Assessing the Capacity of Primary Healthcare Facilities and Healthcare Workers in Managing Diabetes and Hypertension in Kisumu County, Kenya

Assessing the Capacity of Primary Healthcare Facilities and Healthcare Workers in Managing Diabetes and Hypertension in Kisumu County, Kenya | 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 Assessing the Capacity of Primary Healthcare Facilities and Healthcare Workers in Managing Diabetes and Hypertension in Kisumu County, Kenya Ogol Japheth Ouma, Dickens Omondi, Elijah Museve, Jane Owenga, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6743764/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Health Services Research → Version 1 posted 14 You are reading this latest preprint version Abstract Background The burden of non-communicable diseases (NCDs) like hypertension and diabetes is rapidly increasing in sub-Saharan Africa, with cardiovascular conditions contributing about 40% of all NCD-related morbidity. This poses considerable challenges, including governance, prevention of risk factors, monitoring, surveillance, and evaluation of health systems. In Kenya, NCD-related mortality is approximately 600 per 100,000 for males and 500,000 per 100,000 for females, with Kisumu County reporting approximately 1,118 per 100,000 population annually, compounded by a high HIV burden. Primary healthcare (PHC) provides essential care that could ensure proactive, patient-centered, community-based, and sustainable care to prevent and manage NCDs, yet its implementation remains weak with large regional and subnational differences. Methods This mixed-methods study was conducted between October 2023 and September 2024 in Kisumu County, Kenya, and included a facility assessment survey, PHC worker surveys, and focus group discussions (FGDs) with 20 patients living with DM and/or HTN. Ten facilities out of 29, classified as level 2 to 4 under the Kenya Essential Package for Health (KEPH), were purposively selected for the study. The evaluation assessed service availability and performance in NCD care using the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) toolkit. Key aspects included essential drugs, guidelines, equipment, patient follow-up, counseling systems, support supervision, and the training, knowledge, perceptions, and practices of PHC workers. Results While most facilities conducted routine DM and HTN screenings, only 20% [95% Confidence Interval: 5.7%, 51.0%] displayed national management guidelines. Over 80% of PHC workers had not received post-basic training in DM and HTN management, and only 50% were proficient, with an average knowledge score of 2.2 out of 4. Nearly 80% [95% CI: 49.0%, 94.3%] of facilities referred patients to higher-level facilities due to inadequate clinical capacity or a lack of essential medicines. Patient follow-up and counseling on self-care and lifestyle changes were rated poorly, averaging 2.9 [95% CI: 1.4, 4.4] out of 6. Qualitative study through FGDs revealed frequent medication shortages, a lack of basic equipment, and insufficient patient information on self-care, diet, and exercise. Conclusions and recommendations: Significant gaps exist in the organizational and workforce capacity of PHC facilities in Kisumu County, Kenya. Addressing these modifiable issues requires defining specific strategies for improvement and identifying necessary investments to scale up effective interventions. This could proffer far-reaching implications for health outcomes and overall health system efficiency. Mixed methods Health System Referrals Guidelines Patient follow-up Figures Figure 1 Background Non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension (HTN), are rising significantly in low- and middle-income countries (LMICs) like Kenya[ 1 , 2 ]. These conditions contribute approximately 15 million premature deaths globally among individuals aged 30–69 years [ 3 , 4 ], of which 85–90% occur in LMICs [ 5 , 6 ]. While trends of NCD incidence and mortality are declining in high-income countries (HICs), new cases and NCD mortality are disproportionately higher in the LMICs. Africa, in particular, faces a rapidly increasing burden of NCDs, with projections indicating a significant increase in NCD-related deaths. By 2030, NCDs are expected to pose a greater global challenge than communicable, maternal, neonatal, and nutritional diseases (CMNNDs) combined [ 7 , 8 ]. In Kenya, NCDs account for over half of inpatient hospital admissions and 39% of all deaths annually [ 9 , 10 ]. According to the International Diabetes Federation (IDF) (2021), approximately 15,284 adults aged 20 to 79 years were linked to diabetes in Kenya[ 11 , 12 ]. In Kisumu County, Kenya, the mortality rate is 1,118 per 100,000 populations, significantly exceeding both the national average of 659 deaths per 100,000 and the average observed in other LMICs at 547 per 100,000. In addition to the high burden of HIV in this region, a considerable 48% of all deaths are attributed to NCDs as compared to 58.1% (50%-88%) as reported in other LMICs[ 13 , 14 ] with intrinsic variation between countries, highlighting the urgent need for effective NCD prevention strategies, considering the uncertainty and variability in these estimates. The concurrent burden of communicable diseases in the region exacerbates this issue. These chronic conditions result in high morbidity, mortality, and treatment costs, primarily due to complications, highlighting the urgent need for effective NCD prevention and management interventions. Although effective interventions exist for noncommunicable disease, they are not widely implemented satisfactorily, with large subnational differences[ 15 ]. Appropriate mechanisms are required to support implementation of policy and programs, including health system strengthening and advocacy, community participation, and inter-sectoral and interdisciplinary collaboration[ 15 ]. Delivery of essential services through PHC approach could ensure proactive, patient-centered, community-based, and sustainable essential care to prevent and manage NCDs[ 16 ]. Evidence suggests that the implementation of effective PHC can substantially reduce the morbidity and mortality rates associated with NCDs[ 17 ], for instance, by enhancing the early detection and management of conditions like HTN and DM, resulting in improved health outcomes[ 18 ]. The implementation of a PHC approach in LMICs to improve NCD coverage faces significant barriers [ 19 ] including unreliable medical supply chains, inadequate health financing, and weak health information systems[ 20 – 22 ]. Suboptimal clinical guidelines and a lack of implementation strategies, such as technical support and supervision for PHC workers, exacerbate inequities in access and care quality [ 24 , 26 – 30 , 32 – 34 ]. Shortages of essential medical supplies and equipment, like blood pressure machines and glucometers, hinder PHC workers from delivering quality care [ 23 ], leading to suboptimal diagnosis and treatment of NCDs[ 24 – 28 ]. Human resource limitations, including inadequate training and insufficient competencies among PHC workers, further restrict effective PHC implementation[ 28 – 33 ]. Additionally, PHC facilities often lack the means for organizing referrals, conducting laboratory tests, and ensuring proper patient follow-up[ 29 , 34 – 36 ], with evidence indicating that about 71.4% of facilities refer patients to higher-level facilities immediately after DM diagnosis[ 37 ]. Patient experiences and perceptions highlight unmet needs and barriers to accessing care, especially in rural settings where individuals at an increased risk of or living with NCDs may be unaware, undiagnosed, or lack access to treatment and support interventions[ 38 ]. These issues highlight the need for strengthening support for the implementation of policies and programs targeting priority NCDs, such as hypertension and diabetes[ 39 ]. The improvement interventions could focus on patient scheduling to reduce time and cost burden and increase compliance[ 40 ]; advocacy to enhance community engagement, participation, and experience in prevention and quality care[ 20 ]. The Kenya Ministry of Health embarked on policy reforms following the 2011 UN declaration on mitigation for NCDs by developing and distributing the national strategic plan, currently in its second edition, and the national clinical guidelines for DM and HTN management in 2024 to strengthen PHC[ 41 ]. The reported implementation gaps, especially for hypertension and diabetes, highlight the need for context-specific evidence on the implementation of effective interventions to inform priority setting. As a priority, Kenya adopted the WHO Package of Essential Non-communicable Disease Interventions (WHO PEN) for low-resource settings[ 42 , 43 ]. Both frameworks emphasize a chronic care approach due to their public health impact. However, implementation remains challenging, especially in rural areas like Kisumu County, due to limited input of local evidence in the guidelines as well as systems and resource constraints, including a shortage of experienced frontline health workers[ 44 ], competing priorities with communicable diseases, and inadequate infrastructure. The current study reports an evaluation of the capacity of PHC facilities in Kisumu County, Kenya, to provide quality care for the prevention and management of HTN and DM and the mechanisms for implementing strategic guidelines for hypertension and diabetes management. Specifically, it: (1) determined the current status of structural elements in PHC settings, which facilitate the delivery of quality care for the prevention and management of HTN and DM; (2) assessed the care processes provided by PHC workers in managing DM and HTN; and (3) explored experiences and perceptions of patients regarding the care they receive for these conditions in PHC settings. The study objectives are of high public health relevance as the findings reveal core stakeholder perspectives across the care continuum, priority training, and advocacy intervention points. These findings will be valuable in informing strategic improvement interventions to enhance service quality, efficiency, and effectiveness. Methods Study setting This study was conducted in Kisumu County, one of Kenya’s 47 counties, from October 2023 to September 2024. The County is located on the shores of Lake Victoria, in western Kenya, and comprises seven sub-counties. The county’s approximately 1.2 million people are served by about 70 PHC facilities (levels 2, 3, and 4), which include dispensaries, health centers, and sub-county hospitals. Nursing Officers are the key clinical staff at majority of the dispensaries (level 2), with Clinical Officers being the lead clinicians at health centers (level 3) and Medical Officers at the sub-county hospitals (level 4). All services are integrated and, where staff establishment allows, are provided through an interdisciplinary approach, integrating the roles of nutritionists, public health Officers, occupational therapists, and physiotherapists. These facilities provide various levels of NCD care services for DM and HTN based on a tiered approach as defined in the Kenya Essential Package of Health (KEPH) guideline. Case referral is based on the Kenya Health Sector Referral Implementation Guidelines within the context of Primary Care Networks (PCNs). The PCNs operate on a hub and spoke model, where the hub (a higher-level health facility) provides advanced care and supports the surrounding spoke facilities (lower-level health facilities). The purpose is to enhance cross-level integration of healthcare delivery and coordination of multidisciplinary health teams within the county, thereby ensuring continuity and efficiency of care through case referrals and counter-referrals. The current study was based in Seme sub-county, which was selected purposively based on the organizational and logistical capacities. Research design This study adopted a cross-sectional design with parallel mixed-methods approach to assess the capacity of PHC facilities in Kisumu County to deliver high-quality care for the prevention and management of HTN and DM. We employed a structured questionnaire to obtain quantitative data and conducted FGDs to gain qualitative insights into HPC services. Study population and sampling strategy The study population comprised of PHC workers and patients from PHC facilities in Seme sub-county. To ensure our research to be in line with local health policies, we consulted county and sub-county representatives from the Department of Health, incorporating stakeholder feedback, for instance to select study facilities. The study sites included mainly public PHC facilities, a limited number of private facilities (level 3) to gain limited insights from the private sector without making any strong claim on the differences between public and private sectors due to the underrepresentation of the private facilities. Sample selection The selection of samples was conducted in three stages: Stage 1: County and sub-county Selection County and sub-county Selection : One county was purposively selected where the prevalence of NCDs is notably high at 22%[ 45 ] compared to other counties to represent the broader region in which one sub-county was also purposively selected. This study was nested within a larger study targeting six counties in Kenya under the School of Health Sciences of Jaramogi Oginga Odinga University of Science and Technology (JOOUST). 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. Stage 2: Facility Selection Facility Selection : We purposively selected ten out of 29 PHC facilities classified as level 2 to 4 facilities according to Kenya Essential Package for Health (KEPH). These facilities included health centers, maternity homes, and sub-county hospitals, providing relatively complex PHC services (e.g., maternity care, minor surgeries, and specialized consultations). Stage 3: PHC Workers & Patients Selection PHC Workers and Patients Selection : Purposive sampling for both qualitative and quantitative data collection was conducted per facility, with the following target numbers for each facility level considered: Level 2 : One PHC worker (either a nurse or clinical officer) per facility. No focus group discussions (FGDs) were conducted at this level due to a low caseload of patients. Level 3 : Two PHC workers and 1–2 patients per facility. Level 4 : Five PHC workers and 1–2 patients per facility. The facility in-charges expressed a willingness to participate through informed consent, and the county and sub-county team deemed the selection appropriate, ensuring alignment with the study's objectives. For quantitative data collection, a total 24 PHC workers were selected from the 10 PHC facilities, representing 25% of the total workforce (i.e., 96 PHC workers in 29 facilities). This sampling facilitate targeted conversations within PHC settings and ensure a varied representation of perspectives across different cadres. The PHC workers included clinical officers, nurses, and nutritionists, who provided informed consent and actively worked in the selected facilities. The distribution of PHC workers observed reflects broader trends in the Kenyan health system, with data from July 2024 indicating that there were two medical officers, 33 clinical officers, 57 nursing officers, and four nutritionists working across various facilities in Seme sub-county. Additionally, we collected extensive qualitative data from 20 patients about their experiences with hypertension and diabetes mellitus and care received in the selected settings. They were selected through sampling from level 3 and 4 facilities based on specific criteria: aged 18 years or above, capable of providing informed consent, and had been living with DM and/or HTN for at least six months. We specifically targeted individuals seeking routine care at the clinic, including regular visits, to ensure comprehensive discussions. Two FGDs were conducted, each comprising about 9 and 11 patients respectively. For additional details, see Fig. 1 . Measurements and data collection We collected data at the health system, patient, and PHC worker level using standard survey procedures and tools adapted from the WHO PEN framework [ 46 ] and the WHO Innovative Care for Chronic Conditions (ICCC) Framework [ 47 – 49 ]. Table 1 provides a comprehensive overview of the variables, instruments, and data collection methodologies for specific research questions. For Research Question (RQ) 1, the outcome measurements assessed included the availability of essential drugs for managing DM and HTN, basic medical equipment (e.g., blood pressure monitors, glucometers), guidelines and diagnostic algorithms, information, education, and communication (IEC) materials for community outreach, structures for patient follow-up and counseling, trained PHC workers on DM and HTN management, and regular support supervision received by the PHC facility. For RQ2, the outcomes included the knowledge of PHC workers, their perceptions, practices related to healthy counseling and education, training received, and support systems such as mentorship while for RQ3, the outcomes were patient satisfaction, perceived barriers and facilitators to accessing care, and self-care practices related to DM and HTN management. Incorporating user experience as a metric for the quality of care [ 20 , 50 ] is advisable, as it aligns well with the principles of patient-centered care (PCC). Supplement 1 in the Appendix details the process used to calculate each indicator score for PHC workers managing DM and HTN in terms of care processes. This method is derived from the organization Room to Read[ 51 ], which implements literacy programs and gender equality and employs a similar approach to calculate teachers’ knowledge, perception and practices scores, and validated extensively in similar sub-Saharan African settings. Therefore, adapting this instrument can assist in evaluating PHC workers' knowledge, perceptions, and practices in managing DM and HTN, ensuring its relevance in the health facility context and contributing to improved patient care outcomes. We utilized the mobile application Kobo Collect to program and gather quantitative data, which quickened the data entry process and enhanced the efficiency of quality checks. Data collection was conducted through structured one-on-one interviews, ensuring comprehensive assessments. We also held two FGDs in quiet environments, each lasting between 1 and 1.5 hours, in both local languages and Swahili, to capture patients' emerging experiences while seeking NCD-related care services at PHC settings. We digitally recorded all interviews and manually transcribed them. Table 1 Variable definition and measurements Research Question (RQ) Concepts/Key information required Instrument and process of data collection Reference or name of instrument 1) What are the current structural elements in PHC settings that facilitate the delivery of quality care for the prevention and management of DM and HTN? Availability of essential drugs for managing DM and HTN: - A structured observation checklist to assess the availability of essential drugs for DM and HTN. Each drug available was assigned 1, else 0 and a composite score is derived by summing these scores. Kenya Essential Medicines List 2023 and other sources from Isadru et al., 2021[ 52 ], 22nd WHO model list of essential medicines 2021 [ 53 ], WHO ICCC Framework [ 47 – 49 ], and WHO SARA tool [ 54 ]. Availability of basic medical equipment (e.g., blood pressure monitors, glucometers) and diagnostic parameters - Structured observation checklist followed with a guided interview with the in-charges on equipment use including: availability and functionality of sphygmomanometer, stethoscope, weighing scale, glucometer, and glucometer stripes. Each equipment availability and functionality was assigned 1, else 0 and a composite score is derived by summing these scores. List of basic equipment and diagnostic parameters from Isadru et al., 2021[ 52 ], WHO ICCC Framework [ 47 – 49 ], and WHO SARA tool [ 54 ]. Availability of guidelines and diagnostic algorithms for care of DM and HTN Structured observation checklist and interviews with facility in charges. Each guideline, diagnostic algorithms, and IEC materials availability was assigned 1, else 0 and a composite score is derived by summing these scores. Availability of DM and HTN guidelines and diagnostics assessed as per Isadru et al., 2021 [ 52 ] and WHO SARA tool [ 54 ]. IEC materials for community outreaches Isadru et al., 2021 [ 52 ] and WHO SARA tool [ 54 ]. Availability of structures and process for patient follow-up and counselling Guided interview with the facility in-charges using a checklist in a binary format (Yes/No) with items on who, what and how of counselling, and tracing and a composite score is derived by summing these scores. Self-developed based on general management information from literatures and DM and HTN guidelines. PHC facility has trained PHC workers on DM and HTN management, received quarterly or annual supervisory support visits from CHMT and/or S/CHMT Guided interview with the facility in-charges using a checklist in a binary format (Yes/No): trained workers on HTN and diabetes management in the last 2 years (2023 and 2024), facility received regular or quarterly support supervision visit from the higher level (county and/ or sub county health management team). A composite score is derived by summing these scores. Isadru et al., 2021 [ 52 ] and WHO SARA tool [ 54 ]. 