Community-based Approaches to improve hypertension treatment among people living with HIV

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Adedokun, Nanna R. Ripiye, Adaku Nwankwo, Idowu Omisile, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7123440/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract BACKGROUND HIV/AIDS is a significant public health problem in sub-Saharan Africa (SSA), accounting for 70% of the global disease burden. Meanwhile, HIV mortality in SSA has declined due to expanded access to anti-retroviral therapy (ART). Some of the strategies that have contributed to this decline in SSA, apart from access to highly active anti-retroviral medications, are task sharing, which uses non-physician community healthcare workers (CHW). Leveraging such non-physician CHW support for the treatment of hypertension in persons living with HIV (PLHIV) is desirable, especially with the increasing burden of cardiovascular disease and their risk factors, especially hypertension in this population. And with the community-based approach for HIV treatment, the need to integrate non-communicable diseases (NCD) screening and management into such an approach cannot be over emphasized. OBJECTIVE We aimed to examine the context, facilitators, and barriers to implementing CHW support and home blood pressure (BP) monitoring in hypertensive PLHIV in HIV Clinics in Nigeria’s Federal Capital Territory (FCT) using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. METHODS We purposively sampled and conducted qualitative semi-structured key informant interviews with five each of hypertensive PLHIV, Community Health Extension Workers (CHEWs), Physicians, healthcare policymakers, Community Pharmacists, and Community nurses. Interviews were tape-recorded, transcribed, and coded based on themes identified. We analyzed data to describe the context, facilitators, and barriers to implementing CHW support and home BP monitoring in hypertensive PLHIV. RESULTS Contextual observations include existing donor-funded community ART refill mechanisms managed by volunteers. Proposed facilitators include providing policy framework, advocacy to stakeholders, government funding support, incentivizing volunteers and patients, identifying champions for home BP monitoring in hypertensive PLHIV, training, supportive supervision, and patient involvement. Barriers identified include financial constraints, non-existing policy framework, implementation guidelines, or dedicated human resources for home BP monitoring in hypertensive PLHIV, as well as provider, community, and patient resistance issues. CONCLUSION We identified facilitators and barriers for CHW support and home BP monitoring in hypertensive PLHIV, with existing donor-funded community ART refill mechanism being a major contextual factor. Barriers Community Health Worker (CHW) Facilitators Home Blood Pressure Hypertension Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) CONTRIBUTIONS TO THE LITERATURE Home-based management strategy has contributed immensely to the successes recorded in the fight against HIV/AIDS. These strategies have not been adopted for cardiovascular diseases like hypertension in the Nigerian environment. This study provides context, facilitators, and barriers to adopting home-based management of hypertension in HIV positive hypertensive patients in the Nigerian context. INTRODUCTION HIV/AIDS is a major public health problem in sub-Saharan Africa (SSA), accounting for 70% of the global disease burden ( 1 ). According to the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), HIV prevalence amongst adults aged 15–64 years in Nigeria is 1.4% ( 2 ), with about 89% on antiretroviral therapy (ART) as at 2020 ( 3 ). Meanwhile, HIV mortality rate in SSA, including Nigeria, has remarkably declined owing to expanded access to anti-retroviral therapy (ART) ( 4 ). This success has resulted in increased life expectancy of HIV-infected individuals ( 5 ), which is unfortunately associated with a higher burden of hypertension and related cardiovascular mortality ( 6 ), which has also been on the rise. This, in HIV-infected patients, appears to be independent of traditional risk factors such as urbanization, dietary and lifestyle factors, which are on the rise. In addition, HIV-infected patients receiving ART have been found to have a higher prevalence of hypertension compared to those not receiving treatment. A major factor that led to the successful HIV programme in SSA is task sharing with concerted involvement of non-physician healthcare workers, for example, the community anti-retroviral treatment (CART) programme ( 7 – 9 ). It will therefore be necessary to leverage such non-physician community healthcare worker support for the treatment of hypertension in persons living with HIV. Meanwhile, home blood pressure monitoring allows multiple readings, when taken over an extended period. Home blood pressure monitoring also has the added advantages of overcoming the issue of white-coat hypertension, being reproducible and predicting cardiovascular morbidity and mortality better than office BP measurements. It is also useful in the diagnosis of masked hypertension and allows for better incorporation of patients into their management ( 10 ). This research project examined the context, facilitators, and barriers to implementing Community Health worker support and home blood pressure monitoring on the treatment and control of blood pressure in Nigerian hypertensive HIV patients assessing care in HIV Clinics in tertiary, secondary and primary facilities in the FCT of Nigeria. METHODS Study Area or Location This study was implemented in tertiary, secondary and primary healthcare facilities within the FCT of Nigeria. Study design It was a qualitative study with semi-structured interviews of Community Health Workers to understand the context, facilitators, and barriers to implementing Community Health worker support and home blood pressure monitoring in hypertensive HIV patients in Nigeria. Using purposive sampling, we interviewed key stakeholders in managing HIV in Nigeria at the tertiary, secondary, and primary healthcare (community levels) levels in the FCT between 12th August 2022 to 20th February 2023. Our target stakeholders included 5 hypertensive patients living with HIV, 5 CHEWs, 5 Physicians, and 5 healthcare policymakers, making a total of 30 interviews. Participants were adults aged 18 years or older who were able and willing to provide informed consent. We excluded staff members who had worked for less than three months in the target organization and those who could not complete the interview for any reason. Study Procedures Using the I-PARiHS framework, we conducted semi-structured qualitative interviews with key stakeholders to understand the context, facilitators, and barriers to implementing Community Health worker support and home blood pressure monitoring on blood pressure (BP) treatment and control in hypertensive HIV patients in Nigeria. These interviews explored the underlying factors and support systems required to successfully implement Community Health worker support and home blood pressure monitoring. Questions focused on stakeholders’ understanding of the purpose of community and health worker support and home blood pressure monitoring, and suggestions on how they can become engaged in facilitating its adoption. The stakeholder interviews included surveys and semi-structured key informant interviews using the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) to understand the context, facilitators, and barriers of implementing a Community Health worker support and home blood pressure monitoring on blood pressure (BP) treatment and control in hypertensive HIV patients in Nigeria. Interviews lasted about one hour and were audio-taped, transcribed and entered into NVivo version 11 for data analysis. Research Locations All surveys, key informants, and in-depth interviews took place in the stakeholders’ workplace with COVID-19 safety precautions in place. Procedures Involved We telephoned participants to schedule an appointment with them for recruitment through our existing contacts, especially governmental officers involved in HIV care in the FCT of Nigeria. We provided a participant information sheet to seek their interest in participating and scheduled an interview time, and informed consent for participation was sought. Participants were asked to provide informed consent to participate separately for audio recording. All contact information was maintained securely in Microsoft Excel and kept separate from study data, linked only by a unique study ID. After providing written informed consent, participants completed a brief (15-minute) paper survey, which captured participants’ demographics, knowledge and attitudes about HIV care and management of hypertension in persons living with HIV. P articipants then took part in a key informant in-depth interview. Data analysis The interviews were transcribed and analyzed according to key themes using NVivo software. We used the framework approach to qualitative data analysis, which is a 5-step process: (a) familiarization, (b) developing a theoretical framework, (c) indexing, (d) summarizing data in an analytical framework, and (e) data synthesis and interpretation. Following this framework, data were independently coded by three experienced research staff to reduce the potential for bias. Inter-rater reliability was determined, and discrepancies in coded data were resolved by consensus. All transcripts were coded into concepts reflecting the aims of the pre-implementation phase. For example, responses were coded according to evidence or core elements of community health worker support and home blood pressure monitoring likely to influence its adoption within HIV clinics in the Federal Capital Territory of Nigeria. The identified concepts were grouped into categories and themes, uniting the categories. A detailed analysis of the interviews was used to generate a conceptual model of the facilitators and barriers to uptake, and domains of a practice facilitation strategy tailored to the Nigerian healthcare system. RESULTS Study Respondent Characteristics The sociodemographic characteristics of the study respondents, as presented in Table 1 showed their age, gender, marital status, education level, occupation, and stakeholder groups. Majority of the respondents were above 50 years (46.6%), 26.7% were between 40–49 years, and 26.7% were less than 40 years (26.7%). The mean age was 47.2 ± 8.67 years and the gender distribution showed 43.3% males and 56.7% females, while the distribution by marital status showed that a vast majority (86.7%) were married, 10.0% were single, and 3.3% were widowed. Almost all (96.7%) respondents had tertiary education, while only 3.3% had secondary education. Eight study respondents practiced as Physicians, 5 as Pharmacists, 5 as Nurses, 5 as CHEWs, 2 were into business, 2 were civil servants, 1 was a social worker, 1 was a driver and the last a housewife. A further breakdown of these respondents into occupational groups showed that there were 6 stakeholder groups of Hypertensive PLHIV, CHEWs, Physicians, Health Policy Makers, Community Pharmacists, and Nurses, each of which had 5 (16.7%) respondents per group. Table 1 Characteristics of Study Respondents Characteristic Frequency Percentage Age of participant Mean age ( 47.17 ± 8.67 ) - 50 14 46.6 Gender Male 13 43.3 Female 17 56.7 Marital Status Single 3 10.0 Married 26 86.7 Widowed 1 3.3 Education Secondary 1 3.3 Tertiary 29 96.7 Occupation Business 2 6.7 Community Health Extension Worker 5 16.7 Civil Servant 2 6.7 Nurse 5 16.7 Pharmacist 5 16.7 Physician 8 26.7 Social Work 1 3.3 Others 2 6.7 Stakeholder Group Hypertensive PLHIV 5 16.7 Community Health Extension Worker 5 16.7 Physician 5 16.7 Health Policy Maker 5 16.7 Community Pharmacist 5 16.7 Nurse 5 16.7 Context General Contextual Issues Respondents indicated that there is an existing HIV care and treatment programme with a community-based component, whereby home visits are made to PLHIV to deliver antiretroviral drugs and other medications. “The HIV programme is already in existence, the blood pressure programme that is being initiated would complement…” (004- Health Policy Maker, DIRECTOR OF PRIMARY HEALTH CARE) “Okay…this community … services that we are doing, erm, …has helped so much, where we go right to their homes and then give them drugs. Some may not be able to come, we’ll collect your phone number – we have all their phone numbers…we have that of maybe their next of kin. So well, you didn’t come to clinic today…we’ll check the” system, prescribe, take the drugs to the person”. (006 - Physician UATH) The existing HIV programme including the community component, is supported by PEPFAR through its implementing partners, with little or no financial support from government. “…You know this place is still financially under IHVN. So, all this community services am talking to you, they are being handled by IHVN - when it comes to financial aspect. So, government is not doing anything concerning this one.” (006 - Physician UATH) Community ART delivery is also sometimes facilitated through community pharmacists, thus cutting the cost of transportation for the PLHIV. The patients only need to visit the health facility once in 6 months to consult with their doctors and have samples collected for their routine monitoring tests. “they do, they do… you know, they see.... even though we operate community pharmacy, community services, they come here every six months for review. They are not left, hundred percent in the… after six months, they come. And the feedback is that erm, they are enjoying it, they like it, it has cut a lot of costs…and they appreciate it…that is the feedback we are getting” (006 - Physician UATH). The HIV programme also established support groups comprising PLHIV, which facilitates meaningful involvement of the PLHIV themselves in their own care. In some instances, support group representatives collect drugs on behalf of their members and deliver to them within the community, thus saving the cost of seeking care. “Yes, the support group has been very helpful in terms of HIV management. Support group at different levels. And we are equally doing quality improvement meetings and what have you, because of HIV. So, it helps us to review what has been done, and how far we have been doing it.” (008 - Township Clinic Physician) To maximize the available human resources at the facilities, the HIV programme also facilitates task shifting among healthcare workers at the facility. In high-volume facilities with limited numbers of doctors, nurses see the stable patients and refer them to the pharmacy for their ART refill, while the more unstable patients are seen by doctors. “Okay, you know, when this clinic started, there’s what we call task shifting…Task shifting… before, only the Doctors were seeing the patients, whether stable patients or those that had complaints. Then we did it like a kind of erm…where Nurses were seeing stable patients… Nurses were prescribing drugs… it was something that nobody was going to accept. But we were doing it here because the patients were so many, and there were four Doctors on ground. So, we said no this thing… four o’clock we’ll still be running clinic. And it’s after the clinic that the pharmacist will now sit down to enter everything that we did… later, IHVN adopted it and then there’s task-shifting worldwide that is being accepted…” (006 - Physician UATH) In addition to the home delivery of ART, the health workers also organize periodic community mobilization outreaches to improve the health-seeking behaviour of the populace. “Health-seeking behavior. Yes, the facility as a whole has been doing so much to that effect. Just like I said, on our own, once in a while, we even organize community mobilization sensitization, all those things is to see how we improve on their health-seeking behaviour.” (008 - Township Clinic Physician) Respondents were of the opinion that home monitoring of blood pressure can be leveraged on the existing home care for PLHIV. “Home support and home care is very key in HIV treatment and follow-up. Then adding blood pressure monitoring like I said is going a step further, with this approach we are likely going to unveil those that have you know prehypertension and hypertension and those that we can treat at home.” (030 - Health Policy Maker GWARIMPA GENERAL HOSPITAL) “Okay, erm, yes it can be adopted, like their advocating…that HIV programme has a lot of facilities in most African countries…so why can’t we use that same platform? So we don’t need to build another structure for non-communicable diseases among HIV patients, but let’s, because those structures are already functioning, why can’t we use that same platform? And they are really using it.” (011 - Physician UATH) Facilitators of Home Blood Pressure Management Respondents identified the following as facilitators of home-based management of hypertension advocacy, leadership, policy, incentives, government support, training and tools, supportive supervision, as well as patient involvement (Table 2 ). Table 2 Facilitators of home blood pressure management Identified Facilitators Inference Relevant Quotes Advocacy At the community level, the respondents proposed adequate community advocacy and awareness to make it easier to enter the community and implement the programme. Other respondents proposed that all necessary stakeholders should be engaged in the programme, while another recommended taking the local context into consideration in the design of the programme. Some of their responses are as shown: “Okay. If I were the one to undertake, number one is that erm, since it’s community-based, I will go to the community, do advocacy visit, have a town hall meeting with the community people, get the leaders of the community, the traditional rulers to own…to see it as a programme that is going to benefit them.” (006 - Physician UATH) “No how I will, as I said, I have mentioned some of them. I will start by personally bringing, I will start with stakeholders, bringing the stakeholders that I feel will help. The stakeholders does not mean only from the health facility, both the community, religious all round.” (008 - Township Clinic Physician) "I will write to the government or to the local government Chairman, to tell him my… to tell him what I want to do, and how I want to go about it. "Well, it has to start from those we have identified as patients. They are the best advocates. For instance, somebody who has HIV and hypertension, when he or she is able to talk about the advantage of the knowledge he has acquired concerning the disease, it will help others to also come out because many a times when people die from this type of diseases, it is assumed that a witch or something has killed them." (019 - Health Policy Maker UATH) Some respondents proposed that, relevant advocacy efforts should also be made to local government chairmen and donors for funding, while healthcare workers and patients’ inputs should be sought in the design of the programme and advocacy efforts. “So, the support there will start for me… I mean he’ll start by telling me okay, this is how you go about it, this is how you go about it, when you write a letter I will submit it, when it’s approved, then we can give you go ahead on how to start the programme. Then from there, it’s from the letter that I wrote to the local Chairman, that’s where I will state something like a proposal to them, and a breakdown of the proposal. This… I want finance, this will be used for this, this will be… and if it’s approved, luckily, if I’m lucky and it’s approved, then they’ll get back to me then from there I will kick start the programme." (002- IST CHEW UATH) "…then I’ll have to look for donor that is able… that is ready to sponsor or to fund the initiative because the ministry might not be able to, yes." (033 - Health Policy Maker (FMOH)) "Well I will