Stakeholder perspectives to inform the implementation of a community health worker-delivered home management of hypertension intervention in Zimbabwe

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Abstract

Objective

Implementing evidence-based innovations often fails to translate into meaningful outcomes in practice due to dynamic real-world contextual factors. Identifying these influencing factors is pivotal to implementation success. This study aimed to determine the barriers and facilitators of implementing a community health worker (CHW)-delivered home management of hypertension (HoMHyper) intervention from a stakeholder’s perspective using the Consolidated Framework for Implementation Research (CFIR).

Design

Exploratory qualitative study.

Setting

Five primary healthcare facilities in Mutare City, Zimbabwe.

Participants

25 CHWs, 10 health facility nurses and 3 Mutare City health administrators.

Results

Perceived barriers to implementation of the HoMHyper intervention were staff shortage, patient privacy and confidentiality, limited access to antihypertensive medication, CHW incentivisation and equipment shortage, as well as patient knowledge and beliefs about hypertension. The proposed intervention was superior to the current practice, easy to implement and adaptable in the local context. Perceived facilitating factors were commitment from health system leadership, CHW training and support, regular engagement between CHWs and health providers, community partnerships, and CHW self-efficacy and knowledge and skills.

Conclusion

Integrating CHWs into chronic disease management can potentially improve health service access in low-resource settings. Well-coordinated planning guided by implementation evidence frameworks such as the CFIR significantly enhances the identification of important barriers and facilitators to inform implementation.

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Most cited references 43

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Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Laura Damschroder, David Aron, Rosalind E Keith … (2009)

Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

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Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

José Huerta (2022)

Summary Background Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. Methods We used data from 1990 to 2019 on people aged 30–79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. Findings The number of people aged 30–79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306–359) million women and 317 (292–344) million men in 1990 to 626 (584–668) million women and 652 (604–698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55–62) of women and 49% (46–52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43–51) of women and 38% (35–41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20–27) for women and 18% (16–21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. Interpretation Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. Funding WHO.

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Making sense of implementation theories, models and frameworks

Per Torgeir E Nilsen (2015)

Background Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers. Discussion Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). Summary This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited “how-to” support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.

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Author and article information

Contributors

Paddington Tinashe Mundagowa:

ORCID: http://orcid.org/0000-0002-7788-4874

Malvin Musariri

Pamela Magande

Tendai Hlabangana

Linda Jane Mukwambo

Pemberai Zambezi

Priscillah Muchemwa-Munasirei

Fadzai Mukora-Mutseyekwa

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2024

Publication date (Electronic): 20 December 2024

Volume: 14

Issue: 12

Electronic Location Identifier: e085211

Affiliations

[1 ]Africa University , Mutare, Manicaland, Zimbabwe

[2 ]University of South Carolina Arnold School of Public Health , Columbia, South Carolina, USA

[3 ]University of Wolverhampton , Wolverhampton, UK

[4 ]Africa University College of Social Sciences Theology Humanities and Education , Mutare, Zimbabwe

Author notes

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

None declared.

Paddington TinasheMundagowa; mundagowap@ 123456africau.edu

Author information

Paddington Tinashe Mundagowa http://orcid.org/0000-0002-7788-4874

Article

Publisher ID: bmjopen-2024-085211

DOI: 10.1136/bmjopen-2024-085211

PMC ID: 11667306

PubMed ID: 39806716

SO-VID: 4f2d8486-552a-4f1b-b55b-179d8b896a78

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 08 February 2024

Date accepted : 28 November 2024

Funding

Funded by: Fogarty International Center (U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy (S/GAC) and the President’s Emergency Plan for AIDS Relief (PEPFAR)) of the National Institutes of Health;

Award ID: R25 TW011215

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Stakeholder perspectives to inform the implementation of a community health worker-delivered home management of hypertension intervention in Zimbabwe

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Abstract

Abstract

Objective

Design

Setting

Participants

Results

Conclusion

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Annual Reviews HIV/AIDS: Public Health and Society

Most cited references 43

Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

Making sense of implementation theories, models and frameworks

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