2) How do PHC workers manage DM and HTN in terms of care processes? Knowledge of PHC workers PHC worker’s knowledge assessment survey and in the knowledge test, PHC workers received 1 point for each correct mention. The total scores were summed to create a composite indicator score, which is measured on a 4-point scale. This means that the maximum possible score is 4 out of 4., see Supplement 1, part A. Self-developed based on general management information from literatures and DM and HTN guidelines. Perception PHC workers survey to gauge their level of (dis)agreement with statements on DM and HTN management, to understand to their perceptions of effective practices in managing these conditions. This definition differs from knowledge, which refers to factual understanding or awareness of medical concepts and guidelines. For example, while a respondent may agree that patient education is critical (indicating a perception), their actual knowledge about specific lifestyle changes or medical adherence may vary. The indicators tested assess both the recognition of important management strategies and the underlying beliefs that influence patient care practices. For additional details, see Table 7 , indicator 4 in the appendix section. Self-developed based on general management information from literatures and DM and HTN guidelines. Practices by PHC workers on healthy counselling and education Checklist with activities to manage DM and HTN, can be listed. For every item mentioned, PHC workers score 1 and these scores were summed up to get a composite 6-point indicator score on practices with higher scores reflecting a broader engagement in effective management practices based on their reported activities related to DM and HTN management. This concept covers the actual activities and methods employed by PHC workers in managing DM and HTN, including counselling techniques and the ability to adjust these based on patient feedback, see Supplement 1, part B. Adapted from the information in the HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care [ 55 ]. PHC worker’s training The survey form for PHC workers uses a binary format (Yes/No) to determine whether they have attended any training on NCDs in the years 2023 or 2024. If they answered "Yes," they were prompted to specify the trainings they attended to provide a clear picture of the training attendance and the collection of detailed information on specific training. The training attended by PHC workers was evaluated in two aspects. First, the extent of coverage regarding the methods and strategies to teach patients about the management and prevention of DM and HTN during the training. Isadru et al., 2021 [ 52 ] PHC worker’s support system e.g. mentorship Checklist: regular technical support visits from NCD Coordinator (Yes/No?). The assessment also required active recall of examples of mentorship provided. (Table 11 Appendix). A composite score is derived by summing these scores. Isadru et al., 2021[ 52 ] 3) What are the experiences and perceptions of patients regarding the care they receive for DM and HTN in PHC settings? Patient satisfaction FGD combining both explicit/overt (direct responses) and latent (non-verbal, underlying emotions) meanings to ensure a comprehensive understanding of the respondent’s perspectives and contextual relevancy, providing more nuanced details of the topic from the collected data. More details in Supplement 2. Self-developed based on general management information from literatures and DM and HTN guidelines. Perceived barriers and facilitators to access care Self-care practices Data analysis Quantitative analysis Quantitative data cleaning and analysis was conducted using STATA version 17. To address RQ1 and RQ2, Means and Standard Deviations (SD) were reported for continuous variables, absolute and relative frequencies (expressed as percentages) for categorical variables. In addition, we estimated means and proportions by constructing asymptotic 95% confidence intervals (CIs) for the population means, and 95% Wilson-score CIs for population proportions. These results are presented using tables and charts. Qualitative analysis For RQ3, we conducted qualitative analysis employing both inductive and deductive coding methodologies. For the inductive coding, we identified themes from the data without preconceived categories. This was followed by deductive coding, where we applied thematic analysis framework proposed by Braun and Clarke (2006) due to its flexibility to categorize the data consisting of six key phases. Particularly, these phases guided the authors to analyze qualitative data and include: (1) familiarizing with the data; (2) coding initial themes; (3) grouping related codes; (4) reviewing themes; (5) defining and naming themes; and (6) finally presenting their significance to the research questions in a structured format[ 56 ]. This coding process was conducted independently by a minimum of two members of the research team using Dedoose qualitative analysis software. We selected a sample of 10% of the transcripts to develop a common codebook, ensuring the reliability of code applications between coders through inter-coder reliability testing in Dedoose. After finalizing the codebook, all transcripts were re-coded by the first author (OJO). The coded transcripts were subsequently exported to Excel for analysis, allowing us to identify emerging themes. This triangulation of data sources was essential in exploring how PHC workers manage DM and HTN in terms of care processes. Results To provide a solid statistical foundation, we presented quantitative information on structural elements in PHC for HTN and DM care and care processes by PHC workers for HTN and DM management. Numerical data reveals the prevalence of structural elements such as medication availability and patient referral rates, as well as care processes by PHC workers, including their knowledge, perceptions, and practices, which are crucial for understanding NCD care. These quantitative insights are supplemented by integrating qualitative findings on patients' experiences with NCD care, such as patient counseling, treatment barriers, and subjective experiences, to avoid repetition of the findings. Qualitative data adds context and depth to quantitative results, uncovering PHC system barriers and facilitators. In this section, we have combined these findings to demonstrate how both quantitative and qualitative data inform our understanding of NCD care. PHC workers’ characteristics The study revealed that 58% of PHC workers were female with a mean age across all HPC workers of 36.3 years (SD: 4.7). The findings further indicate that among the professional cadre, 42% were Clinical Officers, 50% were Registered Nurses, and 8% were Nutritionists. See Table 2 for additional details. Table 2: PHC worker’s characteristics Variable N (%) or Mean (SD) Number of PHC workers interviewed 24 (100%) Gender Male 10 (42%) Female 14 (58%) Age (in years) 36.3 (4.7) Marital status Married 20 (83%) Single 3 (13%) Widowed 1 (4%) Highest level of education completed Diploma 19 (79%) Bachelors 5 (21%) Professional cadre Clinical officer 10 (42%) Registered Nurse 12 (50%) Nutritionist 2 (8%) Contract type Permanent and pensionable 8 (33%) Short term contract 16 (67%) PHC worker worked in other facilities before current one 20 (83%) Years of experience in current PHC facility (in years) 2.8 (3.2) Years of experience working in PHC before (in years)* 7.6 (4.4) Table Legend*- In this indicator, out of 24 PHC workers surveyed, only 20 had prior experience working in PHC facilities, while 4 were new to the role. The missing data regarding the experience of the 4 PHC workers does not necessitate advanced missing data techniques due to the descriptive nature of our analyses. We focused on summarizing the characteristics of the PHC workers and their experiences, which provides valuable insights into the workforce dynamics within the current facility. The qualitative analysis identified five key themes regarding patients' experiences and perceptions of NCD care in PHC settings. Themes identified were: inadequate counseling and follow-up, patients feeling that dietary and exercise advice was not useful, and a desire for practical demonstrations that fit their daily lives, inadequate counseling time, inconsistent counseling practices, a focus on medication availability, a lack of practical demonstration during counseling, limited staff, inadequate training, communication issues, time constraints, inadequate access to recommended healthy diets, inconsistent exercise, and inadequate reference materials. In the deductive phase, we organized themes and related themes identified in literature and theoretical frameworks related to patient care such as principles of patient-centered care and medical adherence. This led to new themes such as barriers to patient adherence, insufficient equipment and screening practices, limited access to essential medications, lack of awareness, delayed diagnosis, lack of drugs, patient trust issues, discouragement, and frustration. Through this dual approach in our analysis, we were able to elicit explicit spontaneous experiences of patients and more latent meanings, such as underlying attitudes and contextual elements affecting patients' experiences. Details of these qualitative findings are integrated in the section aside to the quantitative results. Structural elements in PHC for HTN and DM care Essential drugs and basic medical equipment availability The findings in Table 3 reveal that the majority of PHC facilities are without essential medications for treating HTN (N = 9 out of a total of 10 health facilities included in the study) and DM (N = 8). Specifically, 90% [95% CI: 59.6%, 98.2%] of the facilities lack key hypertension drugs such as Losartan, Enalapril, and Nifedipine. Furthermore, 80% [95% CI: 49.0%, 94.3%] of the facilities do not have critical diabetes medications like Insulin, Metformin, and Empagliflozin. Most PHC facilities have essential equipment for NCD care; however, the availability of specific items such as lancets and test strips (60% [95% CI: 31.3%, 83.2%]), sphygmomanometers (20% [95% CI: 5.7%, 51.0%]), and tape measures (10% [95% CI: 1.8%, 4.0%]) is insufficient. None of the facilities had HbA1c testing devices, foot care tools, or retinal screening equipment, all required by national guidelines. Only 60% of the facilities have access to written care guidelines and management algorithms. Similarly, 80% [95% CI: 49.0%, 94.3%] of the facilities did not have essential materials for counselling, and education (Figure 2 in Supplement 1 of the Appendix). Respondents in the patient FGD confirm that they experienced the lack of screening equipment and medications as a barrier to diagnosis and management. This contributed to their dissatisfaction with care, trust in the services and made adherence to treatment more difficult. Table 3: Availability of essential drugs and equipment for hypertension (HTN) and diabetes mellitus (DM) Item N (%) Wilson-score [95% confidence interval] Availability of essential drugs for managing HTN 1 (10%) 1.8%, 4.0% Availability of essential drugs for managing DM 2 (20%) 5.7%, 51.0% Facility has access to written guidelines of care, and diagnostic and treatment algorithms for NCD care 6 (60%) 31.3%, 83.2% Facility has necessary supplies 2 (20%) 5.7%, 51.0% PHC facility has the following equipment for NCD care Blood pressure monitors 10 (100%) 72.2%, 100.0% Sphygmomanometer- manual (cuff for different arm sizes) 2 (20%) 5.7%, 51.0% Height Measuring Tape 10 (100%) 72.2%, 100.0% Stethoscope 10 (100%) 72.2%, 100.0% Glucometers 10 (100%) 72.2%, 100.0% Urine test strips (for glucose and ketones) 9 (90%) 59.6%, 98.2% Lancets and test strips 6 (60%) 31.3%, 83.2% Tape measure 1 (10%) 1.8%, 4.0% Patient follow-up and counselling Patient follow-up, counselling on self-care and lifestyle modifications were rated poorly, with an average score of 2.9 [95% CI: 1.4, 4.4] out of 6 (Table 4). Many patients expressed that the dietary and exercise advice provided was not useful, highlighting a desire for practical demonstrations tailored to their daily lives. Additionally, issues such as insufficient counseling time and inconsistent practices among staff were noted, contributing to overall dissatisfaction with the care received. Table 4: Patient counselling and follow-up Item N (%) or Mean (SD) Wilson-score [95% confidence interval] Patient counselling and follow-up score ( out of a total score of 6) 2.9 (2.1) 1.4, 4.4 Availability of staff assigned for patient counselling 2 (20%) 5.7%, 51.0% Availability of patient counselling tools/materials 3 (30%) 10.8%, 60.3% Availability of a framework for conducting group counselling and individual counselling for patients 5 (50%) 23.7%, 76.3% Availability of a system for tracking initial defaulters 3 (30%) 10.8%, 60.3% Availability of a functional system for patient reminder and follow-up? 3 (30%) 10.8%, 60.3% Availability of a trained staff in DM and/or HTN diagnosis and treatment in the facility 7 (70%) 31.3%, 83.2% Care processes by PHC workers for HTN and DM management PHC worker’s knowledge, perception and practices Overall, 50% of PHC workers showed proficiency in managing NCDs like DM and HTN with a mean knowledge score of 2.2 (95% CI: 1.8-2.6) out of a total score of 4 (Table 5). Only 46% [95% CI: 27.9-64.9%] of PHC workers could identify over half of the components of NCD management out of nineteen components, such as healthy diets and timely screenings. Additionally, 21% [95% CI: 9.2%, 40.5%] could mention more than half out of nine of the essential characteristics for effectively managing DM and HTN as outlined in Supplement 1, Table 7 under the third indicator. The perception of PHC workers towards NCD management is largely positive, with 92% [95% CI: 74.2%, 97.7%] of PHC workers responding favorably to statements related to key aspects such as prevention, patient education, and the importance of routine monitoring. For example, PHC workers stressed the importance of teaching patients about healthy lifestyles to effectively manage and prevent diabetes and high blood pressure. They also stressed how important it is to start helping newly diagnosed patients right away and how essential it is to keep learning as a professional. For additional details, see Table 7, Indicator 4 of Supplement 1 in the Appendix. The results show that only 50% of PHC workers engaged in practices related to managing and preventing DM and HTN, as evidenced by practices score of 3.0 [95% CI: 2.6, 3.5] out of a total score of 6 (see Table 5). Table 5: PHC worker’s knowledge, perception and practices N (%) or Mean (SD) Wilson-score [95% confidence interval] PHC worker’s knowledge score on NCDs management, focusing on DM and HTN (out of a total score of 4) 2.2 (1.0) 1.8, 2.6 Knowledge (NCD Management): Mentioned 50%+ of the listed different components of NCD management. 11 (46%) 27.9%, 64.9% Knowledge (Trainings): Knew when PHC workers should acquire the knowledge, skills and abilities to manage DM and HTN. 14 (58%) 38.8%, 75.5% Knowledge (NCD provider): Mentioned 50%+ of the listed characteristics of skilled PHC workers to effectively manage DM and HTN. 5 (21%) 9.2%, 40.5% Perception: Gave favorable response on 50%+ of the statements on DM and HTN management 22 (92%) 74.2%, 97.7% PHC worker's practices score on management and prevention of DM and HTN (out of a total score of 6) 3.0 (1.1) 2.6, 3.5 Practice: Mentioned 50%+ of the listed practices used to manage DM and HTN among patients diagnosed with these conditions. 8 (33%) 18.0%, 53.3% Practice (teaching): Mentioned 50%+ of the listed methods used to teach patients to manage DM and HTN. 4 (17%) 6.7%, 35.9% Practice (assessment): Mentioned 50%+ of the listed assessment processes of understanding patients during self-management education. 7 (29%) 14.9%, 49.2% Practice (assessment frequency): Provide patient education, including counselling services, to patients living with DM and/or HTN at every consultation during clinic schedules. 18 (75%) 55.1%, 88.0% Practice (adaptation): Ability to adjust patient education and counselling strategies based on assessments and patient feedback. 23 (96%) 79.8%, 99.3% Practice (examples of adaptation): Mentioned 50%+ of the listed patient education and counselling strategies. 