call a meeting of the staff and intimate them of this programme and ask them, the staff as a whole, what are their fears, what do they think is the barriers and then by the time we brainstorm together, we will arrive at this is what we want to do, let us give it a trial but there will be a need for me to push and push and encourage all those that will be involved to key into it, since our ultimate goal in the facility is for the patient." (009 - Community Nurse, Township Clinic) Leadership In the leadership context, the interview responses indicated that the successful implementation of home-based hypertension care would succeed with the support of mainly people who occupy up to directorial positions within the facilities in such roles as an Assistant Director, ART Focal Person, Departmental Head, Matron or even the CMD. On the other hand, outside the facility, the key people who are needed to provide support include community leaders, village heads, community chiefs or community health workers, as depicted by the following statement: “Of course, you know trees make a forest. If the key person or the focal person agrees, other departments should be carried along because the ultimate aim is for the benefit of the patient and so other health workers need to be incorporated and carried along based on both training and retraining to key into the arrangement.” (009 - Community Nurse, Township Clinic) The discussions evaluated the reasons why the key healthcare facility personnel were considered crucial to the championing of the programme implementation and the respondents provided a broad array of reasons for this. In their responses, they mentioned that the healthcare focal persons were important because of their personality and their office. The key persons were found to be people who were approachable and had genuine passion for their occupation and for the clients. These were determined to be important in ensuring that the programme kickstarts and runs successfully as shown in one of the responses as follows: “It has to be with the two – the passion, feeling concerned about the welfare of the patients, because even if he is knowledgeable, if he is not having passion…” (022 - Community Nurse General Hospital, Gwarimpa) In the aspect of professional standing, the respondents mentioned that the focal persons occupy a pivotal point which makes them able to drive the activities of other stakeholders in a desired direction. By virtue of their office, everyone would listen to them and thus follow their directions. One of the respondents said, “Once she accepts it, definitely we will also accept it and the patients too will accept it.” (002- IST CHEW UATH) Further, questions bordered on whether the health facility head holds service providers accountable for collaboration and coordination in this effort towards community health worker support and home blood pressure monitoring in hypertensive HIV patients, if introduced. One respondent affirmed that: “Yes, as far as I know who she is, she likes you doing the right thing at all times…And she supervises every person, whether you are Doctor directly under her, or…you are answerable to somebody before… she goes right to every level to see what work you are doing. So, I think she’s… once she has agreed go and do this, she will hold you accountable if the thing is not properly done.” (006 - Physician UATH) Policy The respondents identified appropriate policy and guidelines as an important facilitator of home management of hypertension. They spoke about different forms of engagement that they would have with the government, and they mentioned issues such as stakeholders’ policy meetings, support in programme publicity and public sensitization, programme financing and development of operational guidelines. "like our physicians here that are just coming back from policy stakeholders meeting, such stakeholders meeting should be arranged and of course by the health department, by the policy makers and also should involve those who should be key players in the field." (009 - Community Nurse, Township Clinic) "ehhh guidelines, then bringing out the guidelines on how you want the project to go. Then financing the project and tell them that okay, this project, if this project at the end of the is successful, it will even bring up more employment to the youths." (002- IST CHEW UATH) Incentives The availability of incentives for staff to carry out the implementation of community health worker support and home blood pressure monitoring in hypertensive HIV patients was also identified as a critical facilitator for home-based management of hypertension. A respondent stated that provision of incentives for transportation will not be out of place. The respondents identified incentives such as stipends for healthcare workers, transport fare for healthcare workers and bed nets as for household members. This was seen in some responses as follows: “ Well, I’ll say, if there is, it will not be out of place. But even if there isn’t… you know if I’ll be the one that’ll be sent to the village now that means I’m not going to do my work here. So instead of doing my work here, I’ve just been asked to go to the village and do. What may be is that what I may ask is that how do I get to the village. So that is where the incentive may need to come. How do I get to the village? But, since it is my work, if I go to the village I’m not going to the clinic, so I don’t have any problem be that. But getting to the village is what may bring the need for the incentive.” (006 - Physician UATH) “Our time… and as I said earlier, now you are working in a health facility like you have to make your time, it’s the time, if we can give out our time we’ll put our best. And all that best comes from you are being taken care of.” (013 -PHC CHEW Karamajiji) “Then incentives of course you know will play an important role too. Yes, once an incentive is introduced into a programme it can help, especially service providers to bring out the beat in them.” (004- Health Policy Maker, Director of Primary Health Care) Government Support The respondents identified government support for the programme as a critical facilitator, especially provision of funds, recruitment of more manpower and provision of necessary infrastructure. These are shown in some of the responses as follows: "Who is them, The owner of the programme? It should be the government. You are asking whether there should be government, government should support and finance the programme, so that the programme can succeed." (009 - Community Nurse, Township Clinic) "the manpower is very important as I’ve said. Then you know government can even come in, even if it is not through cash, it can even be through transportation. if they can provide vehicle, this is the way you move people around, not necessarily even cash." (022 - Community Nurse General Hospital, Gwarimpa) There were mixed reactions on whether successful adoption necessitates the creation of new organizational roles. More of the respondents stated that there would be no need to create new roles while others thought it would be good to create new roles. Those who stated that new roles won’t be necessary explained that it would only require integration into the existing system while existing hands could be trained. One of them said: “There shouldn’t be new roles – everybody should key into it, so that when A is not around B should fall in, so that it keeps going on and on.” (001- Community Nurse, Deidei (Part Two)) “So, I don’t think we need to create new roles, I don’t think so, because HIV, hypertension… so we’ve been working together…what we can do is just to probably integrate what is already on ground, yeah – so we can integrate, so we don’t necessarily need to create a new role. We can still make use of these roles.” (033 - Health Policy Maker (FMOH)) On the other hand, those who proposed new roles opined that it would be important to create new roles, such as Hypertensive Pharmacists, Medical laboratory scientists, supervisors, supportive and advocacy positions, to ensure more efficient execution. Also, creating new roles would help to bridge generational gaps and to increase manpower. Furthermore, it was mostly indicated that the new roles would not lead to roles crossing boundaries. The perspectives of the respondents are shown thus: “For example, in the facility if I can remember, the last time they recruited new ones. The gap is so wide that there is, will I call it generational gap in the system or what? I don’t know because if there are no new ones to be mentored then it becomes a problem when one person does everything. If the person is not there, what happens, so, they need to expand by engaging more hands. (009 - Community Nurse, Township Clinic) “It may lead to creation of new roles because some new people will be joining into the existing one, understand? You know the former body existing; they were created to do certain job before, but now, the traditional work which we may decide to give another name. if it were just committee for HIV alone, now, it would now be HIV-hypertension programme.” (010 - Township Clinic Pharmacist) Training and Tools Training, retraining, and provision of service guidelines and tools for the engaged human resource was also identified as critical facilitators. The following responses demonstrate this: “Yes, the guidelines are very important tools to work with. The guidelines are to direct you on what to do, even though they are not rules suiting as tools, but you always go within what the guidelines says…” (006 - Physician UATH) “Okay, best practices. One, develop a tool. That is the first thing. You must develop a tool that will be able to meet the needs of the service user and the service provider. Yes. The tool one.” (015 - Physician 2, Gwarimpa General Hospital) “Then training and retraining. So, we had training, we had refresher training, because after some time some of these trained workers will leave the clinic and so we had to do a refresher training so, that one is also part of it too, then which other one again?” (033 - Health Policy Maker (FMOH)) “It now comes to issue of training group of persons. Training and retraining and also supporting them to buy in into the training because in the community, you will see those who are market persons, they are farmers, but you want them to listen to this training and key in into it and carried it on…” (009 - Community Nurse, Township Clinic) Supportive Supervision In addition to training, supportive supervision with the provision of a feedback mechanism to plough back learnings into the programme was also identified as a facilitator. “Some of the best practices we had was that erm, in the State, we had, okay there are NCD focal, then in the primary health care centers we had NCD focal – so these people like time to time go to those facilities to conduct supportive supervisory visits…” (033 - Health Policy Maker (FMOH)) "make sure there is a feedback mechanism there, and then make sure I institute a supportive supervisory team which will continue to review most of these issues." (004- Health Policy Maker, Director of Primary Health Care) Having set all the necessary mechanisms in place, it was mentioned that there should be a proper monitoring system to ensure that all programme runs effectively. "Even if you train, there must be monitoring. So, if there is monitoring it will go well." (022 - Community Nurse General Hospital, Gwarimpa) Patient Involvement The respondents mentioned some best practices that could be adopted from other existing initiatives. Suggested best practices recommended as facilitators include involvement of existing implementing partners in the new initiative; teaching patients to monitor their blood pressure; peer-to-peer learning through support groups; and patient education. “Okay. Actually, during the programme we were advised to encourage patients to keep a record of their fasting blood sugar. So, I just feel in this programme too, if the patients can have their machine, and if they can keep a record too, maybe, because all patients do usually go for follow ups.” (014 - Physician 1, Gwarimpa General Hospital) “And peer to peer learning. It’s not, you won’t call it…it’s not a support group per se because a support group is basically, you have both clients, it’s more of patients doing the discussion and whatever. But peer to peer learning is where we get different facilities to come and discuss so that people can talk about their challenges, their experience, others can learn from how to solve some other similar problems and what have you. So, support group, peer to peer learning and improved, I’m using improved twice, improved quality improvement.” (008 - Township Clinic Physician) Barriers to Home Blood Pressure Management Identified barriers to home-based management of hypertension were community acceptance, financial barriers, manpower constraints, policy/operational barriers, provider resistance, and user acceptability issues (Table 3 ). Table 3 Barriers to home blood pressure management Identified Barriers Inference Relevant Quotes Community Acceptance Respondents identified community acceptance as a potential barrier to home management of hypertension. They opined that gaining the community’s trust, especially that of the critical opinion leaders like the traditional rulers, was integral to getting the community to accept the initiative. A respondent also said that if the community opinion leaders are not carried along and they have wrong misconceptions about the initiative, it would be difficult to obtain community acceptance. “…that is where the much work is, in the community, because it’s those people they are going to meet. It’s left on how you will talk to them to accept you. How they will trust you that okay this thing you are bringing into their community will help them. The main problem there is how to gain their trust.” (002- IST CHEW UATH) “…in every system, it depends, the sociocultural background of people varies from places to places. It could be their community opinion molders. If you don’t carry such people along, maybe the traditional rulers, for instance or their opinion leaders, so if you neglect them, they can tag it anything and as soon as that is tagged, they will not, you may not have access to such community.” (019 - Health Policy Maker UATH) “But the only peculiar thing is erm, because it’s HIV related, the stigma and bias that could come with that, but I think that could only account for a small fraction of the problem.” (034 - Health Policy Maker (FMOH)) Some respondents believed that if the home treatment of hypertension is nested on the HIV treatment programme, it may not be acceptable to the community members because of the stigma associated with HIV. There may also be inadvertent disclosure of HIV status of individuals to their household members. Another potential sociocultural barrier which may impede community acceptance is the concern about female patients being attended to in their homes by male caregivers. "some, even this -HIV something, some, you can if you don’t know how to carry it out. You can lead to breaking of marriage - somebody’s marriage because some of us are taking our drugs without even disclosing to their wives or to their husbands. We try as much as possible despite that you interview them, you tell them that they should open up to their spouse… " (010 - Township Clinic Pharmacist) “No, there’s nobody I can think of now. The only thing I can think of is erm…. Though maybe we may still say something about that, the only thing I can think of, which I think we can handle, is based on cultural beliefs and issues, a male cannot enter some females home to go and start checking B.P which other that case it means that a female has to. But I can’t think of anybody that will kick against this particular programme.” (008 - Township Clinic Physician) Other respondents were, however, of the opinion that the initiative would be beneficial both within the community and the health facility and, therefore, would be acceptable to the community members. “No, it will be seen both outside and inside the health facility. You know for health care workers to come to the community, come to their house, interact with them, gist with them, check their BP, that one gives a…, we already know that the majority of our health challenges are psycho-social, so it would go a long way…” (008 - Township Clinic Physician) Some of the proposed solutions by respondents to address issues surrounding HIV stigma and community acceptance were health education to community members to disabuse their minds about HIV stigma, as well as working through the PLHIV support groups to reach their members and organize them in such a way that they can receive services without the risk of inadvertent disclosure. “Yes, they have support group meeting. They know themselves. So, involvement, when you get to the facility, you’ll get somebody who will be the one coordinating. How do I meet these people? How do we get there? Are we going to be moving from house to house or we’ll get them at a particular place? So that we’ll see them (006 - Physician UATH)” Financial Barriers Funding was identified by most respondents as a major barrier to home blood pressure monitoring. “I think the only barrier would have to be funding, because funding actually is a major issue when it comes to actually running out programmes in Nigeria, because the budget, you know, what is actually given as support for most programmes, especially health programmes in Nigeria.” (004- Health Policy Maker, DIRECTOR OF PRIMARY HEALTH CARE) “…then funding and then manpower.” (003-COMMUNITY NURSE UATH). “I am also looking at finance here now because all these ones involve finance. Using those who have what it takes to arrange it because it has to go through a process before it can be fully accepted” (009 - Community Nurse, Township Clinic) Identified cost elements which may serve as barriers to home blood pressure management include, cost of staffing, communication costs for the staff, costs for refreshments, among others. “…if we look at the health system … it may be difficult to have adequate staff in Nigeria. If we have a reasonable number of staff who can do the work, you find out that it’s a matter of finding out where somebody is staying…the person can even do it after working hours. Those are when cost comes in; if you’re talking about cost now, that’s why I say marginal cost. You have to talk about communication cost, eh there could be need for refreshment at times because based on the number of staff we have, you cannot be using working hours all the time. So, people can do it at extra time and all those may entail some level of cost… eh which other one? Basically, in terms of communication, that’s the major thing.” (008 - Township Clinic Physician) The introduction of user fees was also considered as a significant barrier because people in the community would be unwilling or unable to pay for home blood pressure management due to their low socio-economic status. “User-fee… Somehow, to my own understanding, if you want to talk about home blood pressure management based on my knowledge in the community, there won’t be any need for a user fee. You can’t go to a community and come and start telling them to pay money you want to come and measure…. that will create problems. So, for me, I will advise if you want to make use of home blood measurement there won’t be any need for a user fee.” (008 - Township Clinic Physician) "Yes, negative feedback, one of the negative feedback I will say is that erm, like the one you are talking of fee, it usually fails" (027 - Community Pharmacist 2 Gwagwalada) Many respondents believed people would cooperate if the services were free but agreed it might be difficult to get government funding. “The equipment, the finance. If not talk of the community they will cooperate if it is free. But to get maybe government to do that will be a difficult