Addressing Priority Gaps in Access and Quality of NCD Services in Primary Care Settings in Rural Kenya: A Participatory Approach to Intervention Development

Addressing Priority Gaps in Access and Quality of NCD Services in Primary Care Settings in Rural Kenya: A Participatory Approach to Intervention Development | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Addressing Priority Gaps in Access and Quality of NCD Services in Primary Care Settings in Rural Kenya: A Participatory Approach to Intervention Development Ogol Japheth Ouma, Dickens Omondi, Ivy Akinyi, Nichodemus Were Amollo, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6077243/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Apr, 2026 Read the published version in BMC Primary Care → Version 1 posted 11 You are reading this latest preprint version Abstract Background Projections show non-communicable diseases (NCDs) such as heart disease, cancer, diabetes, and chronic respiratory diseases in Africa will cause more deaths by 2030 than communicable and perinatal diseases combined. However, most countries, including Kenya, are not on track to meeting the 25x25 global target for reducing premature mortality. This underscores the strategic emphasis on enhancing the prevention, early detection, and management of the priority NCDs, which account for a significant portion of global morbidity and mortality. Effective primary-level interventions can reduce the incidence of these diseases. At the same time, early detection increases the chances of successful management, thus contributing to better outcomes, survival rates, and quality of life. To enhance relevance, long-term acceptance, and effectiveness of primary health services for NCDs, this study employed a participatory research design to develop and implement interventions aimed at improving care delivery, specifically focusing on diabetes mellitus (DM) and hypertension (HTN) in primary healthcare (PHC) settings in Kisumu County, Western Kenya. Methods We used a participatory research design with a five-step procedure: (1) situation analysis; (2) establish a common vision by gathering stakeholder input to identify gaps and challenges in PHC service delivery for DM and HTN; (3) identify and select priority interventions; (4) plan and implement the identified interventions considering implementation factors; and (5) monitoring and evaluation—set up a system for data collection and analysis, create an action plan, and share findings with stakeholders. Two workshops were conducted with various stakeholders, including health management teams, PHC workers, community health promoters, patients, and researchers. The study was conducted in Seme Sub-County, Kisumu County, Kenya. Stakeholders were identified using purposive and snowball sampling. Data analysis included quantitative scoring in Excel and qualitative synthesis in Dedoose software. Results Four main gaps identified were: (1) insufficient college training for health workers in managing DM and HTN; (2) knowledge gaps regarding DM and HTN diseases; (3) inadequate patient care, characterized by long wait times and insufficient follow-up; and (4) a lack of standardized care packages for DM/HTN patients. The recommended priority interventions included: training PHC workers, improving access to treatment guidelines, providing mentorship and supervision, organizing community outreach, and ensuring the availability of diagnostics tools and essential medication. The main challenges identified include modifiable challenges such as non-need-based training, inconsistent support systems, and poor documentation, which can be addressed with little to moderate investments, alongside non-modifiable challenges like inadequate infrastructure, lack of medication and supplies which requires substantial long-term investments; recommendations include training PHC workers and operationalizing community outreach programs. Conclusion The study underscores the value of the participatory approach to intervention development (PAID), engaging stakeholders in identifying service needs, interventions, and local factors to enhance DM and HTN care. Figures Figure 1 Figure 2 INTRODUCTION Low- and middle-income countries (LMICs) account for 78% of all NCD related deaths worldwide with 85% being premature. However, most countries, including Kenya, are not on track to meeting the 25x25 global target for reducing premature mortality[1]. By 2022, approximately 828 million adults aged 18 and older were diagnosed with diabetes, marking an increase of 630 million since 1990[2]. Of these, around 445 million adults aged 30 years or older with diabetes did not receive treatment, representing a 3.5 fold increase since 1990[2]. The increasing burden of diabetes is most significant in LMICs where health care systems are fragile and overburdened. Diabetes is associated with increased risk for amputations, vision loss, renal failure, cardiovascular conditions as well as dementia, cancers and infections. The combined presence of diabetes and hypertension or other comorbidities significantly increases the risk of poor complications in a patient. The prevalence of DM in Kenya is estimated at 2-6.6%, with more than half of people over 40 years old having HTN yet, only less than a third of individuals affected are aware of their status with approximately 10% being on treatment[3–5]. Effective implementation and coordination of primary healthcare strategies are essential to significantly halt and reverse the increasing burden of NCD at the population level. In Kenya, NCDs account for over 50% of inpatient hospital admissions and approximately 39% of annual deaths[6, 7], with diabetes alone causing around 10,000 deaths[8]. The rising burden of these conditions places a significant strain on the healthcare system, which is also dealing with infectious disease demands[9]. In addition to severe constraints on the health systems performance, NCDs cause multiple individual-level challenges, including increased risk of death from infections, delayed diagnosis and treatment initiation, behavioral risk factors, and catastrophic expenditures on care. In sub-Saharan Africa, the burden of NCDs is projected to surpass that of communicable, maternal, neonatal, and nutritional (CMNN) diseases combined as the leading cause of morbidity and mortality by 2030[10, 11]. Most people at increased risk of or already suffering from NCDs, including diabetes and hypertension, remain unaware, under-diagnosed, or lack access to life-saving interventions. This issue is particularly acute among rural populations, where implementation of and access to recommended services is quite constrained [12]. Diabetes mellitus and hypertension are important public health concerns because they jointly contribute significantly to cardiovascular diseases, which are responsible for over 40% of the non-communicable disease burden. These conditions are often linked to risk factors that can be modified, making interventions to alter these factors crucial for the prevention and management of NCDs. To enhance disease prevention, control services, and access to quality primary healthcare, Kenya launched the Primary Care Network (PCN) Guideline in 2021[13]. This initiative created a coordinated network of health facilities to improve patient referrals, disease diagnosis and care, aiming for Universal Health Coverage (UHC) and efficient resource use. The PCN guideline addresses the issues of diabetes mellitus and hypertension by promoting early detection, appropriate referral, and treatment. Furthermore, in 2024, the national clinical guidelines for managing DM[12] and HTN[14] were introduced to guide health systems improvement strategies for strengthening delivery and access to basic screening and diagnostic services, integrated care, and community participation through task-shifting[15]. They equip healthcare workers with skills to assess, diagnose, manage, and refer patients according to protocols[16, 17]. Implementation of strategic PHC activities across Kenya's counties varies significantly and faces numerous challenges[18]. Improving efficiency and effectiveness at the PHC level is essential to make health systems resilient and adaptable to expanding epidemiologic difficulties. Improvement interventions could include training healthcare workers on NCD detection and management, integrating care pathways, enhancing data use at service points, engaging communities, promoting risk reduction, and efficient resource allocation to ensure equitable access to affordable, and quality healthcare services[16, 17]. While PHC strategies are specific and action-oriented, the World Health Organization's Health System (HS) building blocks provide a holistic view of health system strengthening, making their relationship pivotal. This interaction is crucial for understanding why current interventions for DM and HTN are not performing as expected. Therefore, aligning the critical elements of the health system with specific PHC strategies may help address systemic weaknesses, thus improving the overall functionality of the PHC system in preventing and controlling NCDs in Kenya[19]. Deficits in PHC delivery pathways affect the many initiatives designed to improve management of DM and HTN. Efforts such as the national PHCN strategies aimed to create a more integrated and effective PHC system in Kenya have shown promise in improving NCD outcomes. Other interventions, such as scaled-up training on non-physicians and paramedical clinical as well as non-clinical staff to provide primary clinical care, support patient self-care at home[20, 21], and educate the public on risk factors for diabetes, signs and symptoms of the condition, could accelerate universal healthcare for NCDs [22, 23]. However, scaling up and sustaining these initiatives remains a challenge[24]. There is a need for interventions that are designed and implemented at the local level, considering the realities of the district and involving local stakeholders and communities. These interventions should account for limited resources and consider context-specific factors[25]. This approach can lead to interventions that are locally relevant and feasible, thereby improving local accountability and leadership[26]. Participatory research (PAR) involves stakeholders, especially end users, actively participating as partners in research design and evaluation. This method enhances understanding, addresses felt needs, and anticipates future requirements to meet the contextual needs[27]. It enables communities to identify critical strategic needs, fostering the creation of culturally relevant and sustainable solutions that are more likely to be adopted at scale, ultimately improving health outcomes[28]. It produces evidence useful for stakeholders, including policymakers, thus contributing to efficient community health outcomes. Evidence in the literature suggests that participatory approaches to planning community-directed interventions can not only improve access to essential community services[29], but also, are an effective means of implementing equitable policies[30], such as primary health care quality improvement strategies[27, 31, 32]. Therefore, this study utilized a participatory research design to identify health services delivery needs and develop implementation intervention solutions for improving the delivery of primary healthcare services for DM and HTN in Kisumu County, Kenya. Specific study objectives were: To perform a joint analysis of facility-level data from a baseline survey of PHC settings to identify gaps in implementing service delivery packages for DM and HTN care in Kisumu County, Kenya. To identify and co-design tailored improvement interventions to address key barriers to satisfactory implementation of solutions to enhance access to quality services for DM and HTN in Kisumu County, Kenya. METHODS Research design and setting Kisumu county is one of the 47 counties in Kenya and is also considered a leader in the implementation of PHC and UHC coverage indicators[33]. We conducted the study in Seme sub-county, one of the seven sub-counties in Kisumu County, which is located on the northern end of Lake Victoria (Fig. 1). According to the 2019 Kenya National Population Census, the sub-county has a total population of 121,667, 65 PHC health facilities (Ministry of Health (MoH) level 4= 4; level 3= 12; level 2= 13) and 36 Community Health Units). The current study was nested within the framework of a larger study under the School of Health Sciences of Jaramogi Oginga Odinga University of Science and Technology. The parent study is a sub-project in the institutional capacity building project titled: ‘Strengthening Jaramogi Oginga Odinga University of Science and Technology Capacity in Natural Resource Management, Food Security and Health’ (Study number 001). Clinical trial number: not applicable. We adopted a participatory research design following five steps adapted from Cornish, et, al, 2023[35]. These steps include: (Step 1) Situation analysis; (Step 2) identify a common vision: establish a common change project by gathering stakeholder input to pinpoint gaps and challenges in PHC service delivery for managing diabetes and hypertension, using a consensus-building approach; (Step 3) identify, and select priority interventions to strengthen PHC service delivery for DM and HTN management; (Step 4) plan and implement the identified priority interventions considering implementation factors; and (Step 5) Monitoring and Evaluation—Set up a system for collecting and analyzing data from interventions that have been put in place; collect and analyze relevant data to make it easy to understand key findings; based on the analysis, make an action plan based on the findings; and share the findings and action plan with key stakeholders, making sure that end users are involved at every step (Table 1). As part of the planning process for this participatory research, the primary author and other core research team members generated prompts to guide the process for each step (Table 2 in the Webannex section). The approach comprised two main workshops: in step 2, one to discuss the situational analysis results to find gaps and challenges, and to build consensus and find a common vision. In step 3, a workshop to identify and select priority interventions. Table 3 in the Webannex section indicate a summary of each step participants, sample, data collection and analysis. Step 1: Situation analysis In this step, we explored specific concerns elicited from the baseline survey of a sample of the Ministry of Health level 2-4 facilities which was conducted to assess the Kisumu County health