12 (50%) 31.4%, 68.6% The majority of PHC facilities, 80% [95% CI: 49.0%, 94.3%], were referring patients to the higher-level facilities for further care related to HTN or DM. The main reasons for referral were poor control of the condition despite treatment; 50% [95% CI: 23.7%, 76.3%], severe complications such as stroke, heart attack, or kidney failure; 30% [95% CI: 10.8%, 60.3%], and a lack of diagnostic equipment at the facility; 20% [95% CI: 5.7%, 51.0%] (Table 12 in the Appendix). When asked for their needs in relation to follow-up, FGD participants felt that they did not receive reminders to attend to their scheduled routine hospital clinic days. As a result, they often missed counseling services, which they deemed essential for managing their conditions. Participants indicated a lack of uniform health information with no standardized package of care during patient education and counseling sessions within PHC settings (Table 6). Furthermore, participants indicated that they were not receiving consistent practical counseling on dietary and exercise plans for managing DM and HTN. Some PHC workers were providing differing advice on different clinic visits, leading to confusion. They expressed a need for practical illustrations and education that can apply to their mundane daily lives. This highlights a disconnect between the counseling provided and their real-life experiences and felt needs (Table 6). PHC worker’s support and training Over 80% of PHC workers who completed basic training have not received further training on managing and preventing NCDs. This is reflected by a training score of 1 [95% CI: 0.2, 1.8] out of a total score of 6 (see Table 10 for specific components thereabout). In 2023-2024, only 21% [95% CI: 9.2%, 40.5%] were trained on DM or HTN management, and just 17% [95% CI: 6.7%, 35.9%] on both (Table 11 in the Appendix). Out of those who received training, about half of them believed the training covered these topics to a great or very great extent. Secondly, in terms of ease of understanding, 67% [95% CI: 30.0%, 90.3%] of the PHC workers found it easy or very easy to understand these topics. Additionally, in a test example, only one-third could list over half of the tools they use for patient self-management, such as self-care illustrations, follow-up calls or messages, home care visits, and peer mentoring support systems. The majority of PHC workers; 75% [95% CI: 55.1%, 88.0%] reported receiving regular technical support visits from County or Sub County NCD coordinators, but only a third confirmed these occurred quarterly. During these visits, 67% [95% CI: 46.7%, 82.0%] received mentorship for DM and HTN management. Thirteen percent [95% CI: 4.3%, 31.0%] could identify examples of mentorship provided, including Patient Data Documentation, Community Outreach Programs, Drug Management, and On-the-Job Training. Regarding the qualitative findings on the patient’s experiences and perceptions of NCD care, Table 6 provides illustrative quotes from each theme, illustrating both spontaneous and latent insights obtained from the participants' responses. Table 6: Patient’s experiences and perceptions of NCD care Barriers Sample quotes Major themes: Inadequate counselling Sub-themes: · Inadequate counselling time · Inconsistent counselling practices · Medication availability focus · Lack of practical demonstration during counselling “One of the challenges in this facility is inadequate counseling. Nowadays, once the provider asks if you’re feeling better and you confirm yes, the next question is whether you have your medication. If not, you’re referred to the pharmacy, but often the drugs aren’t available there either.” [Female, 37 years, HTN patient, Level 4] “Since I started attending clinics at this facility, I have found the services to be better than at my previous one especially the way the nurse regularly counsels me on what to eat and what to avoid. However, the biggest challenge is the lack of medication and in most cases I have to buy them from nearby shops but very expensive, facility should stock these drugs.” [Male, 48 years, HTN patient, Level 3] “I believe this facility's providers lack counseling time due to the high number of clients and limited number of providers. Therefore, they typically only inquire about my experiences and medication levels. In fact, when I first received the diagnosis, the only advice I received was on what to eat and what not to eat, and that is the only counseling I ever received.” [Female, 48 years, HTN patient, Level 4] Major themes: Language Barriers, Capacity Constraints, and Time Pressure Sub-themes: · Limited staff · Inadequate training · Time constraints · Communication issues “I think the main challenge is the lack of adequate providers. For example, here, there’s only one nurse who doesn’t speak our language [Luo dialect], so trying to explain in Swahili isn’t very clear. In fact, the nurse isn’t even sure how to teach us about preventing these conditions and wants to serve many clients in the morning, so she can’t spend enough time with us.” [Female DM Patient, 63 years, Level 2] Major themes: Lack of practical and individual guidance on diet and physical exercise Sub-themes: · Inadequate access to recommended healthy diets · Inconsistent exercise · Inadequate reference materials “I wish the facility could demonstrate what healthy eating means and, if possible, teach us through practical examples. When we come here, it would be helpful to see specific foods. For instance, I am told to eat fruits, but here in Seme, you can’t even find fruits. So, where am I supposed to get them?” [Female patient living with HTN, 46 years, Level 4 facility]. “Given my age [elderly], nurses typically advise me to exercise as part of managing my condition. ..., providers advise me to engage in home physical activities like grazing animals or gardening instead of prescribing a specific amount and frequency of exercise. Nowadays, I leave these responsibilities to my grandchildren. It would be helpful to know what specific exercises are suitable for the elderly.” [Male patient living with HTN, 68 years, Level 3 facility]. Major themes: Lack of screening for all patients who walk into the facility Sub-themes: · Inadequate access to screening services · Lack of awareness · Delayed diagnosis “ I learned about my hypertension status during a general check-up at the facility. After screening, my blood pressure was found to be too high, and that’s how I was put on medication. I believe it would be beneficial if all facilities screened everyone who walks in.” [Male, 54 years, Level 3] “The first facility I visited did not have the necessary equipment for blood pressure screening, so they referred me to this facility. It was through this process that I discovered my condition and received medication.” [Female, 42 years, Level 4] Major themes: Frustration over Lack of essential drugs Sub-themes: · Lack of drugs · Trust issues · Patient Discouragement · Patient frustration “Sometimes, it’s very discouraging to keep coming to the hospital when there are no drugs available instead you are being told to buy from private outside pharmacies which are very expensive. Why do they open every day if clients can’t be treated and given medication? I’d rather stay at home because going to the hospital makes no difference if I can’t get the drugs I need.” [Male participant, 55 years, Level 4] Discussion This study aimed to evaluate the capacity of the PHC system in Kisumu County to provide quality care for the prevention and management of HTN and DM and its found crucial gaps. We found that 80% of patients are referred for further care due to poor control or complications, underscoring a critical gap in the ability of PHC facilities to manage these conditions at the primary care level. While these findings are specific to Kisumu, they provide insights that have implications for the broader Kenyan devolved county PHC system nationwide. First, the findings highlight significant gaps in the availability of essential medicines and health products, including IEC materials, which are critical for effective self-management. Patient experiences corroborate these findings, which negatively impacted their adherence to treatment and understanding of their conditions. Findings also highlighting a gap in follow up systems such as reminders for follow-up appointments. This situation is similar to that in other LMICs in the African continent such as Nigeria, Benin, Eritrea, and Sudan[ 57 , 58 ]. Addressing these broader issues is crucial for improving overall PHC delivery. Recommendations include strengthening supply chains for essential medicines, improving patient education materials, and implementing effective tracking systems especially to rural areas that are less populated and face many barriers related to and access. Second, the capacity of PHC workers is critically inadequate, both in terms of numbers and quality. Inadequate numbers lead to heavy workloads of PHC workers, illustrated by high patient-to-provider (Nurse) ratios of 1:1250, despite the WHO recommendation of 1:120[ 59 ]. Time constraints during consultations hinder meaningful interactions, while unclear dietary and exercise advice further complicates patient management. Patients also experienced that nurses have to attend to a large number of patients simultaneously, compromising the opportunity for individual counseling. The quality of counseling also needs better contextualization. Many PHC workers are not fluent in the local dialect (Luo), exacerbating engagement issues and complicating care delivery. This communication gap leads to misunderstandings and insufficient patient education. Patient experiences reveal a pervasive sentiment of ineffective counseling and self-management education. Primary care staff receives little training to increase their capacity for NCD management. Only 22% of PHC workers in sub-Saharan Africa reported receiving hypertension training in the past year [ 58 , 60 ]. Our findings illustrate the need of PHC workers for comprehensive training tailored to the cultural and language needs of their patients. Third, findings revealed that over two-thirds of PHC workers are employed on short-term contracts. This potentially contributes to a high attrition rate among PHC workers, as indeed indicated in another Kenyan study on motivation of health workers[ 61 , 62 ]. Such instability raises significant concerns about the sustainability of the devolved health sector in Kenya and potentially in other regions facing similar challenges. Many county governments struggle to provide permanent positions for health workers, leading to a workforce that is frequently in flux as employees seek more stable opportunities elsewhere. This trend not only affects the continuity of care for patients but also undermines the overall effectiveness of health systems. Addressing the employment conditions of PHC workers is crucial for fostering a stable workforce and ensuring the delivery of quality health services. Fourth, we also found that there are technical support visits from NCD coordinators, but that the consistency and reliability of these support visits seems lacking. For instance, the absence of a standard checklist for these visits may lead to variability in information, support and mentorship. Indeed, PHC workers overwhelmingly expressed their need for more support and mentoring[ 63 ]. Evidence indicate that nurses receiving mentorship can adhere to NCDs treatment protocol[ 64 ], suggesting the need to further investigation this in the Kisumu context. Strengths and limitations The study employed a mixed-methods approach with triangulation to achieve a comprehensive understanding of the objectives. It applied internationally validated frameworks—WHO Health System PEN, WHO ICCC, and the HEARTS Technical Package—alongside locally tailored tools, enhancing the validity of the findings. Additionally, the surveys were conducted in collaboration with county and sub-county health management teams, leveraging their goodwill and mutual understanding of institutional challenges and strengths. Facility in-charges and the researchers jointly reviewed the health facility reports and the status of equipment such as glucometers, weighing scales, sphygmomanometers, and medications available. This provided more ownership of data, common realization of situation analysis, increasing urgency for health authorities to take action. This approach could enhance buy-in and readiness to implement recommended changes while fostering a stronger alignment between policy makers and health facility management. This study has some limitations. The survey evaluation data collected were not representative of the Kenyan primary healthcare system. The focus here was rather at the sub-county level with surveys conducted in specific rural areas, which may have led to an overestimation of the capacity of PHC facilities in these regions. Due to the purposive selection of the facilities, PHC workers, and patients, we cannot generalize the findings to other PHC settings or populations. Also, the wide confidence intervals reflect the variability in equipment availability across facilities and suggest a need for caution in interpreting these estimates. Furthermore, our findings may be limited by selection bias of participants and response bias. The focus on only three categories of healthcare workers (Clinical Officers, Nursing Officers, and Nutritionists) may have limited the perspectives represented in the study. We did not interview any doctors, health records officers, pharmacists, and public health officials, as they were not present in our facilities. Moreover, participants may have altered their responses based on perceived expectations from the research team and county representatives during data collection. This response bias could potentially skew the results toward more favorable perceptions both by staff and patient respondents. To mitigate these and ensure consistency in observations and measurements, the study recruited experienced researchers, all of whom were trained in interview techniques and the use of the study tools. Real-time feedback and debriefings were provided daily to validate some of the observer's findings. The including of patient perspectives is considered a strength. Despite these limitations, our findings have generated locally relevant evidence that can inform local action in PHC for NCDs. Conclusion The evaluation of PHC facilities in Kisumu County reveals critical structural deficiencies that significantly impede the delivery of high-quality care for hypertension and diabetes management and patient satisfaction. This highlights the urgent need to enhance both the structural and procedural aspects of care within these facilities. The findings of this evaluation underscore the critical importance of such investments and provide a roadmap for targeted interventions to enhance the quality of care in Kisumu County and similar rural contexts. Declarations Ethic s and Consent The study protocol was reviewed and approved by the Jaramogi Oginga Odinga University of Science and Technology (JOOUST) and the National Commission for Science, Technology and Innovation (NACOSTI), with approval license numbers ERC/5/24-06 and NACOSTI/P/23/25192, respectively. Additional approvals were obtained from the County Government, and individual informed consent was signed by each PHC worker and FGD participant before data collection began. During the informed consent process, interviewers emphasized the voluntary nature of the study, ensuring participants understood the risks and benefits and were willing to participate. We confirm that all methods were carried out in accordance with relevant guidelines and standards including in accordance with the Declaration of Helsinki, adhering to the approved protocol. Consent for publication Not applicable Availability of data and materials Data is accessible and available upon reasonable request to the corresponding author (OJO) to ensure that the use of data is in line with the terms of ethics approvals and principals. 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 extend our heartfelt gratitude to all the participants who participated in this study. This includes patients living with diabetes and/or hypertension, county and sub-county health management teams, facility in-charges, PHC workers, and the PhD and master’s students who assisted with data collection. Competing interests None declared. Contributors OJO conceptualized the study, conducted the desk review research, developed and programmed the data collection tools, and analyzed the data. DO, EM, JO, SA, JB, and JvO contributed to the study’s conception and reviewed the manuscript. OJO, EM, and DO were involved in data collection with JO with relevant qualifications and prior experience in qualitative research methodology led the focus groups. OJO conducted data cleaning and analysis. DO, JB, SA, and JvO provided technical guidance and critical suggestions for the manuscript. All authors read and approved the final submission. OJO holds full responsibility for the study, including data access and publication decisions. References Schutte AE, et al. Hypertension in low-and middle-income countries. Circul Res. 2021;128(7):808–26. Murray CJ. The global burden of disease study at 30 years. Nat Med. 2022;28(10):2019–26. Organization WH. Noncommunicable diseases progress monitor 2020. World Health Organization; 2020. Budreviciute A, et al. Management and prevention strategies for non-communicable diseases (NCDs) and their risk factors. Front public health. 2020;8:574111. Organization WH. World Health Organization. Noncommunicable diseases. Key Facts; 2018 Available from : https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. Accessed 525, 2019. 2018. Organization WH. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. World Health Organization; 2013. Bigna JJ, Noubiap JJ. The rising burden of non-communicable diseases in sub-Saharan Africa. Lancet Global Health. 2019;7(10):e1295–6. 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 Plann. 2022;37(4):452–60. Statistics BO. 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. Atlas D. IDF diabetes atlas. International Diabetes Federation (9th editio) . 2019. Sun H et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes research and clinical practice, 2022. 183: p. 109119. Waruiru W, et al. All-cause and cause-specific mortality rates for Kisumu County: a comparison with Kenya, low-and middle-income countries. BMC Public Health. 2022;22(1):1828. Organization WH. Continuum of care for noncommunicable disease management during the migration cycle. World Health Organization; 2022. Owusu MF, et al. Tackling the non-communicable disease epidemic: a framework for policy action in low-and middle-income countries. Pan Afr Med J. 2024;47:82. Agyepong IA, et al. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet. 2017;390(10114):2803–59. Haque M et al. Strengthening primary health-care services to help prevent and control long-term (chronic) non-communicable diseases in low-and middle-income countries. Risk management and healthcare policy, 2020: pp. 409–426. Jamison DT et al. Disease control priorities in developing countries. 2006. Soors W, Dkhimi F, Criel B. Lack of access to health care for African indigents: a social exclusion perspective. Int J Equity Health. 2013;12:1–9. Akachi Y, Kruk ME. Quality of care: measuring a neglected driver of improved health. Bull World Health Organ. 2017;95(6):465. Akhlaq A, et al. Barriers and facilitators to health information exchange in low-and middle-income country settings: a systematic review. Health Policy Plann. 2016;31(9):1310–25. Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context–global shortages and international migration. Global health action. 2014;7(1):23611. Douglas M, et al. Facilitators and barriers in prevention of cardiovascular disease in Limpopo, South Africa: a qualitative study conducted with primary health care managers. BMC Cardiovasc Disord. 2021;21:1–9. Mulupi S, et al. What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries. BMJ open. 2022;12(7):e052105. Ayandipo O et al. Cancer ecosystem assessment in West Africa: Health systems gaps to prevent and control cancers in three countries: Ghana, Nigeria and Senegal. Pan Afr Med J, 2020. 35. Nyaaba G, et al. Factors hindering hypertension control: perspectives of front-line health professionals in rural Ghana. Public Health. 2020;181:16–23. Wollum A, et al. Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project. PLoS ONE. 2018;13(3):e0192603. 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 Serv Res. 2018;18(1):1–9. Adinan J, et al. Preparedness of health facilities in managing hypertension & diabetes mellitus in Kilimanjaro, Tanzania: a cross sectional study. BMC Health Serv Res. 2019;19:1–9. 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):e007334. Tesema AG, 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):e009025. Witter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Global Health. 