something.” (022 - Community Nurse General Hospital, Gwarimpa) A respondent said that only a small fraction of community members will be willing to pay for such services. Many of those who would normally not seek care in the clinic would not see the need to pay for home blood pressure monitoring. “Those are part of the things we want to mitigate. So, some of the category of people you’ll be going to check their BP, if you give them their own option, maybe more than 50% of them will not come to the clinic. So, to them, there won’t be any need for them to pay. However, you may see, you may get a small percentage of the community that will be happy to pay and be happy that you are coming to them, but that would be a small fraction.” (008 - Township Clinic Physician) Another respondent said that people see primary health care services as services which should be accessed free of charge, hence they would be unwilling to pay for home blood pressure management. This is within the backdrop that the government, through the basic health care provision fund is providing some subsidy for health services at the primary health care level. “Because once we bring the idea of them paying in their community, it may not be so easy. Unless you are talking about, if you come to the community we have designated, just like the community pharmacist. Some people would be there, and people could be coming there. But once we are talking about checking, we want to come to your home to check your BP, you are going to pay? A lot of community people see primary health care as something they should be benefiting with least amount of financial commitment, so that is my own thinking.” (008 - Township Clinic Physician) “Based on subsidizing, I feel the government is doing a bit because in the course of my discussion, I mentioned something like basic health care provision fund, that’s an avenue whereby the Federal Government has mapped out some little, small percentage to see that eh… accessing health services is subsidized at primary health care levels, so I feel there’s little contribution….” (008 - Township Clinic Physician) Another respondent’s viewpoint was that people like free services, but some educated people might be willing to pay a token when they recognize the benefits of the initiative and the cost savings they would make by receiving treatment at home. “Emm… well, you know Nigeria, we like free things, so he wouldn’t mind even if you do it free of charge. But if the person is educated on the lot of risk that has been reduced for you, I don’t think there will be any problem. And again, maybe to get acceptance, maybe the charges should be minimal. If the charges are minimal, and the person knows that by them coming to meet me, I have saved so, so, so amount of money, he will accept it.” (006 - Physician UATH) From the responses on the strategies that were adopted in dealing with existing programme challenges, certain propositions for programme financing were identified. With regards to user fees, it was recommended that the programme should either start as free and have payment introduced later, provide subsidized drugs and services or have a flexible payment plan for the patients so that they can be able to pay based on their convenience. All three options will enable patients to be able to pay for the programme conveniently. Some of the responses are as follows: "I will suggest you first of all start it free" (002- IST CHEW UATH) "We have already become very familiar with our staff, but nevertheless if they don’t have money they still have to pay, we consider them and give them time. We have their records; we have their data, where they stay. Assessment of their drugs is periodic, if they don’t have money to pay this period; next time they come; they make sure they come with the money. It’s not given in that condition but the pay, we make it very flexible for them; they pay." (031-Community Pharmacist New Kutunku) "Yes, they subsidize because you take a packet of this drug that if you get this one in the chemist, it’s about four thousand five hundred, they sell at one thousand five hundred. they have tried. Even the manufacturers came from outside, we sat one on one, and I told them this is what I am begging for. They should not compromise the strength and the active ingredient inside the drug. I want original drug because if we give them, they will go outside and start buying fake drugs. Then they told us, we had MOU, how much they are able to produce to sell it outside. That this is what they can sell for us. At least we have tried in that aspect. It’s been subsidized" (010 - Township Clinic Pharmacist) Other proposed solutions to funding challenges include advocacy to potential funding partners, well-to-do community members, and donors. "So, I was talking of advocacy, like getting advocacy to the community, on the other side is getting advocacy to partners, to people that might be potential partners to help provide funding." (005 - Pharmacist UATH) "So, one of the ways to overcoming that is that I think erm, we could also opt for partners or donors to help" (034 - Health Policy Maker (FMOH)) Manpower Constraints Some of the respondents mentioned that the work processes would be disrupted with the introduction of community health worker support and home blood pressure monitoring, and the disruption would be in the form of limited manpower. “So, if I’m leaving my work here to go to the community, who does the work that I have left behind here? So that calls for manpower. But if there’s anybody that can handle the work, I can go to the community because somebody will do the work I’m supposed to do here. But if nobody is assigned, then the few people left behind, the work will be too much for them to do”. (006 - Physician UATH) Other respondents identified health worker fatigue resulting from additional workload as another potential problem. Having to move from patients’ house to house could lead to fatigue and poor work concentration for the healthcare providers. The respondent described it as follows: “And fatigue can be a case because you know at times, if you are in the clinic focusing on seeing patients, your thought pattern may be more aligned than if you go to the community, you come back, you go. So, there’s fatigue and articulation on the side of the health care workers…” (008 - Township Clinic Physician) “ There will be some disruptions in the services. Eh you know as you are saying these disruptions, these disruptions are tied to some of these things I’m talking about, as in it will affect the level of concentration of the health care workers to manage patients in the clinic. ” (008 - Township Clinic Physician) In addition to the service disruptions, increased workload, and health worker fatigue, there may also be increased patient waiting time. “No, the little disruption depends on how it’s handled as we said. If you need people to go during the working period, it will actually contribute to, the other way round, the patients that have obvious reasons to come to the clinic, their waiting time will increase because we have a smaller number of people attending to them.” (008 - Township Clinic Physician) “There will be some disruptions in the services. Eh you know as you are saying these disruptions, these disruptions are tied to some of these things I’m talking about, as in it will affect the level of concentration of the health care workers to manage patients in the clinic. And it can equally affect the time, the duration of waiting of the patient.” (008 - Township Clinic Physician) Suggestions on how to overcome the challenges with process disruptions include the adoption of a community-tailored approach where healthcare workers get days off to rest and to carry out home visits within their communities. “…we will still take it back to what I said just before now that it would be better tailored people that stays in different communities, so that there are times some health care workers may be their off day when they’re off, though you may tell me that would have been their time to rest and do other things, they can use it to do the work or at their own leisure time. You know some people can even do this thing as leisure since it’s within the community, it’s a way of getting to interact with your neighborhood, go there.” (008 - Township Clinic Physician)” Policy/Operational Barriers Policy/operational barriers are described to refer to issues that border around the actions or inactions of the government and policy formulators. A sizeable number of respondents indicated that they were not aware if any policy existed in the first place. “I am not aware of the policy, but I know particularly my training as a nurse, you have to treat hypertension because you know, you read anatomy of the heart.” (025 - Community Nurse PHC Lugbe) Others were assertive in their claim that there was no policy to support the adoption and implementation of community health worker support and home blood pressure monitoring in hypertensive HIV patients yet, two respondents said; “ Yes, because if we look at the Nigerian policy, I am not aware whether someone who is not a doctor can institute treatment for hypertension. Yes, they can make the diagnosis but to just institute the treatment and continue follow up.” (015 - PHYSICIAN 2 GWARIMPA GENERAL HOSPITAL) “Currently there is none that is been implemented. There could have been some or several that have been drafted, but implementation is the main thing, so there may be a need to still approach the Federal Ministry of Health - the policy maker to put those things on ground…” (011 - Physician UATH) Provider Resistance From the professional perspectives, the respondents raised concerns about rivalry and protection of personal and occupational interests, such as community pharmacists who may think that business is being taken away from them by providing care for patients at home; doctors who may think other professions are trying to take over their work, or that they are likely to mismanage patients; and other care providers who may be worried about additional burden of work in having to take care of patients at home. Some respondents explained the matter thus: “so the community pharmacist will not be happy about it, is that what…Because that means he can no longer sell hypertensive drugs and make profit from it.” (005 - Pharmacist UATH) “Okay, yes, there are. As I’ve said; inter professional rivalry. I know some cardiologists will say no, we should take… you understand me. That one will be there, and even some physicians also – even in maybe most of the local government, maybe they have only one medical Doctor, and the person may want to be the champion of every… so decentralizing care to non-health care related persons may be opposed.” (011 - Physician UATH) “Okay, yes. It’s natural even in the hospital setting. The rivalry between the pharmacist, the doctors, and the nurses everybody is trying to raise his shoulders above the other.” (031-Community Pharmacist New Kutunku) "well, I’ve seen cases… where traditional birth attendance take delivery, when a patient is having complications, they don’t refer. Some of them are very bold enough to keep, you know, managing a patient when it has reach the level to refer to a secondary health facility or a tertiary health facility and then they lose the patient eventually… " (005 - Pharmacist UATH) "Eventually still result in a poorly managed patient. Because the persons that the patients will be seeing are the community health workers with limited knowledge, and so, for instance, if a patient is showing signs of neurological damage, or cardiac… the community worker might not be able to help, you understand." (005 - Pharmacist UATH) “erm… yes I think there’ll be people like that, yes. First of all even the health centers or the community works might actually resist it initially. Reason being that they will think you are bringing additional work to us, yeah.” (034 - Health Policy Maker (FMOH)) Other respondents mentioned that there may be health worker acceptability issues due to insecurity issues. However, to address this challenge, community health workers should be recruited and deployed to work within their own communities. "You understand, this period of insecurity that everybody is guarding and this thing if not the adopting would have been very nice but the insecurities that is on the ground; you cannot just enter somebody’s house. He may not know where you are from and all that." (010 - Township Clinic Pharmacist) “You know when I was talking about “Mai Lafiya,” I said when the security situations used to be better. You know the angle I’m seeing this project eh…. You know what we are learning in primary health care, we don’t want to develop a completely new concept of doing things or ways. I’m looking at this project, if you see me emphasizing on the challenges in the area of manpower, either of training people, or communication, I’m looking at this project picking people from a particular vicinity to administer this process. Not necessarily coming to the clinic, in the normal way of I want to recruit so and so, be going to……Anybody you want to recruit from a particular ward, the person has to come from the ward, the person has to come from the ward and possibly if we can get somebody from that particular community. That will be better”. (008 - Township Clinic Physician) In resolving professional rivalry among healthcare workers, some respondents proposed round table talks where all parties are brought to the table and made to understand pros and cons of the initiative. This, they say, should dispel their reservations. “I do not think that there are unresolved, but I know that there are things that are workable. There are things that are workable because if everybody is brought round the table and then the benefits, the pros and cons are brought out in the fore, I don’t think that there should be barriers or restrictions or reservations to this anymore.” (002- IST CHEW UATH) “Continuous information, continuous enlightenment, then for the professional rivalry we have to see how we can educate ourselves to understand that the most important key element is the patient.” (027 - Community Pharmacist 2 Gwagwalada) Another respondent said that standard operating procedures should be provided, so that community health workers who are engaged to provide home management of hypertension know their limits, they are to monitor patient blood pressure, provide counselling including adherence counselling and refer cases to the hospital. They should not be responsible for making diagnosis of hypertension or its complications. Another respondent said that community health workers should be properly trained for their work in home management of hypertension before deploying them. "There must be standard of operation for these health care workers, so they know their limits, they know, o you are just there to monitor the BP, and probably proffer counseling – drug adherence counseling to these patients, and not in any way to diagnose, if you see elevated blood pressure you know when to refer you know" (033 - Health Policy Maker (FMOH)) "Once community health supporters are sent to the field, they should be erm, they will provide training for them on what to specifically do. What they are expected to do and when they are to refer patients." (005 - Pharmacist UATH) User Acceptability Issues The community's health-seeking behavior was another response given. This was due to people not seeing their health condition as a problem and, as such, have no need to measure or check their blood pressure: “…Which means some people you were going there to check their BP; some may not see their condition as if it’s a problem. So, they won’t come to the clinic. They can only come to the clinic when the problem becomes very serious.” (008 - Township Clinic Physician) Patient acceptability issues revolve around the patients’ perspectives towards the programme, their level of involvement and how to deal with issues of concern that could arise. One of the key issues that was mentioned was about confidentiality. One of the respondents mentioned that when a healthcare worker starts to visit someone at home, neighbours may begin to be curious about the reasons for the visits and that might eventually expose the HIV status of the client. This was explained as follows: “So, questions will start coming – who are these people that they are coming to take only their own blood pressure? What about me? Me am in the community, I want to take too, and you say no, we will not take for you – what is your reason? So, we may end up exposing the status of the other patients – we are taking only for HIV patients. And that is where the patient will not even accept it. You know, if you will have a way of doing it for everybody then we come and… we know who is HIV positive. Then when we come, we select only the ones for the HIV positive. Then, if not, if you are coming to me every time and I… my neighbor you are not doing it for him. My neighbor will start asking, what is wrong with this person that they are always coming to take his BP? I’ll start asking, and before you know it, the HIV positive – hypertensive patient may begin to reject the whole thing together” (006 - Physician UATH) Another consideration was about the people’s possible belief about the treatment to be administered or the fear of possible side effects, both of which may cause them to be negatively averse to having the care service. “No there may be possibility of that based on eh… you know, perception, people’s belief differs. Because even as simple as immunization we used to do, there are some people who come to their place. They say No, they don’t want you to give their children immunization. They don’t want to. Why? They cannot even… Some would even tell you that they are health professionals in the field. Some may want to attribute problems that somebody had too. So, there could be some resistance.” (008 - Township Clinic Physician) Meanwhile, many strongly believe that even the reluctant individuals can be brought on board by involving them generally through advocacy, grassroots health education and provision of apparatus which will further serve as incentives in motivating them. A respondent said: “You’ve told them the importance. That see this is the importance of this, this is the importance of this, this is the importance of this. I believe that those that accept it and start using it and they see the benefit, it will motivate those that are against it to join the programme.” (002- IST CHEW UATH) Another proposed solution was for patients to be involved in monitoring their own blood pressure. This is expected to improve their cooperation. A respondent explained it thus: “oh yes now, if not how do we get the… if they are not involved, how do we get their cooperation to be monitoring their BP – because since we are going to be monitoring, it’s not just a once something. You will keep on coming” (006 - Physician UATH) Discussion We aimed to find out the context, facilitators, and barriers of home management of hypertension among people living with HIV (PLHIV) using the iPHARIS framework. Our findings regarding context indicated that there was existing home-based care for PLHIV supported by PEPFAR through its implementing partners across many study sites. This provides a framework on which home-based management of hypertension could be leveraged. However, there is currently no policy backing home-based management of hypertension. The identified facilitators of home-based management of hypertension include advocacy at every level especially at the level of policymakers, donors, healthcare workers, community members and patients. Leadership was also considered a critical facilitator of home-based management of hypertension. Leaders at supervisory and decision-making levels with passion for their profession and compassion towards patients were considered crucial to drive adoption. Provision of appropriate