 60 56 (93) Confirm hypertension diagnosis, n (%) 60 50 (83) Dispense initial treatment for hypertension, n (%) 60 34 (57) Dispense follow-up treatment for hypertension, n (%) 60 34 (57) Monitor patients with hypertension, n (%) 60 48 (80) Provide long term care for patients with hypertension, n (%) 60 36 (60) Equipment and Supplies for Hypertension Guidelines, n (%) 55 7 (13) Treatment algorithms, n (%) 55 3 (5) Information, education, and communication, n (%) 55 1 (2) Functional blood pressure apparatus, n (%) 60 55 (92) Information Systems Use of electronic patient records, n (%) 60 0 (0) Functional landline phone, n (%) 60 13 (22) Functional cellular phone, n (%) 60 29 (48) Functional computer, n (%) 60 10 (17) Access to email or internet, n (%) 60 5 (8) Availability of Blood Pressure Lowering Medications Angiotensin Converting Enzyme Inhibitor, n (%) 59 10 (17) Angiotensin Receptor Blocker, n (%) 59 3 (5) Beta Blocker, n (%) 59 5 (8) Calcium Channel Blocker, n (%) 59 19 (32) Central acting agent, n (%) 59 11 (19) Fixed Dose Combinations, n (%) 59 4 (7) Diuretic, b n (%) 59 15 (25) Vasodilator, n (%) 59 4 (7) Number of 30-day treatment regimens in stock, median (IQR) 59 0 (0-20) No 30-day treatment regimens in stock, n (%) 59 35 (59) a Including all reported full-time clinicians or paramedics, nursing professionals, pharmacists, laboratory technicians, community health extension workers, and community health officers. b Including furosemide, spironolactone, thiazide or other diuretic. CVD, Cardiovascular Disease; IQR, Inter-Quartile Range Table 2. General and Cardiovascular Disease Service Availability and Readiness Indicators for 60 Primary Healthcare Center in the Federal Capital Territory, Nigeria. Service Availability and Readiness Indicator a Local Government Area Council Abaji (n=8) AMAC (n=15) Bwari (n=8) Gwagwalada (n=11) Kuje (n=8) Kwali (n=10) General Service Readiness Basic Amenities b 52.1 48.9 56.3 43.9 41.7 28.3 Basic Equipment c 67.5 80.0 100.0 70.9 57.5 74.0 Infection Prevention d 93.8 56.7 81.3 68.2 75.0 90.0 Diagnostic Capacity e 59.4 83.3 90.6 61.4 62.5 62.5 Essential Medicines f 6.3 24.4 29.2 13.6 6.3 5.0 Cardiovascular Disease Service Availability Availability g 100.0 100.0 100.0 100.0 87.5 90.0 Cardiovascular Disease Readiness Indicators Guidelines h 12.5 6.7 0.0 0.0 0.0 20.0 Equipment i 70.9 84.4 100 69.7 66.7 73.4 Medicines j 7.5 28.0 30.0 16.4 7.5 6.0 b The item "Room with auditory and visual privacy for patient consultations" was not included. c The item “Child scale” was not included. d The items “Safe final disposal of infectious wastes”, “Appropriate storage of sharps waste”, “Appropriate storage of infectious waste”, “Disinfectant”, “Single use —standard disposable or auto-disable syringes”, “Soap and running water or alcohol-based hand rub” and “Latex gloves” were not included. e The items “Malaria diagnostic capacity”, “HIV diagnostic capacity”, “Syphilis rapid test” and “Urine test for pregnancy” were not included. f Items "CCB", "Aspirin", "Beta Blockers", "ACE", "Statin" and "Thiazide" were included. g Calculated as the proportion of facilities offering cardiovascular disease diagnosis and/or management. h The item “guidelines for diagnosis and treatment of chronic cardiovascular conditions” was included. i The items “Stethoscope”, “Blood pressure apparatus” and “Adult scale” were included. j The items "CCB", "Aspirin", "Beta Blockers", "ACE" and "Thiazide” were included. Cite Share Download PDF Status: Published Journal Publication published 09 Apr, 2021 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Minor revision 09 Feb, 2021 Review # 2 received at journal 04 Nov, 2020 Review # 1 received at journal 04 Nov, 2020 Reviewer # 2 agreed at journal 27 Oct, 2020 Reviewer # 1 agreed at journal 08 Oct, 2020 Reviewers invited by journal 07 Oct, 2020 First submitted to journal 23 Sep, 2020 Editor assigned by journal 23 Sep, 2020 Submission checks completed at journal 22 Sep, 2020 Editor invited by journal 22 Sep, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-76952","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3031874,"identity":"a0b1b8ea-2afb-4f60-baf1-8f99bc160471","order_by":0,"name":"Ikechukwu Anthony Orji","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDCCA2DShoeNvxnElJAhQgsziEyT45M4lgDSwkOslsPGcgw5BiAWYS18t88ffFzYxpzYxnDm86sbNRY8DOyHj27Ap0XyXDKz8cw2tsQ25t5t1jnHgA7jSUu7gU+LwRlmNmneNh6gLWe3GeewAbVI8JgRo0UCqCXnmXHOP+K1GBizMeQwP85tI0KL5BlmY2OecwlybBLHzJhz+yR42Aj5he8M48PHPGX/eeT7mx9/zvlWJ8fPfvgYXi1gwMgGptgkwCRB5WDwB0wyfyBO9SgYBaNgFIw0AAChc0LHicGcXAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-5028-5428","institution":"Cardiovascular Research Unit, University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria.","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ikechukwu","middleName":"Anthony","lastName":"Orji","suffix":""},{"id":3031875,"identity":"ea3a4196-3300-423e-ae51-bcbe01d94c06","order_by":1,"name":"Abigail S. Baldridge","email":"","orcid":"","institution":"Northwestern University - Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abigail","middleName":"S.","lastName":"Baldridge","suffix":""},{"id":3031876,"identity":"ccc0ef57-7abc-4d93-8da8-027702e35941","order_by":2,"name":"Kasarachi Omitiran","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kasarachi","middleName":"","lastName":"Omitiran","suffix":""},{"id":3031877,"identity":"27c87fa6-f3bf-493d-b214-ac0eccec2111","order_by":3,"name":"Mainzhao Guo","email":"","orcid":"","institution":"Northwestern University - Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mainzhao","middleName":"","lastName":"Guo","suffix":""},{"id":3031878,"identity":"f69cf193-e65f-478e-bc7f-848162f468a9","order_by":4,"name":"Whenayon Simeon Ajisegiri","email":"","orcid":"","institution":"University of New South Wales","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Whenayon","middleName":"Simeon","lastName":"Ajisegiri","suffix":""},{"id":3031879,"identity":"40d218cd-173b-4419-a1e6-dd1ca3b6b9e4","order_by":5,"name":"Tunde M. Ojo","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tunde","middleName":"M.","lastName":"Ojo","suffix":""},{"id":3031880,"identity":"3f750ceb-8b1c-47b0-be37-d8cbcb98eb20","order_by":6,"name":"Gabriel Shedul","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"","lastName":"Shedul","suffix":""},{"id":3031881,"identity":"d24cc71d-4054-403a-a69c-b3db2ace22b3","order_by":7,"name":"Namratha R. Kandula","email":"","orcid":"","institution":"Northwestern University - Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Namratha","middleName":"R.","lastName":"Kandula","suffix":""},{"id":3031882,"identity":"b5389d0a-614a-4709-96a9-c24cfca81a30","order_by":8,"name":"Lisa R. Hirschhorn","email":"","orcid":"","institution":"Northwestern University - Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"R.","lastName":"Hirschhorn","suffix":""},{"id":3031883,"identity":"42832ecc-fde5-4311-9dfe-de2565e7e1ac","order_by":9,"name":"Mark D. Huffman","email":"","orcid":"","institution":"Northwestern University Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mark","middleName":"D.","lastName":"Huffman","suffix":""},{"id":3031884,"identity":"9071bcae-8fca-4c1b-b604-5823b82dc842","order_by":10,"name":"Dike B. Ojji","email":"","orcid":"","institution":"University of Abuja","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dike","middleName":"B.","lastName":"Ojji","suffix":""}],"badges":[],"createdAt":"2020-09-13 10:17:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-76952/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-76952/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-021-06320-8","type":"published","date":"2021-04-09T19:04:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2804994,"identity":"57badf6c-5aa2-496e-8fad-ba54295d6925","added_by":"auto","created_at":"2020-10-06 14:55:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89119,"visible":true,"origin":"","legend":"STROBE Site Flow Chart.","description":"","filename":"Fig1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-76952/v1/70b3710be72120c7c9f73865.JPG"},{"id":2804995,"identity":"a8e2bb78-f714-479b-a7fe-d698ea716bd5","added_by":"auto","created_at":"2020-10-06 14:55:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42876,"visible":true,"origin":"","legend":"Selected Primary Healthcare Centers within the Federal Capital Territory.","description":"","filename":"Fig2.JPG","url":"https://assets-eu.researchsquare.com/files/rs-76952/v1/88c580c0d5eafd640132be58.JPG"},{"id":2804996,"identity":"b4f43548-804a-4945-ab22-1c397a4d02f0","added_by":"auto","created_at":"2020-10-06 14:55:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":80796,"visible":true,"origin":"","legend":"Hypertension Treatment Cascade by Council Area.","description":"","filename":"Fig3.JPG","url":"https://assets-eu.researchsquare.com/files/rs-76952/v1/ab73b24baa1ae168efa49c73.JPG"},{"id":2804997,"identity":"df02eb3c-124a-4be9-b767-663736a345fb","added_by":"auto","created_at":"2020-10-06 14:55:19","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":50609,"visible":true,"origin":"","legend":"Drugs Available for 30-Day Regimens by Drug Class among Selected PHCs (n=59). ","description":"","filename":"Fig4.JPG","url":"https://assets-eu.researchsquare.com/files/rs-76952/v1/1743dc213778a969e75ff286.JPG"},{"id":13599934,"identity":"135d29e3-a1fd-4f67-b982-db21cd742c6a","added_by":"auto","created_at":"2021-09-17 05:41:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":686336,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-76952/v1/65fc906a-5c9b-46a1-aab9-49eb2027cdef.