systems capacity, service availability, and readiness for prevention and control of DM and HTN (analyses to be reported in another publication). Data collected included the functional characteristics of the facilities (across health records, health administration, in-/out-patient clinical departments, and the respective in-charges). Qualitative data on patients’ experiences with follow-up for hypertension and diabetes were collected using standard survey procedures using tools adapted from the WHO-PEN framework[36, 37] and WHO Innovative Care for Chronic Conditions (ICCC) Framework [38-40]. Following preliminary analysis of the formative assessment of the health service delivery for hypertension and diabetes, a consensus orientation meeting was held with the County Health Management Team (CHMT) members. Also, the CHMT was appraised on the study objectives, methodologies, and intervention framework for their input and adoption. The procedures for selecting PHC facilities and cadres of staff to be involved in the intervention for next steps were discussed and adopted as well. This was a crucial step to ensure facility staff participation during the study implementation period (between October 2024 and October 2025) and ownership. Step 2: Identify Stakeholder Priorities for PHC Service Gaps in Diabetes and Hypertension Management Workshops and Goals: The first consensus-building workshop for stakeholders targeted county and sub-county health management teams, health facility in-charges, primary healthcare workers, community health promoters, patients with diabetes and/or hypertension, representatives from non-communicable disease program organizations, and researchers. Stakeholders (Table 1) were identified using purposive and snowball sampling techniques to ensure equal representation, particularly among PHC workers and patients. To ensure inclusive participation and effective communication with all stakeholders from each administrative Ward, the two coordinators of the non-communicable diseases prevention and control program in the county and sub-county under study were designated as the primary contact persons. A master trainer prepared the workshop agenda, defined facilitator roles, and outlined stakeholder engagement objectives, together with the core research team. Prompts were developed to guide discussions (Table 2 in the Webannex section) and a closed-ended questionnaire on feasibility and relevance to collect stakeholder feedback (Table 12 in the Webannex section). The team used structured techniques such as the Delphi method[41] and group discussions to address stakeholder differences, tensions, and power relations, ensuring inclusive participation and respect for all voices. We maintained regular check-ins and open communication channels, including a WhatsApp group, to manage conflicts and foster ongoing collaboration. This platform also had a broader function and a longer lifetime, facilitating ongoing communication and coordination. First Workshop: Prior to the first workshop, the core team reviewed the situational analysis based on WHO health system building blocks, identifying 46 key challenges and gaps (Table 4 in the Webannex section). An online survey (Table 12 in the Webannex section) was created to rate the feasibility and relevance of these gaps. The relevance was defined as the degree to which each gap or challenge contribute to the core problem of inadequate care for HTN and DM in PHC. Participants were expected to assign a score (0 to 10) for each health system gap based on perceived relevance (0 = not relevant at all, 10 = highly relevant) and feasibility (0 = not feasible at all, 10 = highly feasible). We conducted descriptive statistical analysis in Excel, calculating medians, and separately ranked the relevance and feasibility of the identified gaps and challenges Qualitative data on recommendations and strategies to address the identified gaps in managing DM and HTN in the region was collected through group discussions, which facilitated open dialogue among stakeholders. The qualitative responses and feedback from individual participants were documented using real-time note-taking on whiteboards, observations, and sticky notes. These were analyzed thematically based on a priori codes from the WHO Health System Building Blocks framework, including health service delivery, workforce, financing, information systems, leadership and governance, and medical products, vaccines, and technologies. We excluded 12 gaps and challenges that did not appear relevant from further discussions. Furthermore, we presented refined findings and collected further feedback through an online survey. Participants rated the feasibility and relevance of 34 gaps, retaining 19 for further consideration, which were then presented for final consensus through a prioritization exercise. As a result, four main priority gaps and challenges affecting PHC service delivery were identified, which the core research team members presented in the second workshop for identification of potential interventions. Step 3: Priority Interventions for Strengthening PHC Service Delivery in DM and HTN Management Building on the results from step 2, where we identified four priority gaps and challenges affecting primary health care for DM and HTN, we conducted a second two-day participatory workshop with stakeholders aiming to collaboratively explore potential interventions to address these priority gaps identified. Stakeholders were divided into five distinct groups based on their designations and responsibilities: Health facility in-charges County and sub-county health management teams, along with representatives from organizations implementing NCD programs. Community health promoters (CHPs) Primary health care (PHC) workers Patients living with diabetes mellitus (DM) and/or hypertension (HTN) Disaggregation encouraged participants to contribute freely based on their experiences and tasks, reducing power imbalances. They used discussion guides to brainstorm potential interventions and the respective implementers, considering implementation requirements. Each group documented and presented their responses to the larger group. The issues that were observed more frequently across the groups were deemed to be of higher priority. We used tools like flip charts, whiteboards, the Delphi method, and sticky notes to collect and record stakeholder responses. We conducted a qualitative synthesis and summary of these responses using Dedoose software to summarize themes. The core research team compiled these interventions, considering key insights, and reported them back to participants for further consideration of any factors that might influence their implementation in the selected facilities. Stakeholders prioritized the interventions listed by both groups as the highest priority. Step 4: Plan and implement identified priority interventions This step describes the planning and implementation of the 5 broad categories of priority interventions (step 3 output), which were co-designed based on the four 4 main gaps identified earlier. The emphasis is on effectively carrying out these interventions, with proper program monitoring and evaluation to measure their primary and intermediate outcomes. Table 5 provides the objectives, activities, implementation timeline, responsible parties, and expected outcomes for each priority intervention. Step 5: Establish a Framework for Data Collection and Analysis To assess the effectiveness of these interventions for managing DM and HTN in a PHC setting, a comprehensive and simultaneous program monitoring and evaluation is necessary. The project core team members established a framework for data collection and analysis to clearly interpret key findings, identify insights for further action, and communicate the results to key stakeholders. Table 11 outlines the methods for data collection, analysis, and dissemination of the results. RESULTS Given that a participatory approach is an iterative process, the results sections are described sequentially, as indicated in the methods section above. Step 1: Situation analysis Ten PHC facilities were assessed in Kisumu County, Kenya. The results identified several key barriers: most facilities lacked NCD management guidelines, essential NCD drugs, and diagnostic equipment. Additionally, most PHC workers had not received training focused on NCD management, particularly for DM and HTN. Consequently, facilities were often unable to manage DM and HTN, leading to frequent patient referrals. Other issues included poor patient counseling and follow-up and a lack of standardized NCD care packages, resulting in poor patient outcomes. Step 2: Identify Stakeholder Priorities for PHC Service Gaps in Diabetes and Hypertension Management 53 out of 55 invited stakeholders (96%) participated in the first part of the workshop 1. Participants included 17 (32%) PHC workers from ten selected PHC facilities in Seme Sub County, Kisumu County, 8 (15%) representatives from the Seme sub-county health management team, 3 (6%) from the Kisumu county health management team, which consisted of the director of medical health services and the public health NCD screening coordinator, 5 (9%) community health promoters, and 3 (6%) patients living with DM and/or HTN who were living at and going to the ten chosen PHC facilities for clinic services. Additionally, 14 (26%) experts worked at universities, 2 (4%) were representatives from NCD implementing partners, and 1 (2%) was a member of a research institution. Out of the 46 initially identified gaps and challenges, a majority of these were in service delivery (14), followed by the health information system (8), health financing (7), and the health workforce, medical products, vaccines, and technologies, each accounting for 6 gaps and challenges. Leadership and governance had the fewest identified gaps and challenges, with only 5 (see Table 4 in the Webannex section for more details). Overall, the relevance scores for addressing the core problem of inadequate care for DM and HTN in PHC ranged from 48.6 to 115.8 (median = 70.4, IQR = 28.9), while feasibility scores ranged from 62.9 to 102.4 (median = 72.9, IQR = 20.5). We retained 34 out of these 46 challenges and gaps. We found 12 relevant but not feasible, 3 feasible but not relevant, and 19 relevant and feasible. On the other hand, we removed 12 challenges and gaps because they were neither relevant nor feasible, as rated by participants, see Table 6 for more details. In the second part of Workshop 1, we presented the 34 gaps and challenges identified in the first part of workshop 1 to the participants. Particularly, we presented only the light green items (19). Out of the 55 invited stakeholders, 47 (85%) participated to identify priority gaps and challenges. The participants included 28 (59%) PHC workers from the ten selected PHC facilities, 4 (9%) community health practitioners (CHPs), 4 (9%) members of the county and sub-county management teams, 1 (2%) member of a research institution, and 10 (21%) experts from universities. The exercise identified several priority challenges and gaps as both highly feasible and relevant (see Table 3 in the Webannex section). These included the lack of trained and competent staff in DM and HTN management (relevance score = 9.2, feasibility score = 7.1), the knowledge gap in DM and HTN (relevance score = 8.9, feasibility score = 6.8), inadequate patient care, characterized by long wait times and insufficient follow-up (relevance score = 8.5, feasibility score = 6.4), and an unstandardized package of care for patients (relevance score = 8.1, feasibility score = 6.5). For additional details, see Table 7. Step 3: Priority Interventions for Strengthening PHC Service Delivery in DM and HTN Management A total of 104 stakeholders participated in the second workshop. Each group of stakeholders engaged in their own group discussions, with the number of participants in each group ranging from 11 to 40 (see Table 8). About a third of the stakeholders were PHC workers. The remaining participants included patients living with DM and/or HTN, as well as CHPs. Identification of priority interventions We initially identified 12 priority interventions, with number 1 being the highest priority and number 12 being the least. However, through a consensus-building procedure (Delphi method), stakeholders further discussed and refined these interventions, resulting in 8 being grouped under 5 broad categories. Training PHC workers on DM and HTN management Continuous Mentorship and Supportive Supervision Access to Treatment Guidelines and Protocols Community Outreach and Advocacy Resource Availability Figure 2 illustrates the priority interventions identified during the co-designing workshop aimed at addressing the core problem of inadequate care for DM and HTN within the PHC setting. These interventions align with the three primary goals of the Primary Healthcare Network. During the co-creation sessions, the stakeholders made clear references to the Kenyan guidelines that were already in place, such as the PHCN, DM, and HTN guidelines, to make sure that the suggestions, which included interventions, were in line with them. These were the primary goals of the PHCN: (1) Enhancing access to quality PHC services : Training PHC workers on DM and HTN management, along with providing adequate access to treatment guidelines and protocols, is likely to equip them with the necessary skills, knowledge, and resources to improve NCD care. This training is expected to enhance the quality of care delivered to patients and the general population in the community. (2) Enhancing PHC service coordination and integration : Well-organized and continuous mentorship and support supervision structures are likely to improve coordination among PHC workers. This ensures that these interventions are well integrated into the broader PHC system, which is crucial for improving the management of these chronic conditions. (3) Enhancing community engagement and participation in PHC : To raise awareness and encourage community involvement in DM and HTN prevention and management, outreach and advocacy initiatives become critical. Advocating for the availability of resources supports these efforts by ensuring that the necessary tools and support for community engagement are available. Perceived priority interventions for strengthening PHC service delivery for NCDs with a focus on DM and HTN diseases Stakeholders emphasized the need to enhance PHC workers' skills and competencies, particularly in managing DM and HTN, through orientation on NCD guidelines and training in essential skills like patient communication