policies by the government was also considered an important facilitator. Other facilitators include incentives for healthcare workers and patients; government support through funding, manpower recruitment, and provision of infrastructure; training and retraining of healthcare workers and provision of appropriate tools and guidelines. In addition, monitoring and supportive supervision with establishment of a feedback mechanism to plough back learnings from implementation into improving the programme, as well as patient involvement in the design and implementation of the project through patient education and self-monitoring of blood pressure were noted to be very important facilitators by participants. The facilitators identified in this study also align with factors that have been shown to support the successful implementation of community-based health interventions. Among the most critical factors that have been previously identified are advocacy and leadership, which are important to gain support and for driving the adoption of new programmes ( 9 , 11 ). Similar to the findings of this study, government support, including funding, policy formulation, and provision of necessary infrastructure are critical to the sustainability of health interventions including home-based hypertension treatment ( 5 ). In evaluating the role of healthcare professionals, among the various incentives that can facilitate their participation include training and retraining programmes ( 12 ), availability of appropriate tools, and guidelines, all of which are necessary for effective implementation ( 6 , 10 ). It has also been shown that supportive supervision and monitoring, with a proper feedback mechanism will facilitate quality and consistent health intervention ( 8 , 13 ). Lastly, when healthcare providers involve patients in the design and implementation of their health programmes, it enhances acceptance and adherence to treatments ( 14 ). We found that the major barriers to home-based management of hypertension include community acceptance issues due to sociocultural beliefs, lack of trust, and issues related to stigma especially for PLHIVs. Financial barriers include cost of communication, transport costs, cost of refreshments and introduction of user fees. Manpower constraints leading to disruption of work with new work schedules for home visits, increased workload leading to healthcare worker fatigue, poor quality services and increased patient waiting times were also identified as barriers. Other barriers include a lack of policy framework, provider resistance issues such as inter-professional rivalries, concerns about additional workload, concerns about diminished quality of care as a result of task shifting, as well as security concerns. Lastly, user acceptance issues such as poor health-seeking behaviour, user perception and concerns about confidentiality may serve as barriers to home-based management of hypertension. The barriers identified in this study are consistent with extant literature on the challenges of implementing community-based health interventions. One of the key issues relating to sociocultural beliefs and stigma are significant issues of concern in SSA ( 1 , 15 ). Prevailing negative beliefs and attitudes towards HIV and diseases make health-seeking behaviour a secretive act, and any home-based care will become a cause of suspicion and risk of exposure of the patient’s illness, which would not be likely avoided. Financial constraints, including the cost of communication and transportation, stand as another common barrier, especially in resource-limited settings like Nigeria ( 4 , 16 ). It is also recognized in literature that a lack of policy framework and provider resistance due to inter-professional rivalries and concerns about workload are system-related challenges in the implementation of new health programmes ( 7 ). Additionally, there are considerations around issues relating to user acceptance, such as poor health-seeking behaviour and concerns about confidentiality, which are also highlighted in studies on community health interventions ( 17 , 18 ). Limitations of our study A particular limitation of the study was that it was limited to a few selected healthcare facilities within the FCT of Nigeria, which can limit its scope of generalization to the rest of the country. However, the study was carried out with sufficient due diligence that it is able to provide a template for subsequent studies across other locations. Furthermore, its methodology was carefully designed and implemented in line with previous studies, making it methodologically realistic. Strengths of our study The current study has three important strengths. First, it demonstrated a comprehensive coverage that cut across primary, secondary, and tertiary facilities, thereby providing a holistic view of the facilitators and barriers to the implementation of home-based hypertension management. Next, it involved a diverse perspective from various stakeholders including policy makers, service providers and beneficiaries. Finally, the study employed a tested implementation science approach through tie i-PHARIS framework, to systematically identify barriers and facilitators. Implications of our findings Overall, this study has significant implications for policy, practice and future research. The findings are able to provide guidelines for policy formulation by the Federal Ministry of Health (FMOH) to inform home-based management of hypertension. Also, it provides opportunities for demonstrating the possibilities in practice of home-based hypertension management, where an understanding of the facilitators and barriers helps in quality practice implementation. Finally, the evidence from this study provides an opportunity to replicate the findings across other climes of Nigeria to demonstrate replicability and implementation. Conclusion We conclude that many participants felt that home-based care of HIV hypertensives is feasible and holds significant potential for improving quality and access to care. Facilitating factors include advocacy to relevant stakeholders, identification of early adopters and leaders, government support through funding, policy formulation, manpower training and deployment, infrastructure provision, appropriate monitoring mechanisms, supportive supervision, and patient involvement in the care process. Barriers to the successful implementation of these include systemic barriers within the healthcare system, barriers from the community, challenges from patients and their caregivers, as well as issues relating to government inactivity. Abbreviations ART Antiretroviral therapy AIDS Acquired Immune Deficiency Syndrome BP Blood Pressure CART Community Antiretroviral Treatment CHEW Community Health Extension Worker CHW Community Health Worker COVID-19 Coronal Virus Disease 2019 FCT Federal Capital Territory FMOH Federal Ministry of Health HIV Human Immunodeficiency Virus ID Identification i-PARIHS Integrated Promoting Action on Research Implementation in Health Services NAIIS Nigeria HIV/AIDS Indicator and Impact Survey NCD Non-Communicable Diseases NIH National Institutes of Health PEPFAR President’s Emergency Plan for AIDS Relief PLHIV Persons Living with HIV SRP Small Research Project SSA Sub-Saharan Africa UATH University of Abuja Teaching Hospital Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the human research and ethics committee of the University of Abuja Teaching Hospital, Gwagwalada (Approval number UATH/HREC/PR/2022/04/020). Study procedures were guided by the principles of human subject research ethics in accordance with the declarations of Helsinki. All study respondents provided signed informed consent. Consent for publication Not applicable Availability of data and materials The datasets generated and/or analysed during this study are not yet publicly available but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Funding for this study was provided by the National Institutes of Health (NIH) through the HLB-SIMPLe Alliance Small Research Project (SRP) programme. Clinical trial number: not applicable. Authors' contributions TAA, DBO, and OAA conceptualized the study, TAA, NRR, BA, AN collected the data, IO analyzed the data, TAA, OAA, and IO wrote the initial draft manuscript, DBO provided expert review. All authors reviewed the manuscript. 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Rural-urban health-seeking behaviours for non-communicable diseases in Sierra Leone. BMJ Glob Heal. 2020;5(2). Musinguzi G, Anthierens S, Nuwaha F, Van Geertruyden JP, Wanyenze RK, Bastiaens H. Factors Influencing Compliance and Health Seeking Behaviour for Hypertension in Mukono and Buikwe in Uganda: A Qualitative Study. Int J Hypertens. 2018;2018. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Sep, 2025 Reviews received at journal 19 Sep, 2025 Reviews received at journal 11 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers invited by journal 30 Jul, 2025 Editor invited by journal 22 Jul, 2025 Editor assigned by journal 19 Jul, 2025 Submission checks completed at journal 19 Jul, 2025 First submitted to journal 14 Jul, 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-7123440","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494388286,"identity":"4ceef752-d313-477d-9617-1c2f43ce7519","order_by":0,"name":"Taiwo A. Adedokun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYFCCBAaGBwwMjA0MCcxAng0QMzYeIKglAaElDaSlgSQth8FieLXwtycffJBQYyfbz5582Jh3x3m7te2HgbbU2ETj0iJx5lmyQcKxZOOZPc+Sk3nP3E7ediYRqOVYWm4DLj03cswkEtiYEzfcyDE+zNt2O9nsAFALY8NhnFrkb+R/k0j4V5+4H6LlXLLZ+Yf4tRjcyGGTSGw7nLhBIsc4mbftgJ3ZDQK2GJ55ZmyQ2HfceAbQU4Zz25ITzG4AbUnA4xe548kPH3z4Vi3b3558WOJtm5292fl0oEiNDW7vo4NEsMoEYpWDgD0pikfBKBgFo2BkAADQNWpTgm6d6gAAAABJRU5ErkJggg==","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Taiwo","middleName":"A.","lastName":"Adedokun","suffix":""},{"id":494388288,"identity":"469794a3-621e-475f-a3ec-b246b105b8f7","order_by":1,"name":"Nanna R. Ripiye","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nanna","middleName":"R.","lastName":"Ripiye","suffix":""},{"id":494388291,"identity":"a9964a81-4379-474b-8afe-6adf662ed83d","order_by":2,"name":"Adaku Nwankwo","email":"","orcid":"","institution":"Gwarinpa General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Adaku","middleName":"","lastName":"Nwankwo","suffix":""},{"id":494388292,"identity":"69cdb73c-72f4-4b49-984a-ebe4760c6519","order_by":3,"name":"Idowu Omisile","email":"","orcid":"","institution":"Obafemi Awolowo University","correspondingAuthor":false,"prefix":"","firstName":"Idowu","middleName":"","lastName":"Omisile","suffix":""},{"id":494388293,"identity":"a53979f6-0126-4759-bbbc-2fa2f29802b9","order_by":4,"name":"Blessing Akor","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Blessing","middleName":"","lastName":"Akor","suffix":""},{"id":494388294,"identity":"8622658e-9505-4210-9c96-7259a5b0e99c","order_by":5,"name":"Oluwasanmi A. Adedokun","email":"","orcid":"","institution":"University of Maryland, Baltimore (UMB)","correspondingAuthor":false,"prefix":"","firstName":"Oluwasanmi","middleName":"A.","lastName":"Adedokun","suffix":""},{"id":494388295,"identity":"a5cdc73a-06f8-4fa6-8274-7eea1c480b0b","order_by":6,"name":"Dike B. Ojji","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dike","middleName":"B.","lastName":"Ojji","suffix":""}],"badges":[],"createdAt":"2025-07-14 17:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7123440/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7123440/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88278425,"identity":"ad25a08b-5058-4b7c-b166-052411544460","added_by":"auto","created_at":"2025-08-04 18:57:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1159884,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7123440/v1/b5255ada-7ffb-4b9b-b199-320afcd9a6c5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community-based Approaches to improve hypertension treatment among people living with HIV","fulltext":[{"header":"CONTRIBUTIONS TO THE LITERATURE","content":"\u003cul\u003e\n \u003cli\u003eHome-based management strategy has contributed immensely to the successes recorded in the fight against HIV/AIDS.\u003c/li\u003e\n \u003cli\u003eThese strategies have not been adopted for cardiovascular diseases like hypertension in the Nigerian environment.\u003c/li\u003e\n \u003cli\u003eThis study provides context, facilitators, and barriers to adopting home-based management of hypertension in HIV positive hypertensive patients in the Nigerian context.\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"INTRODUCTION","content":"\u003cp\u003eHIV/AIDS is a major public health problem in sub-Saharan Africa (SSA), accounting for 70% of the global disease burden (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). According to the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), HIV prevalence amongst adults aged 15–64 years in Nigeria is 1.4% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), with about 89% on antiretroviral therapy (ART) as at 2020 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Meanwhile, HIV mortality rate in SSA, including Nigeria, has remarkably declined owing to expanded access to anti-retroviral therapy (ART) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This success has resulted in increased life expectancy of HIV-infected individuals (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), which is unfortunately associated with a higher burden of hypertension and related cardiovascular mortality (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), which has also been on the rise. This, in HIV-infected patients, appears to be independent of traditional risk factors such as urbanization, dietary and lifestyle factors, which are on the rise. In addition, HIV-infected patients receiving ART have been found to have a higher prevalence of hypertension compared to those not receiving treatment. A major factor that led to the successful HIV programme in SSA is task sharing with concerted involvement of non-physician healthcare workers, for example, the community anti-retroviral treatment (CART) programme (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It will therefore be necessary to leverage such non-physician community healthcare worker support for the treatment of hypertension in persons living with HIV.\u003c/p\u003e\u003cp\u003eMeanwhile, home blood pressure monitoring allows multiple readings, when taken over an extended period. Home blood pressure monitoring also has the added advantages of overcoming the issue of white-coat hypertension, being reproducible and predicting cardiovascular morbidity and mortality better than office BP measurements. It is also useful in the diagnosis of masked hypertension and allows for better incorporation of patients into their management (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This research project examined the context, facilitators, and barriers to implementing Community Health worker support and home blood pressure monitoring on the treatment and control of blood pressure in Nigerian hypertensive HIV patients assessing care in HIV Clinics in tertiary, secondary and primary facilities in the FCT of Nigeria.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy Area or Location\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was implemented in tertiary, secondary and primary healthcare facilities within the FCT of Nigeria.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIt was a qualitative study with semi-structured interviews of Community Health Workers to understand the context, facilitators, and barriers to implementing Community Health worker support and home blood pressure monitoring in hypertensive HIV patients in Nigeria.\u003c/p\u003e\u003cp\u003eUsing purposive sampling, we interviewed key stakeholders in managing HIV in Nigeria at the tertiary, secondary, and primary healthcare (community levels) levels in the FCT between 12th August 2022 to 20th February 2023. Our target stakeholders included 5 hypertensive patients living with HIV, 5 CHEWs, 5 Physicians, and 5 healthcare policymakers, making a total of 30 interviews. Participants were adults aged 18 years or older who were able and willing to provide informed consent. We excluded staff members who had worked for less than three months in the target organization and those who could not complete the interview for any reason.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Procedures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUsing the I-PARiHS framework, we conducted semi-structured qualitative interviews with key stakeholders to understand the context, facilitators, and barriers to implementing Community Health worker support and home blood pressure monitoring on blood pressure (BP) treatment and control in hypertensive HIV patients in Nigeria.\u003c/p\u003e\u003cp\u003eThese interviews explored the underlying factors and support systems required to successfully implement Community Health worker support and home blood pressure monitoring. Questions focused on stakeholders’ understanding of the purpose of community and health worker support and home blood pressure monitoring, and suggestions on how they can become engaged in facilitating its adoption.\u003c/p\u003e\u003cp\u003eThe stakeholder interviews included surveys and semi-structured key informant interviews using the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) to understand the context, facilitators, and barriers of implementing a Community Health worker support and home blood pressure monitoring on blood pressure (BP) treatment and control in hypertensive HIV patients in Nigeria. Interviews lasted about one hour and were audio-taped, transcribed and entered into NVivo version 11 for data analysis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResearch Locations\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAll surveys, key informants, and in-depth interviews took place in the stakeholders’ workplace with COVID-19 safety precautions in place.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eProcedures Involved\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e We telephoned participants to schedule an appointment with them for recruitment through our existing contacts, especially governmental officers involved in HIV care in the FCT of Nigeria. We provided a participant information sheet to seek their interest in participating and scheduled an interview time, and informed consent for participation was sought. Participants were asked to provide informed consent to participate separately for audio recording. All contact information was maintained securely in Microsoft Excel and kept separate from study data, linked only by a unique study ID. After providing written informed consent, participants completed a brief (15-minute) paper survey, which captured participants’ demographics, knowledge and attitudes about HIV care and management of hypertension in persons living with HIV. \u003cem\u003eP\u003c/em\u003earticipants then took part in a key informant in-depth interview.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe interviews were transcribed and analyzed according to key themes using NVivo software. We used the framework approach to qualitative data analysis, which is a 5-step process: (a) familiarization, (b) developing a theoretical framework, (c) indexing, (d) summarizing data in an analytical framework, and (e) data synthesis and interpretation. Following this framework, data were independently coded by three experienced research staff to reduce the potential for bias. Inter-rater reliability was determined, and discrepancies in coded data were resolved by consensus. All transcripts were coded into concepts reflecting the aims of the pre-implementation phase. For example, responses were coded according to evidence or core elements of community health worker support and home blood pressure monitoring likely to influence its adoption within HIV clinics in the Federal Capital Territory of Nigeria. The identified concepts were grouped into categories and themes, uniting the categories. A detailed analysis of the interviews was used to generate a conceptual model of the facilitators and barriers to uptake, and domains of a practice facilitation strategy tailored to the Nigerian healthcare system.