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eCapacity and Site Readiness for Hypertension Control Program Implementation in the Federal Capital Territory of Nigeria: A Cross-sectional Study\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eNigeria faces an increase in the burden of non-communicable diseases (NCDs), causing an estimated 29% of all deaths in Nigeria, including 22% of premature deaths.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Moreover, more than one-third of all NCD-related deaths in Nigeria are due to cardiovascular diseases (CVDs).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Meanwhile, hypertension is the leading modifiable risk factor for CVD-related morbidity and mortality in Nigeria.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The estimated prevalence of hypertension among adults in Nigeria, defined as blood pressure (BP) of 140/90\u0026nbsp;mm Hg or higher or taking one or more BP-lowering drug(s), ranges from 25\u0026ndash;40% of adults.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Despite this high burden, hypertension awareness (14%-30%), treatment (\u0026lt;\u0026thinsp;20%), and control (9%) rates are low.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Newer definitions of hypertension based on lower blood pressure thresholds raise these hypertension prevalence estimates even higher.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFollowing the United Nations' Sustainable Development Goals, Target 3.4, Nigeria set a national goal of reducing the risk of premature (30\u0026ndash;69\u0026nbsp;years) mortality from NCDs, including CVDs, by one-third by 2030. The country will not achieve this target without substantially better BP control delivered through Nigeria\u0026rsquo;s primary health care system, where most Nigerians receive their care.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Primary Healthcare Centers (PHCs) in low- and middle-income countries (LMICs) frequently lack system capacity for hypertension screening, diagnosis, registration of diagnosed patients, follow-up, provision of essential drugs, and treatment protocols for hypertension management.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In Nigeria, as of 2017, only 30% of PHCs reported availability of essential NCDs medicines, no PHCs had CVD management guidelines, and none offered CVD risk stratification services.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The World Health Organization (WHO) 2018 HEARTS Technical Package provides guidance for PHCs on hypertension training, diagnosis, treatment protocols, and monitoring systems to address these NCD gaps, based on the Kaiser Permanente Northern California model of hypertension care, which increased hypertension control from 44\u0026ndash;90% in the United States.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn response to these needs and context, the Hypertension Treatment in Nigeria Program (NCT04158154) aims to develop implementation pathways and intervention packages for a system-level, large-scale hypertension program adapted from WHO's HEARTS and the Kaiser Permanente Northern California model to improve hypertension diagnosis, treatment, and control rates among patients attending public PHCs in the Federal Capital Territory of Nigeria.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e During the formative phase of this Program, we performed facility-based capacity and readiness assessments among participating PHCs in the Federal Capital Territory of Nigeria to inform the implementation and adaptation strategies for a system-level hypertension control program. These activities were implemented in collaboration with key partners, including the Federal Ministry of Health in Nigeria, Federal Capital Territory Primary Health Care Board, WHO Nigeria office, and Resolve to Save Lives.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurvey Adaptation\u003c/h2\u003e \u003cp\u003eThis formative study used an adaptation of the Service Availability and Readiness Assessment (SARA) tool to assess 60 PHCs across the six area councils of the Federal Capital Territory in Nigeria (the adapted tool is available at doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18131/g3-rknh-rr75\u003c/span\u003e\u003c/span\u003e). The WHO designed the SARA tool to assess health facilities\u0026rsquo; availability and readiness to offer the services to inform the evidence-based decision to plan and manage the health systems.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e It generates a set of core indicators on the health system's critical inputs and outputs to measure the health system strengthening over time. There are three main domains: 1) service availability, 2) general service readiness, and 3) service-specific readiness.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe research team adapted the SARA tool with input from the NCD divisions of the WHO Nigeria, Nigeria Federal Ministry of Health, and other relevant stakeholders, including the Federal Capital Territory Primary Health Care Board and Federal Capital Territory Public Health Department; to focus on non-communicable diseases diagnosis, treatment, and management, specifically hypertension and diabetes. The SARA tool has 13 sections: 1) service availability, 2) patient access, 3) staffing capacity, 4) infrastructure, 5) basic client amenities, 6) infection control, 7) healthcare waste management, 8) clinical mentoring, 9) basic equipment, 10) available services for non-communicable diseases and diagnostics, 11) supply chain, 12) medicines and vaccines, and 13) commodities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSite Selection\u003c/h2\u003e \u003cp\u003eWe identified all (n\u0026thinsp;=\u0026thinsp;243) public PHCs within the six council areas and 62 wards in the Federal Capital Territory of Nigeria. Health facility-level characteristics, including the number of staff, the cadre of staff, the mean number of hypertension cases per month, and the number of bed spaces (if applicable), were collected from each PHC. Facilities with a ward focal person (i.e., a community health extension worker with a supervisory role over other PHCs in the ward) and facilities receiving basic healthcare provision funds from the federal government were enumerated to account for these factors in the sample selection process. Consistent with the SARA methodology, a sub-nationally representative sample of PHCs were selected using a multi-stage sampling process (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Some PHCs (n\u0026thinsp;=\u0026thinsp;90) were excluded from the sample based on the feasibility of study implementation and evaluation. These include the PHCs that had fewer than two paid full-time staff (n\u0026thinsp;=\u0026thinsp;77); and the ones associated with security concerns based on local knowledge (n\u0026thinsp;=\u0026thinsp;6); also those with no or poor road access (n\u0026thinsp;=\u0026thinsp;6), and the PHCs that were non-functional defined by lack of provision of patient services at the time of assessment (n\u0026thinsp;=\u0026thinsp;1). The remaining eligible PHCs (n\u0026thinsp;=\u0026thinsp;153) represented 51 wards within the Federal Capital Territory (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe research team performed the multi-stage sampling process using SAS proc survey select, with sampling weights for each of the 153 eligible PHCs proportional to the estimated mean number of patients with hypertension seen at each PHC per month. The sampling process included three steps: 1) Identification of sites (n\u0026thinsp;=\u0026thinsp;37 PHCs) that housed a ward focal person (i.e., a healthcare worker with a supervisory responsibility across the ward), and one PHC with a ward focal person from each ward was randomly sampled (n\u0026thinsp;=\u0026thinsp;36 PHCs in 36 wards); 2) within the remaining 15 wards (n\u0026thinsp;=\u0026thinsp;38 PHCs) with no ward focal person in any PHC, one site per ward was randomly sampled (n\u0026thinsp;=\u0026thinsp;15 PHCs, in 15 wards); and 3) within the remaining PHCs (n\u0026thinsp;=\u0026thinsp;102 PHCs), the team randomly sampled sites from the Abuja Municipal (n\u0026thinsp;=\u0026thinsp;6 PHCs), Gwagwalada (n\u0026thinsp;=\u0026thinsp;2 PHCs), and Kuje (n\u0026thinsp;=\u0026thinsp;1 PHCs) area councils to approximate geographic representation by population density.