TASO Tororo was the highest performing for all the six cascade steps. Mulanda HC IV was intermediate for screening, diagnosis, initiation of treatment, and control but lowest for retention and monitoring. Nagongera HC IV was the lowest for all the six cascade steps having achieved the same with Mulanda HC IV in retention and monitoring. (Figure 2).
Apart from the DHT member, the male to female ratios of participants were 1:1 in all FGDs, IDIs and KIIs. (Table 2).
Of the 39 CFIR constructs assessed, 17 were relevant to either barriers or facilitators to HTN/HIV integration. We found six constructs which strongly distinguished performance, three of which were in the Inner setting (Organizational Incentives & Rewards, Available Resources, and Access to Knowledge & Information); two in Characteristics of individuals (Knowledge & Beliefs about the Intervention and Self-efficacy) and one in Intervention characteristics (Design Quality & Packaging). Four additional constructs distinguished performance weakly. All ten distinguishing constructs negatively influenced HTN/HIV integration. There were four constructs [Relative advantage, Adaptability, the simplicity (non-complex nature) of the intervention and Compatibility] which had positive influence for HTN/HIV integration at all the three HIV clinics but did not distinguish performance. These four factors related to the intervention are the key facilitators for HTN/HIV integration. The remaining three constructs negatively influenced HTN/HIV integration but were non- distinguishing. (Table 3). Below, we present the detailed results in the context of the five CFIR domains.
Healthcare providers at all three HIV clinics perceived HTN/HIV integration as a relative advantage and more effective compared to alternative modes of care for hypertensive PLHIV. Health care providers noted that integrated HTN/HIV saves time since patients received care for both HTN and HIV in the same clinic on the same appointment date, hence reducing costs on transport and improving retention.
“It is extremely important because if I were a patient having two chronic conditions, I would not want to spend my time going to a hospital for condition A and then go to another for condition B. HIV clinics should be a one-stop centre … (KII, health facility manager HIV clinic C)
Adaptability was a facilitator for HTN/HIV integration since respondents at all the clinics perceived that HTN/HIV integration fits within their routine care provision. Health care providers stated: “HTN services can be tailored and refined to meet health needs of PLHIV.”
“Yes, hypertension management fits very well within our HIV care programs. (KII, health facility manager HIV clinic C).
Inadequacies in the design quality and packaging of HTN/HIV integration especially when the program was being initiated was a barrier to the implementation. Health care providers reported that the implementation of HTN/HIV integration policy by MoH was suboptimal. This strongly distinguishing construct mainly affected the low performing clinics. Health care providers at these clinics reported insufficiencies in the preparation, packaging and support for HTN/HIV integration including lack of: staff and professional training systems such as initial orientation to the new health guidelines: These healthcare providers noted that;
“The introduction of this program was not well communicated to the staff. A clear plan for HTN service provision should have been given to us and may be an official launch involving patients and we healthcare providers. (KII, facility manager, HIV clinic A).
Although the presentation and design of the integration were cited as insufficient, healthcare providers at the high implementing HIV clinic noted that they receive some support through their organisation arrangements which has helped them to get acquainted with the HTN/HIV integration program.
“We didn’t have any capacity building at the start. However, as an organisation, we regularly have Continuous Medical Education (CME) on non-communicable diseases to boost the staffs’ knowledge. So we got some information on the suggested HTN/HIV integration strategies.” (KII, clinician, site C).
Complexity was a facilitator for HTN/HIV integration. Across the HIV clinics, healthcare providers perceived provision of HTN care services as a task which was not complex and that activities for integrated HTN/HIV care were straightforward. However, an increased number of hypertensive PLHIV at the HIV clinics with few healthcare providers would increase provider work load and complexity of handling all patients. A member of the DHT stated:
“For now, running the HIV clinics when providing care for opportunistic infections (OIs) and other NCDs isn’t difficult at these clinics. Although …. when patients are many, it could be challenging for the few staff to offer care for the many tasks.”(KII, DHT).
Patient needs and resources was a barrier to HTN/HIV integration and weakly distinguished performance across the three HIV clinics. Both health care providers and patients were in agreement that, to a large extent, HTN services at the HIV clinics were suboptimal to meeting the needs of PLHIV. Providers at lower performing HIV clinics added that HTN services were not adequately prioritized as evidenced by the low demand.
“Save for the good HIV care, it [HTN management] is almost not provided at this centre. … So, I seek treatment outside this centre.” (IDI 1, HIV clinic A).
“Patients are mainly interested in getting the HIV medicine [ART] refills. They do not demand for extra care unless their health has deteriorated. Most are not aware of other clinical service we provide including HTN management.” (Lead nurse HIV clinic B).
“We also like to work on all patients’ conditions but we are sometimes limited by resources. Even now, not much is being done to support HTN integration.” (KII, DHO).
Because the low implementing HIV clinics were not in a position to meet PLHIV’s needs for HTN management, hypertensive PLHIV were often referred to other health facilities, a strategy which HTN patients were not comfortable with.
“I was sent to Tororo general clinic (private for profit) to get checked and I was diagnosed with hypertension. I have the results with me but I’m always told to go back for care at the hospital.” (P2, FGD 2, HIV clinic A).
External Policy and Incentives was a weekly distinguishing construct that negatively influenced HTN/HIV integration. There were few external strategies for HTN/HIV integration through policies and guidelines. Although at the high performing site, healthcare providers stated implementing the national HIV guidelines, their emphasis was on the HIV component:
Currently we are implementing the 2016 National guidelines for HIV/AIDS with emphasis on test and treat.” (Lead clinician HIV clinic C).