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eStudy Respondent Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe sociodemographic characteristics of the study respondents, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed their age, gender, marital status, education level, occupation, and stakeholder groups. Majority of the respondents were above 50 years (46.6%), 26.7% were between 40\u0026ndash;49 years, and 26.7% were less than 40 years (26.7%). The mean age was 47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.67 years and the gender distribution showed 43.3% males and 56.7% females, while the distribution by marital status showed that a vast majority (86.7%) were married, 10.0% were single, and 3.3% were widowed. Almost all (96.7%) respondents had tertiary education, while only 3.3% had secondary education.\u003c/p\u003e\u003cp\u003eEight study respondents practiced as Physicians, 5 as Pharmacists, 5 as Nurses, 5 as CHEWs, 2 were into business, 2 were civil servants, 1 was a social worker, 1 was a driver and the last a housewife. A further breakdown of these respondents into occupational groups showed that there were 6 stakeholder groups of Hypertensive PLHIV, CHEWs, Physicians, Health Policy Makers, Community Pharmacists, and Nurses, each of which had 5 (16.7%) respondents per group.\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\u003eCharacteristics of Study Respondents\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge of participant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMean age (\u003c/em\u003e47.17\u0026thinsp;\u0026plusmn;\u0026thinsp;8.67\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;40\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e40\u0026ndash;49\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;50\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c3\"\u003e\u003cp\u003e86.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eWidowed\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSecondary\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTertiary\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBusiness\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCommunity Health Extension Worker\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCivil Servant\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNurse\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePharmacist\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysician\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSocial Work\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOthers\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStakeholder Group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eHypertensive PLHIV\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCommunity Health Extension Worker\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysician\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eHealth Policy Maker\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCommunity Pharmacist\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNurse\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eContext\u003c/b\u003e\u003c/p\u003e\u003cp\u003eGeneral Contextual Issues\u003c/p\u003e\u003cp\u003eRespondents indicated that there is an existing HIV care and treatment programme with a community-based component, whereby home visits are made to PLHIV to deliver antiretroviral drugs and other medications.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The HIV programme is already in existence, the blood pressure programme that is being initiated would complement\u0026hellip;\u0026rdquo; (004- Health Policy Maker, DIRECTOR OF PRIMARY HEALTH CARE)\u003c/em\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay\u0026hellip;this community \u0026hellip; services that we are doing, erm, \u0026hellip;has helped so much, where we go right to their homes and then give them drugs. Some may not be able to come, we\u0026rsquo;ll collect your phone number \u0026ndash; we have all their phone numbers\u0026hellip;we have that of maybe their next of kin. So well, you didn\u0026rsquo;t come to clinic today\u0026hellip;we\u0026rsquo;ll check the\u0026rdquo; system, prescribe, take the drugs to the person\u0026rdquo;. (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe existing HIV programme including the community component, is supported by PEPFAR through its implementing partners, with little or no financial support from government.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;You know this place is still financially under IHVN. So, all this community services am talking to you, they are being handled by IHVN - when it comes to financial aspect. So, government is not doing anything concerning this one.\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCommunity ART delivery is also sometimes facilitated through community pharmacists, thus cutting the cost of transportation for the PLHIV. The patients only need to visit the health facility once in 6 months to consult with their doctors and have samples collected for their routine monitoring tests.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;they do, they do\u0026hellip; you know, they see.... even though we operate community pharmacy, community services, they come here every six months for review. They are not left, hundred percent in the\u0026hellip; after six months, they come. And the feedback is that erm, they are enjoying it, they like it, it has cut a lot of costs\u0026hellip;and they appreciate it\u0026hellip;that is the feedback we are getting\u0026rdquo; (006 - Physician UATH).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe HIV programme also established support groups comprising PLHIV, which facilitates meaningful involvement of the PLHIV themselves in their own care. In some instances, support group representatives collect drugs on behalf of their members and deliver to them within the community, thus saving the cost of seeking care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, the support group has been very helpful in terms of HIV management. Support group at different levels. And we are equally doing quality improvement meetings and what have you, because of HIV. So, it helps us to review what has been done, and how far we have been doing it.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTo maximize the available human resources at the facilities, the HIV programme also facilitates task shifting among healthcare workers at the facility. In high-volume facilities with limited numbers of doctors, nurses see the stable patients and refer them to the pharmacy for their ART refill, while the more unstable patients are seen by doctors.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, you know, when this clinic started, there\u0026rsquo;s what we call task shifting\u0026hellip;Task shifting\u0026hellip; before, only the Doctors were seeing the patients, whether stable patients or those that had complaints. Then we did it like a kind of erm\u0026hellip;where Nurses were seeing stable patients\u0026hellip; Nurses were prescribing drugs\u0026hellip; it was something that nobody was going to accept. But we were doing it here because the patients were so many, and there were four Doctors on ground. So, we said no this thing\u0026hellip; four o\u0026rsquo;clock we\u0026rsquo;ll still be running clinic. And it\u0026rsquo;s after the clinic that the pharmacist will now sit down to enter everything that we did\u0026hellip; later, IHVN adopted it and then there\u0026rsquo;s task-shifting worldwide that is being accepted\u0026hellip;\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn addition to the home delivery of ART, the health workers also organize periodic community mobilization outreaches to improve the health-seeking behaviour of the populace.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Health-seeking behavior. Yes, the facility as a whole has been doing so much to that effect. Just like I said, on our own, once in a while, we even organize community mobilization sensitization, all those things is to see how we improve on their health-seeking behaviour.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eRespondents were of the opinion that home monitoring of blood pressure can be leveraged on the existing home care for PLHIV.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Home support and home care is very key in HIV treatment and follow-up. Then adding blood pressure monitoring like I said is going a step further, with this approach we are likely going to unveil those that have you know prehypertension and hypertension and those that we can treat at home.\u0026rdquo; (030 - Health Policy Maker GWARIMPA GENERAL HOSPITAL)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, erm, yes it can be adopted, like their advocating\u0026hellip;that HIV programme has a lot of facilities in most African countries\u0026hellip;so why can\u0026rsquo;t we use that same platform? So we don\u0026rsquo;t need to build another structure for non-communicable diseases among HIV patients, but let\u0026rsquo;s, because those structures are already functioning, why can\u0026rsquo;t we use that same platform? And they are really using it.\u0026rdquo; (011 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFacilitators of Home Blood Pressure Management\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRespondents identified the following as facilitators of home-based management of hypertension advocacy, leadership, policy, incentives, government support, training and tools, supportive supervision, as well as patient involvement (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFacilitators of home blood pressure management\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentified Facilitators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRelevant Quotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAdvocacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAt the community level, the respondents proposed adequate community advocacy and awareness to make it easier to enter the community and implement the programme. Other respondents proposed that all necessary stakeholders should be engaged in the programme, while another recommended taking the local context into consideration in the design of the programme. Some of their responses are as shown:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay. If I were the one to undertake, number one is that erm, since it\u0026rsquo;s community-based, I will go to the community, do advocacy visit, have a town hall meeting with the community people, get the leaders of the community, the traditional rulers to own\u0026hellip;to see it as a programme that is going to benefit them.\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No how I will, as I said, I have mentioned some of them. I will start by personally bringing, I will start with stakeholders, bringing the stakeholders that I feel will help. The stakeholders does not mean only from the health facility, both the community, religious all round.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I will write to the government or to the local government Chairman, to tell him my\u0026hellip; to tell him what I want to do, and how I want to go about it.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Well, it has to start from those we have identified as patients. They are the best advocates. For instance, somebody who has HIV and hypertension, when he or she is able to talk about the advantage of the knowledge he has acquired concerning the disease, it will help others to also come out because many a times when people die from this type of diseases, it is assumed that a witch or something has killed them.\" (019 - Health Policy Maker UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome respondents proposed that, relevant advocacy efforts should also be made to local government chairmen and donors for funding, while healthcare workers and patients\u0026rsquo; inputs should be sought in the design of the programme and advocacy efforts.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, the support there will start for me\u0026hellip; I mean he\u0026rsquo;ll start by telling me okay, this is how you go about it, this is how you go about it, when you write a letter I will submit it, when it\u0026rsquo;s approved, then we can give you go ahead on how to start the programme. Then from there, it\u0026rsquo;s from the letter that I wrote to the local Chairman, that\u0026rsquo;s where I will state something like a proposal to them, and a breakdown of the proposal. This\u0026hellip; I want finance, this will be used for this, this will be\u0026hellip; and if it\u0026rsquo;s approved, luckily, if I\u0026rsquo;m lucky and it\u0026rsquo;s approved, then they\u0026rsquo;ll get back to me then from there I will kick start the programme.\" (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"\u0026hellip;then I\u0026rsquo;ll have to look for donor that is able\u0026hellip; that is ready to sponsor or to fund the initiative because the ministry might not be able to, yes.\" (033 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Well I will call a meeting of the staff and intimate them of this programme and ask them, the staff as a whole, what are their fears, what do they think is the barriers and then by the time we brainstorm together, we will arrive at this is what we want to do, let us give it a trial but there will be a need for me to push and push and encourage all those that will be involved to key into it, since our ultimate goal in the facility is for the patient.\" (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eLeadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn the leadership context, the interview responses indicated that the successful implementation of home-based hypertension care would succeed with the support of mainly people who occupy up to directorial positions within the facilities in such roles as an Assistant Director, ART Focal Person, Departmental Head, Matron or even the CMD. On the other hand, outside the facility, the key people who are needed to provide support include community leaders, village heads, community chiefs or community health workers, as depicted by the following statement:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Of course, you know trees make a forest. If the key person or the focal person agrees, other departments should be carried along because the ultimate aim is for the benefit of the patient and so other health workers need to be incorporated and carried along based on both training and retraining to key into the arrangement.\u0026rdquo; (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe discussions evaluated the reasons why the key healthcare facility personnel were considered crucial to the championing of the programme implementation and the respondents provided a broad array of reasons for this. In their responses, they mentioned that the healthcare focal persons were important because of their personality and their office. The key persons were found to be people who were approachable and had genuine passion for their occupation and for the clients. These were determined to be important in ensuring that the programme kickstarts and runs successfully as shown in one of the responses as follows:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It has to be with the two \u0026ndash; the passion, feeling concerned about the welfare of the patients, because even if he is knowledgeable, if he is not having passion\u0026hellip;\u0026rdquo; (022 - Community Nurse General Hospital, Gwarimpa)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn the aspect of professional standing, the respondents mentioned that the focal persons occupy a pivotal point which makes them able to drive the activities of other stakeholders in a desired direction. By virtue of their office, everyone would listen to them and thus follow their directions. One of the respondents said,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Once she accepts it, definitely we will also accept it and the patients too will accept it.\u0026rdquo; (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFurther, questions bordered on whether the health facility head holds service providers accountable for collaboration and coordination in this effort towards community health worker support and home blood pressure monitoring in hypertensive HIV patients, if introduced. One respondent affirmed that:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, as far as I know who she is, she likes you doing the right thing at all times\u0026hellip;And she supervises every person, whether you are Doctor directly under her, or\u0026hellip;you are answerable to somebody before\u0026hellip; she goes right to every level to see what work you are doing. So, I think she\u0026rsquo;s\u0026hellip; once she has agreed go and do this, she will hold you accountable if the thing is not properly done.\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolicy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe respondents identified appropriate policy and guidelines as an important facilitator of home management of hypertension. They spoke about different forms of engagement that they would have with the government, and they mentioned issues such as stakeholders\u0026rsquo; policy meetings, support in programme publicity and public sensitization, programme financing and development of operational guidelines.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"like our physicians here that are just coming back from policy stakeholders meeting, such stakeholders meeting should be arranged and of course by the health department, by the policy makers and also should involve those who should be key players in the field.\" (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"ehhh guidelines, then bringing out the guidelines on how you want the project to go. Then financing the project and tell them that okay, this project, if this project at the end of the is successful, it will even bring up more employment to the youths.\" (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncentives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe availability of incentives for staff to carry out the implementation of community health worker support and home blood pressure monitoring in hypertensive HIV patients was also identified as a critical facilitator for home-based management of hypertension. A respondent stated that provision of incentives for transportation will not be out of place.\u003c/p\u003e\u003cp\u003eThe respondents identified incentives such as stipends for healthcare workers, transport fare for healthcare workers and bed nets as for household members. This was seen in some responses as follows:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWell, I\u0026rsquo;ll say, if there is, it will not be out of place. But even if there isn\u0026rsquo;t\u0026hellip; you know if I\u0026rsquo;ll be the one that\u0026rsquo;ll be sent to the village now that means I\u0026rsquo;m not going to do my work here. So instead of doing my work here, I\u0026rsquo;ve just been asked to go to the village and do. What may be is that what I may ask is that how do I get to the village. So that is where the incentive may need to come. How do I get to the village? But, since it is my work, if I go to the village I\u0026rsquo;m not going to the clinic, so I don\u0026rsquo;t have any problem be that. But getting to the village is what may bring the need for the incentive.