2022;7(Suppl 7):e008115. Shayo EH, et al. The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania. BMC Health Serv Res. 2022;22(1):655. Ammoun R, et al. Readiness of health facilities to deliver non-communicable diseases services in Kenya: a national cross-sectional survey. BMC Health Serv Res. 2022;22(1):1–11. Kamvura TT, et al. Barriers to the provision of non-communicable disease care in Zimbabwe: a qualitative study of primary health care nurses. BMC Nurs. 2022;21(1):1–12. Shiferaw F et al. Non-communicable Diseases in Ethiopia: Disease burden, gaps in health care delivery and strategic directions. Ethiop J Health Dev, 2018. 32(3). Tulshian P, et al. An assessment of facility-based care of diabetes, hypertension, and heart failure across western Kenya. East Afr Med J. 2018;95(10):2014–22. Hwang CK, et al. Rural diabetes prevalence quintuples over twenty-five years in low-and middle-income countries: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2012;96(3):271–85. Jonkman LJ, et al. Patient experiences in managing non-communicable diseases in Namibia. Res Social Administrative Pharm. 2020;16(11):1550–7. Peer N, et al. Care and management of a double burden of chronic diseases: Experiences of patients and perceptions of their healthcare providers. PLoS ONE. 2020;15(7):e0235710. Ministry of Health, Division of Non-communicable Diseases. National Clinical Guidelines on Management of Diabetes Mellitus, 2023 Edition. Nairobi, Kenya: DNCD, August 2023. Demaio AR, et al. Primary Health Care: a strategic framework for the prevention and control of chronic non-communicable disease. Global health action. 2014;7(1):24504. Narain JP. Integrating services for noncommunicable diseases prevention and control: use of primary health care approach. Indian J Community Med. 2011;36(Suppl1):S67–71. Okello S, et al. Hypertension prevalence, awareness, treatment, and control and predicted 10-year CVD risk: a cross-sectional study of seven communities in East and West Africa (SevenCEWA). BMC Public Health. 2020;20:1–13. Mogaka JN, et al. Prevalence and factors associated with hypertension among adults with and without HIV in Western Kenya. PLoS ONE. 2022;17(1):e0262400. Organization WH. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020. Wagner EH, et al. A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q. 1999;7(3):56–66. Epping-Jordan JE. Integrated approaches to prevention and control of chronic conditions. Kidney Int. 2005;68:S86–8. 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;14:1–7. Organization WH. WHO global strategy on people-centred and integrated health services: interim report. World Health Organization; 2015. Read Rt. Calculating teacher's scores in understanding their knowledge, perception and practices in developing children's literacy skills . 2024. Isadru VR, Nanyonga RC, Alege JB. Health facilities’ readiness to manage hypertension and diabetes cases at primary health facilities in bidibidi refugee settlement, Yumbe District, Uganda. J Trop Med. 2021;2021(1):1415794. Organization WH. WHO model list of essential medicines-22nd list, 2021. Doc: Tech; 2021. p. 2021. Organization WH. Service Availability and Readiness Assessment (SARA): an annual monitoring system for service delivery. Geneva: World Health Organization; 2015. Organization WH. Hearts: technical package for cardiovascular disease management in primary health care: risk-based CVD management. World Health Organization; 2020. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Mendis S, et al. Gaps in capacity in primary care in low-resource settings for implementation of essential noncommunicable disease interventions. Int J Hypertens. 2012;2012(1):584041. Adejumo O, et al. Assessment of hypertension service availability in some primary health centres in Nigeria: a mixed-methods study. BMJ open. 2023;13(8):e073833. Challenges facing the attainment of Universal Health Coverage in Kenya , in Kenya Medical Association . 2021: https://kma.co.ke/component/content/article/79-blog/125-challenges-facing-the-attainment-of-universal-health-coverage-in-kenya#:~:text=According%20to%20WHO%2C%20the%20recommended,care%20in%20public%20healthcare%20facilities Mashaba RG, et al. Recognition of language barriers in comprehending non-communicable disease management among rural elderly people in the DIMAMO surveillance area: a case of AWI-Gen participants. BMC Public Health. 2024;24(1):2782. Ojakaa D, Olango S, Jarvis J. Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya. Hum Resour health. 2014;12:1–13. Willis-Shattuck M, et al. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res. 2008;8:1–8. Munabi NC, et al. The influence of an all-female healthcare environment on mentorship and empowerment of female healthcare professionals. PLOS Global Public Health. 2022;2(3):e0000081. Ndayisaba A, et al. A clinical mentorship and quality improvement program to support health center nurses manage type 2 diabetes in rural Rwanda. J Diabetes Res. 2017;2017(1):2657820. Contributors. OJO conceptualized the study, conducted the desk review. research, developed and programmed the data collection tools, and analyzed the data. DO, EM, JO, SA, JB, and JvO contributed to the study’s conception and reviewed the manuscript. OJO, EM, and DO were involved in data collection with JO with relevant qualifications and prior experience in qualitative research methodology led the focus groups. OJO conducted data cleaning and analysis. DO, JB, SA, and JvO provided technical guidance and critical suggestions for the manuscript. All authors read and approved the final submission. OJO holds full responsibility for the study, including data access and publication decisions. Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 04 Aug, 2025 Reviews received at journal 01 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviews received at journal 27 Jul, 2025 Reviewers agreed at journal 25 Jul, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviews received at journal 04 Jul, 2025 Reviewers agreed at journal 10 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor assigned by journal 03 Jun, 2025 Editor invited by journal 02 Jun, 2025 Submission checks completed at journal 30 May, 2025 First submitted to journal 30 May, 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6743764","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469165788,"identity":"f1b81c9c-af60-49a2-bde3-0247bfa080a0","order_by":0,"name":"Ogol Japheth Ouma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIie3RvYoCMRDA8dkLxGY0bYLgvcIegeUeZ7exEhtLLQ4WtlKv3cbqXuDewDkCqQRbwS30hK2usBIrOb/q3ZSC+RchxfwIYQB8vscsIAkQA2CwASA3cyMcWehO4Ea4dCJCfBG9j4q+eJ3YIY6KjgC2/V1VEJWXMUlbDlTW6q7Rllp9cK17FSRcLUKS3CTfFqM1Xi6EvF1PTiaZn8kATy5kOQ5JZedJjhFrZg5E5TwmNS2T3Pa0mk2NVmnNX4QwPzt5KJLPdPG2/zuYjmik210VARkDk/d1vODlZFXj12cIgv2dBMe6aZ/P53vK/gHvZFW+Wvv5igAAAABJRU5ErkJggg==","orcid":"","institution":"University of Antwerp","correspondingAuthor":true,"prefix":"","firstName":"Ogol","middleName":"Japheth","lastName":"Ouma","suffix":""},{"id":469165789,"identity":"efa45ea0-3746-4603-bb42-6716f9e52ce8","order_by":1,"name":"Dickens Omondi","email":"","orcid":"","institution":"Jaramogi Oginga Odinga University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Dickens","middleName":"","lastName":"Omondi","suffix":""},{"id":469165790,"identity":"0ab2cb2d-45b3-49ee-ab5d-ee368d7a627e","order_by":2,"name":"Elijah Museve","email":"","orcid":"","institution":"Jaramogi Oginga Odinga University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Elijah","middleName":"","lastName":"Museve","suffix":""},{"id":469165791,"identity":"735df4e5-8c0d-4f91-a163-d6952cb9b82d","order_by":3,"name":"Jane Owenga","email":"","orcid":"","institution":"Jaramogi Oginga Odinga University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Owenga","suffix":""},{"id":469165792,"identity":"7a4e964e-9b48-453b-a3d2-4a7356bffef7","order_by":4,"name":"Johannes Bogers","email":"","orcid":"","institution":"University of Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Johannes","middleName":"","lastName":"Bogers","suffix":""},{"id":469165793,"identity":"566a6dc2-d154-4181-aad1-22631b8ad080","order_by":5,"name":"Steven Abrams","email":"","orcid":"","institution":"University of Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"","lastName":"Abrams","suffix":""},{"id":469165794,"identity":"72975f65-aedf-4876-a2c4-d75589b33152","order_by":6,"name":"Josefien van Olmen","email":"","orcid":"","institution":"University of Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Josefien","middleName":"van","lastName":"Olmen","suffix":""}],"badges":[],"createdAt":"2025-05-25 12:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6743764/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6743764/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13390-5","type":"published","date":"2025-09-30T15:57:38+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84662422,"identity":"1efa1772-bcd4-4f0e-b236-1ab786de542b","added_by":"auto","created_at":"2025-06-16 04:57:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":684643,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart depicting the general sampling strategy for the mixed-methods study conducted in Kisumu County, Kenya, between 2024 and 2024.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6743764/v1/d3b06a62b7c503dfb5bf3558.jpg"},{"id":92884444,"identity":"621491d6-8a35-4ce3-b2b3-7e51ca41dbc2","added_by":"auto","created_at":"2025-10-06 16:12:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2360338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6743764/v1/3ea84084-9e15-4a19-8d9c-0a210d2d3ea2.pdf"},{"id":84662421,"identity":"bae9b24a-02a3-43e6-801c-15b562175074","added_by":"auto","created_at":"2025-06-16 04:57:57","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":35691,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6743764/v1/c71632bdce5de7ac5ad93f73.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the Capacity of Primary Healthcare Facilities and Healthcare Workers in Managing Diabetes and Hypertension in Kisumu County, Kenya","fulltext":[{"header":"Background","content":"\u003cp\u003eNon-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension (HTN), are rising significantly in low- and middle-income countries (LMICs) like Kenya[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These conditions contribute approximately 15\u0026nbsp;million premature deaths globally among individuals aged 30\u0026ndash;69 years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], of which 85\u0026ndash;90% occur in LMICs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While trends of NCD incidence and mortality are declining in high-income countries (HICs), new cases and NCD mortality are disproportionately higher in the LMICs. Africa, in particular, faces a rapidly increasing burden of NCDs, with projections indicating a significant increase in NCD-related deaths. By 2030, NCDs are expected to pose a greater global challenge than communicable, maternal, neonatal, and nutritional diseases (CMNNDs) combined [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Kenya, NCDs account for over half of inpatient hospital admissions and 39% of all deaths annually [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to the International Diabetes Federation (IDF) (2021), approximately 15,284 adults aged 20 to 79 years were linked to diabetes in Kenya[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In Kisumu County, Kenya, the mortality rate is 1,118 per 100,000 populations, significantly exceeding both the national average of 659 deaths per 100,000 and the average observed in other LMICs at 547 per 100,000. In addition to the high burden of HIV in this region, a considerable 48% of all deaths are attributed to NCDs as compared to 58.1% (50%-88%) as reported in other LMICs[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] with intrinsic variation between countries, highlighting the urgent need for effective NCD prevention strategies, considering the uncertainty and variability in these estimates. The concurrent burden of communicable diseases in the region exacerbates this issue. These chronic conditions result in high morbidity, mortality, and treatment costs, primarily due to complications, highlighting the urgent need for effective NCD prevention and management interventions. Although effective interventions exist for noncommunicable disease, they are not widely implemented satisfactorily, with large subnational differences[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Appropriate mechanisms are required to support implementation of policy and programs, including health system strengthening and advocacy, community participation, and inter-sectoral and interdisciplinary collaboration[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Delivery of essential services through PHC approach could ensure proactive, patient-centered, community-based, and sustainable essential care to prevent and manage NCDs[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Evidence suggests that the implementation of effective PHC can substantially reduce the morbidity and mortality rates associated with NCDs[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], for instance, by enhancing the early detection and management of conditions like HTN and DM, resulting in improved health outcomes[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implementation of a PHC approach in LMICs to improve NCD coverage faces significant barriers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] including unreliable medical supply chains, inadequate health financing, and weak health information systems[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Suboptimal clinical guidelines and a lack of implementation strategies, such as technical support and supervision for PHC workers, exacerbate inequities in access and care quality [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Shortages of essential medical supplies and equipment, like blood pressure machines and glucometers, hinder PHC workers from delivering quality care [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], leading to suboptimal diagnosis and treatment of NCDs[\u003cspan additionalcitationids=\"CR25 CR26 CR27\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Human resource limitations, including inadequate training and insufficient competencies among PHC workers, further restrict effective PHC implementation[\u003cspan additionalcitationids=\"CR29 CR30 CR31 CR32\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Additionally, PHC facilities often lack the means for organizing referrals, conducting laboratory tests, and ensuring proper patient follow-up[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], with evidence indicating that about 71.4% of facilities refer patients to higher-level facilities immediately after DM diagnosis[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatient experiences and perceptions highlight unmet needs and barriers to accessing care, especially in rural settings where individuals at an increased risk of or living with NCDs may be unaware, undiagnosed, or lack access to treatment and support interventions[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These issues highlight the need for strengthening support for the implementation of policies and programs targeting priority NCDs, such as hypertension and diabetes[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The improvement interventions could focus on patient scheduling to reduce time and cost burden and increase compliance[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]; advocacy to enhance community engagement, participation, and experience in prevention and quality care[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Kenya Ministry of Health embarked on policy reforms following the 2011 UN declaration on mitigation for NCDs by developing and distributing the national strategic plan, currently in its second edition, and the national clinical guidelines for DM and HTN management in 2024 to strengthen PHC[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The reported implementation gaps, especially for hypertension and diabetes, highlight the need for context-specific evidence on the implementation of effective interventions to inform priority setting. As a priority, Kenya adopted the WHO Package of Essential Non-communicable Disease Interventions (WHO PEN) for low-resource settings[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Both frameworks emphasize a chronic care approach due to their public health impact. However, implementation remains challenging, especially in rural areas like Kisumu County, due to limited input of local evidence in the guidelines as well as systems and resource constraints, including a shortage of experienced frontline health workers[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], competing priorities with communicable diseases, and inadequate infrastructure.\u003c/p\u003e \u003cp\u003e The current study reports an evaluation of the capacity of PHC facilities in Kisumu County, Kenya, to provide quality care for the prevention and management of HTN and DM and the mechanisms for implementing strategic guidelines for hypertension and diabetes management. Specifically, it: (1) determined the current status of structural elements in PHC settings, which facilitate the delivery of quality care for the prevention and management of HTN and DM; (2) assessed the care processes provided by PHC workers in managing DM and HTN; and (3) explored experiences and perceptions of patients regarding the care they receive for these conditions in PHC settings. The study objectives are of high public health relevance as the findings reveal core stakeholder perspectives across the care continuum, priority training, and advocacy intervention points. These findings will be valuable in informing strategic improvement interventions to enhance service quality, efficiency, and effectiveness.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eThis study was conducted in Kisumu County, one of Kenya\u0026rsquo;s 47 counties, from October 2023 to September 2024. The County is located on the shores of Lake Victoria, in western Kenya, and comprises seven sub-counties. The county\u0026rsquo;s approximately 1.2\u0026nbsp;million people are served by about 70 PHC facilities (levels 2, 3, and 4), which include dispensaries, health centers, and sub-county hospitals. Nursing Officers are the key clinical staff at majority of the dispensaries (level 2), with Clinical Officers being the lead clinicians at health centers (level 3) and Medical Officers at the sub-county hospitals (level 4). All services are integrated and, where staff establishment allows, are provided through an interdisciplinary approach, integrating the roles of nutritionists, public health Officers, occupational therapists, and physiotherapists. These facilities provide various levels of NCD care services for DM and HTN based on a tiered approach as defined in the Kenya Essential Package of Health (KEPH) guideline. Case referral is based on the Kenya Health Sector Referral Implementation Guidelines within the context of Primary Care Networks (PCNs). The PCNs operate on a hub and spoke model, where the hub (a higher-level health facility) provides advanced care and supports the surrounding spoke facilities (lower-level health facilities). The purpose is to enhance cross-level integration of healthcare delivery and coordination of multidisciplinary health teams within the county, thereby ensuring continuity and efficiency of care through case referrals and counter-referrals. The current study was based in Seme sub-county, which was selected purposively based on the organizational and logistical capacities.