This construct was highlighted by healthcare providers at the low performing site that they lacked comprehensive guidelines for HTN/HIV integration:
“We also lack specific standard operating procedures or documents to be followed in the HTN/HIV integration.” (KII, Lead clinician HIV clinic A).
Besides, healthcare providers also reported insufficient support supervision from the health authorities including MoH, DHT, and implementing partners in relation to HTN management.
“No! We have not received any supervision at the HIV clinic, may be at the OPD [outpatient department]. Besides, when we are asked about the clinic, we are often asked about HIV care and supplies”. (KII, Lead nurse HIV clinic A).
Three sub-constructs under Implementation Climate were relevant to HTN/HIV integration. These were: compatibility, relative priority and organization incentives and rewards. Compatibility was a facilitator for HTN/HIV integration. Healthcare providers perceived that HTN/HIV integration was compatible and would fit within the existing workflows at the HIV clinics. One of the healthcare providers noted:
“Yes, hypertension services do fit within our routine HIV care service provision.” (KII, lead clinician HIV clinic A).
Relative priority, was a weakly distinguishing construct which negatively influenced HTN/HIV integration. Although health care providers reported that HTN management would fit within the HIV clinic workflow, we found a relatively lower priority attached to HTN management by the healthcare providers compared to HIV care. Healthcare providers reported irregular provision of HTN services at the HIV clinic and providers from the low and intermediate performing facilities explicitly stated that:
“Basically, we provide the necessary HIV care services... and often patients are many; much work to do, so we prioritize HIV care”. (KII, lead clinician HIV clinic B).
“We often check the BP for patients with known hypertension and prescribe for them the medicines. However, those ones who are not yet known, we may check once in six months or when they complain with signs and symptoms suggestive of hypertension.” (KII, Lead clinician HIV clinic A).
Organization incentives and rewards was a barrier that strongly distinguished HTN/HIV integration. While healthcare providers at the high performing HIV clinic seemed to be motivated by the availability of equipment and other supplies to manage HTN, providers at the lower preforming sites expressed the need to receive incentives like functional BP equipment and HTN treatment supplies or rewards to motivate their action for additional HTN services:
“Even the medicines and other equipment should be available. But we are still struggling to get better BP machines.” (KII, Lead clinician HIV clinic A).
“The HIV clinic does not receive special facilitation [payment] for managing hypertension cases.” (KII, Lead clinician HIV clinic B).
The two sub-constructs Available resources and Access to knowledge and information under the Readiness for implementation construct were barriers to HTN/HIV integration.
Available resources for HTN services within the HIV clinics was a strongly distinguishing factor because the high performing site reported having adequate resources including staff who manage HTN, functional BP machines at each department, and medicines for HTN:
“Yes, I think we have adequate support. We have resources like drugs, equipment they are there, human resource.” (KII, Lead clinician HIV clinic C).
On the contrary, low and intermediate performing HIV clinics reported lack of enough equipment especially functional BP machines. They also experience frequent stockouts of the medicines for HTN and the lack of specific funding towards HTN services:
“… sometimes the [BP] machine at the clinic breaks down and it takes a longer process to get another. Yes. Most times we experience stockout of these HTN drugs, so we end up referring the patients.” (KII, facility manager HIV clinic B).
Similarly, access to information and knowledge was a barrier that strongly distinguished HTN/HIV integration between high and low performing clinics. At the high performing clinic, healthcare providers reported often having trainings including continuing medical education (CMEs) sessions. Some of the CMEs would be refresher trainings and education on NCDs care including HTN.
“We always have CMEs on hypertension cases, we have had workshops and trainings, management of OIs and hypertension is part of it, that one has been done.” (KII, Lead clinician HIV clinic C).
On the other hand, healthcare providers at lower performing sites stated low access to information and knowledge about HTN care for PLHIV. They identified lack of trainings, few available trained staff at their sites, and poor learning environment as contributing factors.
“We have not had [trainings or capacity building sessions on hypertension management] for some time and that is the challenge that we have.” (KII, facility manager A).
Characteristics of individuals
Knowledge and beliefs about HTN/HIV integration was a strongly distinguishing construct and a barrier. At the high and intermediate sites, healthcare providers were acquainted with knowledge and skill to offer HTN services like BP measurement and prescription of medicine while at the low performance site, some of the health care providers lacked the skills to appropriately screen and treat HTN:
“I realized that health workers would report inconsistent BP measurements from patients. In case the triage says the blood pressure is high, I would measure again in the clinical room. Okay, there are some acceptable variations but there are those that are out of range. So it creates the need for more trainings.” (KII, lead clinician HIV clinic A).
Self-efficacy, a strongly distinguishing construct, was a barrier to HTN/HIV integration at the low and intermediate sites. While healthcare providers at the high performing site expressed confidence in their own ability to screen and treat HTN, some providers at the lower performing clinics expressed low self-efficacy to screen and prescribe medicines for HTN. One health care provider stated:
“Patients often present to us [with] different symptoms, in case you follow only these symptoms, you may think its pressure yet it’s not. I have sometimes used the BP machine, but because I don’t use it frequently, I don’t think I get exact measurements to conclude that one has pressure.” (KII Lead nurse HIV clinic B).
Execution of HTN/HIN integration was a weakly distinguishing construct as responses across the three clinics expressed sub optimal HTN services. A healthcare providers at the low performing HIV clinic mentioned:
“… we concentrate on the HIV care package ... We sometimes include hypertension, but not frequently. (KII, lead clinician HIV clinic A).
Results for the three CFIR constructs which were non-distinguishing and negatively influencing HTN/HIV integration namely: Peer pressure, Reflecting and Evaluating and Engaging opinion leaders are presented in the appendix.