\u003c/p\u003e \u003cp\u003eThe researchers contacted selected sites to confirm their willingness to participate in the Hypertension Treatment in Nigeria Program, including a baseline SARA assessment and interview; all sites confirmed willingness to participate. They traveled to each selected PHC to invite and obtain written informed consent from the highest-level site staff or officer-in-charge and unit heads of nursing, pharmacy, and laboratory domains, to perform interviews and site assessment. The overall assessment included directly observing operations, equipment, medications, and supplies present at the site on the day of the interview. The research team completed all SARA interviews by speaking directly with the site staff to respond to survey questions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eGraphical representations were used to assess the facility-based capacity and readiness for hypertension diagnosis and treatment. Continuous measures were summarized by mean and standard deviation, or median and interquartile range if non-parametrically distributed. Readiness and capacity were assessed based on domains of interest, including personnel, general service delivery, and cardiovascular service delivery in the hypertension treatment cascade, equipment and supplies, information systems, and blood pressure-lowering medications. Indicator scores for general and cardiovascular service readiness were calculated based on the proportion of sites with available amenities, equipment, diagnostic tests, or medicines within the SARA defined question bank. For statistical analysis, the study team used SAS version 9.4 (SAS, Cary, NC, USA) and R version 3.5.1 (R Foundation, Vienna, Austria)\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe team completed SARA assessments at all (n\u0026thinsp;=\u0026thinsp;60) PHCs between May 2019 \u0026ndash; October 2019. Among 60 participating PHCs, 36 had a ward focal person, and 34 were sites of interest to the Federal Capital Territory Primary Health Care Board as target facilities for investments to achieve universal health coverage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStaff and Service Delivery\u003c/h2\u003e \u003cp\u003eStaffing levels, based on full or part-time status, and service delivery were tabulated based on interviews with the officer in charge. Most PHCs (n\u0026thinsp;=\u0026thinsp;54; 90%) had sufficient human resource capacity according to the self-report of two or more full-time staff (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median (interquartile range [IQR]) number of full-time staff was 5 (3\u0026ndash;8), and predominantly comprised community health extension workers (CHEWs; median\u0026thinsp;=\u0026thinsp;3; IQR 2\u0026ndash;5) and nurses (median\u0026thinsp;=\u0026thinsp;1; IQR 0\u0026ndash;2). Few (n\u0026thinsp;=\u0026thinsp;8; 15%) sites received any training to diagnose and manage cardiovascular diseases within the previous two years. Nearly all PHCs (n\u0026thinsp;=\u0026thinsp;58, 97%) had sufficient capacity for screening, and most had capacity for diagnosis (n\u0026thinsp;=\u0026thinsp;56; 93%) and confirmation (n\u0026thinsp;=\u0026thinsp;50; 83%) of hypertension. Over half had capacity for dispensing initial (n\u0026thinsp;=\u0026thinsp;34; 57%) or follow-up (n\u0026thinsp;=\u0026thinsp;34; 57%) blood pressure-lowering medications and for providing long-term continued care (n\u0026thinsp;=\u0026thinsp;36; 60%) for patients with hypertension.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e demonstrates the hypertension treatment cascade components across the Federal Capital Territory's six area councils, from screening and diagnosis to monitoring and long-term care. Among the components, the highest rates were related to screening and diagnosis across all area councils and were highest in Bwari. The lowest rates were related to dispensing initial treatment regimen, follow-up treatment, and long-term care overall, with the lowest rates in Bwari.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGeneral and Cardiovascular Service Readiness\u003c/h2\u003e \u003cp\u003eAcross the six area councils within the FCT, variability in general service readiness indicator scores for basic amenities, equipment, infection prevention, diagnostic capacity, and essential medicines were found (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Cardiovascular service availability was consistently high within the six area councils of the Federal Capital Territory (i.e., Abaji, Abuja Municipal Area Council [AMAC], Bwari, and Gwagwalada wards); all the PHCs reported offering cardiovascular disease diagnosis and management services. However, the study demonstrated wide variability in cardiovascular service readiness indicator scores for the presence of guidelines, equipment, and medicines. The Bwari area council consistently had the highest indicator score across general and cardiovascular domains, ranging from 29.2% for general essential medicines to 100% for equipment and cardiovascular service availability. Essential cardiovascular medicines scores, based on the availability of calcium channel blockers, aspirin, beta-blockers, ACE-I, statins, or thiazides, were low in comparison to other domains and were very low for hypertension medicines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEquipment, Supplies, \u0026amp; Information Systems\u003c/h2\u003e \u003cp\u003eEquipment, supplies, and information systems were assessed in consultation with the officer-in-charge and staff in charge of medical records and data and based on direct observation to determine the availability and function of equipment on the day of assessment. Few PHCs had guidelines (n\u0026thinsp;=\u0026thinsp;7; 13%), treatment algorithms (n\u0026thinsp;=\u0026thinsp;3; 5%), or information materials (n\u0026thinsp;=\u0026thinsp;1; 2%) for hypertension diagnosis or management within the clinic on the day of assessment. Most sites (n\u0026thinsp;=\u0026thinsp;55; 92%) had at least one functional BP apparatus present. All sites relied on paper-based longitudinal records, and relatively few had a functional computer (n\u0026thinsp;=\u0026thinsp;10; 17%) or access to the internet or email (n\u0026thinsp;=\u0026thinsp;5; 8%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMedications\u003c/h2\u003e \u003cp\u003eHypertension medications were tabulated based on direct observation of the pharmaceutical inventory against record logs, where available. The adapted SARA tool classified medications into broad classes. Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e reported the number of 30-day treatment regimens available on the day of assessment by class. At one site, the pharmaceutical inventory was not accessible on the day of the visit. The most commonly stocked medications were calcium channel blockers (n\u0026thinsp;=\u0026thinsp;19; 32%), followed by diuretics (n\u0026thinsp;=\u0026thinsp;15; 25%), central acting agents (n\u0026thinsp;=\u0026thinsp;11; 19%), and angiotensin-converting enzyme inhibitors (ACE-I; n\u0026thinsp;=\u0026thinsp;10; 17%). Despite their inclusion on the WHO and Nigeria essential medicines lists, few PHCs (n\u0026thinsp;=\u0026thinsp;4; 7%) had fixed-dose combinations for hypertension treatment. The median (IQR) number of 30-day treatment regimens of all blood pressure-lowering medications in stock on the day of assessment was 0 (0\u0026ndash;20) regimens, and 35 (59%) PHCs had zero 30-day treatment regimens of BP-lowering medication in stock.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eWhile Nigeria has set a national goal of reducing the risk of premature (30\u0026ndash;69\u0026nbsp;years) mortality from NCDs, including CVDs, by one-third by 2030, the country has not fully translated into action within the PHCs, necessary components to implement a system-level hypertension service. Although cardiovascular service availability is high in the Federal Capital Territory, there is wide variability in readiness to provide these services identified, including the presence of guidelines, equipment, and medicines. We demonstrated the feasibility of implementing the Hypertension Treatment in Nigeria Program based on the workforce, equipment, and paper-based information systems, but identified critical needs for health worker training, protocol implementation, and essential medicine supply strengthening for hypertension treatment and control.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStaff and Service Delivery\u003c/h2\u003e \u003cp\u003eOur study shows that full-time staff members were primarily CHEWs and nurses, who comprise the cadre of non-physician health workers needed to provide service delivery in community-based care. PHCs need qualified, trained staff to implement an effective task-shifting strategy for improved NCDs management, including hypertension.