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResearch design\u003c/h3\u003e\n\u003cp\u003e This study adopted a cross-sectional design with parallel mixed-methods approach to assess the capacity of PHC facilities in Kisumu County to deliver high-quality care for the prevention and management of HTN and DM. We employed a structured questionnaire to obtain quantitative data and conducted FGDs to gain qualitative insights into HPC services.\u003c/p\u003e\n\u003ch3\u003eStudy population and sampling strategy\u003c/h3\u003e\n\u003cp\u003eThe study population comprised of PHC workers and patients from PHC facilities in Seme sub-county. To ensure our research to be in line with local health policies, we consulted county and sub-county representatives from the Department of Health, incorporating stakeholder feedback, for instance to select study facilities. The study sites included mainly public PHC facilities, a limited number of private facilities (level 3) to gain limited insights from the private sector without making any strong claim on the differences between public and private sectors due to the underrepresentation of the private facilities.\u003c/p\u003e\n\u003ch3\u003eSample selection\u003c/h3\u003e\n\u003cp\u003eThe selection of samples was conducted in three stages:\u003c/p\u003e\n\u003ch3\u003eStage 1: County and sub-county Selection\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCounty and sub-county Selection\u003c/b\u003e: One county was purposively selected where the prevalence of NCDs is notably high at 22%[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] compared to other counties to represent the broader region in which one sub-county was also purposively selected. This study was nested within a larger study targeting six counties in Kenya under the School of Health Sciences of Jaramogi Oginga Odinga University of Science and Technology (JOOUST). 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 \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStage 2: Facility Selection\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFacility Selection\u003c/b\u003e: We purposively selected ten out of 29 PHC facilities classified as level 2 to 4 facilities according to Kenya Essential Package for Health (KEPH). These facilities included health centers, maternity homes, and sub-county hospitals, providing relatively complex PHC services (e.g., maternity care, minor surgeries, and specialized consultations).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStage 3: PHC Workers \u0026 Patients Selection\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePHC Workers and Patients Selection\u003c/b\u003e: Purposive sampling for both qualitative and quantitative data collection was conducted per facility, with the following target numbers for each facility level considered:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eLevel 2\u003c/b\u003e: One PHC worker (either a nurse or clinical officer) per facility. No focus group discussions (FGDs) were conducted at this level due to a low caseload of patients.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eLevel 3\u003c/b\u003e: Two PHC workers and 1\u0026ndash;2 patients per facility.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eLevel 4\u003c/b\u003e: Five PHC workers and 1\u0026ndash;2 patients per facility.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe facility in-charges expressed a willingness to participate through informed consent, and the county and sub-county team deemed the selection appropriate, ensuring alignment with the study's objectives. For quantitative data collection, a total 24 PHC workers were selected from the 10 PHC facilities, representing 25% of the total workforce (i.e., 96 PHC workers in 29 facilities). This sampling facilitate targeted conversations within PHC settings and ensure a varied representation of perspectives across different cadres. The PHC workers included clinical officers, nurses, and nutritionists, who provided informed consent and actively worked in the selected facilities. The distribution of PHC workers observed reflects broader trends in the Kenyan health system, with data from July 2024 indicating that there were two medical officers, 33 clinical officers, 57 nursing officers, and four nutritionists working across various facilities in Seme sub-county.\u003c/p\u003e \u003cp\u003eAdditionally, we collected extensive qualitative data from 20 patients about their experiences with hypertension and diabetes mellitus and care received in the selected settings. They were selected through sampling from level 3 and 4 facilities based on specific criteria: aged 18 years or above, capable of providing informed consent, and had been living with DM and/or HTN for at least six months. We specifically targeted individuals seeking routine care at the clinic, including regular visits, to ensure comprehensive discussions. Two FGDs were conducted, each comprising about 9 and 11 patients respectively. For additional details, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eMeasurements and data collection\u003c/h3\u003e\n\u003cp\u003eWe collected data at the health system, patient, and PHC worker level using standard survey procedures and tools adapted from the WHO PEN framework [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] and the WHO Innovative Care for Chronic Conditions (ICCC) Framework [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a comprehensive overview of the variables, instruments, and data collection methodologies for specific research questions.\u003c/p\u003e \u003cp\u003e For Research Question (RQ) 1, the outcome measurements assessed included the availability of essential drugs for managing DM and HTN, basic medical equipment (e.g., blood pressure monitors, glucometers), guidelines and diagnostic algorithms, information, education, and communication (IEC) materials for community outreach, structures for patient follow-up and counseling, trained PHC workers on DM and HTN management, and regular support supervision received by the PHC facility. For RQ2, the outcomes included the knowledge of PHC workers, their perceptions, practices related to healthy counseling and education, training received, and support systems such as mentorship while for RQ3, the outcomes were patient satisfaction, perceived barriers and facilitators to accessing care, and self-care practices related to DM and HTN management. Incorporating user experience as a metric for the quality of care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] is advisable, as it aligns well with the principles of patient-centered care (PCC).\u003c/p\u003e \u003cp\u003eSupplement 1 in the Appendix details the process used to calculate each indicator score for PHC workers managing DM and HTN in terms of care processes. This method is derived from the organization Room to Read[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], which implements literacy programs and gender equality and employs a similar approach to calculate teachers\u0026rsquo; knowledge, perception and practices scores, and validated extensively in similar sub-Saharan African settings. Therefore, adapting this instrument can assist in evaluating PHC workers' knowledge, perceptions, and practices in managing DM and HTN, ensuring its relevance in the health facility context and contributing to improved patient care outcomes.\u003c/p\u003e \u003cp\u003eWe utilized the mobile application Kobo Collect to program and gather quantitative data, which quickened the data entry process and enhanced the efficiency of quality checks. Data collection was conducted through structured one-on-one interviews, ensuring comprehensive assessments. We also held two FGDs in quiet environments, each lasting between 1 and 1.5 hours, in both local languages and Swahili, to capture patients' emerging experiences while seeking NCD-related care services at PHC settings. We digitally recorded all interviews and manually transcribed them.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVariable definition and measurements\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch Question (RQ)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcepts/Key information required\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstrument and process of data collection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference or name of instrument\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e1) What are the current structural elements in PHC settings that facilitate the delivery of quality care for the prevention and management of DM and HTN?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of essential drugs for managing DM and HTN:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- A structured observation checklist to assess the availability of essential drugs for DM and HTN. Each drug available was assigned 1, else 0 and a composite score is derived by summing these scores.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKenya Essential Medicines List 2023 and other sources from Isadru et al., 2021[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], 22nd WHO model list of essential medicines 2021 [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], WHO ICCC Framework [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], and WHO SARA tool [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of basic medical equipment (e.g., blood pressure monitors, glucometers) and diagnostic parameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Structured observation checklist followed with a guided interview with the in-charges on equipment use including: availability and functionality of sphygmomanometer, stethoscope, weighing scale, glucometer, and glucometer stripes.\u003c/p\u003e \u003cp\u003eEach equipment availability and functionality was assigned 1, else 0 and a composite score is derived by summing these scores.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eList of basic equipment and diagnostic parameters from Isadru et al., 2021[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], WHO ICCC Framework [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], and WHO SARA tool [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of guidelines and diagnostic algorithms for care of DM and HTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStructured observation checklist and interviews with facility in charges. Each guideline, diagnostic algorithms, and IEC materials availability was assigned 1, else 0 and a composite score is derived by summing these scores.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAvailability of DM and HTN guidelines and diagnostics assessed as per Isadru et al., 2021 [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] and WHO SARA tool [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIEC materials for community outreaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIsadru et al., 2021 [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] and WHO SARA tool [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of structures and process for patient follow-up and counselling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuided interview with the facility in-charges using a checklist in a binary format (Yes/No) with items on who, what and how of counselling, and tracing and a composite score is derived by summing these scores.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-developed\u003c/p\u003e \u003cp\u003ebased on general management information from literatures and DM and HTN guidelines.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC facility has trained PHC workers on DM and HTN management, received quarterly or annual supervisory support visits from CHMT and/or S/CHMT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuided interview with the facility in-charges using a checklist in a binary format (Yes/No): trained workers on HTN and diabetes management in the last 2 years (2023 and 2024), facility received regular or quarterly support supervision visit from the higher level (county and/ or sub county health management team). A composite score is derived by summing these scores.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIsadru et al., 2021 [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] and WHO SARA tool [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e2) How do PHC workers manage DM and HTN in terms of care processes?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge of PHC workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePHC worker\u0026rsquo;s knowledge assessment survey and in the knowledge test, PHC workers received 1 point for each correct mention. The total scores were summed to create a composite indicator score, which is measured on a 4-point scale. This means that the maximum possible score is 4 out of 4., see Supplement 1, part A.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-developed based on general management information from literatures and DM and HTN guidelines.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePHC workers survey to gauge their level of (dis)agreement with statements on DM and HTN management, to understand to their perceptions of effective practices in managing these conditions. This definition differs from knowledge, which refers to factual understanding or awareness of medical concepts and guidelines. For example, while a respondent may agree that patient education is critical (indicating a perception), their actual knowledge about specific lifestyle changes or medical adherence may vary. The indicators tested assess both the recognition of important management strategies and the underlying beliefs that influence patient care practices. For additional details, see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e7\u003c/span\u003e, indicator 4 in the appendix section.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-developed based on general management information from literatures and DM and HTN guidelines.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractices by PHC workers on healthy counselling and education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChecklist with activities to manage DM and HTN, can be listed. For every item mentioned, PHC workers score 1 and these scores were summed up to get a composite 6-point indicator score on practices with higher scores reflecting a broader engagement in effective management practices based on their reported activities related to DM and HTN management. This concept covers the actual activities and methods employed by PHC workers in managing DM and HTN, including counselling techniques and the ability to adjust these based on patient feedback, see Supplement 1, part B.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdapted from the information in the HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC worker\u0026rsquo;s training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe survey form for PHC workers uses a binary format (Yes/No) to determine whether they have attended any training on NCDs in the years 2023 or 2024. If they answered \"Yes,\" they were prompted to specify the trainings they attended to provide a clear picture of the training attendance and the collection of detailed information on specific training. The training attended by PHC workers was evaluated in two aspects. First, the extent of coverage regarding the methods and strategies to teach patients about the management and prevention of DM and HTN during the training.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIsadru et al., 2021 [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC worker\u0026rsquo;s support system e.g. mentorship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChecklist: regular technical support visits from NCD Coordinator (Yes/No?). The assessment also required active recall of examples of mentorship provided. (Table\u0026nbsp;\u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e Appendix). A composite score is derived by summing these scores.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIsadru et al., 2021[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3) What are the experiences and perceptions of patients regarding the care they receive for DM and HTN in PHC settings?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFGD combining both explicit/overt (direct responses) and latent (non-verbal, underlying emotions) meanings to ensure a comprehensive understanding of the respondent\u0026rsquo;s perspectives and contextual relevancy, providing more nuanced details of the topic from the collected data.\u003c/p\u003e \u003cp\u003eMore details in Supplement 2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSelf-developed based on general management information from literatures and DM and HTN guidelines.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived barriers and facilitators to access care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care practices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative analysis\u003c/h2\u003e \u003cp\u003eQuantitative data cleaning and analysis was conducted using STATA version 17. To address RQ1 and RQ2, Means and Standard Deviations (SD) were reported for continuous variables, absolute and relative frequencies (expressed as percentages) for categorical variables. In addition, we estimated means and proportions by constructing asymptotic 95% confidence intervals (CIs) for the population means, and 95% Wilson-score CIs for population proportions. These results are presented using tables and charts.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eQualitative analysis\u003c/h2\u003e \u003cp\u003eFor RQ3, we conducted qualitative analysis employing both inductive and deductive coding methodologies. For the inductive coding, we identified themes from the data without preconceived categories. This was followed by deductive coding, where we applied thematic analysis framework proposed by Braun and Clarke (2006) due to its flexibility to categorize the data consisting of six key phases. Particularly, these phases guided the authors to analyze qualitative data and include: (1) familiarizing with the data; (2) coding initial themes; (3) grouping related codes; (4) reviewing themes; (5) defining and naming themes; and (6) finally presenting their significance to the research questions in a structured format[\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. This coding process was conducted independently by a minimum of two members of the research team using Dedoose qualitative analysis software. We selected a sample of 10% of the transcripts to develop a common codebook, ensuring the reliability of code applications between coders through inter-coder reliability testing in Dedoose.