\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our time\u0026hellip; and as I said earlier, now you are working in a health facility like you have to make your time, it\u0026rsquo;s the time, if we can give out our time we\u0026rsquo;ll put our best. And all that best comes from you are being taken care of.\u0026rdquo; (013 -PHC CHEW Karamajiji)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Then incentives of course you know will play an important role too. Yes, once an incentive is introduced into a programme it can help, especially service providers to bring out the beat in them.\u0026rdquo; (004- Health Policy Maker, Director of Primary Health Care)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eGovernment Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe respondents identified government support for the programme as a critical facilitator, especially provision of funds, recruitment of more manpower and provision of necessary infrastructure. These are shown in some of the responses as follows:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Who is them, The owner of the programme? It should be the government. You are asking whether there should be government, government should support and finance the programme, so that the programme can succeed.\" (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"the manpower is very important as I\u0026rsquo;ve said. Then you know government can even come in, even if it is not through cash, it can even be through transportation. if they can provide vehicle, this is the way you move people around, not necessarily even cash.\" (022 - Community Nurse General Hospital, Gwarimpa)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere were mixed reactions on whether successful adoption necessitates the creation of new organizational roles. More of the respondents stated that there would be no need to create new roles while others thought it would be good to create new roles. Those who stated that new roles won\u0026rsquo;t be necessary explained that it would only require integration into the existing system while existing hands could be trained. One of them said:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There shouldn\u0026rsquo;t be new roles \u0026ndash; everybody should key into it, so that when A is not around B should fall in, so that it keeps going on and on.\u0026rdquo; (001- Community Nurse, Deidei (Part Two))\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, I don\u0026rsquo;t think we need to create new roles, I don\u0026rsquo;t think so, because HIV, hypertension\u0026hellip; so we\u0026rsquo;ve been working together\u0026hellip;what we can do is just to probably integrate what is already on ground, yeah \u0026ndash; so we can integrate, so we don\u0026rsquo;t necessarily need to create a new role. We can still make use of these roles.\u0026rdquo; (033 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOn the other hand, those who proposed new roles opined that it would be important to create new roles, such as Hypertensive Pharmacists, Medical laboratory scientists, supervisors, supportive and advocacy positions, to ensure more efficient execution. Also, creating new roles would help to bridge generational gaps and to increase manpower. Furthermore, it was mostly indicated that the new roles would not lead to roles crossing boundaries. The perspectives of the respondents are shown thus:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For example, in the facility if I can remember, the last time they recruited new ones. The gap is so wide that there is, will I call it generational gap in the system or what? I don\u0026rsquo;t know because if there are no new ones to be mentored then it becomes a problem when one person does everything. If the person is not there, what happens, so, they need to expand by engaging more hands. (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It may lead to creation of new roles because some new people will be joining into the existing one, understand? You know the former body existing; they were created to do certain job before, but now, the traditional work which we may decide to give another name. if it were just committee for HIV alone, now, it would now be HIV-hypertension programme.\u0026rdquo; (010 - Township Clinic Pharmacist)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTraining and Tools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraining, retraining, and provision of service guidelines and tools for the engaged human resource was also identified as critical facilitators. The following responses demonstrate this:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, the guidelines are very important tools to work with. The guidelines are to direct you on what to do, even though they are not rules suiting as tools, but you always go within what the guidelines says\u0026hellip;\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, best practices. One, develop a tool. That is the first thing. You must develop a tool that will be able to meet the needs of the service user and the service provider. Yes. The tool one.\u0026rdquo; (015 - Physician 2, Gwarimpa General Hospital)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Then training and retraining. So, we had training, we had refresher training, because after some time some of these trained workers will leave the clinic and so we had to do a refresher training so, that one is also part of it too, then which other one again?\u0026rdquo; (033 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It now comes to issue of training group of persons. Training and retraining and also supporting them to buy in into the training because in the community, you will see those who are market persons, they are farmers, but you want them to listen to this training and key in into it and carried it on\u0026hellip;\u0026rdquo; (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSupportive Supervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn addition to training, supportive supervision with the provision of a feedback mechanism to plough back learnings into the programme was also identified as a facilitator.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of the best practices we had was that erm, in the State, we had, okay there are NCD focal, then in the primary health care centers we had NCD focal \u0026ndash; so these people like time to time go to those facilities to conduct supportive supervisory visits\u0026hellip;\u0026rdquo; (033 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"make sure there is a feedback mechanism there, and then make sure I institute a supportive supervisory team which will continue to review most of these issues.\" (004- Health Policy Maker, Director of Primary Health Care)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHaving set all the necessary mechanisms in place, it was mentioned that there should be a proper monitoring system to ensure that all programme runs effectively.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Even if you train, there must be monitoring. So, if there is monitoring it will go well.\" (022 - Community Nurse General Hospital, Gwarimpa)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient Involvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe respondents mentioned some best practices that could be adopted from other existing initiatives. Suggested best practices recommended as facilitators include involvement of existing implementing partners in the new initiative; teaching patients to monitor their blood pressure; peer-to-peer learning through support groups; and patient education.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay. Actually, during the programme we were advised to encourage patients to keep a record of their fasting blood sugar. So, I just feel in this programme too, if the patients can have their machine, and if they can keep a record too, maybe, because all patients do usually go for follow ups.\u0026rdquo; (014 - Physician 1, Gwarimpa General Hospital)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And peer to peer learning. It\u0026rsquo;s not, you won\u0026rsquo;t call it\u0026hellip;it\u0026rsquo;s not a support group per se because a support group is basically, you have both clients, it\u0026rsquo;s more of patients doing the discussion and whatever. But peer to peer learning is where we get different facilities to come and discuss so that people can talk about their challenges, their experience, others can learn from how to solve some other similar problems and what have you. So, support group, peer to peer learning and improved, I\u0026rsquo;m using improved twice, improved quality improvement.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers to Home Blood Pressure Management\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIdentified barriers to home-based management of hypertension were community acceptance, financial barriers, manpower constraints, policy/operational barriers, provider resistance, and user acceptability issues (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBarriers to home blood pressure management\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentified Barriers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRelevant Quotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eCommunity Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRespondents identified community acceptance as a potential barrier to home management of hypertension. They opined that gaining the community\u0026rsquo;s trust, especially that of the critical opinion leaders like the traditional rulers, was integral to getting the community to accept the initiative. A respondent also said that if the community opinion leaders are not carried along and they have wrong misconceptions about the initiative, it would be difficult to obtain community acceptance.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;that is where the much work is, in the community, because it\u0026rsquo;s those people they are going to meet. It\u0026rsquo;s left on how you will talk to them to accept you. How they will trust you that okay this thing you are bringing into their community will help them. The main problem there is how to gain their trust.\u0026rdquo; (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;in every system, it depends, the sociocultural background of people varies from places to places. It could be their community opinion molders. If you don\u0026rsquo;t carry such people along, maybe the traditional rulers, for instance or their opinion leaders, so if you neglect them, they can tag it anything and as soon as that is tagged, they will not, you may not have access to such community.\u0026rdquo; (019 - Health Policy Maker UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But the only peculiar thing is erm, because it\u0026rsquo;s HIV related, the stigma and bias that could come with that, but I think that could only account for a small fraction of the problem.\u0026rdquo; (034 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome respondents believed that if the home treatment of hypertension is nested on the HIV treatment programme, it may not be acceptable to the community members because of the stigma associated with HIV. There may also be inadvertent disclosure of HIV status of individuals to their household members. Another potential sociocultural barrier which may impede community acceptance is the concern about female patients being attended to in their homes by male caregivers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"some, even this -HIV something, some, you can if you don\u0026rsquo;t know how to carry it out. You can lead to breaking of marriage - somebody\u0026rsquo;s marriage because some of us are taking our drugs without even disclosing to their wives or to their husbands. We try as much as possible despite that you interview them, you tell them that they should open up to their spouse\u0026hellip; \" (010 - Township Clinic Pharmacist)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No, there\u0026rsquo;s nobody I can think of now. The only thing I can think of is erm\u0026hellip;. Though maybe we may still say something about that, the only thing I can think of, which I think we can handle, is based on cultural beliefs and issues, a male cannot enter some females home to go and start checking B.P which other that case it means that a female has to. But I can\u0026rsquo;t think of anybody that will kick against this particular programme.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther respondents were, however, of the opinion that the initiative would be beneficial both within the community and the health facility and, therefore, would be acceptable to the community members.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No, it will be seen both outside and inside the health facility. You know for health care workers to come to the community, come to their house, interact with them, gist with them, check their BP, that one gives a\u0026hellip;, we already know that the majority of our health challenges are psycho-social, so it would go a long way\u0026hellip;\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome of the proposed solutions by respondents to address issues surrounding HIV stigma and community acceptance were health education to community members to disabuse their minds about HIV stigma, as well as working through the PLHIV support groups to reach their members and organize them in such a way that they can receive services without the risk of inadvertent disclosure.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, they have support group meeting. They know themselves. So, involvement, when you get to the facility, you\u0026rsquo;ll get somebody who will be the one coordinating. How do I meet these people? How do we get there? Are we going to be moving from house to house or we\u0026rsquo;ll get them at a particular place? So that we\u0026rsquo;ll see them (006 - Physician UATH)\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eFinancial Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding was identified by most respondents as a major barrier to home blood pressure monitoring.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the only barrier would have to be funding, because funding actually is a major issue when it comes to actually running out programmes in Nigeria, because the budget, you know, what is actually given as support for most programmes, especially health programmes in Nigeria.\u0026rdquo; (004- Health Policy Maker, DIRECTOR OF PRIMARY HEALTH CARE)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;then funding and then manpower.\u0026rdquo;\u003c/em\u003e (003-COMMUNITY NURSE UATH).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I am also looking at finance here now because all these ones involve finance. Using those who have what it takes to arrange it because it has to go through a process before it can be fully accepted\u0026rdquo; (009 - Community Nurse, Township Clinic)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIdentified cost elements which may serve as barriers to home blood pressure management include, cost of staffing, communication costs for the staff, costs for refreshments, among others.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;if we look at the health system \u0026hellip; it may be difficult to have adequate staff in Nigeria. If we have a reasonable number of staff who can do the work, you find out that it\u0026rsquo;s a matter of finding out where somebody is staying\u0026hellip;the person can even do it after working hours. Those are when cost comes in; if you\u0026rsquo;re talking about cost now, that\u0026rsquo;s why I say marginal cost. You have to talk about communication cost, eh there could be need for refreshment at times because based on the number of staff we have, you cannot be using working hours all the time. So, people can do it at extra time and all those may entail some level of cost\u0026hellip; eh which other one? Basically, in terms of communication, that\u0026rsquo;s the major thing.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe introduction of user fees was also considered as a significant barrier because people in the community would be unwilling or unable to pay for home blood pressure management due to their low socio-economic status.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;User-fee\u0026hellip; Somehow, to my own understanding, if you want to talk about home blood pressure management based on my knowledge in the community, there won\u0026rsquo;t be any need for a user fee. You can\u0026rsquo;t go to a community and come and start telling them to pay money you want to come and measure\u0026hellip;. that will create problems. So, for me, I will advise if you want to make use of home blood measurement there won\u0026rsquo;t be any need for a user fee.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Yes, negative feedback, one of the negative feedback I will say is that erm, like the one you are talking of fee, it usually fails\" (027 - Community Pharmacist 2 Gwagwalada)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMany respondents believed people would cooperate if the services were free but agreed it might be difficult to get government funding.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The equipment, the finance. If not talk of the community they will cooperate if it is free. But to get maybe government to do that will be a difficult something.\u0026rdquo; (022 - Community Nurse General Hospital, Gwarimpa)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA respondent said that only a small fraction of community members will be willing to pay for such services. Many of those who would normally not seek care in the clinic would not see the need to pay for home blood pressure monitoring.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Those are part of the things we want to mitigate. So, some of the category of people you\u0026rsquo;ll be going to check their BP, if you give them their own option, maybe more than 50% of them will not come to the clinic. So, to them, there won\u0026rsquo;t be any need for them to pay. However, you may see, you may get a small percentage of the community that will be happy to pay and be happy that you are coming to them, but that would be a small fraction.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother respondent said that people see primary health care services as services which should be accessed free of charge, hence they would be unwilling to pay for home blood pressure management. This is within the backdrop that the government, through the basic health care provision fund is providing some subsidy for health services at the primary health care level.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Because once we bring the idea of them paying in their community, it may not be so easy. Unless you are talking about, if you come to the community we have designated, just like the community pharmacist. Some people would be there, and people could be coming there. But once we are talking about checking, we want to come to your home to check your BP, you are going to pay? A lot of community people see primary health care as something they should be benefiting with least amount of financial commitment, so that is my own thinking.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Based on subsidizing, I feel the government is doing a bit because in the course of my discussion, I mentioned something like basic health care provision fund, that\u0026rsquo;s an avenue whereby the Federal Government has mapped out some little, small percentage to see that eh\u0026hellip; accessing health services is subsidized at primary health care levels, so I feel there\u0026rsquo;s little contribution\u0026hellip;.