Study Participants
The HIV clinics that participated in the survey represented 20 local government areas in Lagos, creating variability in the organizational characteristics and context. The vast majority of the health facilities surveyed were public, government-operated clinics (97%, n=28/29). Among the health facility representative surveyed, 62% (n=18/29) of the respondents were females, the median age of 40 years (IQR: 37 – 45 years), and had worked at the current institution for less than 10 years (n=21/29). On average, clinic providers care for 394 HIV patients per month. The number of hypertensives, HIV patients are seen at the facility ranged from 5 to 73 patients per month. Among the participants who attended the stakeholders meeting, 8 of the participants were health providers (noted as HP in the quotes), such as physicians and nurses, within HIV clinics, whereas 11 of them were key informants (noted as SH in the quotes) from the Ministry of Health at the local government level and/or national level.
Implementation Climate for TASSH
As shown in Table 1, most of the scale measures had good-excellent internal reliability in these samples, with Cronbach’s alpha for most subscales ranging from 0.84 to 0.96. The total average score on the organizational context scale was 1.23 (SD=0.46). The focus on TASSH subscale (1.77 (SD=0.59)) and educational support (1.31 (SD=0.68)) subscale demonstrated the highest mean score. The selection for openness to TASSH and recognition for utilizing TASSH subscales were rated slightly lower at 1.15 (SD=0.73) and 1.14 (SD=0.79), respectively. The rewards for utilizing TASSH subscale were rated the lowest at 0.73 (SD=0.48), which indicates that financial incentives for TASSH use may be uncommon within the clinics.
Responses mapped to CFIR
Of the 39 CFIR constructs assessed, 11 of the constructs emerged either as barriers or facilitators of integrating task-shifting strategies for HTN control within HIV clinics. Figure 1 provides a visual representation of key areas where additional effort or support could be important for successful implementation. Some constructs were found to be more dominant than others based on the degree of importance articulated by the stakeholders and clinic representatives. The CFIR constructs were more concentrated in the inner settings domain compared to the other 4 domains. The relevant constructs within each domain are reported below, including illustrative quotations [table 2].
CFIR-based facilitators with integrating TASSH within HIV Clinics
The relative advantage of TASSH
By delegating certain tasks to less specialized health cadres (i.e. nurses), the majority of the stakeholders perceived this model as a solution to make more efficient use of the existing workforce and reduce the workload of overburdened healthcare professionals.
A few health providers highlighted that the rational distribution of the clinical duties among cadres will allow the more specialized healthcare workers to focus solely on clinical tasks and procedures restricted to higher-level cadres. One of the healthcare providers’ notes:
“key aspect in the management of hypertension is diet, physical activity, taking appropriate medication and stress management which don’t require the attention of a doctor to achieve…if this task is shifted to them, the Doctors could focus on more complex tasks that require co-morbid management.” (HP 1)
Nonetheless, 79% (n=23/29) of the HIV clinic representatives surveyed reported that doctors were the sole providers of lifestyle-related information for HTN management such as prompting heart-healthy diet, low sodium intake, physical activity, and eliminating tobacco and caffeine intake.
Another advantage mentioned was the fact that integrating TASSH into routine care for PLHIV will offer patients the ability to access care in the same clinic or location, which may reduce clinic wait times and stigma associated with care-seeking among PLHIV in some settings.
“Integrating HIV and Hypertension care would reduce the stigma; it would reduce waiting time and there would be more Doctors available to attend to the patient.” (SH 1)
Compatibility with existing workflows and processes
Similar to the network and communications construct, several stakeholders suggested the integration of the existing community health extension workers (CHEWs) into the referral systems, as this may strengthen the compatibility of TASSH intervention within the HIV clinics.
“Community Health Extension Workers (CHEWs) could be useful in the tracking of patients, given their close understanding of the community and direct connections with the community members, which could help take some burden off the Nurses. They could serve as a liaison to provide a comprehensive system which starts from the home down to the health system to further strengthen the referral network for the intervention.” (SH3)
Within the HIV clinics, less than a quarter of the clinic representatives surveyed indicated that CHEWs and other community health officers are responsible for identifying (21%, n=6/29) and referring (14%, n=4/29) HIV patients who are hypertensive, suggesting significant gaps in the continuum of care for HTN.
Access to knowledge and information
Access to training opportunities and educational resources, about TASSH and how to incorporate it into the existing organizational processes were perceived as important facilitators for promoting initial uptake and sustained use of new processes within the facilities. This is particularly important as only 52% (n=15/29) of health facilities surveyed reported that there were training materials, journals, and other educational resources available for evidence-based practice for hypertension management within the HIV clinics. Similarly, 52% (n=15/29) indicated that their facilities provide specific conferences, workshops, or seminars on evidence-based practices. To illustrate the importance of training, one of the stakeholders provided an example where initial training of staff to implement a new process within the clinic gave them a sense of empowerment, thereby increasing their self-efficacy to carry out the given process.
“The training allowed them to do things they never imagined they could do and it was realized that research training was important to them as it enhanced implementation across the system and made the Nurses feel empowered” (SH12)
Needs and resources of those served by the intervention
Patient needs was a major implementation driver. Majority of the stakeholders supported the goal of the TASSH intervention because they felt that it addressed their long-standing concerns about the growing burden of NCDs among HIV patients at their facilities and how to integrate HTN care into HIV clinics, as described by a stakeholder that,
“patients are no longer dying of AIDS at the rapid rate they used to, they are living longer; thus, NCD’s such as cardiovascular diseases and hypertension are now becoming more problematic; the question now is, how can we integrate the treatment of NCD’s within an already existing HIV care” (SH12)
Incentives
Stakeholders expressed that health workers at the facilities would expect some form of non-monetary incentives that are both intrinsically and extrinsically motivating to enhance the productivity of health workers with new or additional responsibilities. Some of the suggestions to accommodate the need to incentivize the health workers included social recognition, an increase in professional status, and/or competencies backed by certification.