\u003c/p\u003e \u003cp\u003eAfter finalizing the codebook, all transcripts were re-coded by the first author (OJO). The coded transcripts were subsequently exported to Excel for analysis, allowing us to identify emerging themes. This triangulation of data sources was essential in exploring how PHC workers manage DM and HTN in terms of care processes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTo provide a solid statistical foundation, we presented quantitative information on structural elements in PHC for HTN and DM care and care processes by PHC workers for HTN and DM management. Numerical data reveals the prevalence of structural elements such as medication availability and patient referral rates, as well as care processes by PHC workers, including their knowledge, perceptions, and practices, which are crucial for understanding NCD care. These quantitative insights are supplemented by integrating qualitative findings on patients' experiences with NCD care, such as patient counseling, treatment barriers, and subjective experiences, to avoid repetition of the findings. Qualitative data adds context and depth to quantitative results, uncovering PHC system barriers and facilitators. In this section, we have combined these findings to demonstrate how both quantitative and qualitative data inform our understanding of NCD care.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003ePHC workers\u0026rsquo; characteristics\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study revealed that 58% of PHC workers were female with a mean age across all HPC workers of 36.3 years (SD: 4.7). The findings further indicate that among the professional cadre, 42% were Clinical Officers, 50% were Registered Nurses, and 8% were Nutritionists.\u003c/p\u003e\n\u003cp\u003eSee Table 2 for additional details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: PHC worker\u0026rsquo;s characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"648\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%) or Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eNumber of PHC workers interviewed\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e24 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e10 (42%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e14 (58%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (in years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e36.3 (4.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e20 (83%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eSingle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e3 (13%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eWidowed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e1 (4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eHighest level of education completed\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eDiploma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e19 (79%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eBachelors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e5 (21%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eProfessional cadre\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eClinical officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e10 (42%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eRegistered Nurse\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e12 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eNutritionist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e2 (8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eContract type\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003ePermanent and pensionable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e8 (33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003eShort term contract\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e16 (67%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003ePHC worker worked in other facilities before current one\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e20 (83%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eYears of experience in current PHC facility (in years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e2.8 (3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"420\"\u003e\n\u003cp\u003e\u003cstrong\u003eYears of experience working in PHC before (in years)*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"229\"\u003e\n\u003cp\u003e7.6 (4.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable Legend*- \u003cem\u003eIn this indicator, out of 24 PHC workers surveyed, only 20 had prior experience working in PHC facilities, while 4 were new to the role. The missing data regarding the experience of the 4 PHC workers does not necessitate advanced missing data techniques due to the descriptive nature of our analyses. We focused on summarizing the characteristics of the PHC workers and their experiences, which provides valuable insights into the workforce dynamics within the current facility.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative analysis identified five key themes regarding patients' experiences and perceptions of NCD care in PHC settings. Themes identified were: inadequate counseling and follow-up, patients feeling that dietary and exercise advice was not useful, and a desire for practical demonstrations that fit their daily lives, inadequate counseling time, inconsistent counseling practices, a focus on medication availability, a lack of practical demonstration during counseling, limited staff, inadequate training, communication issues, time constraints, inadequate access to recommended healthy diets, inconsistent exercise, and inadequate reference materials. In the deductive phase, we organized themes and related themes identified in literature and theoretical frameworks related to patient care such as principles of patient-centered care and medical adherence. This led to new themes such as barriers to patient adherence, insufficient equipment and screening practices, limited access to essential medications, lack of awareness, delayed diagnosis, lack of drugs, patient trust issues, discouragement, and frustration. Through this dual approach in our analysis, we were able to elicit explicit spontaneous experiences of patients and more latent meanings, such as underlying attitudes and contextual elements affecting patients' experiences. Details of these qualitative findings are integrated in the section aside to the quantitative results.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStructural elements in PHC for HTN and DM care \u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEssential drugs and basic medical equipment availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings in Table 3 reveal that the majority of PHC facilities are without essential medications for treating HTN (N = 9 out of a total of 10 health facilities included in the study) and DM (N = 8). Specifically, 90% [95% CI: 59.6%, 98.2%] of the facilities lack key hypertension drugs such as Losartan, Enalapril, and Nifedipine. Furthermore, 80% [95% CI: 49.0%, 94.3%] of the facilities do not have critical diabetes medications like Insulin, Metformin, and Empagliflozin. Most PHC facilities have essential equipment for NCD care; however, the availability of specific items such as lancets and test strips (60% [95% CI: 31.3%, 83.2%]), sphygmomanometers (20% [95% CI: 5.7%, 51.0%]), and tape measures (10% [95% CI: 1.8%, 4.0%]) is insufficient. None of the facilities had HbA1c testing devices, foot care tools, or retinal screening equipment, all required by national guidelines. Only 60% of the facilities have access to written care guidelines and management algorithms. Similarly, 80% [95% CI: 49.0%, 94.3%] of the facilities did not have essential materials for counselling, and education (Figure 2 in Supplement 1 of the Appendix). Respondents in the patient FGD confirm that they experienced the lack of screening equipment and medications as a barrier to diagnosis and management. This contributed to their dissatisfaction with care, trust in the services and made adherence to treatment more difficult.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Availability of essential drugs and equipment for hypertension (HTN) and diabetes mellitus (DM)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"674\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e\u003cstrong\u003eWilson-score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[95% confidence interval]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eAvailability of essential drugs for managing HTN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e1 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e1.8%, 4.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eAvailability of essential drugs for managing DM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e2 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e5.7%, 51.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eFacility has access to written guidelines of care, and diagnostic and treatment algorithms for NCD care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e6 (60%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e31.3%, 83.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eFacility has necessary supplies\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e2 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e5.7%, 51.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003e\u003cstrong\u003ePHC facility has the following equipment for NCD care\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eBlood pressure monitors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e10 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e72.2%, 100.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eSphygmomanometer- manual (cuff for different arm sizes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e2 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e5.7%, 51.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eHeight Measuring Tape\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e10 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e72.2%, 100.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eStethoscope\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e10 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e72.2%, 100.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eGlucometers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e10 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e72.2%, 100.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eUrine test strips (for glucose and ketones)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e9 (90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e59.6%, 98.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eLancets and test strips\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e6 (60%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e31.3%, 83.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"390\"\u003e\n\u003cp\u003eTape measure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e1 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e1.8%, 4.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePatient follow-up and counselling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient follow-up, counselling on self-care and lifestyle modifications were rated poorly, with an average score of 2.9 [95% CI: 1.4, 4.4] out of 6 (Table 4). Many patients expressed that the dietary and exercise advice provided was not useful, highlighting a desire for practical demonstrations tailored to their daily lives. Additionally, issues such as insufficient counseling time and inconsistent practices among staff were noted, contributing to overall dissatisfaction with the care received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Patient counselling and follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"628\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%) or \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e\u003cstrong\u003eWilson-score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[95% confidence interval]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient counselling and follow-up score (\u003c/strong\u003e\u003cstrong\u003eout of a total score of 6)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e2.9 (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e1.4, 4.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAvailability of staff assigned for patient counselling\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e2 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e5.7%, 51.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAvailability of patient counselling tools/materials\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e3 (30%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e10.8%, 60.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAvailability of a framework for conducting group counselling and individual counselling for patients\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e5 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e23.7%, 76.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAvailability of a system for tracking initial defaulters\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e3 (30%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e10.8%, 60.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAvailability of a functional system for patient reminder and follow-up?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e3 (30%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e10.8%, 60.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAvailability of a trained staff in DM and/or HTN diagnosis and treatment in the facility\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e7 (70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"218\"\u003e\n\u003cp\u003e31.3%, 83.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003eCare processes by PHC workers for HTN and DM management\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePHC worker\u0026rsquo;s knowledge, perception and practices\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 50% of PHC workers showed proficiency in managing NCDs like DM and HTN with a mean knowledge score of 2.2 (95% CI: 1.8-2.6) out of a total score of 4 (Table 5). Only 46% [95% CI: 27.9-64.9%] of PHC workers could identify over half of the components of NCD management out of nineteen components, such as healthy diets and timely screenings. Additionally, 21% [95% CI: 9.2%, 40.5%] could mention more than half out of nine of the essential characteristics for effectively managing DM and HTN as outlined in Supplement 1, Table 7 under the third indicator.\u003c/p\u003e\n\u003cp\u003eThe perception of PHC workers towards NCD management is largely positive, with 92% [95% CI: 74.2%, 97.7%] of PHC workers responding favorably to statements related to key aspects such as prevention, patient education, and the importance of routine monitoring. For example, PHC workers stressed the importance of teaching patients about healthy lifestyles to effectively manage and prevent diabetes and high blood pressure. They also stressed how important it is to start helping newly diagnosed patients right away and how essential it is to keep learning as a professional. For additional details, see Table 7, Indicator 4 of Supplement 1 in the Appendix.\u003c/p\u003e\n\u003cp\u003eThe results show that only 50% of PHC workers engaged in practices related to managing and preventing DM and HTN, as evidenced by practices score of 3.0 [95% CI: 2.6, 3.5] out of a total score of 6 (see Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: PHC worker\u0026rsquo;s knowledge, perception and practices\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"669\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%) or \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e\u003cstrong\u003eWilson-score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[95% confidence interval]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003e\u003cstrong\u003ePHC worker\u0026rsquo;s knowledge score on NCDs management, focusing on DM and HTN (out of a total score of 4)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e2.2 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e1.8, 2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003eKnowledge (NCD Management): Mentioned 50%+ of the listed different components of NCD management.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e11 (46%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e27.9%, 64.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003eKnowledge (Trainings): Knew when PHC workers should acquire the knowledge, skills and abilities to manage DM and HTN.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e14 (58%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e38.8%, 75.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003eKnowledge (NCD provider): Mentioned 50%+ of the listed characteristics of skilled PHC workers to effectively manage DM and HTN.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e5 (21%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e9.2%, 40.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePerception: Gave favorable response on 50%+ of the statements on DM and HTN management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e22 (92%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e74.2%, 97.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003e\u003cstrong\u003ePHC worker's practices score on management and prevention of DM and HTN (out of a total score of 6)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e3.0 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e2.6, 3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePractice: Mentioned 50%+ of the listed practices used to manage DM and HTN among patients diagnosed with these conditions.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e8 (33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e18.0%, 53.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePractice (teaching): Mentioned 50%+ of the listed methods used to teach patients to manage DM and HTN.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e4 (17%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e6.7%, 35.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePractice (assessment): Mentioned 50%+ of the listed assessment processes of understanding patients during self-management education.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e7 (29%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e14.9%, 49.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePractice (assessment frequency): Provide patient education, including counselling services, to patients living with DM and/or HTN at every consultation during clinic schedules.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e18 (75%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e55.1%, 88.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePractice (adaptation): Ability to adjust patient education and counselling strategies based on assessments and patient feedback.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e23 (96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e79.8%, 99.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"379\"\u003e\n\u003cp\u003ePractice (examples of adaptation): Mentioned 50%+ of the listed patient education and counselling strategies.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e12 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"194\"\u003e\n\u003cp\u003e31.4%, 68.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe majority of PHC facilities, 80% [95% CI: 49.0%, 94.3%], were referring patients to the higher-level facilities for further care related to HTN or DM. The main reasons for referral were poor control of the condition despite treatment; 50% [95% CI: 23.7%, 76.3%], severe complications such as stroke, heart attack, or kidney failure; 30% [95% CI: 10.8%, 60.3%], and a lack of diagnostic equipment at the facility; 20% [95% CI: 5.7%, 51.0%] (Table 12 in the Appendix).