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Our benchmark of including PHCs with at least two full-time staff as sufficient human resource capacity for implementing the Hypertension Treatment in Nigeria Program aligns closely with the minimum number of CHEWs required to operate a PHC.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The relatively large number of non-physician health workers in PHCs in this study, including CHEWs, may be partially attributed to the cumulative density of schools of health technology, which are training institutions for CHEWs in Nasarawa, Kogi, Kaduna, and Niger states, that share boundary with the Federal Capital Territory.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e This contrasts with the 2018 report from Garcia de Quevedo et al., who identified limited NCDs workforce as a challenge in Mozambique, Colombia, and the Dominican Republic based on the high rate of temporary contract workers for NCD-related care.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Moucheraud reported low staff and training readiness scores for NCD diagnosis and management using Service Provision Assessment surveys across PHCs in Bangladesh (24%), Haiti (29%), Malawi (18%), Nepal (4%), and Tanzania (12%),\u003csup\u003e17\u003c/sup\u003e signifying that low staff and service delivery readiness is common throughout LMICs. These differences between the current study and data reported by Garcia de Quevedo et al. and Moucheraud are due, at least in part, to the current study's inclusion criterion of PHCs with at least two full-time health workers for Hypertension Treatment in Nigeria Program implementation. While staff in the current study were integrated into the broader PHC delivery system in Nigeria, they also had responsibilities beyond hypertension and NCDs.\u003c/p\u003e \u003cp\u003eWe identified substantial gaps in training for diagnosing and managing CVDs, including gaps in standing orders for CHEW-based CVD- and hypertension-related care, unlike other chronic conditions such as human immunodeficiency virus (HIV). Lack of adequate staff training is a recurring challenge in health program implementation in LMICs.\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e These results inform initial training and longitudinal re-training activities before and during the Hypertension Treatment implementation in Nigeria Program, given the fundamental need for training and supportive supervision. Further investments in staff and staff training and development and implementation of standing orders for managing CVD and hypertension may be needed to keep pace with these conditions' growing burden.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eService Readiness\u003c/h2\u003e \u003cp\u003eIn terms of general service readiness, the domains of basic equipment, infection prevention, and diagnostic capacity reported across all area councils revealed that more than half of facilities met general readiness criteria. Meeting these criteria may have been influenced by federal and local government support and commitments for other disease control programs in these PHCs, including maternal and child health. In terms of basic amenities (e.g., portable water, toilet facility, power supply), only two out of six area councils had more than half of their PHCs meeting the criteria. Further, essential medicine provision indices were low across all the area councils, demonstrating the heterogeneous investments in capital-intensive infrastructure. According to Oyekale et al.,\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e the effective delivery of healthcare services at the PHC system requires adequate infrastructure, diagnostic medical equipment, essential medicines, and well-trained health workers. Therefore, there is a need to strengthen service readiness for effective Hypertension Treatment in Nigeria Program service delivery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEquipment, Supplies, \u0026amp; Information Systems\u003c/h2\u003e \u003cp\u003eWe found low availability of guidelines, treatment algorithms, and information materials for hypertension, similar to previous reports in other sub-Saharan African countries, including Tanzania.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e We found that while most sites had at least one functional BP apparatus, only a few PHCs had hypertension guidelines, treatment algorithms, information, education, and communication materials. These results also underscore the importance of Nigeria\u0026rsquo;s Federal Ministry of Health's recent steps to integrate the WHO-recommended Package of Essential NCD interventions (PEN) into PHCs in collaboration with crucial stakeholders, \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e to address this gap. Although few PHCs had computers or internet access available onsite with no sites reporting electronic patient records, Nigeria\u0026rsquo;s PHCs generally have a well-developed paper-based information management system for programs like HIV infection, antenatal care, and family planning, which can be leveraged for the treatment of hypertension and other NCDs. Substantial investments in infrastructure, hardware, software, secure internet access, and training will be needed to upgrade to an electronic data management system to achieve the WHO's four functions of health information systems: 1) data generation, 2) compilation, 3) analysis and synthesis, and 4) communication and use within care teams and patients.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Our results are similar to reports of lower availability of CVDs guidelines and higher availability of equipment for CVDs among health facilities in LMICs,\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e but differ from other findings which describe lack of essential equipment as a critical barrier to providing quality NCDs services at the primary care level.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMedications\u003c/h2\u003e \u003cp\u003eWe found that while most PHCs had sufficient capacity for screening, diagnosis, and confirmation of hypertension, more than half of them did not have any 30-day treatment regimens of blood pressure-lowering medicines with significant variability across area councils. This finding is similar to that of Moucheraud et al.,\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e who reported that most facilities in LMICs studied had limited essential cardiovascular medicines. Low availability of cardiovascular medicines at PHCs has also been reported in other LMICs such as Tanzania (25\u0026ndash;40%), Bangladesh (30%), Nepal (28%), and higher rates have been reported in Malawi (67%) and Haiti (93%).\u003csup\u003e17,22\u003c/sup\u003e Provision of essential medicines for hypertension is generally a challenge within PHC systems in sub-Saharan Africa. The scarcity of medications may be explained by a lack of government-supported programs for NCDs within PHC systems. There are opportunities for support, mainly through strengthening drug revolving funds, which rely upon initial investments and recurring reduced out-of-pocket costs to sustain the funds and subsequent medicine supplies. Drug revolving funds may improve the availability of BP-lowering drugs in the PHCs until community insurance programs are fully funded and established.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e "},{"header":"Strengths And Limitations","content":"\u003cp\u003e Key strengths of the current study include 1) sampling frame to maximize generalizability in the Federal Capital Territory, 2) adaptation of the SARA instrument to hypertensive services and local context and topic, and 3) engagement with PHCs, and other stakeholders, including the Federal Ministry of Health. This study also has significant limitations. First, the study excluded facilities with fewer than two full-time staff and, therefore, is not representative of all PHCs in the Federal Capital Territory or all of Nigeria, limiting generalizability. Nevertheless, the Hypertension Treatment in Nigeria Program aims to improve hypertension treatment and control rates, and the presence of full-time staff is necessary for it to be effective. Besides, the SARA instrument collects cross-sectional data, and therefore temporal changes in service availability and readiness among the included PHCs were not captured. However, our team will perform annual repeated cross-sectional assessments using the adapted SARA instrument throughout the Hypertension Treatment in Nigeria Program to address this limitation. The SARA instrument is also susceptible to recall and reporting biases by deriving responses from the highest-level site staff or officer-in-charge. The research team mitigated this risk by direct observation of supplies and equipment where possible. Also, the BP-lowering drug availability estimates do not include the availability of essential medicines through private pharmacies, where out-of-pocket costs are often higher than public pharmacies.