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother respondent\u0026rsquo;s viewpoint was that people like free services, but some educated people might be willing to pay a token when they recognize the benefits of the initiative and the cost savings they would make by receiving treatment at home.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Emm\u0026hellip; well, you know Nigeria, we like free things, so he wouldn\u0026rsquo;t mind even if you do it free of charge. But if the person is educated on the lot of risk that has been reduced for you, I don\u0026rsquo;t think there will be any problem. And again, maybe to get acceptance, maybe the charges should be minimal. If the charges are minimal, and the person knows that by them coming to meet me, I have saved so, so, so amount of money, he will accept it.\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrom the responses on the strategies that were adopted in dealing with existing programme challenges, certain propositions for programme financing were identified. With regards to user fees, it was recommended that the programme should either start as free and have payment introduced later, provide subsidized drugs and services or have a flexible payment plan for the patients so that they can be able to pay based on their convenience. All three options will enable patients to be able to pay for the programme conveniently. Some of the responses are as follows:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"I will suggest you first of all start it free\" (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We have already become very familiar with our staff, but nevertheless if they don\u0026rsquo;t have money they still have to pay, we consider them and give them time. We have their records; we have their data, where they stay. Assessment of their drugs is periodic, if they don\u0026rsquo;t have money to pay this period; next time they come; they make sure they come with the money. It\u0026rsquo;s not given in that condition but the pay, we make it very flexible for them; they pay.\" (031-Community Pharmacist New Kutunku)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Yes, they subsidize because you take a packet of this drug that if you get this one in the chemist, it\u0026rsquo;s about four thousand five hundred, they sell at one thousand five hundred. they have tried. Even the manufacturers came from outside, we sat one on one, and I told them this is what I am begging for. They should not compromise the strength and the active ingredient inside the drug. I want original drug because if we give them, they will go outside and start buying fake drugs. Then they told us, we had MOU, how much they are able to produce to sell it outside. That this is what they can sell for us. At least we have tried in that aspect. It\u0026rsquo;s been subsidized\" (010 - Township Clinic Pharmacist)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther proposed solutions to funding challenges include advocacy to potential funding partners, well-to-do community members, and donors.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"So, I was talking of advocacy, like getting advocacy to the community, on the other side is getting advocacy to partners, to people that might be potential partners to help provide funding.\" (005 - Pharmacist UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"So, one of the ways to overcoming that is that I think erm, we could also opt for partners or donors to help\" (034 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eManpower Constraints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome of the respondents mentioned that the work processes would be disrupted with the introduction of community health worker support and home blood pressure monitoring, and the disruption would be in the form of limited manpower.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, if I\u0026rsquo;m leaving my work here to go to the community, who does the work that I have left behind here? So that calls for manpower. But if there\u0026rsquo;s anybody that can handle the work, I can go to the community because somebody will do the work I\u0026rsquo;m supposed to do here. But if nobody is assigned, then the few people left behind, the work will be too much for them to do\u0026rdquo;. (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther respondents identified health worker fatigue resulting from additional workload as another potential problem. Having to move from patients\u0026rsquo; house to house could lead to fatigue and poor work concentration for the healthcare providers. The respondent described it as follows:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And fatigue can be a case because you know at times, if you are in the clinic focusing on seeing patients, your thought pattern may be more aligned than if you go to the community, you come back, you go. So, there\u0026rsquo;s fatigue and articulation on the side of the health care workers\u0026hellip;\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThere will be some disruptions in the services. Eh you know as you are saying these disruptions, these disruptions are tied to some of these things I\u0026rsquo;m talking about, as in it will affect the level of concentration of the health care workers to manage patients in the clinic.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn addition to the service disruptions, increased workload, and health worker fatigue, there may also be increased patient waiting time.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No, the little disruption depends on how it\u0026rsquo;s handled as we said. If you need people to go during the working period, it will actually contribute to, the other way round, the patients that have obvious reasons to come to the clinic, their waiting time will increase because we have a smaller number of people attending to them.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There will be some disruptions in the services. Eh you know as you are saying these disruptions, these disruptions are tied to some of these things I\u0026rsquo;m talking about, as in it will affect the level of concentration of the health care workers to manage patients in the clinic. And it can equally affect the time, the duration of waiting of the patient.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSuggestions on how to overcome the challenges with process disruptions include the adoption of a community-tailored approach where healthcare workers get days off to rest and to carry out home visits within their communities.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;we will still take it back to what I said just before now that it would be better tailored people that stays in different communities, so that there are times some health care workers may be their off day when they\u0026rsquo;re off, though you may tell me that would have been their time to rest and do other things, they can use it to do the work or at their own leisure time. You know some people can even do this thing as leisure since it\u0026rsquo;s within the community, it\u0026rsquo;s a way of getting to interact with your neighborhood, go there.\u0026rdquo; (008 - Township Clinic Physician)\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePolicy/Operational Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicy/operational barriers are described to refer to issues that border around the actions or inactions of the government and policy formulators. A sizeable number of respondents indicated that they were not aware if any policy existed in the first place.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I am not aware of the policy, but I know particularly my training as a nurse, you have to treat hypertension because you know, you read anatomy of the heart.\u0026rdquo; (025 - Community Nurse PHC Lugbe)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers were assertive in their claim that there was no policy to support the adoption and implementation of community health worker support and home blood pressure monitoring in hypertensive HIV patients yet, two respondents said;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eYes, because if we look at the Nigerian policy, I am not aware whether someone who is not a doctor can institute treatment for hypertension. Yes, they can make the diagnosis but to just institute the treatment and continue follow up.\u0026rdquo; (015 - PHYSICIAN 2 GWARIMPA GENERAL HOSPITAL)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Currently there is none that is been implemented. There could have been some or several that have been drafted, but implementation is the main thing, so there may be a need to still approach the Federal Ministry of Health - the policy maker to put those things on ground\u0026hellip;\u0026rdquo; (011 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eProvider Resistance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrom the professional perspectives, the respondents raised concerns about rivalry and protection of personal and occupational interests, such as community pharmacists who may think that business is being taken away from them by providing care for patients at home; doctors who may think other professions are trying to take over their work, or that they are likely to mismanage patients; and other care providers who may be worried about additional burden of work in having to take care of patients at home. Some respondents explained the matter thus:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;so the community pharmacist will not be happy about it, is that what\u0026hellip;Because that means he can no longer sell hypertensive drugs and make profit from it.\u0026rdquo; (005 - Pharmacist UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, yes, there are. As I\u0026rsquo;ve said; inter professional rivalry. I know some cardiologists will say no, we should take\u0026hellip; you understand me. That one will be there, and even some physicians also \u0026ndash; even in maybe most of the local government, maybe they have only one medical Doctor, and the person may want to be the champion of every\u0026hellip; so decentralizing care to non-health care related persons may be opposed.\u0026rdquo; (011 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, yes. It\u0026rsquo;s natural even in the hospital setting. The rivalry between the pharmacist, the doctors, and the nurses everybody is trying to raise his shoulders above the other.\u0026rdquo; (031-Community Pharmacist New Kutunku)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"well, I\u0026rsquo;ve seen cases\u0026hellip; where traditional birth attendance take delivery, when a patient is having complications, they don\u0026rsquo;t refer. Some of them are very bold enough to keep, you know, managing a patient when it has reach the level to refer to a secondary health facility or a tertiary health facility and then they lose the patient eventually\u0026hellip; \" (005 - Pharmacist UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Eventually still result in a poorly managed patient. Because the persons that the patients will be seeing are the community health workers with limited knowledge, and so, for instance, if a patient is showing signs of neurological damage, or cardiac\u0026hellip; the community worker might not be able to help, you understand.\" (005 - Pharmacist UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;erm\u0026hellip; yes I think there\u0026rsquo;ll be people like that, yes. First of all even the health centers or the community works might actually resist it initially. Reason being that they will think you are bringing additional work to us, yeah.\u0026rdquo; (034 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther respondents mentioned that there may be health worker acceptability issues due to insecurity issues. However, to address this challenge, community health workers should be recruited and deployed to work within their own communities.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"You understand, this period of insecurity that everybody is guarding and this thing if not the adopting would have been very nice but the insecurities that is on the ground; you cannot just enter somebody\u0026rsquo;s house. He may not know where you are from and all that.\" (010 - Township Clinic Pharmacist)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You know when I was talking about \u0026ldquo;Mai Lafiya,\u0026rdquo; I said when the security situations used to be better. You know the angle I\u0026rsquo;m seeing this project eh\u0026hellip;. You know what we are learning in primary health care, we don\u0026rsquo;t want to develop a completely new concept of doing things or ways. I\u0026rsquo;m looking at this project, if you see me emphasizing on the challenges in the area of manpower, either of training people, or communication, I\u0026rsquo;m looking at this project picking people from a particular vicinity to administer this process. Not necessarily coming to the clinic, in the normal way of I want to recruit so and so, be going to\u0026hellip;\u0026hellip;Anybody you want to recruit from a particular ward, the person has to come from the ward, the person has to come from the ward and possibly if we can get somebody from that particular community. That will be better\u0026rdquo;. (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn resolving professional rivalry among healthcare workers, some respondents proposed round table talks where all parties are brought to the table and made to understand pros and cons of the initiative. This, they say, should dispel their reservations.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I do not think that there are unresolved, but I know that there are things that are workable. There are things that are workable because if everybody is brought round the table and then the benefits, the pros and cons are brought out in the fore, I don\u0026rsquo;t think that there should be barriers or restrictions or reservations to this anymore.\u0026rdquo; (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Continuous information, continuous enlightenment, then for the professional rivalry we have to see how we can educate ourselves to understand that the most important key element is the patient.\u0026rdquo; (027 - Community Pharmacist 2 Gwagwalada)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother respondent said that standard operating procedures should be provided, so that community health workers who are engaged to provide home management of hypertension know their limits, they are to monitor patient blood pressure, provide counselling including adherence counselling and refer cases to the hospital. They should not be responsible for making diagnosis of hypertension or its complications. Another respondent said that community health workers should be properly trained for their work in home management of hypertension before deploying them.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"There must be standard of operation for these health care workers, so they know their limits, they know, o you are just there to monitor the BP, and probably proffer counseling \u0026ndash; drug adherence counseling to these patients, and not in any way to diagnose, if you see elevated blood pressure you know when to refer you know\" (033 - Health Policy Maker (FMOH))\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Once community health supporters are sent to the field, they should be erm, they will provide training for them on what to specifically do. What they are expected to do and when they are to refer patients.\" (005 - Pharmacist UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eUser Acceptability Issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe community's health-seeking behavior was another response given. This was due to people not seeing their health condition as a problem and, as such, have no need to measure or check their blood pressure:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;Which means some people you were going there to check their BP; some may not see their condition as if it\u0026rsquo;s a problem. So, they won\u0026rsquo;t come to the clinic. They can only come to the clinic when the problem becomes very serious.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient acceptability issues revolve around the patients\u0026rsquo; perspectives towards the programme, their level of involvement and how to deal with issues of concern that could arise. One of the key issues that was mentioned was about confidentiality. One of the respondents mentioned that when a healthcare worker starts to visit someone at home, neighbours may begin to be curious about the reasons for the visits and that might eventually expose the HIV status of the client. This was explained as follows:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, questions will start coming \u0026ndash; who are these people that they are coming to take only their own blood pressure? What about me? Me am in the community, I want to take too, and you say no, we will not take for you \u0026ndash; what is your reason? So, we may end up exposing the status of the other patients \u0026ndash; we are taking only for HIV patients. And that is where the patient will not even accept it. You know, if you will have a way of doing it for everybody then we come and\u0026hellip; we know who is HIV positive. Then when we come, we select only the ones for the HIV positive. Then, if not, if you are coming to me every time and I\u0026hellip; my neighbor you are not doing it for him. My neighbor will start asking, what is wrong with this person that they are always coming to take his BP? I\u0026rsquo;ll start asking, and before you know it, the HIV positive \u0026ndash; hypertensive patient may begin to reject the whole thing together\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother consideration was about the people\u0026rsquo;s possible belief about the treatment to be administered or the fear of possible side effects, both of which may cause them to be negatively averse to having the care service.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No there may be possibility of that based on eh\u0026hellip; you know, perception, people\u0026rsquo;s belief differs. Because even as simple as immunization we used to do, there are some people who come to their place. They say No, they don\u0026rsquo;t want you to give their children immunization. They don\u0026rsquo;t want to. Why? They cannot even\u0026hellip; Some would even tell you that they are health professionals in the field. Some may want to attribute problems that somebody had too. So, there could be some resistance.\u0026rdquo; (008 - Township Clinic Physician)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMeanwhile, many strongly believe that even the reluctant individuals can be brought on board by involving them generally through advocacy, grassroots health education and provision of apparatus which will further serve as incentives in motivating them. A respondent said:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You\u0026rsquo;ve told them the importance. That see this is the importance of this, this is the importance of this, this is the importance of this. I believe that those that accept it and start using it and they see the benefit, it will motivate those that are against it to join the programme.\u0026rdquo; (002- IST CHEW UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother proposed solution was for patients to be involved in monitoring their own blood pressure. This is expected to improve their cooperation. A respondent explained it thus:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;oh yes now, if not how do we get the\u0026hellip; if they are not involved, how do we get their cooperation to be monitoring their BP \u0026ndash; because since we are going to be monitoring, it\u0026rsquo;s not just a once something. You will keep on coming\u0026rdquo; (006 - Physician UATH)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe aimed to find out the context, facilitators, and barriers of home management of hypertension among people living with HIV (PLHIV) using the iPHARIS framework. Our findings regarding context indicated that there was existing home-based care for PLHIV supported by PEPFAR through its implementing partners across many study sites. This provides a framework on which home-based management of hypertension could be leveraged. However, there is currently no policy backing home-based management of hypertension.