\u003c/p\u003e\n\u003cp\u003eWhen asked for their needs in relation to follow-up, FGD participants felt that they did not receive reminders to attend to their scheduled routine hospital clinic days. As a result, they often missed counseling services, which they deemed essential for managing their conditions. Participants indicated a lack of uniform health information with no standardized package of care during patient education and counseling sessions within PHC settings (Table 6). Furthermore, participants indicated that they were not receiving consistent practical counseling on dietary and exercise plans for managing DM and HTN. Some PHC workers were providing differing advice on different clinic visits, leading to confusion. They expressed a need for practical illustrations and education that can apply to their mundane daily lives. This highlights a disconnect between the counseling provided and their real-life experiences and felt needs (Table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePHC worker\u0026rsquo;s support and training\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver 80% of PHC workers who completed basic training have not received further training on managing and preventing NCDs. This is reflected by a training score of 1 [95% CI: 0.2, 1.8] out of a total score of 6 (see Table 10 for specific components thereabout). In 2023-2024, only 21% [95% CI: 9.2%, 40.5%] were trained on DM or HTN management, and just 17% [95% CI: 6.7%, 35.9%] on both (Table 11 in the Appendix). Out of those who received training, about half of them believed the training covered these topics to a great or very great extent. Secondly, in terms of ease of understanding, 67% [95% CI: 30.0%, 90.3%] of the PHC workers found it easy or very easy to understand these topics. Additionally, in a test example, only one-third could list over half of the tools they use for patient self-management, such as self-care illustrations, follow-up calls or messages, home care visits, and peer mentoring support systems.\u003c/p\u003e\n\u003cp\u003eThe majority of PHC workers; 75% [95% CI: 55.1%, 88.0%] reported receiving regular technical support visits from County or Sub County NCD coordinators, but only a third confirmed these occurred quarterly. During these visits, 67% [95% CI: 46.7%, 82.0%] received mentorship for DM and HTN management. Thirteen percent [95% CI: 4.3%, 31.0%] could identify examples of mentorship provided, including Patient Data Documentation, Community Outreach Programs, Drug Management, and On-the-Job Training. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the qualitative findings on the patient\u0026rsquo;s experiences and perceptions of NCD care, Table 6 provides illustrative quotes from each theme, illustrating both spontaneous and latent insights obtained from the participants' responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Patient\u0026rsquo;s experiences and perceptions of NCD care\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"654\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"438\"\u003e\n\u003cp\u003e\u003cstrong\u003eSample quotes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajor themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInadequate counselling\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub-themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inadequate counselling time\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inconsistent counselling practices\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Medication availability focus\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Lack of practical demonstration during counselling\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"438\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One of the challenges in this facility is inadequate counseling. Nowadays, once the provider asks if you\u0026rsquo;re feeling better and you confirm yes, the next question is whether you have your medication. If not, you\u0026rsquo;re referred to the pharmacy, but often the drugs aren\u0026rsquo;t available there either.\u0026rdquo; [Female, 37 years, HTN patient, Level 4]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Since I started attending clinics at this facility, I have found the services to be better than at my previous one especially the way the nurse regularly counsels me on what to eat and what to avoid. However, the biggest challenge is the lack of medication and in most cases I have to buy them from nearby shops but very expensive, facility should stock these drugs.\u0026rdquo;\u003c/em\u003e\u003cem\u003e [Male, 48 years, HTN patient, Level 3]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe this facility's providers lack counseling time due to the high number of clients and limited number of providers. Therefore, they typically only inquire about my experiences and medication levels. In fact, when I first received the diagnosis, the only advice I received was on what to eat and what not to eat, and that is the only counseling I ever received.\u0026rdquo; [Female, 48 years, HTN patient, Level 4]\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajor themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLanguage Barriers, Capacity Constraints, and Time Pressure\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub-themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Limited staff\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inadequate training\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Time constraints\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Communication issues\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"438\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the main challenge is the lack of adequate providers. For example, here, there\u0026rsquo;s only one nurse who doesn\u0026rsquo;t speak our language [Luo dialect], so trying to explain in Swahili isn\u0026rsquo;t very clear. In fact, the nurse isn\u0026rsquo;t even sure how to teach us about preventing these conditions and wants to serve many clients in the morning, so she can\u0026rsquo;t spend enough time with us.\u0026rdquo; [Female DM Patient, 63 years, Level 2]\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajor themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLack of practical and individual guidance on diet and physical exercise\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub-themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inadequate access to recommended healthy diets\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inconsistent exercise\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inadequate reference materials\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"438\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I wish the facility could demonstrate what healthy eating means and, if possible, teach us through practical examples. When we come here, it would be helpful to see specific foods. For instance, I am told to eat fruits, but here in Seme, you can\u0026rsquo;t even find fruits. So, where am I supposed to get them?\u0026rdquo; [Female patient living with HTN, 46 years, Level 4 facility].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Given my age [elderly], nurses typically advise me to exercise as part of managing my condition. ..., providers advise me to engage in home physical activities like grazing animals or gardening instead of prescribing a specific amount and frequency of exercise. Nowadays, I leave these responsibilities to my grandchildren. It would be helpful to know what specific exercises are suitable for the elderly.\u0026rdquo; [Male patient living with HTN, 68 years, Level 3 facility].\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajor themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLack of screening for all patients who walk into the facility\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub-themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inadequate access to screening services\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Lack of awareness\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Delayed diagnosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"438\"\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI learned about my hypertension status during a general check-up at the facility. After screening, my blood pressure was found to be too high, and that\u0026rsquo;s how I was put on medication. I believe it would be beneficial if all facilities screened everyone who walks in.\u0026rdquo; [Male, 54 years, Level 3]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The first facility I visited did not have the necessary equipment for blood pressure screening, so they referred me to this facility. It was through this process that I discovered my condition and received medication.\u0026rdquo; [Female, 42 years, Level 4]\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajor themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrustration over Lack of essential drugs\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub-themes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Lack of drugs\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Trust issues\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Patient Discouragement\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Patient frustration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"438\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes, it\u0026rsquo;s very discouraging to keep coming to the hospital when there are no drugs available instead you are being told to buy from private outside pharmacies which are very expensive. Why do they open every day if clients can\u0026rsquo;t be treated and given medication? I\u0026rsquo;d rather stay at home because going to the hospital makes no difference if I can\u0026rsquo;t get the drugs I need.\u0026rdquo; [Male participant, 55 years, Level 4]\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to evaluate the capacity of the PHC system in Kisumu County to provide quality care for the prevention and management of HTN and DM and its found crucial gaps. We found that 80% of patients are referred for further care due to poor control or complications, underscoring a critical gap in the ability of PHC facilities to manage these conditions at the primary care level. While these findings are specific to Kisumu, they provide insights that have implications for the broader Kenyan devolved county PHC system nationwide.\u003c/p\u003e \u003cp\u003eFirst, the findings highlight significant gaps in the availability of essential medicines and health products, including IEC materials, which are critical for effective self-management. Patient experiences corroborate these findings, which negatively impacted their adherence to treatment and understanding of their conditions. Findings also highlighting a gap in follow up systems such as reminders for follow-up appointments. This situation is similar to that in other LMICs in the African continent such as Nigeria, Benin, Eritrea, and Sudan[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Addressing these broader issues is crucial for improving overall PHC delivery. Recommendations include strengthening supply chains for essential medicines, improving patient education materials, and implementing effective tracking systems especially to rural areas that are less populated and face many barriers related to and access.\u003c/p\u003e \u003cp\u003eSecond, the capacity of PHC workers is critically inadequate, both in terms of numbers and quality. Inadequate numbers lead to heavy workloads of PHC workers, illustrated by high patient-to-provider (Nurse) ratios of 1:1250, despite the WHO recommendation of 1:120[\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Time constraints during consultations hinder meaningful interactions, while unclear dietary and exercise advice further complicates patient management. Patients also experienced that nurses have to attend to a large number of patients simultaneously, compromising the opportunity for individual counseling. The quality of counseling also needs better contextualization. Many PHC workers are not fluent in the local dialect (Luo), exacerbating engagement issues and complicating care delivery. This communication gap leads to misunderstandings and insufficient patient education. Patient experiences reveal a pervasive sentiment of ineffective counseling and self-management education. Primary care staff receives little training to increase their capacity for NCD management. Only 22% of PHC workers in sub-Saharan Africa reported receiving hypertension training in the past year [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Our findings illustrate the need of PHC workers for comprehensive training tailored to the cultural and language needs of their patients.\u003c/p\u003e \u003cp\u003eThird, findings revealed that over two-thirds of PHC workers are employed on short-term contracts. This potentially contributes to a high attrition rate among PHC workers, as indeed indicated in another Kenyan study on motivation of health workers[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Such instability raises significant concerns about the sustainability of the devolved health sector in Kenya and potentially in other regions facing similar challenges. Many county governments struggle to provide permanent positions for health workers, leading to a workforce that is frequently in flux as employees seek more stable opportunities elsewhere. This trend not only affects the continuity of care for patients but also undermines the overall effectiveness of health systems. Addressing the employment conditions of PHC workers is crucial for fostering a stable workforce and ensuring the delivery of quality health services.\u003c/p\u003e \u003cp\u003eFourth, we also found that there are technical support visits from NCD coordinators, but that the consistency and reliability of these support visits seems lacking. For instance, the absence of a standard checklist for these visits may lead to variability in information, support and mentorship. Indeed, PHC workers overwhelmingly expressed their need for more support and mentoring[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Evidence indicate that nurses receiving mentorship can adhere to NCDs treatment protocol[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], suggesting the need to further investigation this in the Kisumu context.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe study employed a mixed-methods approach with triangulation to achieve a comprehensive understanding of the objectives. It applied internationally validated frameworks\u0026mdash;WHO Health System PEN, WHO ICCC, and the HEARTS Technical Package\u0026mdash;alongside locally tailored tools, enhancing the validity of the findings. Additionally, the surveys were conducted in collaboration with county and sub-county health management teams, leveraging their goodwill and mutual understanding of institutional challenges and strengths. Facility in-charges and the researchers jointly reviewed the health facility reports and the status of equipment such as glucometers, weighing scales, sphygmomanometers, and medications available. This provided more ownership of data, common realization of situation analysis, increasing urgency for health authorities to take action. This approach could enhance buy-in and readiness to implement recommended changes while fostering a stronger alignment between policy makers and health facility management.\u003c/p\u003e \u003cp\u003eThis study has some limitations. The survey evaluation data collected were not representative of the Kenyan primary healthcare system. The focus here was rather at the sub-county level with surveys conducted in specific rural areas, which may have led to an overestimation of the capacity of PHC facilities in these regions. Due to the purposive selection of the facilities, PHC workers, and patients, we cannot generalize the findings to other PHC settings or populations. Also, the wide confidence intervals reflect the variability in equipment availability across facilities and suggest a need for caution in interpreting these estimates. Furthermore, our findings may be limited by selection bias of participants and response bias. The focus on only three categories of healthcare workers (Clinical Officers, Nursing Officers, and Nutritionists) may have limited the perspectives represented in the study. We did not interview any doctors, health records officers, pharmacists, and public health officials, as they were not present in our facilities. Moreover, participants may have altered their responses based on perceived expectations from the research team and county representatives during data collection. This response bias could potentially skew the results toward more favorable perceptions both by staff and patient respondents. To mitigate these and ensure consistency in observations and measurements, the study recruited experienced researchers, all of whom were trained in interview techniques and the use of the study tools. Real-time feedback and debriefings were provided daily to validate some of the observer's findings. The including of patient perspectives is considered a strength.\u003c/p\u003e \u003cp\u003eDespite these limitations, our findings have generated locally relevant evidence that can inform local action in PHC for NCDs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The evaluation of PHC facilities in Kisumu County reveals critical structural deficiencies that significantly impede the delivery of high-quality care for hypertension and diabetes management and patient satisfaction. This highlights the urgent need to enhance both the structural and procedural aspects of care within these facilities. The findings of this evaluation underscore the critical importance of such investments and provide a roadmap for targeted interventions to enhance the quality of care in Kisumu County and similar rural contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthic\u003c/strong\u003e\u003cstrong\u003es and Consent\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Jaramogi Oginga Odinga University of Science and Technology (JOOUST) and the National Commission for Science, Technology and Innovation (NACOSTI), with approval license numbers ERC/5/24-06 and NACOSTI/P/23/25192, respectively. Additional approvals were obtained from the County Government, and individual informed consent was signed by each PHC worker and FGD participant before data collection began. During the informed consent process, interviewers emphasized the voluntary nature of the study, ensuring participants understood the risks and benefits and were willing to participate. We confirm that all methods were carried out in accordance with relevant guidelines and standards including in accordance with the Declaration of Helsinki, adhering to the approved protocol.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData is accessible and available upon reasonable request to the corresponding author (OJO) to ensure that the use of data is in line with the terms of ethics approvals and principals.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h2\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\u003ch2\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWe extend our heartfelt gratitude to all the participants who participated in this study. This includes patients living with diabetes and/or hypertension, county and sub-county health management teams, facility in-charges, PHC workers, and the PhD and master’s students who assisted with data collection.