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Finally, measures of service availability and readiness may not capture the quality and experience of service provision, which have generally become a larger contributor to health loss in LMICs compared with service availability alone.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study is the first systematic assessment of capacity and readiness for a system-level hypertension control program within the Federal Capital Territory of Nigeria. We demonstrated the feasibility of implementing hypertension treatment and control based on the workforce, equipment, and existing information systems. Nevertheless, we identified critical needs for capital intensive infrastructure investments, health worker training, hypertension treatment protocol implementation, and essential medicine supply strengthening in Nigeria. These data highlight the need for upfront and longitudinal investments across health system building blocks to deliver high-quality hypertension care at PHCs in Nigeria. These investments will be critical for Nigeria\u0026rsquo;s health system to not only respond to the current and projected burden of hypertension-related diseases but also to improve its resilience in the face of other emerging health threats.\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAMAC\u003c/strong\u003e: Abuja Municipal Area Council\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACE-I\u003c/strong\u003e: Angiotensin Converting Enzyme Inhibitors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCVD\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e: Cardiovascular Diseases\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCHEW\u003c/strong\u003e: Community Health Extension Worker\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFCT\u003c/strong\u003e: Federal Capital Territory\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHEARTS\u003c/strong\u003e: \u003ca href=\"https://apps.who.int/iris/bitstream/handle/10665/260422/WHO-NMH-NVI-18.1-eng.pdf?sequence=1\"\u003e\u003cstrong\u003eH\u003c/strong\u003eealthy-lifestyle counselling\u003c/a\u003e; \u003ca href=\"http://apps.who.int/iris/bitstream/10665/260421/1/WHO-NMH-NVI-18.2-eng.pdf?ua=1\"\u003e\u003cstrong\u003eE\u003c/strong\u003evidence-based treatment protocols\u003c/a\u003e; \u003ca href=\"http://apps.who.int/iris/bitstream/10665/260420/1/WHO-NMH-NVI-18.3-eng.pdf?ua=1\"\u003e\u003cstrong\u003eA\u003c/strong\u003eccess to essential medicines and technology\u003c/a\u003e; \u003ca href=\"https://apps.who.int/iris/bitstream/handle/10665/333221/9789240001367-eng.pdf\"\u003e\u003cstrong\u003eR\u003c/strong\u003eisk-based CVD management;\u0026nbsp;\u003c/a\u003e\u003ca href=\"http://apps.who.int/iris/bitstream/10665/260424/1/WHO-NMH-NVI-18.4-eng.pdf?ua=1\"\u003e\u003cstrong\u003eT\u003c/strong\u003eeam-based care\u003c/a\u003e; \u003ca href=\"http://apps.who.int/iris/bitstream/10665/260423/1/WHO-NMH-NVI-18.5-eng.pdf?ua=1\"\u003e\u003cstrong\u003eS\u003c/strong\u003eystems for monitoring\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIV\u003c/strong\u003e: Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e: Inter-Quartile Range\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMICs\u003c/strong\u003e: Low-and Middle-Income Countries\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNCDs\u003c/strong\u003e: Non-Communicable Diseases\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePEN\u003c/strong\u003e: Package of Essential NCD interventions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHC\u003c/strong\u003e: Primary Healthcare Center\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSARA\u003c/strong\u003e: Service Availability and Readiness Assessment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants in this study. The study was reviewed by the Northwestern University Institutional Review Board and Health Research Ethics Committees of University of Abuja Teaching Hospital and Federal Capital Territory (FHREC/2019/01/03/16-01-19). All procedures followed were in accordance with the ethical standards of the ethics committees and institutional review board and the Helsinki Declaration of 1975, as revised in 2000.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Huffman reports grants from American Heart Association, Verily, AstraZeneca, personal fees from American Medical Association, outside the submitted work. The George Institute for Global Health has a patent, license, and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. All other authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by National Heart Lung and Blood Institutes grant #R01HL144708. The funding body had no direct role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDesign and concept of study: MDH, DO; Acquisition of data: SA, AB, MG, LH, MH, NK, DO, TO, KO, IO, GS; Data analysis and interpretation: AB, MG, IO; Manuscript draft: AB, LH, MH, NK, DO, TO, KO, IO, GS; Statistical expertise: AB; Acquisition of funding: MH, DO; Administrative: AB, MG; Supervision: MDH, DO. All the authors have read and approved this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by National Heart Lung and Blood Institutes grant #R01HL144708. We are very appreciative to Regina Asuku, Charity Akor, Confidence Joseph-Alo, Elizabeth Nggada Bosede and Dr. Helen Eze for assistance with data collection and management. We would like to thank the clinicians who oversee the participating PHCs as well as those who participated in the patients\u0026rsquo;/Health-workers\u0026rsquo; interviews, including: Dr. Joel Abu, Dr. Haruna Abubakar, Dr. Blessing Akor, Dr. Nana Ripiye, Dr. Odo Emmanuel, Dr. Douglas Okoye, Dr. Okpetu Emmanuel, Dr. Christian Ukeh, Dr. Dorothy Ihegazie, Dr. Archibong U. Christine, Dr. Osuji Alice, Dr. Mercy U. Ikechukwu-Orji, Dr. Egenti Nonye and Dr. Rosemary Okoli.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Information (Optional):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eReliefweb.Nigeria Fulfils Commitment, launches Plan for the Prevention and Control of Non-Communicable Diseases. United Nations Office for the Coordination of Humanitarian Affairs (OCHA) services;2019 Aug 07. \u003ca href=\"https://reliefweb.int/report/nigeria/nigeria-fulfils-commitment-launches-plan-prevention-and-control-non-communicable\"\u003ehttps://reliefweb.int/report/nigeria/nigeria-fulfils-commitment-launches-plan-prevention-and-control-non-communicable\u003c/a\u003e. Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003eOgah OS, Okpechi I, Chukwuonye II, Akinyemi JO, Onwubere BJ, Falase AO et al. Blood pressure, prevalence of hypertension and hypertension related complications in Nigerian Africans: A review. World J Cardiol. 2012 Dec 26;4(12):327-340. doi: 10.4330/wjc.v4.i12.327.\u003c/li\u003e\n\u003cli\u003eAdeloye D, Basquill C, Aderemi AV, Thompson JY, Obi FA. An estimate of the prevalence of hypertension in Nigeria: a systematic review and meta-analysis. J Hypertens. 2015;33(2):230-242.\u003c/li\u003e\n\u003cli\u003eWhelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 Jun;71(19):2199-2269. doi: 10.1161/HYP.0000000000000066.\u003c/li\u003e\n\u003cli\u003eSacco RL, Roth GA, Reddy KS, Arnett DK, Bonita R, Gaziano TA, et al. The heart of 25 by 25: achieving the goal of reducing global and regional premature deaths from cardiovascular diseases and stroke: a modeling study from the American Heart Association and World Heart Federation. Circulation. 2016 Jun 7;133(23): e674-690. doi: 10.1161/CIR.0000000000000395.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. High Blood Pressure and the Role of Primary Health Care. \u003ca href=\"http://www.emro.who.int/media/world-health-day/phc-factsheet-2013.html\"\u003ehttp://www.emro.who.int/media/world-health-day/phc-factsheet-2013.html\u003c/a\u003e (c2020). Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Noncommunicable Diseases (NCD) Country Profiles, Nigeria. \u003ca href=\"https://www.who.int/nmh/countries/nga_en.pdf\"\u003ehttps://www.who.int/nmh/countries/nga_en.pdf\u003c/a\u003e (c2018). Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003eJaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013 Aug 21; 310(7):699-705. doi: 10.1001/jama.2013.108769.\u003c/li\u003e\n\u003cli\u003eJaffe MG, Young JD. The Kaiser Permanente Northern California Story: improving hypertension control from 44% to 90% in 13 years (2000 to 2013). J Clin Hypertens (Greenwich). 2016 Apr;18 (4):260-261. doi: 10.1111/jch.12803.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Health statistics and information systems. Service availability and readiness assessment (SARA). https://www.who.int/healthinfo/systems/sara_introduction/en (c2020). Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Service Availability and Readiness Assessment (SARA): an annual monitoring system for service delivery. Geneva, Switzerland. \u003ca href=\"https://www.who.int/healthinfo/systems/SARA_Reference_Manual_Full.pdf\"\u003ehttps://www.who.int/healthinfo/systems/SARA_Reference_Manual_Full.pdf\u003c/a\u003e (c2013). Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003eSheffel A, Karp C, Creanga AA. Use of Service Provision Assessments and Service Availability and Readiness Assessments for monitoring quality of maternal and newborn health services in low-income and middle-income countries. BMJ Glob Health. 2018 Nov 26;3(6):e001011. doi:10.1136/ bmjgh-2018-001011\u003c/li\u003e\n\u003cli\u003eJoshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task shifting for non-communicable disease management in low and middle income countries--a systematic review. PLoS One. 2014 Aug 14;9(8):e103754. doi: 10.1371/journal.pone.0103754.\u003c/li\u003e\n\u003cli\u003eNational Primary Health Care Development agency Publications: PHC Guideline. Operational manual and guideline for development of primary health. http://nphcda.gov.ng/publications (c2020). Accessed 2020 Apr 16.\u003c/li\u003e\n\u003cli\u003eAbdulwali Yahaya. Full list of schools of health technology in Nigeria 2020. Nigerian infopedia. 2019 Nov 13. https://nigerianinfopedia.com.ng/full-list-of-schools-of-health-technology-in-nigeria. Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003eGarcia de Quevedo I, Lobelo F, Cadena L, Soares M, Pratt M. A comprehensive capacity assessment tool for non-communicable diseases in low- to middle-income countries: development and results of pilot testing. Glob Health Promot. 2018 Mar;25(1):43-53. doi: 10.1177/1757975916647008.\u003c/li\u003e\n\u003cli\u003eMoucheraud C. Service Readiness for noncommunicable diseases was low in five countries in 2013-15. Health Aff (Millwood). 2018 Aug;37(8):1321-1330. doi: 10.1377/hlthaff.2018.0151.\u003c/li\u003e\n\u003cli\u003eBintabara D, Mpondo BCT. Preparedness of lower-level health facilities and the associated factors for the outpatient primary care of hypertension: Evidence from Tanzanian national survey. PLoS One. 2018 Feb 15;13(2):e0192942. doi: 10.1371/journal.pone.0192942.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"19\"\u003e\n\u003cli\u003eOyekale AS. Assessment of primary health care facilities' service readiness in Nigeria. BMC Health Serv Res. 2017;17(1):172. https://doi.org/10.1186/s12913-017-2112-8.\u003c/li\u003e\n\u003cli\u003eLeung C, Aris E, Mhalu A, Siril H, Christian B, Koda H, et al. Preparedness of HIV care and treatment clinics for the management of concomitant non-communicable diseases: a cross-sectional survey. BMC Public Health. 2016;16(1):1002. https://doi.org/10.1186/s12889-016-3661-1\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO and Nigerian government move to curb cardiovascular diseases. 2019, October 7. \u003ca href=\"https://www.afro.who.int/news/who-and-nigerian-government-move-curb-cardiovascular-diseases\"\u003ehttps://www.afro.who.int/news/who-and-nigerian-government-move-curb-cardiovascular-diseases\u003c/a\u003e (c2020). Accessed 16 Apr 2020.\u003c/li\u003e\n\u003cli\u003ePeck R, Mghamba J, Vanobberghen F, Kavishe B, Rugarabamu V, Smeeth L, et al. Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey. Lancet Glob Health. 2014 May;2(5):e285-292. doi:\u0026nbsp;\u003ca href=\"https://dx.doi.org/10.1016%2FS2214-109X(14)70033-6\"\u003e10.1016/S2214-109X(14)70033-6\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eUzochukwu BS, Onwujekwe OE, Akpala CO. Effect of the Bamako-Initiative drug revolving fund 23 on availability and rational use of essential drugs in primary health care facilities in south-east Nigeria. Health Policy Plan. 2002;17(4):378-383.\u003c/li\u003e\n\u003cli\u003eWirtz VJ, Hogerzeil HV, Gray AL, Bigdeli M, de Joncheere CP, Ewen MA, et al. Essential medicines for universal health coverage. Lancet. 2017 Jan 28;389(10067):403-476. DOI:\u0026nbsp;\u003ca href=\"https://doi.org/10.1016/s0140-6736(16)31599-9\"\u003e10.1016/S0140-6736(16)31599-9\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eKruk ME, Gage AD, Arsenault C, Jordan K, \u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/?term=Leslie+HH\u0026amp;cauthor_id=30196093\"\u003eLeslie\u003c/a\u003e HH, \u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/?term=Roder-DeWan+S\u0026amp;cauthor_id=30196093\"\u003eRoder-DeWan\u003c/a\u003e S, et al. High- quality health systems in Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018 Nov;6(11): e1196-e1252. DOI:\u0026nbsp;\u003ca href=\"https://doi.org/10.1016/s2214-109x(18)30386-3\"\u003e10.1016/S2214-109X(18)30386-3\u003c/a\u003e26. Kruk ME, Ling EJ, Bitton A, \u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/?term=Cammett+M\u0026amp;cauthor_id=28536191\"\u003eCammett\u003c/a\u003e M, Cavanaugh K, Chopra M, et al. Building resilient health systems: a proposal for a resilience index. BMJ. 2017 May 23;357:j2323. doi: 10.1136/bmj.j2323.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. \u003c/strong\u003eCapacity and Readiness in Federal Capital Territory, Nigeria, for Implementing System-Level Hypertension Control Program within 60 Primary Healthcare Centers.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003e\u003cstrong\u003eSite Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo. Sites Responded\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003ePersonnel and Training\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eSites with two or more full-time staff,\u003csup\u003e a\u003c/sup\u003e n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e54 (90)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eNumber of full-time healthcare professionals, median (IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e5 (3-8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFull-time community health extension workers, median (IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e3 (2-5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFull-time nurses, median (IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e1 (0-2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFull-time doctors (generalists and specialists), median (IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0 (0-0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eReceived CVD training within the past two years, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e8 (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eHypertension Service Delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eScreen for hypertension status, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e58 (97)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eDiagnose hypertension, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e56 (93)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eConfirm hypertension diagnosis, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e50 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eDispense initial treatment for hypertension, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e34 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eDispense follow-up treatment for hypertension, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e34 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eMonitor patients with hypertension, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e48 (80)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eProvide long term care for patients with hypertension, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e36 (60)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eEquipment and Supplies for Hypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eGuidelines, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e7 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eTreatment algorithms, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e3 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eInformation, education, and communication, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e1 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFunctional blood pressure apparatus, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e55 (92)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eInformation Systems\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eUse of electronic patient records, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFunctional landline phone, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e13 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFunctional cellular phone, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e29 (48)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFunctional computer, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e10 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eAccess to email or internet, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e5 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eAvailability of Blood Pressure Lowering Medications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eAngiotensin Converting Enzyme Inhibitor, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e10 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eAngiotensin