and counseling to improve access to quality PHC services. Additionally, the stakeholders recognize the need to strengthen community engagement and participation in the PHC system, as evidenced by stakeholders' perspectives. See Table 9 for more details. As a key intervention, almost all of the stakeholders suggested a need to capacity build the skills of PHC workers. However, in some Level 2 PHC facilities, stakeholders held the opinion that there was a need to train CHPs as alternative providers to support PHC workers in educating the public on the risks and symptoms of NCDs, especially DM and/or HTN. These CHPs will take on an active role in supporting patients at home and act as a link between the primary healthcare facility and the community. CHPs can follow up with patients and remind them to attend scheduled appointments without missing them, reducing complications and late referrals. Nevertheless, the primary emphasis was on the training of other cadres, including nurses, clinicians, nutritionist, and physicians, rather than CHPs, who are at the lowest level (Level 1). These other cadres were preferred for training due to their advanced medical knowledge and capacity to provide comprehensive care, which are critical to the effective management of NCDs. The objective was to improve the quality of care and assure improved patient outcomes by providing these healthcare professionals with the necessary skills. With the launch of the PHCN guidelines, the county’s Ministry of Health has adopted a ward-based health service delivery governance structure. This was consistent with the functional arrangements of the health facilities within the primary care network system, where the better-equipped facilities within the Ward serve as the referral hub for the networked lower- level facilities (hereby referred to spokes). In regards to this context, additional prioritized interventions prioritized included the establishment of 'NCD clinics' in most hubs (level 3s or 4s), which could be supervised by facility in- charges, to increase PHC service coverage and quality within Kisumu County. Step 4: Plan and implement identified priority interventions Key factors influencing local implementation of the interventions, and recommendations to address these factors Further analysis from stakeholder feedback identified various factors that may influence effective implementation of the interventions, including capacity building for the PHC workers, strengthening documentation and reporting, mentorship, supervision, and support systems, and operationalizing community outreach and sensitization awareness. These factors, for example, inadequate PHC workers in facilities hinder training efforts, as operations must continue even when staff are attending training sessions. Additionally, PHC facilities often lack essential screening and management infrastructure, including glucometers, urine strips, blood pressure devices, and weighing scales. Other challenges include the need for alignment with county health goals, a lack of training inventories to track trained providers by year and skill, high staff turnover, non-need-based deployment, and frequent transfers of PHC providers. Strengthening documentation and reporting remains a challenge, particularly due to the absence of a specific NCD register, complicating streamlined reporting. It was recommended that the county health records team, in consultation with the sub-county NCD coordinators, procure and distribute NCD registers to document conditions such as diabetes mellitus and hypertension. Stakeholders noted a predominance of IEC materials focused on communicable diseases, recommending the creation of materials specifically for NCDs, particularly on DM and HTN, to raise awareness about risk factors and symptoms. Recommendations included developing a PHC provider training inventory to track trained providers by year and skill level, which would help identify skills gaps. Additionally, condensing all NCD guidelines into a concise document for PHC workers would enhance their understanding of managing NCDs. The county government should follow the support supervision system and utilize required assessment forms to evaluate guideline implementation in PHC facilities. Reducing frequent, unplanned provider transfers is crucial for improving service delivery. Stakeholders also observed that county and sub-county management teams were not providing the necessary mentorship and supervision. Adherence to supervisory rosters and evaluation forms is essential, particularly for NCD management, to ensure the availability of essential infrastructure in facilities. See Table 10 for more details. Implementation plan The project core team developed Table 5 outlining the linkage between priority interventions with distinct implementation strategies. In addition, Table 5a in the Webannex section indicate a broader category of these implementation activities based on ERIC framework[42]. Step 5: Data Collection and Analysis Framework The project core team members developed a comprehensive framework for monitoring and evaluating the interventions. Table 11 outlines the methods used for data collection, analysis, and results dissemination. DISCUSSION This study employed a participatory approach to enhance the relevance, long-term acceptance, and effectiveness of primary health services for NCDs, specifically DM and HTN, in primary care settings in Kisumu County. The primary objectives were: (1) to perform a joint analysis of facility-level data from a baseline survey of PHC settings to identify gaps in implementing service delivery packages for DM and HTN care in Kisumu County, Kenya and (2) to identify and co-design tailored improvement interventions to address key barriers to satisfactory implementation of solutions to enhance access to quality services for DM and HTN in Kisumu County, Kenya. For the first objective following stakeholder engagement workshops, this study identified four critical gaps and six key interventions. The key interventions are: training PHC workers, improving access to treatment guidelines, providing ongoing mentorship and support, organizing community outreach, and ensuring resource availability. The gaps included a lack of trained and competent staff in managing DM and HTN, knowledge gaps in DM and HTN management, inadequate patient care, characterized by long wait times and insufficient follow-up, and a lack of standardized care packages for patients. These issues are prevalent not only in Kenya but also in other low- and middle-income countries, such as Botswana, Ghana, South Africa, Ethiopia, and Uganda [43–46]. Inadequate training for PHC workers is a widespread issue, and findings from similar contexts in LMICs support this, as evidenced by other studies[47–49]. Primary care workers often lack simplified protocols and sufficient information about guidelines which is echoed in other studies in similar context[50, 51]. The poor service delivery maybe attributed to the knowledge gaps in the management of DM and HTN among PHC workers, which is consistent with the observations made in studies conducted in South Africa, where knowledge gaps impede effective disease management[50]. The dearth of standardized care packages for patients living with DM and HTN aligns with trends noted in other studies in similar context, highlighting a lack of common guidelines in PHC contexts[48, 52]. For the objective 2, the study identified priority actions to the barriers identified in objective 1. The recommendations include: capacity building for PHC workers, strengthening documentation and reporting, mentorship, supervision, support systems, and operationalizing community outreach and awareness were identified as leverages to implement the priority actions. However, it is important to specify that these recommendations (e.g., capacity building, mentorship) are implementation strategies, a method used to put intervention into practice rather than direct interventions like training program aimed at improving skills. For example, although training is vital, it should be regarded as a strategy (e.g., training of trainers who will then deliver the training program) rather than an intervention. Other studies have highlighted similar factors, such as inadequate staffing, lack of essential equipment, lack of alignment with local health goals, lack of training inventories, high staff turnover, non-need-based deployment, and frequent transfers. For example, studies from Tanzania, Cameroon, Ethiopia, and South Africa noted challenges with workforce availability and training resources, making NCD prevention and control difficult[44, 45, 53–55]. A study in Nigeria[56] confirmed a significant shortage of primary care workers and emphasized the need for more training to enhance NCD care capacity. Furthermore, the developed co-designed priority interventions (see Fig. 2 ), will be implemented through distinct activities outlined in the implementation plan (refer to Table 5 ). These implementation activities have been strategically classified along the ERIC framework[42] (see Table 5 a in the Webannex section) to ensure a systematic approach to strengthening PHC delivery. The categories include: (1) conducting educational meetings; (2) ongoing training, which guarantees that the workforce is equipped with the latest skills and practices; and (3) mentorship programs, where experienced professionals are paired with those in the early stages of their careers to facilitate invaluable knowledge transfer among providers. In addition, (4) developing and distributing educational materials will empower healthcare workers and patients to access essential information, thus cultivating a culture of ongoing learning and improvement, particularly enabling PHC workers to adapt to challenges and uphold quality care. Moreover, (5) increasing demand and (6) patient involvement will ensure that patients are actively engaged in their health decision-making processes, rather than being passive recipients of care. Finally, (7) changing physical structures and equipment will create a conducive environment for service delivery in primary healthcare settings. Therefore, integrating these implementation strategies into the overarching framework of prioritized interventions, we establish a holistic approach that addresses both current requirements and long-term sustainability in diabetes mellitus and hypertension care[57]. 4.1.1 Strengths and limitations The strength of this study lies in its participatory development approach with people of all levels in the local health system. This approach incorporates the perspectives of various stakeholders, including PHC workers and individuals living with these conditions. This approach allows for local context adaptation, particularly as some facilities have already initiated NCD clinics while others are still in the planning stages, enhancing the relevance, feasibility and scalability of the proposed interventions in accordance with. The participatory method as how we operationalized it was flexible in delivery, output, and stakeholder engagement, making it suitable for a wide range of health issues[58]. Adopting a structured facilitation was crucial for achieving outcomes and guaranteeing inclusive representation. This study is relevant to the local context, as it aligns with the goals of Kenya's Primary Health Care Network. Specifically, the PHCN aims to strengthen service coordination and integration, as well as improve the quality of care in primary health care settings. The co-designed interventions support these goals by providing continuous mentorship and support supervision to primary health care workers. Additionally, there is a focus on training these workers in DM and HTN management to equip them with the necessary skills and knowledge for effective NCD management. This approach not only addresses immediate service delivery shortages but also establishes a sustainable framework for better health outcomes, thereby advancing the overarching objectives of Universal Health Coverage (UHC) in Kenya. This study acknowledges several limitations. First, the use of purposive sampling limits its generalizability, but including diverse stakeholders helps mitigate this. Secondly, the use of self-reported data might have introduced bias, as participants might have inaccurately shared their experiences. However, using a combination of qualitative methods like group discussions and quantitative methods such as surveys helped triangulate data, validate findings, and reduce bias. 4.1.2 Implication of the findings The findings of our study comprise a number of suggestions for health care practitioners and decision-makers at various levels in the health system. First, the study emphasizes the need for human resource capacity building and ongoing training and mentorship. In Kenya, the county government currently organizes training sessions on critical areas such as emergency obstetric and newborn care (eMOC), post-abortion care, nutrition, tuberculosis, HIV, reproductive, maternal, newborn, child, and adolescent health (RMNCAH), as well as NCDs like cervical cancer, diabetes, and hypertension. These trainings are typically held annually or biennially and are conducted by Trainers of Trainers (ToTs), who also serve as mentors within the counties. The training targets healthcare workers at each facility, but the number of participants is limited, often ranging from 1 to 2 per facility, leaving many primary health care (PHC) workers untrained despite the aim to eventually cover all staff across various health facilities. Therefore, at the local level, the training capacity can be increased by targeting more healthcare workers in each session to ensure more comprehensive coverage of staff within facilities. Furthermore, strengthening ongoing mentorship programs where trained staff can support their peers will help build a culture of continuous learning and improvement. At the national level, there is a need to standardize training guidelines across counties to ensure uniformity in skill development. Additionally, adopting technology, including e-learning modules, to supplement in-person training can make the trainings more accessible to a wider group of healthcare workers. Secondly, the results emphasize the need for an improved data management system that can monitor patient outcomes. Currently, Kisumu County is rolling out a computerized patient data management system in Kenya. All patient data are recorded in daily MoH registers and enter monthly summaries to the Kenya Health Information System (KHIS). Unfortunately, not all facilities have these registers, and some patients lack booklet records, resulting in data gaps. Locally, healthcare workers need to be trained on digital systems, and patient booklets should be available at all facilities. Nationally, infrastructure to support digital data entry and a standardized data documentation protocol must be continuously invested in. Furthermore, the study reveals significant gaps in resource allocation for managing NCDs. It highlights the urgent need to increase funding and support for NCD initiatives at both local and national levels. To achieve this, efforts should be expanded to engage political leaders and decision-makers in advocating for increased resource allocation for NCD management. Additionally, awareness campaigns should be created to educate leaders on the burden of NCDs and their impact on public health, fostering a common understanding and sense of urgency. Where possible, champions for NCDs can be established to lead advocacy campaigns for NCD prevention and control, including resource allocation and influencing policy discussions within political space. This aligns with WHO and national health strategies aimed at improving NCD management. Finally, the study underscores the importance of community engagement initiatives. It reveals a need to strengthen community outreach programs to raise awareness about NCDs, including risk factors, symptoms, and management. This proactive approach will support continuous management of DM and HTN among populations, ultimately leading to better health outcomes. Conclusion Our study used a participatory approach methodology to meaningfully involve a wide range of stakeholders in identifying priority service delivery needs, response interventions, and local factors affecting implementation in the PHC system. Training primary healthcare workers was identified as a priority to address current gaps in service delivery for DM and HTN. Future efforts to manage DM and HTN effectively should focus on these priority interventions, tailored to the local context. Comprehensive monitoring is needed to assess the effectiveness and implementation of such interventions. Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the ethics research committee and National Commission for Science, Technology and Innovation, Kenya; ERC 43/5/24-06 and License No: NACOSTI/P/23/25192). All participants provided informed consent before participation in accordance with the Declaration of Helsinki. Consent for publication Not applicable Availability of data and materials Data is accessible and available upon reasonable request to the corresponding author, Ogol Japheth Ouma, to ensure that the use of data is in line with the terms of ethics approvals and principles. Funding A PhD scholarship from the VLIR-UOS supported the research and the primary author (OJO), fostering partnerships between Flemish universities in Flanders, Antwerp, Belgium, and a partner university, Jaramogi Oginga Odinga University of Science and Technology (JOOUST), in Kenya. However, funders did not contribute to the design of this study, data collection, analysis, interpretation, or writing of the manuscript. Acknowledgements We want to thank all the participants who contributed to this study, including patients living with diabetes and/or hypertension, county and sub-county health management teams, NCD coordinators in the county and sub-county, facility in-charges, primary healthcare workers, health administrators, Kenya Red Cross and OGRA partners implementing NCD programs in the region, Master Trainer Dr. Julius Gwadah, JOOUST VLIR-UOS support team members, both junior and senior researchers focusing on NCDs. Their valuable insights, expertise, and dedication were instrumental in the success of this participatory workshop aimed at improving diabetes and hypertension management in primary healthcare settings in Kisumu County, Kenya. Contributors OJO led the study's conceptualization, while NWA, DO, EM, EO, and JvO contributed to its conception. GA, DO, JO, and JvO provided technical guidance and critical suggestions for the study protocol. OJO, NWA, EO, SO, IA, EM, DO, and JO provided general coordination including facilitation of the workshops and management of data collection. OJO led data cleaning, analysis and developed the first draft of the manuscript, which was verified by NWA, who had access to the raw data. GA, DO, JO, JB, and JvO made critical suggestions and edits to the draft. All authors read and approved the paper submission. Competing interests The authors declare no competing interests. References Kontis, V., et al., Contribution of six risk factors to achieving the 25× 25 non-communicable disease mortality reduction target: a modelling study. The Lancet, 2014. 384 (9941): p. 427-437. Zhou, B., et al., Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants. The Lancet, 2024. 404 (10467): p. 2077-2093. Organization, W.H., Noncommunicable diseases progress monitor 2020 . 2020: World Health Organization. Budreviciute, A., et al., Management and prevention strategies for non-communicable diseases (NCDs) and their risk factors. Frontiers in public health, 2020. 8 : p. 574111. Mohamed, S.F., et al., Prevalence and factors associated with pre-diabetes and diabetes mellitus in Kenya: results from a national survey. BMC public health, 2018. 18 (3): p. 1-11. Statistics, B.O., KENYA STEPwise SURVEY FOR NON COMMUNICABLE DISEASES RISK FACTORS 2015 REPORT. 2015. Kenya, M., Kenya national strategy for the prevention and control of non-communicable diseases 2015–2020. Nairobi: Ministry of Health Division of Non-communicable Diseases, 2015. Organization, W.H., Noncommunicable diseases country profiles 2018. 2018. Wamai, R.G., A.P. Kengne, and N. Levitt, Non-communicable diseases surveillance: overview of magnitude and determinants in Kenya from STEPwise approach survey of 2015. BMC Public Health, 2018. 18 : p. 1-8. Bigna, J.J. and J.J. Noubiap, The rising burden of non-communicable diseases in sub-Saharan Africa. The Lancet Global Health, 2019. 7 (10): p. e1295-e1296. Boudreaux, C., et al., Addressing severe chronic Ncds across Africa: measuring demand for the package of essential non-communicable disease interventions-plus (PEN-plus). Health Policy and Planning, 2022. 37 (4): p. 452-460. Ministry of Health, Division of Non-communicable Diseases. National Clinical Guidelines on Management of Diabetes Mellitus, 2023 Edition. Nairobi, Kenya: DNCD, August 2023. Opanga, Y., et al., Critical Success Factors for Deployment of Primary Health Care Networks and their Impact in Kenya. East African Journal of Health and Science, 2024. 7 (1): p. 10-21. http://guidelines.health.go.ke:8000/media/2024_KENYA_NATIONAL_GUIDELINES_FOR_CVD_MANAGEMENT_3.pdf . Organization, W.H., A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals . 2018, World Health Organization. Varghese, C., et al., Better health and wellbeing for billion more people: integrating non-communicable diseases in primary care. Bmj, 2019. 364 . Demaio, A.R., et al., Primary Health Care: a strategic framework for the prevention and control of chronic non-communicable disease. Global health action, 2014. 7 (1): p. 24504. World Health Organization. Declaration of Alma Ata. World Health Organization; 2000 Available from: http://www.who.int/publications/almaata_declaration_en.pdf. Accessed 531, 2019. Rifkin, S.B., Alma Ata after 40 years: Primary Health Care and Health for All—from consensus to complexity. BMJ global health, 2018. 3 (Suppl 3): p. e001188. Kinuthia, R., et al., The development of task sharing policy and guidelines in Kenya. Human Resources for Health, 2022. 20 (1): p. 61. Vedanthan, R., et al., Community health workers improve linkage to hypertension care in Western Kenya. Journal of the American College of Cardiology, 2019. 74 (15): p. 1897-1906. Mwiti, B.K., Bottom-up design approach: A community-led intervention in fighting lifestyle diseases within urban informal settlements in Nairobi, Kenya . 2020, University of Nairobi. Okubatsion, T.O., Community-based Lifestyle Intervention for the Management and Control of Metabolic Syndrome Among Adults Attending St. Mary’s Mission Hospital, Nairobi, Kenya . 2022, University of Nairobi. Gilson, L., et al., Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa. BMJ global health, 2017. 2 (2): p. e000224. Alleyne, G., et al., Embedding non-communicable diseases in the post-2015 development agenda. The Lancet, 2013. 381 (9866): p. 566-574. Saif-Ur-Rahman, K., et al., Primary healthcare policy and governance in low-income and middle-income countries: an evidence gap map. BMJ global health, 2019. 4 (Suppl 8): p. e001453. Leung, C.L., et al., Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya. BMC health services research, 2020. 20 : p. 1-13. Binagwaho, A., et al., Implementation research: an efficient and effective tool to accelerate universal health coverage. International journal of health policy and management, 2020. 9 (5): p. 182. Fierheller, D., et al., Using community-based participatory research methods to build the foundation for an equitable integrated health data system within a Canadian urban context. International Journal for Equity in Health, 2024. 23 (1): p. 131. Lloyd-Williams, F., et al., The QUEST for effective and equitable policies to prevent non-communicable diseases: co-production lessons from stakeholder workshops. International Journal of Health Policy and Management, 2020. 10 (10): p. 638. Ahmed, S.M., et al., Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared? The Lancet Global Health, 2024. 12 (10): p. e1706-e1719. Makaula, P., et al., Strengthening primary health care at district-level in Malawi-determining the coverage, costs and benefits of community-directed interventions. BMC health services research, 2019. 19 : p. 1-14. OGWENGO, K.O., STRATEGIC INITIATIVES ON UNIVERSAL HEALTH COVERAGE PROGRAM’S PERFORMANCE IN KENYA . 2024, Kabarak University. Sifuna, P., et al., Health & demographic surveillance system profile: the Kombewa health and demographic surveillance system (Kombewa HDSS). International journal of epidemiology, 2014. 43 (4): p. 1097-1104. Cornish, F., et al., Participatory action research. Nature Reviews Methods Primers, 2023. 3 (1): p. 34. Organization, W.H., Integration of NCD care in emergency response and preparedness. 2018. Organization, W.H., WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020. Wagner, E.H., et al., A survey of leading chronic disease management programs: are they consistent with the literature? Managed care quarterly, 1999. 7 (3): p. 56-66. Epping-Jordan, J.E., Integrated approaches to prevention and control of chronic conditions. Kidney International, 2005. 68 : p. S86-S88. Oni, T., et al., Chronic diseases and multi-morbidity-a conceptual modification to the WHO ICCC model for countries in health transition. BMC public health, 2014. 14 : p. 1-7. Keeney, S., H.A. McKenna, and F. Hasson, The Delphi technique in nursing and health research . 2011: John Wiley & Sons. Powell, B.J., et al., A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation science, 2015. 10 : p. 1-14. Tesema, A., et al., Addressing barriers to primary health-care services for noncommunicable diseases in the African Region. Bulletin of the World Health Organization, 2020. 98 (12): p. 906. Harris, P., et al., Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership. BMJ Global Health, 2022. 7 (Suppl 5): p. e007334. Maimela, E., et al., Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa. BMC Health Services Research, 2018. 18 (1): p. 1-9. Okpechi, I.G., et al., Global ehealth capacity: secondary analysis of WHO data on ehealth and implications for kidney care delivery in low-resource settings. BMJ open, 2022. 12 (3): p. e055658. Schneider, H., É.V. Langlois, and A. McKenzie, Measures to strengthen primary health-care systems in low-and middle-income countries. 2020. Kabir, A., M.N. Karim, and B. Billah, Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: a qualitative study. Frontiers in Public Health, 2022. 10 : p. 1015245. Rogers, H.E., et al., Capacity of Ugandan public sector health facilities to prevent and control non-communicable diseases: an assessment based upon WHO-PEN standards. BMC health services research, 2018. 18 : p. 1-13. Parker, A., et al., Health practitioners' state of knowledge and challenges to effective management of hypertension at primary level: cardiovascular topics. Cardiovascular journal of Africa, 2011. 22 (4): p. 186-190. Tapela, N.M., et al., Integrating noncommunicable disease services into primary health care, Botswana. Bulletin of the World Health Organization, 2019. 97 (2): p. 142. Tuobenyiere, J., G.P. Mensah, and K.A. Korsah, Patient perspective on barriers in type 2 diabetes self‐management: A qualitative study. Nursing Open, 2023. 10 (10): p. 7003-7013. Adinan, J., et al., Preparedness of health facilities in managing hypertension & diabetes mellitus in Kilimanjaro, Tanzania: a cross sectional study. BMC Health Services Research, 2019. 19 : p. 1-9. Tesema, A.G., et al., Exploring complementary and competitive relations between non-communicable disease services and other health extension programme services in Ethiopia: a multilevel analysis. BMJ Global Health, 2022. 7 (6): p. e009025. Witter, S., K. Sheikh, and M. Schleiff, Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Global Health, 2022. 7 (Suppl 7): p. e008115. Orji, I.A., et al., Capacity and site readiness for hypertension control program implementation in the Federal Capital Territory of Nigeria: a cross-sectional study. BMC health services research, 2021. 21 (1): p. 1-12. Gregg, E., et al., Improving health outcomes of people with diabetes mellitus: global target setting to reduce the burden of diabetes mellitus by 2030. Lancet (London, England), 2023. 401 (10384): p. 1302. Tieosapjaroen, W., et al., Designathons in health research: a global systematic review. BMJ Global Health, 2024. 9 (3): p. e013961. Tables Tables 1 to 12 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1to12.docx Cite Share Download PDF Status: Published Journal Publication published 06 Apr, 2026 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 22 Jan, 2026 Reviews received at journal 14 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviews received at journal 02 May, 2025 Reviewers agreed at journal 04 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 30 Mar, 2025 Reviewers invited by journal 30 Mar, 2025 Editor assigned by journal 26 Feb, 2025 Submission checks completed at journal 26 Feb, 2025 First submitted to journal 21 Feb, 2025 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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profile\u003c/em\u003e)[34].