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOJO conceptualized the study, conducted the desk review research, developed and programmed the data collection tools, and analyzed the data. DO, EM, JO, SA, JB, and JvO contributed to the study\u0026rsquo;s conception and reviewed the manuscript. OJO, EM, and DO were involved in data collection with JO with relevant qualifications and prior experience in qualitative research methodology led the focus groups. OJO conducted data cleaning and analysis. DO, JB, SA, and JvO provided technical guidance and critical suggestions for the manuscript. All authors read and approved the final submission. OJO holds full responsibility for the study, including data access and publication decisions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchutte AE, et al. Hypertension in low-and middle-income countries. Circul Res. 2021;128(7):808\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray CJ. The global burden of disease study at 30 years. Nat Med. 2022;28(10):2019\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Noncommunicable diseases progress monitor 2020. World Health Organization; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudreviciute A, et al. Management and prevention strategies for non-communicable diseases (NCDs) and their risk factors. Front public health. 2020;8:574111.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. \u003cem\u003eWorld Health Organization. Noncommunicable diseases. Key Facts;\u003c/em\u003e 2018 \u003cem\u003eAvailable from\u003c/em\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases.\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases.\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e \u003cem\u003eAccessed 525, 2019.\u003c/em\u003e 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Global action plan for the prevention and control of noncommunicable diseases 2013\u0026ndash;2020. World Health Organization; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBigna JJ, Noubiap JJ. The rising burden of non-communicable diseases in sub-Saharan Africa. Lancet Global Health. 2019;7(10):e1295\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoudreaux 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 Plann. 2022;37(4):452\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStatistics BO. \u003cem\u003eKENYA STEPwise SURVEY FOR NON COMMUNICABLE DISEASES RISK FACTORS 2015 REPORT.\u003c/em\u003e 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenya M. Kenya national strategy for the prevention and control of non-communicable diseases 2015\u0026ndash;2020. Nairobi: Ministry of Health Division of Non-communicable Diseases; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtlas D. \u003cem\u003eIDF diabetes atlas. International Diabetes Federation (9th editio)\u003c/em\u003e. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun H et al. \u003cem\u003eIDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045.\u003c/em\u003e Diabetes research and clinical practice, 2022. 183: p. 109119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaruiru W, et al. All-cause and cause-specific mortality rates for Kisumu County: a comparison with Kenya, low-and middle-income countries. BMC Public Health. 2022;22(1):1828.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Continuum of care for noncommunicable disease management during the migration cycle. World Health Organization; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOwusu MF, et al. Tackling the non-communicable disease epidemic: a framework for policy action in low-and middle-income countries. Pan Afr Med J. 2024;47:82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgyepong IA, et al. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet. 2017;390(10114):2803\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaque M et al. \u003cem\u003eStrengthening primary health-care services to help prevent and control long-term (chronic) non-communicable diseases in low-and middle-income countries.\u003c/em\u003e Risk management and healthcare policy, 2020: pp. 409\u0026ndash;426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJamison DT et al. \u003cem\u003eDisease control priorities in developing countries.\u003c/em\u003e 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoors W, Dkhimi F, Criel B. Lack of access to health care for African indigents: a social exclusion perspective. Int J Equity Health. 2013;12:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkachi Y, Kruk ME. Quality of care: measuring a neglected driver of improved health. Bull World Health Organ. 2017;95(6):465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkhlaq A, et al. Barriers and facilitators to health information exchange in low-and middle-income country settings: a systematic review. Health Policy Plann. 2016;31(9):1310\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context\u0026ndash;global shortages and international migration. Global health action. 2014;7(1):23611.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDouglas M, et al. Facilitators and barriers in prevention of cardiovascular disease in Limpopo, South Africa: a qualitative study conducted with primary health care managers. BMC Cardiovasc Disord. 2021;21:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulupi S, et al. What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries. BMJ open. 2022;12(7):e052105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyandipo O et al. Cancer ecosystem assessment in West Africa: Health systems gaps to prevent and control cancers in three countries: Ghana, Nigeria and Senegal. Pan Afr Med J, 2020. 35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyaaba G, et al. Factors hindering hypertension control: perspectives of front-line health professionals in rural Ghana. Public Health. 2020;181:16\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWollum A, et al. Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project. PLoS ONE. 2018;13(3):e0192603.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaimela E, et al. Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa. BMC Health Serv Res. 2018;18(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdinan J, et al. Preparedness of health facilities in managing hypertension \u0026amp; diabetes mellitus in Kilimanjaro, Tanzania: a cross sectional study. BMC Health Serv Res. 2019;19:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris 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):e007334.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTesema AG, 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):e009025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWitter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Global Health. 2022;7(Suppl 7):e008115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShayo EH, et al. The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania. BMC Health Serv Res. 2022;22(1):655.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmmoun R, et al. Readiness of health facilities to deliver non-communicable diseases services in Kenya: a national cross-sectional survey. BMC Health Serv Res. 2022;22(1):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamvura TT, et al. Barriers to the provision of non-communicable disease care in Zimbabwe: a qualitative study of primary health care nurses. BMC Nurs. 2022;21(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiferaw F et al. Non-communicable Diseases in Ethiopia: Disease burden, gaps in health care delivery and strategic directions. Ethiop J Health Dev, 2018. 32(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTulshian P, et al. An assessment of facility-based care of diabetes, hypertension, and heart failure across western Kenya. East Afr Med J. 2018;95(10):2014\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang CK, et al. Rural diabetes prevalence quintuples over twenty-five years in low-and middle-income countries: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2012;96(3):271\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJonkman LJ, et al. Patient experiences in managing non-communicable diseases in Namibia. Res Social Administrative Pharm. 2020;16(11):1550\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeer N, et al. Care and management of a double burden of chronic diseases: Experiences of patients and perceptions of their healthcare providers. PLoS ONE. 2020;15(7):e0235710.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eMinistry of Health, Division of Non-communicable Diseases. National Clinical Guidelines on Management of Diabetes Mellitus, 2023 Edition. Nairobi, Kenya: DNCD, August 2023.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemaio AR, et al. Primary Health Care: a strategic framework for the prevention and control of chronic non-communicable disease. Global health action. 2014;7(1):24504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarain JP. Integrating services for noncommunicable diseases prevention and control: use of primary health care approach. Indian J Community Med. 2011;36(Suppl1):S67\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkello S, et al. Hypertension prevalence, awareness, treatment, and control and predicted 10-year CVD risk: a cross-sectional study of seven communities in East and West Africa (SevenCEWA). BMC Public Health. 2020;20:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMogaka JN, et al. Prevalence and factors associated with hypertension among adults with and without HIV in Western Kenya. PLoS ONE. 2022;17(1):e0262400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. \u003cem\u003eWHO package of essential noncommunicable (PEN) disease interventions for primary health care.\u003c/em\u003e 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWagner EH, et al. A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q. 1999;7(3):56\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpping-Jordan JE. Integrated approaches to prevention and control of chronic conditions. Kidney Int. 2005;68:S86\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOni 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;14:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. WHO global strategy on people-centred and integrated health services: interim report. World Health Organization; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRead Rt. \u003cem\u003eCalculating teacher's scores in understanding their knowledge, perception and practices in developing children's literacy skills\u003c/em\u003e. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsadru VR, Nanyonga RC, Alege JB. Health facilities\u0026rsquo; readiness to manage hypertension and diabetes cases at primary health facilities in bidibidi refugee settlement, Yumbe District, Uganda. J Trop Med. 2021;2021(1):1415794.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. WHO model list of essential medicines-22nd list, 2021. Doc: Tech; 2021. p. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Service Availability and Readiness Assessment (SARA): an annual monitoring system for service delivery. Geneva: World Health Organization; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Hearts: technical package for cardiovascular disease management in primary health care: risk-based CVD management. World Health Organization; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendis S, et al. Gaps in capacity in primary care in low-resource settings for implementation of essential noncommunicable disease interventions. Int J Hypertens. 2012;2012(1):584041.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdejumo O, et al. Assessment of hypertension service availability in some primary health centres in Nigeria: a mixed-methods study. BMJ open. 2023;13(8):e073833.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eChallenges facing the attainment of Universal Health Coverage in Kenya\u003c/em\u003e, in \u003cem\u003eKenya Medical Association\u003c/em\u003e. 2021: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://kma.co.ke/component/content/article/79-blog/125-challenges-facing-the-attainment-of-universal-health-coverage-in-kenya#:~:text=According%20to%20WHO%2C%20the%20recommended,care%20in%20public%20healthcare%20facilities\u003c/span\u003e\u003cspan address=\"https://kma.co.ke/component/content/article/79-blog/125-challenges-facing-the-attainment-of-universal-health-coverage-in-kenya#:~:text=According%20to%20WHO%2C%20the%20recommended,care%20in%20public%20healthcare%20facilities\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMashaba RG, et al. Recognition of language barriers in comprehending non-communicable disease management among rural elderly people in the DIMAMO surveillance area: a case of AWI-Gen participants. BMC Public Health. 2024;24(1):2782.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOjakaa D, Olango S, Jarvis J. Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya. Hum Resour health. 2014;12:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillis-Shattuck M, et al. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res. 2008;8:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunabi NC, et al. The influence of an all-female healthcare environment on mentorship and empowerment of female healthcare professionals. PLOS Global Public Health. 2022;2(3):e0000081.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNdayisaba A, et al. A clinical mentorship and quality improvement program to support health center nurses manage type 2 diabetes in rural Rwanda. J Diabetes Res. 2017;2017(1):2657820.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eContributors.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOJO conceptualized the study, conducted the desk review. research, developed and programmed the data collection tools, and analyzed the data. DO, EM, JO, SA, JB, and JvO contributed to the study\u0026rsquo;s conception and reviewed the manuscript. OJO, EM, and DO were involved in data collection with JO with relevant qualifications and prior experience in qualitative research methodology led the focus groups. OJO conducted data cleaning and analysis. DO, JB, SA, and JvO provided technical guidance and critical suggestions for the manuscript. All authors read and approved the final submission. OJO holds full responsibility for the study, including data access and publication decisions.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mixed methods, Health System, Referrals, Guidelines, Patient follow-up","lastPublishedDoi":"10.21203/rs.3.rs-6743764/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6743764/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe burden of non-communicable diseases (NCDs) like hypertension and diabetes is rapidly increasing in sub-Saharan Africa, with cardiovascular conditions contributing about 40% of all NCD-related morbidity. This poses considerable challenges, including governance, prevention of risk factors, monitoring, surveillance, and evaluation of health systems. In Kenya, NCD-related mortality is approximately 600 per 100,000 for males and 500,000 per 100,000 for females, with Kisumu County reporting approximately 1,118 per 100,000 population annually, compounded by a high HIV burden. Primary healthcare (PHC) provides essential care that could ensure proactive, patient-centered, community-based, and sustainable care to prevent and manage NCDs, yet its implementation remains weak with large regional and subnational differences.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis mixed-methods study was conducted between October 2023 and September 2024 in Kisumu County, Kenya, and included a facility assessment survey, PHC worker surveys, and focus group discussions (FGDs) with 20 patients living with DM and/or HTN. Ten facilities out of 29, classified as level 2 to 4 under the Kenya Essential Package for Health (KEPH), were purposively selected for the study. The evaluation assessed service availability and performance in NCD care using the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) toolkit. Key aspects included essential drugs, guidelines, equipment, patient follow-up, counseling systems, support supervision, and the training, knowledge, perceptions, and practices of PHC workers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e While most facilities conducted routine DM and HTN screenings, only 20% [95% Confidence Interval: 5.7%, 51.0%] displayed national management guidelines. Over 80% of PHC workers had not received post-basic training in DM and HTN management, and only 50% were proficient, with an average knowledge score of 2.2 out of 4. Nearly 80% [95% CI: 49.0%, 94.3%] of facilities referred patients to higher-level facilities due to inadequate clinical capacity or a lack of essential medicines. Patient follow-up and counseling on self-care and lifestyle changes were rated poorly, averaging 2.9 [95% CI: 1.4, 4.4] out of 6. Qualitative study through FGDs revealed frequent medication shortages, a lack of basic equipment, and insufficient patient information on self-care, diet, and exercise.\u003c/p\u003e\u003ch2\u003eConclusions and recommendations:\u003c/h2\u003e \u003cp\u003eSignificant gaps exist in the organizational and workforce capacity of PHC facilities in Kisumu County, Kenya. Addressing these modifiable issues requires defining specific strategies for improvement and identifying necessary investments to scale up effective interventions. This could proffer far-reaching implications for health outcomes and overall health system efficiency.\u003c/p\u003e","manuscriptTitle":"Assessing the Capacity of Primary Healthcare Facilities and Healthcare Workers in Managing Diabetes and Hypertension in Kisumu County, Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 04:57:53","doi":"10.21203/rs.3.rs-6743764/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-04T07:36:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-01T07:01:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160104712762448920741169423411541575644","date":"2025-07-28T09:42:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-27T12:44:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108963986292292748554378490356150541694","date":"2025-07-25T10:18:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298149755047890519011157044164899674244","date":"2025-07-23T05:35:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24530193552964344747394509831072410403","date":"2025-07-23T03:14:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-04T19:20:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49945085561005811441863611983289983973","date":"2025-06-10T10:37:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T09:25:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-03T09:26:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-02T22:24:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-31T02:31:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-31T02:27:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dbc79770-51cd-4e98-bdf4-3aab08bdec1a","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:09:04+00:00","versionOfRecord":{"articleIdentity":"rs-6743764","link":"https://doi.org/10.1186/s12913-025-13390-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-09-30 15:57:38","publishedOnDateReadable":"September 30th, 2025"},"versionCreatedAt":"2025-06-16 04:57:53","video":"","vorDoi":"10.1186/s12913-025-13390-5","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13390-5","workflowStages":[]},"version":"v1","identity":"rs-6743764","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6743764","identity":"rs-6743764","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}