Receptor Blocker, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e3 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eBeta Blocker, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e5 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eCalcium Channel Blocker, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e19 (32)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eCentral acting agent, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e11 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eFixed Dose Combinations, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e4 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eDiuretic,\u003csup\u003eb\u003c/sup\u003e n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e15 (25)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eVasodilator, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e4 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eNumber of 30-day treatment regimens in stock, median (IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0 (0-20)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"474\"\u003e\n\u003cp\u003eNo 30-day treatment regimens in stock, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e35 (59)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eIncluding all reported full-time clinicians or paramedics, nursing professionals, pharmacists, laboratory technicians, community health extension workers, and community health officers.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eIncluding furosemide, spironolactone, thiazide or other diuretic.\u003c/p\u003e\n\u003cp\u003eCVD, Cardiovascular Disease; IQR, Inter-Quartile Range\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. \u003c/strong\u003eGeneral and Cardiovascular Disease Service Availability and Readiness Indicators for 60 Primary Healthcare Center in the Federal Capital Territory, Nigeria.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"255\"\u003e\n\u003cp\u003e\u003cstrong\u003eService Availability and Readiness Indicator\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"7\" width=\"445\"\u003e\n\u003cp\u003e\u003cstrong\u003eLocal Government Area Council\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u003cstrong\u003eAbaji\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n=8)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e\u003cstrong\u003eAMAC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n=15)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e\u003cstrong\u003eBwari\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n=8)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u003cstrong\u003eGwagwalada\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n=11)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e\u003cstrong\u003eKuje\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n=8)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003eKwali\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n=10)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"701\"\u003e\n\u003cp\u003eGeneral Service Readiness\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eBasic Amenities\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e52.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e48.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e56.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e43.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e41.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e28.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eBasic Equipment\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e67.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e80.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e100.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e70.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e57.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e74.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eInfection Prevention\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e93.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e56.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e81.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e68.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e75.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e90.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eDiagnostic Capacity\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e59.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e83.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e90.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e61.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e62.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e62.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eEssential Medicines\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e6.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e24.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e29.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e13.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e6.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e5.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"701\"\u003e\n\u003cp\u003eCardiovascular Disease Service Availability\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eAvailability\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"83\"\u003e\n\u003cp\u003e100.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e100.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e100.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e100.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e87.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e90.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"701\"\u003e\n\u003cp\u003eCardiovascular Disease Readiness Indicators\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eGuidelines\u003csup\u003eh\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e12.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e20.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eEquipment\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e70.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e84.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e69.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e66.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e73.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eMedicines\u003csup\u003ej\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e7.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"73\"\u003e\n\u003cp\u003e28.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e30.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e16.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e7.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e6.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"255\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eThe item \"Room with auditory and visual privacy for patient consultations\" was not included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003eThe item \u0026ldquo;Child scale\u0026rdquo; was not included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ed\u003c/sup\u003eThe items \u0026ldquo;Safe final disposal of infectious wastes\u0026rdquo;, \u0026ldquo;Appropriate storage of sharps waste\u0026rdquo;, \u0026ldquo;Appropriate storage of infectious waste\u0026rdquo;, \u0026ldquo;Disinfectant\u0026rdquo;, \u0026ldquo;Single use \u0026mdash;standard disposable or auto-disable syringes\u0026rdquo;, \u0026ldquo;Soap and running water or alcohol-based hand rub\u0026rdquo; and \u0026ldquo;Latex gloves\u0026rdquo; were not included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ee\u003c/sup\u003eThe items \u0026ldquo;Malaria diagnostic capacity\u0026rdquo;, \u0026ldquo;HIV diagnostic capacity\u0026rdquo;, \u0026ldquo;Syphilis rapid test\u0026rdquo; and \u0026ldquo;Urine test for pregnancy\u0026rdquo; were not included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ef\u003c/sup\u003eItems \"CCB\", \"Aspirin\", \"Beta Blockers\", \"ACE\", \"Statin\" and \"Thiazide\" were included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eg\u003c/sup\u003eCalculated as the proportion of facilities offering cardiovascular disease diagnosis and/or management.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eh\u003c/sup\u003eThe item \u0026ldquo;guidelines for diagnosis and treatment of chronic cardiovascular conditions\u0026rdquo; was included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ei\u003c/sup\u003eThe items \u0026ldquo;Stethoscope\u0026rdquo;, \u0026ldquo;Blood pressure apparatus\u0026rdquo; and \u0026ldquo;Adult scale\u0026rdquo; were included.