“there is a need to institutionalize the initiative of providing incentives in form of professional development, as Health workers want something to showcase as part of their achievements in their CVs [Curriculum Vitae]” (SH7)
Furthermore, monetary incentives were perceived by the stakeholders as an unsustainable form of compensation for managing health worker’s productivity. All the clinic representatives surveyed (n=29/29) indicated that providers at their health facility neither receive financial incentives nor commissions to use evidence-based practices for the management of diseases.
Knowledge and beliefs
Despite the potential of strain that could result from adding-on a new responsibility, as highlighted by one of the stakeholders, most of the health providers articulated their belief that the benefits of implementing TASSH within the HIV clinics outweigh any disadvantages. Of the HIV clinic representatives surveyed, 90% (n=26/29) of respondents indicated that evidenced-based practices for hypertension treatment are important to the providers in their health facilities.
Planning
To avoid the potential of overburdening the health workers, a stakeholder felt that the training required to enable a cadre to take on the new responsibilities should accommodate shift preferences and minimize scheduling conflicts. To do this, it was suggested that the research team consider on-site training at the health facilities as compared to offsite training in the different locations. Other suggestions that emerged within this theme was the need to implement simplified data collection tools to ease adaptation to routine data collection at the clinic and accommodate various reading comprehension levels among the participants. It was also important to the stakeholders that the programs’ goals align with the existing national guidelines for NCDs and clinic activities.
“ it is imperative to conform, from the beginning of the project to the existing National guidelines for NCDs so that whatever is used will be in-line with the priority actions in the guideline” (SH12)
Engagement
Critical to the successful development and implementation of the tailored TASSH intervention, the health providers emphasized the importance of engaging and retaining key individuals, particularly those identified as change agents or program champions within the HIV clinics, needed to provide governance. Facilitation of structured training, refresher courses, and adequate supportive supervision were regarded as essential implementation enablers and core leadership qualities needed in the change process. Furthermore, to sustain the intervention, stakeholders recommended continuous stakeholder engagement at every level of implementation and community awareness of the program.
CFIR-based barriers with integrating TASSH within HIV clinics
Complexity of TASSH
Discussion on the perceived difficulties of implementing the TASSH intervention within HIV clinics centered on challenges with dynamic role boundaries. Many cited the potential for disagreements and conflicts over roles and role boundaries among the cadres of health workers. The issues of power and authority were commonly cited as important factors that may influence relationships and patterns of collaboration among the health care teams. In this regard, some of the stakeholders emphasized the need to first understand the scope of practice for the lower-cadre healthcare workers at various facility levels, identify overlapping responsibilities, and then define the roles of the healthcare workers.
“We need to look at how services are delivered by these health workers at the primary and secondary care level especially as most patients in HIV care go to the primary care level.” (SH7)
“persons involved need to know their limitations particularly as Nurses and CHEW are on the same salary scale and have different entry qualifications... We need to clearly define tasks that would be reallocated and let limitations be clearly identified” (SH 5)
Available resources and support
Generally, it was found that primary health facilities were supported by the state ministry of health to ensure the availability of basic supplies, diagnostic equipment and first-line drug regimens related to HIV and hypertension management, but this level of support was not uniform across the different clinics, particularly at lower-level facilities. For instance, only 59% (n=17/29) of the HIV clinics surveyed reported that antihypertensive drugs were often readily available at their clinics. This generated some concerns among the stakeholders as they emphatically stated that this deficiency may stifle the implementation of the TASSH intervention within HIV clinics, as resource availability was viewed to be critical in determining the level of staffs’ readiness.
“there is a gap, a big discrepancy within the system. Within a small locality, there may be a flagship clinic that is better equipped than a general hospital and within that small locality there may be a primary health clinic that has just one Health care worker (HCW) catering to a lot of people” (SH6)
“A select number of flagship clinics are well stocked with drugs and equipment compared to the others. Some buoyant LGA’s have large laboratory which serves the PHC, while at some PHCs, there may have no drugs for the treatment of Hypertension” (SH5)
Networks and communication
In relation to referral channels and communications, most of the participants emphasized the need to strengthen referral networks for HTN management in order to support the decentralization of service delivery in the context of the task-shifting approach. This was seen to be particularly useful in the event that the health worker is faced with patient needs beyond their level of competence which may require higher-level consultation or referral. It was also noted that there were “no proper patient tracking mechanisms” (SH7) in place for intra-clinic referrals and referrals between clinics and hospitals.
External Policies
In the context of national policies, the national Multi-Sectoral Action Plan for the
Prevention and Control of Non-Communicable Diseases (2019-2025) from the Federal Ministry of Health in Nigeria identifies task-shifting as a priority action for NCD
management at all levels of care. In addition, we found that there is an existing task-shifting and task-sharing national policy for essential health care services in Nigeria published in 2014. Although these policies exist, stakeholders highlighted that the policies and guidelines are not implemented at the clinics. Additionally, a stakeholder added that the task-shifting and task-sharing national policy lacked specific actions for minimizing the workload of health workers in the clinics.
“The issue we have now is that there is no policy action that says we can only have a health worker take care of 50 people max, and beyond 50 people no more” (SH12)