\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6077243/v1/2f0f7f1871c3bb5336492cb7.png"},{"id":87027990,"identity":"973afb03-f545-4103-a312-f60e2a1b924c","added_by":"auto","created_at":"2025-07-18 12:29:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97255,"visible":true,"origin":"","legend":"\u003cp\u003eIdentification of priority interventions during the co-designing workshop\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6077243/v1/04f076841a754de331daed5b.png"},{"id":106809416,"identity":"a78688cc-edfd-4e7d-a544-610f69b594fd","added_by":"auto","created_at":"2026-04-13 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Development","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLow- and middle-income countries (LMICs) account for 78% of all NCD related deaths worldwide with 85% being premature. However, most countries, including Kenya, are not on track to meeting the 25x25 global target for reducing premature mortality[1]. By 2022, approximately 828\u0026nbsp;million adults aged 18 and older were diagnosed with diabetes, marking an increase of 630\u0026nbsp;million since 1990[2]. Of these, around 445\u0026nbsp;million adults aged 30 years or older with diabetes did not receive treatment, representing a 3.5 fold increase since 1990[2]. The increasing burden of diabetes is most significant in LMICs where health care systems are fragile and overburdened. Diabetes is associated with increased risk for amputations, vision loss, renal failure, cardiovascular conditions as well as dementia, cancers and infections. The combined presence of diabetes and hypertension or other comorbidities significantly increases the risk of poor complications in a patient. The prevalence of DM in Kenya is estimated at 2-6.6%, with more than half of people over 40 years old having HTN yet, only less than a third of individuals affected are aware of their status with approximately 10% being on treatment[3\u0026ndash;5]. Effective implementation and coordination of primary healthcare strategies are essential to significantly halt and reverse the increasing burden of NCD at the population level.\u003c/p\u003e \u003cp\u003eIn Kenya, NCDs account for over 50% of inpatient hospital admissions and approximately 39% of annual deaths[6, 7], with diabetes alone causing around 10,000 deaths[8]. The rising burden of these conditions places a significant strain on the healthcare system, which is also dealing with infectious disease demands[9]. In addition to severe constraints on the health systems performance, NCDs cause multiple individual-level challenges, including increased risk of death from infections, delayed diagnosis and treatment initiation, behavioral risk factors, and catastrophic expenditures on care. In sub-Saharan Africa, the burden of NCDs is projected to surpass that of communicable, maternal, neonatal, and nutritional (CMNN) diseases combined as the leading cause of morbidity and mortality by 2030[10, 11]. Most people at increased risk of or already suffering from NCDs, including diabetes and hypertension, remain unaware, under-diagnosed, or lack access to life-saving interventions. This issue is particularly acute among rural populations, where implementation of and access to recommended services is quite constrained [12].\u003c/p\u003e \u003cp\u003eDiabetes mellitus and hypertension are important public health concerns because they jointly contribute significantly to cardiovascular diseases, which are responsible for over 40% of the non-communicable disease burden. These conditions are often linked to risk factors that can be modified, making interventions to alter these factors crucial for the prevention and management of NCDs. To enhance disease prevention, control services, and access to quality primary healthcare, Kenya launched the Primary Care Network (PCN) Guideline in 2021[13]. This initiative created a coordinated network of health facilities to improve patient referrals, disease diagnosis and care, aiming for Universal Health Coverage (UHC) and efficient resource use. The PCN guideline addresses the issues of diabetes mellitus and hypertension by promoting early detection, appropriate referral, and treatment. Furthermore, in 2024, the national clinical guidelines for managing DM[12] and HTN[14] were introduced to guide health systems improvement strategies for strengthening delivery and access to basic screening and diagnostic services, integrated care, and community participation through task-shifting[15]. They equip healthcare workers with skills to assess, diagnose, manage, and refer patients according to protocols[16, 17].\u003c/p\u003e \u003cp\u003eImplementation of strategic PHC activities across Kenya's counties varies significantly and faces numerous challenges[18]. Improving efficiency and effectiveness at the PHC level is essential to make health systems resilient and adaptable to expanding epidemiologic difficulties. Improvement interventions could include training healthcare workers on NCD detection and management, integrating care pathways, enhancing data use at service points, engaging communities, promoting risk reduction, and efficient resource allocation to ensure equitable access to affordable, and quality healthcare services[16, 17]. While PHC strategies are specific and action-oriented, the World Health Organization's Health System (HS) building blocks provide a holistic view of health system strengthening, making their relationship pivotal. This interaction is crucial for understanding why current interventions for DM and HTN are not performing as expected. Therefore, aligning the critical elements of the health system with specific PHC strategies may help address systemic weaknesses, thus improving the overall functionality of the PHC system in preventing and controlling NCDs in Kenya[19].\u003c/p\u003e \u003cp\u003eDeficits in PHC delivery pathways affect the many initiatives designed to improve management of DM and HTN. Efforts such as the national PHCN strategies aimed to create a more integrated and effective PHC system in Kenya have shown promise in improving NCD outcomes. Other interventions, such as scaled-up training on non-physicians and paramedical clinical as well as non-clinical staff to provide primary clinical care, support patient self-care at home[20, 21], and educate the public on risk factors for diabetes, signs and symptoms of the condition, could accelerate universal healthcare for NCDs [22, 23]. However, scaling up and sustaining these initiatives remains a challenge[24]. There is a need for interventions that are designed and implemented at the local level, considering the realities of the district and involving local stakeholders and communities. These interventions should account for limited resources and consider context-specific factors[25]. This approach can lead to interventions that are locally relevant and feasible, thereby improving local accountability and leadership[26].\u003c/p\u003e \u003cp\u003eParticipatory research (PAR) involves stakeholders, especially end users, actively participating as partners in research design and evaluation. This method enhances understanding, addresses felt needs, and anticipates future requirements to meet the contextual needs[27]. It enables communities to identify critical strategic needs, fostering the creation of culturally relevant and sustainable solutions that are more likely to be adopted at scale, ultimately improving health outcomes[28]. It produces evidence useful for stakeholders, including policymakers, thus contributing to efficient community health outcomes. Evidence in the literature suggests that participatory approaches to planning community-directed interventions can not only improve access to essential community services[29], but also, are an effective means of implementing equitable policies[30], such as primary health care quality improvement strategies[27, 31, 32]. Therefore, this study utilized a participatory research design to identify health services delivery needs and develop implementation intervention solutions for improving the delivery of primary healthcare services for DM and HTN in Kisumu County, Kenya. Specific study objectives were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo perform a joint analysis of facility-level data from a baseline survey of PHC settings to identify gaps in implementing service delivery packages for DM and HTN care in Kisumu County, Kenya.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify and co-design tailored improvement interventions to address key barriers to satisfactory implementation of solutions to enhance access to quality services for DM and HTN in Kisumu County, Kenya.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003eResearch design and setting\u003c/h2\u003e\n\u003cp\u003eKisumu county is one of the 47 counties in Kenya and is also considered a leader in the implementation of PHC and UHC coverage indicators[33]. We conducted the study in Seme sub-county, one of the seven sub-counties in Kisumu County, which is located on the northern end of Lake Victoria (Fig. 1). According to the 2019 Kenya National Population Census, the sub-county has a total population of 121,667, 65 PHC health facilities (Ministry of Health (MoH) level 4= 4; level 3= 12; level 2= 13) and 36 Community Health Units). The current study was nested within the framework of a larger study under the School of Health Sciences of Jaramogi Oginga Odinga University of Science and Technology. The parent study is a sub-project in the institutional capacity building project titled: \u0026lsquo;Strengthening Jaramogi Oginga Odinga University of Science and Technology Capacity in Natural Resource Management, Food Security and Health\u0026rsquo; (Study number 001). Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eWe adopted a participatory research design following five steps adapted from Cornish, et, al, 2023[35]. These steps include: (Step 1) Situation analysis; (Step 2) identify a common vision: establish a common change project by gathering stakeholder input to pinpoint gaps and challenges in PHC service delivery for managing diabetes and hypertension, using a consensus-building approach; (Step 3) identify, and select priority interventions to strengthen PHC service delivery for DM and HTN management; (Step 4) plan and implement the identified priority interventions considering implementation factors; and (Step 5) Monitoring and Evaluation\u0026mdash;Set up a system for collecting and analyzing data from interventions that have been put in place; collect and analyze relevant data to make it easy to understand key findings; based on the analysis, make an action plan based on the findings; and share the findings and action plan with key stakeholders, making sure that end users are involved at every step (Table 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs part of the planning process for this participatory research, the primary author and other core research team members generated prompts to guide the process for each step (Table 2 in the Webannex section). The approach comprised two main workshops: in step 2, one to discuss the situational analysis results to find gaps and challenges, and to build consensus and find a common vision. In step 3, a workshop to identify and select priority interventions. Table 3 in the Webannex section indicate a summary of each step participants, sample, data collection and analysis.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 1: Situation analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eIn this step, we explored specific concerns elicited from the baseline survey of a sample of the Ministry of Health level 2-4 facilities which was conducted to assess the Kisumu County health systems capacity, service availability, and readiness for prevention and control of DM and HTN (analyses to be reported in another publication). Data collected included the functional characteristics of the facilities (across health records, health administration, in-/out-patient clinical departments, and the respective in-charges). Qualitative data on patients\u0026rsquo; experiences with follow-up for hypertension and diabetes were collected using standard survey procedures using tools adapted from the WHO-PEN framework[36, 37] and WHO Innovative Care for Chronic Conditions (ICCC) Framework [38-40].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing preliminary analysis of the formative assessment of the health service delivery for hypertension and diabetes, a consensus orientation meeting was held with the County Health Management Team (CHMT) members. Also, the CHMT was appraised on the study objectives, methodologies, and intervention framework for their input and adoption. The procedures for selecting PHC facilities and cadres of staff to be involved in the intervention for next steps were discussed and adopted as well. This was a crucial step to ensure facility staff participation during the study implementation period (between October 2024 and October 2025) and ownership.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 2: Identify Stakeholder Priorities for PHC Service Gaps in Diabetes and Hypertension Management\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eWorkshops and Goals:\u003c/strong\u003e The first consensus-building workshop for stakeholders targeted county and sub-county health management teams, health facility in-charges, primary healthcare workers, community health promoters, patients with diabetes and/or hypertension, representatives from non-communicable disease program organizations, and researchers. Stakeholders (Table 1) were identified using purposive and snowball sampling techniques to ensure equal representation, particularly among PHC workers and patients. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo ensure inclusive participation and effective communication with all stakeholders from each administrative Ward, the two coordinators of the non-communicable diseases prevention and control program in the county and sub-county under study were designated as the primary contact persons. A master trainer prepared the workshop agenda, defined facilitator roles, and outlined stakeholder engagement objectives, together with the core research team. Prompts were developed to guide discussions (Table 2 in the Webannex section) and a closed-ended questionnaire on feasibility and relevance to collect stakeholder feedback (Table 12 in the Webannex section). The team used structured techniques such as the Delphi method[41] and group discussions to address stakeholder differences, tensions, and power relations, ensuring inclusive participation and respect for all voices. We maintained regular check-ins and open communication channels, including a WhatsApp group, to manage conflicts and foster ongoing collaboration. This platform also had a broader function and a longer lifetime, facilitating ongoing communication and coordination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFirst Workshop:\u003c/strong\u003e Prior to the first workshop, the core team reviewed the situational analysis based on WHO health system building blocks, identifying 46 key challenges and gaps (Table 4 in the Webannex section). An online survey (Table 12 in the Webannex section) was created to rate the feasibility and relevance of these gaps. The relevance was defined as the degree to which each gap or challenge contribute to the core problem of inadequate care for HTN and DM in PHC. Participants were expected to assign a score (0 to 10) for each health system gap based on perceived relevance (0 = not relevant at all, 10 = highly relevant) and feasibility (0 = not feasible at all, 10 = highly feasible). We conducted descriptive statistical analysis in Excel, calculating medians, and separately ranked the relevance and feasibility of the identified gaps and challenges\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative data on recommendations and strategies to address the identified gaps in managing DM and HTN in the region was collected through group discussions, which facilitated open dialogue among stakeholders. The qualitative responses and feedback from individual participants were documented using real-time note-taking on whiteboards, observations, and sticky notes. These were analyzed thematically based on a priori codes from the WHO Health System Building Blocks framework, including health service delivery, workforce, financing, information systems, leadership and governance, and medical products, vaccines, and technologies. We excluded 12 gaps and challenges that did not appear relevant from further discussions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, we presented refined findings and collected further feedback through an online survey. Participants rated the feasibility and relevance of 34 gaps, retaining 19 for further consideration, which were then presented for final consensus through a prioritization exercise. As a result, four main priority gaps and challenges affecting PHC service delivery were identified, which the core research team members presented in the second workshop for identification of potential interventions.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 3: Priority Interventions for Strengthening PHC Service Delivery in DM and HTN Management\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eBuilding on the results from step 2, where we identified four priority gaps and challenges affecting primary health care for DM and HTN, we conducted a second two-day participatory workshop with stakeholders aiming to collaboratively explore potential interventions to address these priority gaps identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStakeholders were divided into five distinct groups based on their designations and responsibilities:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eHealth facility in-charges\u003c/li\u003e\n \u003cli\u003eCounty and sub-county health management teams, along with representatives from organizations implementing NCD programs.\u003c/li\u003e\n \u003cli\u003eCommunity health promoters (CHPs)\u003c/li\u003e\n \u003cli\u003ePrimary health care (PHC) workers\u003c/li\u003e\n \u003cli\u003ePatients living with diabetes mellitus (DM) and/or hypertension (HTN)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDisaggregation encouraged participants to contribute freely based on their experiences and tasks, reducing power imbalances. They used discussion guides to brainstorm potential interventions and the respective implementers, considering implementation requirements. Each group documented and presented their responses to the larger group. The issues that were observed more frequently across the groups were deemed to be of higher priority. We used tools like flip charts, whiteboards, the Delphi method, and sticky notes to collect and record stakeholder responses. We conducted a qualitative synthesis and summary of these responses using Dedoose software to summarize themes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe core research team compiled these interventions, considering key insights, and reported them back to participants for further consideration of any factors that might influence their implementation in the selected facilities. Stakeholders prioritized the interventions listed by both groups as the highest priority.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 4: Plan and implement identified priority interventions\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis step describes the planning and implementation of the 5 broad categories of priority interventions (step 3 output), which were co-designed based on the four 4 main gaps identified earlier. The emphasis is on effectively carrying out these interventions, with proper program monitoring and evaluation to measure their primary and intermediate outcomes. Table 5 provides the objectives, activities, implementation timeline, responsible parties, and expected outcomes for each priority intervention.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 5: Establish a Framework for Data Collection and Analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTo assess the effectiveness of these interventions for managing DM and HTN in a PHC setting, a comprehensive and simultaneous program monitoring and evaluation is necessary. The project core team members established a framework for data collection and analysis to clearly interpret key findings, identify insights for further action, and communicate the results to key stakeholders. Table 11 outlines the methods for data collection, analysis, and dissemination of the results.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eGiven that a participatory approach is an iterative process, the results sections are described sequentially, as indicated in the methods section above.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 1: Situation analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTen PHC facilities were assessed in Kisumu County, Kenya. The results identified several key barriers: most facilities lacked NCD management guidelines, essential NCD drugs, and diagnostic equipment. Additionally, most PHC workers had not received training focused on NCD management, particularly for DM and HTN. Consequently, facilities were often unable to manage DM and HTN, leading to frequent patient referrals. Other issues included poor patient counseling and follow-up and a lack of standardized NCD care packages, resulting in poor patient outcomes.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 2: Identify Stakeholder Priorities for PHC Service Gaps in Diabetes and Hypertension Management\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e53 out of 55 invited stakeholders (96%) participated in the first part of the workshop 1. Participants included 17 (32%) PHC workers from ten selected PHC facilities in Seme Sub County, Kisumu County, 8 (15%) representatives from the Seme sub-county health management team, 3 (6%) from the Kisumu county health management team, which consisted of the director of medical health services and the public health NCD screening coordinator, 5 (9%) community health promoters, and 3 (6%) patients living with DM and/or HTN who were living at and going to the ten chosen PHC facilities for clinic services. Additionally, 14 (26%) experts worked at universities, 2 (4%) were representatives from NCD implementing partners, and 1 (2%) was a member of a research institution.\u003c/p\u003e\n\u003cp\u003eOut of the 46 initially identified gaps and challenges, a majority of these were in service delivery (14), followed by the health information system (8), health financing (7), and the health workforce, medical products, vaccines, and technologies, each accounting for 6 gaps and challenges. Leadership and governance had the fewest identified gaps and challenges, with only 5 (see Table 4 in the Webannex section for more details).\u003c/p\u003e\n\u003cp\u003eOverall, the relevance scores for addressing the core problem of inadequate care for DM and HTN in PHC ranged from 48.6 to 115.8 (median = 70.4, IQR = 28.9), while feasibility scores ranged from 62.9 to 102.4 (median = 72.9, IQR = 20.5). We retained 34 out of these 46 challenges and gaps. We found 12 relevant but not feasible, 3 feasible but not relevant, and 19 relevant and feasible. On the other hand, we removed 12 challenges and gaps because they were neither relevant nor feasible, as rated by participants, see Table 6 for more details. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the second part of Workshop 1, we presented the 34 gaps and challenges identified in the first part of workshop 1 to the participants. Particularly, we presented only the light green items (19). Out of the 55 invited stakeholders, 47 (85%) participated to identify priority gaps and challenges. The participants included 28 (59%) PHC workers from the ten selected PHC facilities, 4 (9%) community health practitioners (CHPs), 4 (9%) members of the county and sub-county management teams, 1 (2%) member of a research institution, and 10 (21%) experts from universities.\u003c/p\u003e\n\u003cp\u003eThe exercise identified several priority challenges and gaps as both highly feasible and relevant (see Table 3 in the Webannex section). These included the lack of trained and competent staff in DM and HTN management (relevance score = 9.2, feasibility score = 7.1), the knowledge gap in DM and HTN (relevance score = 8.9, feasibility score = 6.8), inadequate patient care, characterized by long wait times and insufficient follow-up (relevance score = 8.5, feasibility score = 6.4), and an unstandardized package of care for patients (relevance score = 8.1, feasibility score = 6.5). For additional details, see Table 7.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 3: Priority Interventions for Strengthening PHC Service Delivery in DM and HTN Management\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA total of 104 stakeholders participated in the second workshop. Each group of stakeholders engaged in their own group discussions, with the number of participants in each group ranging from 11 to 40 (see Table 8). About a third of the stakeholders were PHC workers. The remaining participants included patients living with DM and/or HTN, as well as CHPs.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eIdentification of priority interventions\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eWe initially identified 12 priority interventions, with number 1 being the highest priority and number 12 being the least. However, through a consensus-building procedure (Delphi method), stakeholders further discussed and refined these interventions, resulting in 8 being grouped under 5 broad categories.\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eTraining PHC workers on DM and HTN management\u003c/li\u003e\n \u003cli\u003eContinuous Mentorship and Supportive Supervision\u003c/li\u003e\n \u003cli\u003eAccess to Treatment Guidelines and Protocols\u003c/li\u003e\n \u003cli\u003eCommunity Outreach and Advocacy\u003c/li\u003e\n \u003cli\u003eResource Availability\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFigure 2 illustrates the priority interventions identified during the co-designing workshop aimed at addressing the core problem of inadequate care for DM and HTN within the PHC setting. These interventions align with the three primary goals of the Primary Healthcare Network. During the co-creation sessions, the stakeholders made clear references to the Kenyan guidelines that were already in place, such as the PHCN, DM, and HTN guidelines, to make sure that the suggestions, which included interventions, were in line with them. These were the primary goals of the PHCN:\u003c/p\u003e\n\u003cp\u003e(1) \u003cstrong\u003eEnhancing access to quality PHC services\u003c/strong\u003e: Training PHC workers on DM and HTN management, along with providing adequate access to treatment guidelines and protocols, is likely to equip them with the necessary skills, knowledge, and resources to improve NCD care. This training is expected to enhance the quality of care delivered to patients and the general population in the community.\u003c/p\u003e\n\u003cp\u003e(2) \u003cstrong\u003eEnhancing PHC service coordination and integration\u003c/strong\u003e: Well-organized and continuous mentorship and support supervision structures are likely to improve coordination among PHC workers. This ensures that these interventions are well integrated into the broader PHC system, which is crucial for improving the management of these chronic conditions.\u003c/p\u003e\n\u003cp\u003e(3) \u003cstrong\u003eEnhancing community engagement and participation in PHC\u003c/strong\u003e: To raise awareness and encourage community involvement in DM and HTN prevention and management, outreach and advocacy initiatives become critical. Advocating for the availability of resources supports these efforts by ensuring that the necessary tools and support for community engagement are available.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003ePerceived priority interventions for strengthening PHC service delivery for NCDs with a focus on DM and HTN diseases\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eStakeholders emphasized the need to enhance PHC workers\u0026apos; skills and competencies, particularly in managing DM and HTN, through orientation on NCD guidelines and training in essential skills like patient communication and counseling to improve access to quality PHC services. Additionally, the stakeholders recognize the need to strengthen community engagement and participation in the PHC system, as evidenced by stakeholders\u0026apos; perspectives. See Table 9 for more details.