\u003c/p\u003e\u003cp\u003eThe identified facilitators of home-based management of hypertension include advocacy at every level especially at the level of policymakers, donors, healthcare workers, community members and patients. Leadership was also considered a critical facilitator of home-based management of hypertension. Leaders at supervisory and decision-making levels with passion for their profession and compassion towards patients were considered crucial to drive adoption. Provision of appropriate policies by the government was also considered an important facilitator. Other facilitators include incentives for healthcare workers and patients; government support through funding, manpower recruitment, and provision of infrastructure; training and retraining of healthcare workers and provision of appropriate tools and guidelines. In addition, monitoring and supportive supervision with establishment of a feedback mechanism to plough back learnings from implementation into improving the programme, as well as patient involvement in the design and implementation of the project through patient education and self-monitoring of blood pressure were noted to be very important facilitators by participants.\u003c/p\u003e\u003cp\u003eThe facilitators identified in this study also align with factors that have been shown to support the successful implementation of community-based health interventions. Among the most critical factors that have been previously identified are advocacy and leadership, which are important to gain support and for driving the adoption of new programmes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Similar to the findings of this study, government support, including funding, policy formulation, and provision of necessary infrastructure are critical to the sustainability of health interventions including home-based hypertension treatment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In evaluating the role of healthcare professionals, among the various incentives that can facilitate their participation include training and retraining programmes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), availability of appropriate tools, and guidelines, all of which are necessary for effective implementation (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It has also been shown that supportive supervision and monitoring, with a proper feedback mechanism will facilitate quality and consistent health intervention (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Lastly, when healthcare providers involve patients in the design and implementation of their health programmes, it enhances acceptance and adherence to treatments (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe found that the major barriers to home-based management of hypertension include community acceptance issues due to sociocultural beliefs, lack of trust, and issues related to stigma especially for PLHIVs. Financial barriers include cost of communication, transport costs, cost of refreshments and introduction of user fees. Manpower constraints leading to disruption of work with new work schedules for home visits, increased workload leading to healthcare worker fatigue, poor quality services and increased patient waiting times were also identified as barriers. Other barriers include a lack of policy framework, provider resistance issues such as inter-professional rivalries, concerns about additional workload, concerns about diminished quality of care as a result of task shifting, as well as security concerns. Lastly, user acceptance issues such as poor health-seeking behaviour, user perception and concerns about confidentiality may serve as barriers to home-based management of hypertension.\u003c/p\u003e\u003cp\u003eThe barriers identified in this study are consistent with extant literature on the challenges of implementing community-based health interventions. One of the key issues relating to sociocultural beliefs and stigma are significant issues of concern in SSA (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Prevailing negative beliefs and attitudes towards HIV and diseases make health-seeking behaviour a secretive act, and any home-based care will become a cause of suspicion and risk of exposure of the patient\u0026rsquo;s illness, which would not be likely avoided. Financial constraints, including the cost of communication and transportation, stand as another common barrier, especially in resource-limited settings like Nigeria (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). It is also recognized in literature that a lack of policy framework and provider resistance due to inter-professional rivalries and concerns about workload are system-related challenges in the implementation of new health programmes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additionally, there are considerations around issues relating to user acceptance, such as poor health-seeking behaviour and concerns about confidentiality, which are also highlighted in studies on community health interventions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of our study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA particular limitation of the study was that it was limited to a few selected healthcare facilities within the FCT of Nigeria, which can limit its scope of generalization to the rest of the country. However, the study was carried out with sufficient due diligence that it is able to provide a template for subsequent studies across other locations. Furthermore, its methodology was carefully designed and implemented in line with previous studies, making it methodologically realistic.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths of our study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe current study has three important strengths. First, it demonstrated a comprehensive coverage that cut across primary, secondary, and tertiary facilities, thereby providing a holistic view of the facilitators and barriers to the implementation of home-based hypertension management. Next, it involved a diverse perspective from various stakeholders including policy makers, service providers and beneficiaries. Finally, the study employed a tested implementation science approach through tie i-PHARIS framework, to systematically identify barriers and facilitators.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications of our findings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOverall, this study has significant implications for policy, practice and future research. The findings are able to provide guidelines for policy formulation by the Federal Ministry of Health (FMOH) to inform home-based management of hypertension. Also, it provides opportunities for demonstrating the possibilities in practice of home-based hypertension management, where an understanding of the facilitators and barriers helps in quality practice implementation. Finally, the evidence from this study provides an opportunity to replicate the findings across other climes of Nigeria to demonstrate replicability and implementation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe conclude that many participants felt that home-based care of HIV hypertensives is feasible and holds significant potential for improving quality and access to care. Facilitating factors include advocacy to relevant stakeholders, identification of early adopters and leaders, government support through funding, policy formulation, manpower training and deployment, infrastructure provision, appropriate monitoring mechanisms, supportive supervision, and patient involvement in the care process. Barriers to the successful implementation of these include systemic barriers within the healthcare system, barriers from the community, challenges from patients and their caregivers, as well as issues relating to government inactivity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eART Antiretroviral therapy\u003c/p\u003e\n\u003cp\u003eAIDS Acquired Immune Deficiency Syndrome\u003c/p\u003e\n\u003cp\u003eBP Blood Pressure\u003c/p\u003e\n\u003cp\u003eCART Community Antiretroviral Treatment\u003c/p\u003e\n\u003cp\u003eCHEW Community Health Extension Worker\u003c/p\u003e\n\u003cp\u003eCHW Community Health Worker\u003c/p\u003e\n\u003cp\u003eCOVID-19 Coronal Virus Disease 2019\u003c/p\u003e\n\u003cp\u003eFCT Federal Capital Territory\u003c/p\u003e\n\u003cp\u003eFMOH Federal Ministry of Health\u003c/p\u003e\n\u003cp\u003eHIV Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003eID Identification\u003c/p\u003e\n\u003cp\u003ei-PARIHS Integrated Promoting Action on Research Implementation in Health Services\u003c/p\u003e\n\u003cp\u003eNAIIS Nigeria HIV/AIDS Indicator and Impact Survey\u003c/p\u003e\n\u003cp\u003eNCD Non-Communicable Diseases\u003c/p\u003e\n\u003cp\u003eNIH National Institutes of Health\u003c/p\u003e\n\u003cp\u003ePEPFAR President\u0026rsquo;s Emergency Plan for AIDS Relief\u003c/p\u003e\n\u003cp\u003ePLHIV Persons Living with HIV\u003c/p\u003e\n\u003cp\u003eSRP Small Research Project\u003c/p\u003e\n\u003cp\u003eSSA Sub-Saharan Africa\u003c/p\u003e\n\u003cp\u003eUATH University of Abuja Teaching Hospital\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the human research and ethics committee of the University of Abuja Teaching Hospital, Gwagwalada (Approval number UATH/HREC/PR/2022/04/020). Study procedures were guided by the principles of human subject research ethics in accordance with the declarations of Helsinki. All study respondents provided signed informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during this study are not yet publicly available but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by the National Institutes of Health (NIH) through the HLB-SIMPLe Alliance Small Research Project (SRP) programme.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTAA, DBO, and OAA conceptualized the study, TAA, NRR, BA, AN collected the data, IO analyzed the data, TAA, OAA, and IO wrote the initial draft manuscript, DBO provided expert review. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the contributions of all the study respondents, as well as the funding organization in making this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKharsany ABM, Karim QA. HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities. Open AIDS J. 2016 Apr;10(1):34\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eFederal Ministry of Health. NAIIS 2018 Technical Report. Abuja, Nigeria.; 2019. \u003c/li\u003e\n\u003cli\u003eUNAIDS. HIV and AIDS Estimates Country factsheets: GAMBIA , 2018. https://www.unaids.org/en/regionscountries/countries/gambia [accessed 10 January 2020]. \u003c/li\u003e\n\u003cli\u003eOtieno G, Whiteside YO, Achia T, Kwaro D, Zielinski-Gutierrez E, Ojoo S, et al. Decreased HIV-associated mortality rates during scale-up of antiretroviral therapy, 2011-2016: A population-based cohort study. AIDS. 2019;(33):2423\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eWandeler G, Johnson LF, Egger M. Trends in life expectancy of HIV-positive adults on antiretroviral therapy across the globe: Comparisons with general population. Vol. 11, Current Opinion in HIV and AIDS. Lippincott Williams and Wilkins; 2016. p. 492\u0026ndash;500. \u003c/li\u003e\n\u003cli\u003eTodowede OO, Sartorius B, Magula N, Schutte AE. Association of predicted 10 years cardiovascular mortality risk with duration of HIV infection and antiretroviral therapy among HIV-infected individuals in Durban, South Africa. Diabetol Metab Syndr. 2019 Dec;11(1). \u003c/li\u003e\n\u003cli\u003eSelke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, Shen C, et al. Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: Clinical outcomes of a community-based program in Kenya. J Acquir Immune Defic Syndr. 2010;55(4):483\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eBemelmans M, Baert S, Goemaere E, Wilkinson L, Vandendyck M, van Cutsem G, et al. Community-supported models of care for people on HIV treatment in sub-Saharan Africa. Trop Med Int Heal. 2014;19(8):968\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eSanwo O, Persaud NE, Nwaokoro P, Idemudia A, Akpan U, Toyo O, et al. Differentiated service delivery models among PLHIV in Akwa Ibom and Cross River States, Nigeria during the COVID-19 pandemic: descriptive analysis of programmatic data. J Int AIDS Soc. 2021;24(S6):50\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eGeorge J, MacDonald T. Systemic and Pulmonary Hypertension The Use of Home Blood Pressure Monitoring. Eur Cardiol Rev Syst Pulm Hypertens. 2015;(group 1):95\u0026ndash;101. \u003c/li\u003e\n\u003cli\u003eStewart T. Leadership, Advocacy, Policy, and Quality Improvement BT - Psychiatric-Mental Health Nurse Practitioner Program Companion and Board Certification Exam Review Workbook. In: Stewart T, editor. Cham: Springer Nature Switzerland; 2024. p. 595\u0026ndash;626. \u003c/li\u003e\n\u003cli\u003eSharma G, Mathai M, Dickson KE, Weeks A, Hofmeyr GJ, Lavender T, et al. Quality care during labour and birth: A multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):1\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eAltaras R, Worges M, Torre S La, Audu BM, Mwangi G, Zeh-Meka A, et al. Outreach Training and Supportive Supervision for Quality Malaria Service Delivery: A Qualitative Evaluation in 11 Sub-Saharan African Countries. Am J Trop Med Hyg. 2024;110(Suppl 3):20\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eMiller T, Reihlen M. Assessing the impact of patient-involvement healthcare strategies on patients, providers, and the healthcare system: A systematic review. Patient Educ Couns. 2023;110:107652. \u003c/li\u003e\n\u003cli\u003eWilliams LD. Understanding the Relationships Among HIV/AIDS-Related Stigma, Health Service Utilization, and HIV Prevalence and Incidence in Sub-Saharan Africa: A Multi-level Theoretical Perspective. Am J Community Psychol. 2014;53(1\u0026ndash;2):146\u0026ndash;58. \u003c/li\u003e\n\u003cli\u003eMahmoud Z, Orji AA, Okoye CF, Ameh FO, Jamro-Comer E, Isah A, et al. Facilitators and barriers to optimal home blood pressure management in patients with hypertensive disorders of pregnancy in a tertiary care facility in Abuja, Nigeria: a qualitative research study. BMC Health Serv Res. 2023;23(1):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eIdriss A, Diaconu K, Zou G, Senesi RGB, Wurie H, Witter S. Rural-urban health-seeking behaviours for non-communicable diseases in Sierra Leone. BMJ Glob Heal. 2020;5(2). \u003c/li\u003e\n\u003cli\u003eMusinguzi G, Anthierens S, Nuwaha F, Van Geertruyden JP, Wanyenze RK, Bastiaens H. Factors Influencing Compliance and Health Seeking Behaviour for Hypertension in Mukono and Buikwe in Uganda: A Qualitative Study. Int J Hypertens. 2018;2018. \u003c/li\u003e\n\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":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Barriers, Community Health Worker (CHW), Facilitators, Home Blood Pressure, Hypertension, Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS)","lastPublishedDoi":"10.21203/rs.3.rs-7123440/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7123440/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e\u003cp\u003eHIV/AIDS is a significant public health problem in sub-Saharan Africa (SSA), accounting for 70% of the global disease burden. Meanwhile, HIV mortality in SSA has declined due to expanded access to anti-retroviral therapy (ART). Some of the strategies that have contributed to this decline in SSA, apart from access to highly active anti-retroviral medications, are task sharing, which uses non-physician community healthcare workers (CHW). Leveraging such non-physician CHW support for the treatment of hypertension in persons living with HIV (PLHIV) is desirable, especially with the increasing burden of cardiovascular disease and their risk factors, especially hypertension in this population. And with the community-based approach for HIV treatment, the need to integrate non-communicable diseases (NCD) screening and management into such an approach cannot be over emphasized.\u003c/p\u003e\u003ch2\u003eOBJECTIVE\u003c/h2\u003e\u003cp\u003eWe aimed to examine the context, facilitators, and barriers to implementing CHW support and home blood pressure (BP) monitoring in hypertensive PLHIV in HIV Clinics in Nigeria\u0026rsquo;s Federal Capital Territory (FCT) using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e\u003cp\u003eWe purposively sampled and conducted qualitative semi-structured key informant interviews with five each of hypertensive PLHIV, Community Health Extension Workers (CHEWs), Physicians, healthcare policymakers, Community Pharmacists, and Community nurses. Interviews were tape-recorded, transcribed, and coded based on themes identified. We analyzed data to describe the context, facilitators, and barriers to implementing CHW support and home BP monitoring in hypertensive PLHIV.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e\u003cp\u003eContextual observations include existing donor-funded community ART refill mechanisms managed by volunteers. Proposed facilitators include providing policy framework, advocacy to stakeholders, government funding support, incentivizing volunteers and patients, identifying champions for home BP monitoring in hypertensive PLHIV, training, supportive supervision, and patient involvement. Barriers identified include financial constraints, non-existing policy framework, implementation guidelines, or dedicated human resources for home BP monitoring in hypertensive PLHIV, as well as provider, community, and patient resistance issues.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e\u003cp\u003eWe identified facilitators and barriers for CHW support and home BP monitoring in hypertensive PLHIV, with existing donor-funded community ART refill mechanism being a major contextual factor.\u003c/p\u003e","manuscriptTitle":"Community-based Approaches to improve hypertension treatment among people living with HIV","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 18:25:04","doi":"10.21203/rs.3.rs-7123440/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-20T14:56:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T09:54:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-11T08:49:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182878189814828208881619840563070097527","date":"2025-09-10T18:37:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88326371519329047988440221553340188411","date":"2025-09-10T12:10:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159066314803774231937086234877471560140","date":"2025-08-19T06:49:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104399301588295589456002150764840938074","date":"2025-08-04T05:12:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-30T13:36:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-22T07:44:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-19T11:45:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-19T11:45:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-07-14T16:54:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ce660613-9365-41a7-ab52-93a653535754","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T14:24:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 18:25:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7123440","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7123440","identity":"rs-7123440","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}