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ej\u003c/sup\u003eThe items \"CCB\", \"Aspirin\", \"Beta Blockers\", \"ACE\" and \"Thiazide\u0026rdquo; were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Nigeria, primary health care, capacity, readiness","lastPublishedDoi":"10.21203/rs.3.rs-76952/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-76952/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Nigeria faces an increase in the burden of non-communicable diseases (NCDs), including cardiovascular diseases (CVDs), leading to an estimated 29% of all deaths in the country. Nigeria has an estimated hypertension prevalence ranging from 25% to 40% of her adult population. Despite this high burden, awareness (14-30%),\u003csup\u003e \u003c/sup\u003etreatment (\u0026lt;20%), and control (9%) rates of hypertension are low in Nigeria. Against this backdrop, we sought to perform capacity and readiness assessments of public Primary Healthcare Centers (PHCs) to inform Nigeria's system-level hypertension control program's implementation and adaptation strategies.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The study employed a multi-stage sampling to select 60 from the 243 PHCs in the Federal Capital Territory (FCT) of Nigeria. The World Health Organization (WHO) Service Availability and Readiness Assessment was adapted to focus on hypertension diagnosis and treatment and was administered to PHC staff from May 2019 – October 2019. Indicator scores for general and cardiovascular service readiness were calculated based on the proportion of sites with available amenities, equipment, diagnostic tests, and medications. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Median (interquartile range [IQR]) number of full-time staff was 5 (3-8), and were predominantly community health extension workers (median = 3 [IQR 2-5]). Few sites (n=8; 15%) received cardiovascular disease diagnosis and management training within the previous two years, though most had sufficient capacity for screening (n=58; 97%), diagnosis (n=56; 93%), and confirmation (n=50; 83%) of hypertension. Few PHCs had guidelines (n=7; 13%), treatment algorithms (n=3; 5%), or information materials (n=1; 2%) for hypertension. Most sites (n=55; 92%) had one or more functional blood pressure apparatus. All sites relied on paper records, and few had a functional computer (n=10; 17%) or access to internet (n=5; 8%). Despite inclusion on Nigeria’s essential medicines list, 35 (59%) PHCs had zero 30-day treatment regimens of any blood pressure-lowering medications in stock. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: This first systematic assessment of capacity and readiness for a system-level hypertension control program within the FCT of Nigeria demonstrated implementation feasibility based on the workforce, equipment, and paper-based information systems, but a critical need for essential medicine supply strengthening, health-worker training, and protocols for hypertension treatment and control in Nigeria.\u003c/p\u003e","manuscriptTitle":"Capacity and Site Readiness for Hypertension Control Program Implementation in the Federal Capital Territory of Nigeria: A Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-06 14:55:17","doi":"10.21203/rs.3.rs-76952/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-02-10T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-05T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nI had the pleasure of reviewing this manuscript titled \"Capacity and site readiness for hypertension control program implementation in the federal capital territory of Nigeria: a cross-sectional study\". I found the manuscript to be clearly written, the study to have been rigorously performed, and the results clearly described. Overall, I think this is an excellent paper that other researchers and governments will find useful (especially the open access to their data collection instrument) and would provide an important addition to the literature.\n\nI have just a few comments:\n\nPage 5, line 40, sentence starting with \"The WHO designed...\" is a long sentence that I found confusing. Please simplify/clarify. (minor)\n\nPage 8 and Figure 3: I do have questions about how data for some of the HTN cascade steps were collected and discerned. Specifically, the following warrant further explanation: how did the authors discern between diagnosis and confirmation of HTN (since both require the same tools); how did they discern the difference between facitlies' ability to dispense initial vs follow-up BP medications (since both utilize the same medications- unless a step-up treatment protocol is implied, in which case this needs to be mentioned)?; and how did they define the ability of facilities to provide long-term continued care for HTN? (moderate)\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-11-05T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nBackground\n\n\u003e Page 4, paragraph 2; line 29-31 first sentence; statement needs a reference.\n\u003e Please check if reference 5 is relevant to the statement specifically about Nigeria against which it is quoted (paragraph 2, line 33-38)\n\u003e Page 5, paragraph 1; line 4-6; first sentence; would be useful if a reference to Nigeria's programme (NCT04158154) is added.\n\n\nMethods\n\n\u003e Page 6; sub-section site selection; line 41-42; it would be useful to elaborate on why 77 PHCs with less than two paid full-time staff were excluded from the sampling frame. Also to specify how many PHCs with less than 2 staff members included.\n\u003e The way sampling was designed, it seems there is an over representation of PHCs with a ward focal person in the overall sample although there are more facilities without a resident ward focal person; any reason for sampling it in this way?\n\u003e As a general recommendation it would be useful to include definitions of key indicators (used in the result sections; table 1 and 2) in the methods section. It is important for reader to know these definitions as they read through the paper.\n\u003e Please spell-check the text.\n\n\nResults\n\n\u003e page 8; sub-section staff and service delivery; paragraph 1, line 31-33; its confusing at one hand to have an indicator of two or more staff members labelled as sufficient human resource capacity and at the same time excluding 77 PHCs with less than two paid full-time staff excluded from the sampling frame. This overestimates this indicator.\n\u003e page 8; sub-section staff and service delivery; line 34-38; Since this information is available it would be useful to include the proportion (number) of health facilities having at least one nurse as staff member.\n\u003e The distribution of indicators by local government area councils is useful from programme planning perspective. Since the sampling was done with a focus to differentiate among facilities with ward focal persons and with non-ward focal persons, as well as those under primary health care board or not, adding similar tables with distributions by these characteristics may add the utility of this paper for planners.\n\n\nDiscussion\n\n\u003e Page 10; line 45-47; statement needs a reference.\n\u003e Page 14; sub-section strengths and limitations; line 31 and 38-42; mentioning sampling frame as a strength and excluding facilities with less than 2 staff members as a limitation are contradictory statements.\n\u003e Page 15; sub-section strengths and limitations; line 4-9; a mention of not including availability of BP lowering medicines through private pharmacies in the estimates is not relevant as such unless the discussion include why it could be useful to include it with reference to other studies.\n\n\nConclusions\n\n\u003e It would be better to include a more elaboration of last point (page 15, line 36-42) in the discussion section with reference(s). usually no references are included for conclusions as they mainly summarise what has already been included in the discussion section.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-10-27T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-08T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-10-07T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-09-23T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-23T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-22T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-22T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5a95dd7-74ee-406f-9661-2d3f5a8e0f59","owner":[],"postedDate":"October 6th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":691979,"name":"Health Economics \u0026 Outcomes Research"},{"id":691980,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-08-18T19:20:26+00:00","versionOfRecord":{"articleIdentity":"rs-76952","link":"https://doi.org/10.1186/s12913-021-06320-8","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2021-04-09 19:04:52","publishedOnDateReadable":"April 9th, 2021"},"versionCreatedAt":"2020-10-06 14:55:17","video":"","vorDoi":"10.1186/s12913-021-06320-8","vorDoiUrl":"https://doi.org/10.1186/s12913-021-06320-8","workflowStages":[]},"version":"v1","identity":"rs-76952","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-76952","identity":"rs-76952","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}