\u003c/p\u003e\n\u003cp\u003eAs a key intervention, almost all of the stakeholders suggested a need to capacity build the skills of PHC workers. However, in some Level 2 PHC facilities, stakeholders held the opinion that there was a need to train CHPs as alternative providers to support PHC workers in educating the public on the risks and symptoms of NCDs, especially DM and/or HTN. These CHPs will take on an active role in supporting patients at home and act as a link between the primary healthcare facility and the community. CHPs can follow up with patients and remind them to attend scheduled appointments without missing them, reducing complications and late referrals. Nevertheless, the primary emphasis was on the training of other cadres, including nurses, clinicians, nutritionist, and physicians, rather than CHPs, who are at the lowest level (Level 1). These other cadres were preferred for training due to their advanced medical knowledge and capacity to provide comprehensive care, which are critical to the effective management of NCDs. The objective was to improve the quality of care and assure improved patient outcomes by providing these healthcare professionals with the necessary skills.\u003c/p\u003e\n\u003cp\u003eWith the launch of the PHCN guidelines, the county\u0026rsquo;s Ministry of Health has adopted a ward-based health service delivery governance structure. This was consistent with the functional arrangements of the health facilities within the primary care network system, where the better-equipped facilities within the Ward serve as the referral hub for the networked lower- level facilities (hereby referred to spokes). In regards to this context, additional prioritized interventions prioritized included the establishment of \u0026nbsp;\u0026apos;NCD clinics\u0026apos; in most hubs (level 3s or 4s), which could be supervised by facility in- charges, to increase PHC service coverage and quality within Kisumu County.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 4: Plan and implement identified priority interventions\u003c/strong\u003e\u003c/h3\u003e\n\u003ch4\u003e\u003cstrong\u003eKey factors influencing local implementation of the interventions, and recommendations to address these factors\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eFurther analysis from stakeholder feedback identified various factors that may influence effective implementation of the interventions, including capacity building for the PHC workers, strengthening documentation and reporting, mentorship, supervision, and support systems, and operationalizing community outreach and sensitization awareness.\u003c/p\u003e\n\u003cp\u003eThese factors, for example, inadequate PHC workers in facilities hinder training efforts, as operations must continue even when staff are attending training sessions. Additionally, PHC facilities often lack essential screening and management infrastructure, including glucometers, urine strips, blood pressure devices, and weighing scales. Other challenges include the need for alignment with county health goals, a lack of training inventories to track trained providers by year and skill, high staff turnover, non-need-based deployment, and frequent transfers of PHC providers.\u003c/p\u003e\n\u003cp\u003eStrengthening documentation and reporting remains a challenge, particularly due to the absence of a specific NCD register, complicating streamlined reporting. It was recommended that the county health records team, in consultation with the sub-county NCD coordinators, procure and distribute NCD registers to document conditions such as diabetes mellitus and hypertension.\u003c/p\u003e\n\u003cp\u003eStakeholders noted a predominance of IEC materials focused on communicable diseases, recommending the creation of materials specifically for NCDs, particularly on DM and HTN, to raise awareness about risk factors and symptoms.\u003c/p\u003e\n\u003cp\u003eRecommendations included developing a PHC provider training inventory to track trained providers by year and skill level, which would help identify skills gaps. Additionally, condensing all NCD guidelines into a concise document for PHC workers would enhance their understanding of managing NCDs. The county government should follow the support supervision system and utilize required assessment forms to evaluate guideline implementation in PHC facilities. Reducing frequent, unplanned provider transfers is crucial for improving service delivery.\u003c/p\u003e\n\u003cp\u003eStakeholders also observed that county and sub-county management teams were not providing the necessary mentorship and supervision. Adherence to supervisory rosters and evaluation forms is essential, particularly for NCD management, to ensure the availability of essential infrastructure in facilities. See Table 10 for more details.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eImplementation plan\u0026nbsp;\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe project core team developed Table 5 outlining the linkage between priority interventions with distinct implementation strategies. In addition, Table 5a in the Webannex section indicate a broader category of these implementation activities based on ERIC framework[42].\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 5: Data Collection and Analysis Framework\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe project core team members developed a comprehensive framework for monitoring and evaluating the interventions. Table 11 outlines the methods used for data collection, analysis, and results dissemination.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e This study employed a participatory approach to enhance the relevance, long-term acceptance, and effectiveness of primary health services for NCDs, specifically DM and HTN, in primary care settings in Kisumu County.\u003c/p\u003e \u003cp\u003eThe primary objectives were: (1) to perform a joint analysis of facility-level data from a baseline survey of PHC settings to identify gaps in implementing service delivery packages for DM and HTN care in Kisumu County, Kenya and (2) to identify and co-design tailored improvement interventions to address key barriers to satisfactory implementation of solutions to enhance access to quality services for DM and HTN in Kisumu County, Kenya.\u003c/p\u003e \u003cp\u003eFor the first objective following stakeholder engagement workshops, this study identified four critical gaps and six key interventions. The key interventions are: training PHC workers, improving access to treatment guidelines, providing ongoing mentorship and support, organizing community outreach, and ensuring resource availability. The gaps included a lack of trained and competent staff in managing DM and HTN, knowledge gaps in DM and HTN management, inadequate patient care, characterized by long wait times and insufficient follow-up, and a lack of standardized care packages for patients. These issues are prevalent not only in Kenya but also in other low- and middle-income countries, such as Botswana, Ghana, South Africa, Ethiopia, and Uganda [43\u0026ndash;46]. Inadequate training for PHC workers is a widespread issue, and findings from similar contexts in LMICs support this, as evidenced by other studies[47\u0026ndash;49]. Primary care workers often lack simplified protocols and sufficient information about guidelines which is echoed in other studies in similar context[50, 51]. The poor service delivery maybe attributed to the knowledge gaps in the management of DM and HTN among PHC workers, which is consistent with the observations made in studies conducted in South Africa, where knowledge gaps impede effective disease management[50]. The dearth of standardized care packages for patients living with DM and HTN aligns with trends noted in other studies in similar context, highlighting a lack of common guidelines in PHC contexts[48, 52].\u003c/p\u003e \u003cp\u003eFor the objective 2, the study identified priority actions to the barriers identified in objective 1. The recommendations include: capacity building for PHC workers, strengthening documentation and reporting, mentorship, supervision, support systems, and operationalizing community outreach and awareness were identified as leverages to implement the priority actions. However, it is important to specify that these recommendations (e.g., capacity building, mentorship) are implementation strategies, a method used to put intervention into practice rather than direct interventions like training program aimed at improving skills. For example, although training is vital, it should be regarded as a strategy (e.g., training of trainers who will then deliver the training program) rather than an intervention.\u003c/p\u003e \u003cp\u003eOther studies have highlighted similar factors, such as inadequate staffing, lack of essential equipment, lack of alignment with local health goals, lack of training inventories, high staff turnover, non-need-based deployment, and frequent transfers. For example, studies from Tanzania, Cameroon, Ethiopia, and South Africa noted challenges with workforce availability and training resources, making NCD prevention and control difficult[44, 45, 53\u0026ndash;55]. A study in Nigeria[56] confirmed a significant shortage of primary care workers and emphasized the need for more training to enhance NCD care capacity.\u003c/p\u003e \u003cp\u003eFurthermore, the developed co-designed priority interventions (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), will be implemented through distinct activities outlined in the implementation plan (refer to Table\u0026nbsp;\u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e5\u003c/span\u003e). These implementation activities have been strategically classified along the ERIC framework[42] (see Table\u0026nbsp;\u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e5\u003c/span\u003ea in the Webannex section) to ensure a systematic approach to strengthening PHC delivery. The categories include: (1) conducting educational meetings; (2) ongoing training, which guarantees that the workforce is equipped with the latest skills and practices; and (3) mentorship programs, where experienced professionals are paired with those in the early stages of their careers to facilitate invaluable knowledge transfer among providers. In addition, (4) developing and distributing educational materials will empower healthcare workers and patients to access essential information, thus cultivating a culture of ongoing learning and improvement, particularly enabling PHC workers to adapt to challenges and uphold quality care. Moreover, (5) increasing demand and (6) patient involvement will ensure that patients are actively engaged in their health decision-making processes, rather than being passive recipients of care. Finally, (7) changing physical structures and equipment will create a conducive environment for service delivery in primary healthcare settings. Therefore, integrating these implementation strategies into the overarching framework of prioritized interventions, we establish a holistic approach that addresses both current requirements and long-term sustainability in diabetes mellitus and hypertension care[57].\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.1.1 Strengths and limitations\u003c/h2\u003e \u003cp\u003eThe strength of this study lies in its participatory development approach with people of all levels in the local health system. This approach incorporates the perspectives of various stakeholders, including PHC workers and individuals living with these conditions. This approach allows for local context adaptation, particularly as some facilities have already initiated NCD clinics while others are still in the planning stages, enhancing the relevance, feasibility and scalability of the proposed interventions in accordance with. The participatory method as how we operationalized it was flexible in delivery, output, and stakeholder engagement, making it suitable for a wide range of health issues[58]. Adopting a structured facilitation was crucial for achieving outcomes and guaranteeing inclusive representation.\u003c/p\u003e \u003cp\u003eThis study is relevant to the local context, as it aligns with the goals of Kenya's Primary Health Care Network. Specifically, the PHCN aims to strengthen service coordination and integration, as well as improve the quality of care in primary health care settings. The co-designed interventions support these goals by providing continuous mentorship and support supervision to primary health care workers. Additionally, there is a focus on training these workers in DM and HTN management to equip them with the necessary skills and knowledge for effective NCD management. This approach not only addresses immediate service delivery shortages but also establishes a sustainable framework for better health outcomes, thereby advancing the overarching objectives of Universal Health Coverage (UHC) in Kenya.\u003c/p\u003e \u003cp\u003eThis study acknowledges several limitations. First, the use of purposive sampling limits its generalizability, but including diverse stakeholders helps mitigate this. Secondly, the use of self-reported data might have introduced bias, as participants might have inaccurately shared their experiences. However, using a combination of qualitative methods like group discussions and quantitative methods such as surveys helped triangulate data, validate findings, and reduce bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.1.2 Implication of the findings\u003c/h2\u003e \u003cp\u003eThe findings of our study comprise a number of suggestions for health care practitioners and decision-makers at various levels in the health system. First, the study emphasizes the need for human resource capacity building and ongoing training and mentorship. In Kenya, the county government currently organizes training sessions on critical areas such as emergency obstetric and newborn care (eMOC), post-abortion care, nutrition, tuberculosis, HIV, reproductive, maternal, newborn, child, and adolescent health (RMNCAH), as well as NCDs like cervical cancer, diabetes, and hypertension. These trainings are typically held annually or biennially and are conducted by Trainers of Trainers (ToTs), who also serve as mentors within the counties.\u003c/p\u003e \u003cp\u003eThe training targets healthcare workers at each facility, but the number of participants is limited, often ranging from 1 to 2 per facility, leaving many primary health care (PHC) workers untrained despite the aim to eventually cover all staff across various health facilities. Therefore, at the local level, the training capacity can be increased by targeting more healthcare workers in each session to ensure more comprehensive coverage of staff within facilities. Furthermore, strengthening ongoing mentorship programs where trained staff can support their peers will help build a culture of continuous learning and improvement. At the national level, there is a need to standardize training guidelines across counties to ensure uniformity in skill development. Additionally, adopting technology, including e-learning modules, to supplement in-person training can make the trainings more accessible to a wider group of healthcare workers.\u003c/p\u003e \u003cp\u003eSecondly, the results emphasize the need for an improved data management system that can monitor patient outcomes. Currently, Kisumu County is rolling out a computerized patient data management system in Kenya. All patient data are recorded in daily MoH registers and enter monthly summaries to the Kenya Health Information System (KHIS). Unfortunately, not all facilities have these registers, and some patients lack booklet records, resulting in data gaps. Locally, healthcare workers need to be trained on digital systems, and patient booklets should be available at all facilities. Nationally, infrastructure to support digital data entry and a standardized data documentation protocol must be continuously invested in.\u003c/p\u003e \u003cp\u003eFurthermore, the study reveals significant gaps in resource allocation for managing NCDs. It highlights the urgent need to increase funding and support for NCD initiatives at both local and national levels. To achieve this, efforts should be expanded to engage political leaders and decision-makers in advocating for increased resource allocation for NCD management. Additionally, awareness campaigns should be created to educate leaders on the burden of NCDs and their impact on public health, fostering a common understanding and sense of urgency. Where possible, champions for NCDs can be established to lead advocacy campaigns for NCD prevention and control, including resource allocation and influencing policy discussions within political space. This aligns with WHO and national health strategies aimed at improving NCD management.\u003c/p\u003e \u003cp\u003eFinally, the study underscores the importance of community engagement initiatives. It reveals a need to strengthen community outreach programs to raise awareness about NCDs, including risk factors, symptoms, and management. This proactive approach will support continuous management of DM and HTN among populations, ultimately leading to better health outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e Our study used a participatory approach methodology to meaningfully involve a wide range of stakeholders in identifying priority service delivery needs, response interventions, and local factors affecting implementation in the PHC system. Training primary healthcare workers was identified as a priority to address current gaps in service delivery for DM and HTN. Future efforts to manage DM and HTN effectively should focus on these priority interventions, tailored to the local context. Comprehensive monitoring is needed to assess the effectiveness and implementation of such interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the ethics research committee and National Commission for Science, Technology and Innovation, Kenya; ERC 43/5/24-06 and License No: NACOSTI/P/23/25192). All participants provided informed consent before participation in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\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\u003c/p\u003e\n\u003cp\u003eData is accessible and available upon reasonable request to the corresponding author, Ogol Japheth Ouma, to ensure that the use of data is in line with the terms of ethics approvals and principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA PhD scholarship from the VLIR-UOS supported the research and the primary author (OJO), fostering partnerships between Flemish universities in Flanders, Antwerp, Belgium, and a partner university, Jaramogi Oginga Odinga University of Science and Technology (JOOUST), in Kenya. However, funders did not contribute to the design of this study, data collection, analysis, interpretation, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank all the participants who contributed to this study, including patients living with diabetes and/or hypertension, county and sub-county health management teams, NCD coordinators in the county and sub-county, facility in-charges, primary healthcare workers, health administrators, Kenya Red Cross and OGRA partners implementing NCD programs in the region, Master Trainer Dr. Julius Gwadah, JOOUST VLIR-UOS support team members, both junior and senior researchers focusing on NCDs. Their valuable insights, expertise, and dedication were instrumental in the success of this participatory workshop aimed at improving diabetes and hypertension management in primary healthcare settings in Kisumu County, Kenya.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOJO led the study\u0026apos;s conceptualization, while NWA, DO, EM, EO, and JvO contributed to its conception. GA, DO, JO, and JvO provided technical guidance and critical suggestions for the study protocol. OJO, NWA, EO, SO, IA, EM, DO, and JO provided general coordination including facilitation of the workshops and management of data collection. OJO led data cleaning, analysis and developed the first draft of the manuscript, which was verified by NWA, who had access to the raw data. GA, DO, JO, JB, and JvO made critical suggestions and edits to the draft. All authors read and approved the paper submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003cstrong\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKontis, V., et al., \u003cem\u003eContribution of six risk factors to achieving the 25\u0026times; 25 non-communicable disease mortality reduction target: a modelling study.\u003c/em\u003e The Lancet, 2014. \u003cstrong\u003e384\u003c/strong\u003e(9941): p. 427-437.\u003c/li\u003e\n\u003cli\u003eZhou, B., et al., \u003cem\u003eWorldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants.\u003c/em\u003e The Lancet, 2024. \u003cstrong\u003e404\u003c/strong\u003e(10467): p. 2077-2093.\u003c/li\u003e\n\u003cli\u003eOrganization, W.H., \u003cem\u003eNoncommunicable diseases progress monitor 2020\u003c/em\u003e. 2020: World Health Organization.\u003c/li\u003e\n\u003cli\u003eBudreviciute, A., et al., \u003cem\u003eManagement and prevention strategies for non-communicable diseases (NCDs) and their risk factors.\u003c/em\u003e Frontiers in public health, 2020. \u003cstrong\u003e8\u003c/strong\u003e: p. 574111.\u003c/li\u003e\n\u003cli\u003eMohamed, S.F., et al., \u003cem\u003ePrevalence and factors associated with pre-diabetes and diabetes mellitus in Kenya: results from a national survey.\u003c/em\u003e BMC public health, 2018. \u003cstrong\u003e18\u003c/strong\u003e(3): p. 1-11.\u003c/li\u003e\n\u003cli\u003eStatistics, B.O., \u003cem\u003eKENYA STEPwise SURVEY FOR NON COMMUNICABLE DISEASES RISK FACTORS 2015 REPORT.\u003c/em\u003e 2015.\u003c/li\u003e\n\u003cli\u003eKenya, M., \u003cem\u003eKenya national strategy for the prevention and control of non-communicable diseases 2015\u0026ndash;2020.\u003c/em\u003e Nairobi: Ministry of Health Division of Non-communicable Diseases, 2015.\u003c/li\u003e\n\u003cli\u003eOrganization, W.H., \u003cem\u003eNoncommunicable diseases country profiles 2018.\u003c/em\u003e 2018.\u003c/li\u003e\n\u003cli\u003eWamai, R.G., A.P. 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Mensah, and K.A. Korsah, \u003cem\u003ePatient perspective on barriers in type 2 diabetes self‐management: A qualitative study.\u003c/em\u003e Nursing Open, 2023. \u003cstrong\u003e10\u003c/strong\u003e(10): p. 7003-7013.\u003c/li\u003e\n\u003cli\u003eAdinan, J., et al., \u003cem\u003ePreparedness of health facilities in managing hypertension \u0026amp; diabetes mellitus in Kilimanjaro, Tanzania: a cross sectional study.\u003c/em\u003e BMC Health Services Research, 2019. \u003cstrong\u003e19\u003c/strong\u003e: p. 1-9.\u003c/li\u003e\n\u003cli\u003eTesema, A.G., et al., \u003cem\u003eExploring complementary and competitive relations between non-communicable disease services and other health extension programme services in Ethiopia: a multilevel analysis.\u003c/em\u003e BMJ Global Health, 2022. \u003cstrong\u003e7\u003c/strong\u003e(6): p. e009025.\u003c/li\u003e\n\u003cli\u003eWitter, S., K. Sheikh, and M. Schleiff, \u003cem\u003eLearning health systems in low-income and middle-income countries: exploring evidence and expert insights.\u003c/em\u003e BMJ Global Health, 2022. \u003cstrong\u003e7\u003c/strong\u003e(Suppl 7): p. e008115.\u003c/li\u003e\n\u003cli\u003eOrji, I.A., et al., \u003cem\u003eCapacity and site readiness for hypertension control program implementation in the Federal Capital Territory of Nigeria: a cross-sectional study.\u003c/em\u003e BMC health services research, 2021. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 1-12.\u003c/li\u003e\n\u003cli\u003eGregg, E., et al., \u003cem\u003eImproving health outcomes of people with diabetes mellitus: global target setting to reduce the burden of diabetes mellitus by 2030.\u003c/em\u003e Lancet (London, England), 2023. \u003cstrong\u003e401\u003c/strong\u003e(10384): p. 1302.\u003c/li\u003e\n\u003cli\u003eTieosapjaroen, W., et al., \u003cem\u003eDesignathons in health research: a global systematic review.\u003c/em\u003e BMJ Global Health, 2024. \u003cstrong\u003e9\u003c/strong\u003e(3): p. e013961.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 12 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"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-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6077243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6077243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProjections show non-communicable diseases (NCDs) such as heart disease, cancer, diabetes, and chronic respiratory diseases in Africa will cause more deaths by 2030 than communicable and perinatal diseases combined. However, most countries, including Kenya, are not on track to meeting the 25x25 global target for reducing premature mortality. This underscores the strategic emphasis on enhancing the prevention, early detection, and management of the priority NCDs, which account for a significant portion of global morbidity and mortality. Effective primary-level interventions can reduce the incidence of these diseases. At the same time, early detection increases the chances of successful management, thus contributing to better outcomes, survival rates, and quality of life. To enhance relevance, long-term acceptance, and effectiveness of primary health services for NCDs, this study employed a participatory research design to develop and implement interventions aimed at improving care delivery, specifically focusing on diabetes mellitus (DM) and hypertension (HTN) in primary healthcare (PHC) settings in Kisumu County, Western Kenya.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe used a participatory research design with a five-step procedure: (1) situation analysis; (2) establish a common vision by gathering stakeholder input to identify gaps and challenges in PHC service delivery for DM and HTN; (3) identify and select priority interventions; (4) plan and implement the identified interventions considering implementation factors; and (5) monitoring and evaluation\u0026mdash;set up a system for data collection and analysis, create an action plan, and share findings with stakeholders. Two workshops were conducted with various stakeholders, including health management teams, PHC workers, community health promoters, patients, and researchers. The study was conducted in Seme Sub-County, Kisumu County, Kenya. Stakeholders were identified using purposive and snowball sampling. Data analysis included quantitative scoring in Excel and qualitative synthesis in Dedoose software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour main gaps identified were: (1) insufficient college training for health workers in managing DM and HTN; (2) knowledge gaps regarding DM and HTN diseases; (3) inadequate patient care, characterized by long wait times and insufficient follow-up; and (4) a lack of standardized care packages for DM/HTN patients. The recommended priority interventions included: training PHC workers, improving access to treatment guidelines, providing mentorship and supervision, organizing community outreach, and ensuring the availability of diagnostics tools and essential medication. The main challenges identified include modifiable challenges such as non-need-based training, inconsistent support systems, and poor documentation, which can be addressed with little to moderate investments, alongside non-modifiable challenges like inadequate infrastructure, lack of medication and supplies which requires substantial long-term investments; recommendations include training PHC workers and operationalizing community outreach programs.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e The study underscores the value of the participatory approach to intervention development (PAID), engaging stakeholders in identifying service needs, interventions, and local factors to enhance DM and HTN care.\u003c/p\u003e","manuscriptTitle":"Addressing Priority Gaps in Access and Quality of NCD Services in Primary Care Settings in Rural Kenya: A Participatory Approach to Intervention Development","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 12:29:12","doi":"10.21203/rs.3.rs-6077243/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-22T10:47:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-14T20:44:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2025-12-08T10:33:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-02T20:36:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105637855047948087535397671858530301220","date":"2025-04-05T00:04:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276946264628202889119899366402013771358","date":"2025-04-02T14:48:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49945085561005811441863611983289983973","date":"2025-03-31T02:46:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-30T21:23:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-27T04:36:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-27T04:13:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-02-21T07:38:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dbc79770-51cd-4e98-bdf4-3aab08bdec1a","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:07:55+00:00","versionOfRecord":{"articleIdentity":"rs-6077243","link":"https://doi.org/10.1186/s12875-026-03295-5","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2026-04-06 15:58:29","publishedOnDateReadable":"April 6th, 2026"},"versionCreatedAt":"2025-07-18 12:29:12","video":"","vorDoi":"10.1186/s12875-026-03295-5","vorDoiUrl":"https://doi.org/10.1186/s12875-026-03295-5","workflowStages":[]},"version":"v1","identity":"rs-6077243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6077243","identity":"rs-6077243","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}