Context matters in implementation efforts[29, 30]; thus, it is important to understand the key factors that will enhance or limit the effective implementation of evidence-based interventions in resource-constraint settings like Ghana. The main objective of this study was to identify ways to describe national, regional and district health stakeholders’ perspectives and characterize the array of strategies needed to enhance the implementation of evidence-based TASSH within Ghana’s Community-based Health and Planning Services (CHPS) zones.
Using the GCM, 46 statements grouped under six clusters highlighted
stakeholder’s perceptions of factors likely to influence uptake of TASSH including contextual issues that should be considered and developed with key stakeholders explicitly for the implementation of a task strengthening approach to community-based management of high blood pressure. These findings are relevant particularly in LMICs seeking to implement community-based strategies to ameliorate the burden of high blood pressure.
These six clusters include: 1) Referral Systems; 2) Availability of Equipment; 3) Protocols and Guidelines; 4) Capacity Building/Training; 5) Policy Reform, and 6) Technical Support and Supervision. Cluster 1 highlights how useful a good referral system can facilitate the implementation of the task strengthening strategy to improve hypertension outcomes. Cluster 2 highlights the essence of providing the needed equipment to implement an intervention like this such as the sphygmomanometer, weighing scales as well as height measuring devices. Cluster 3 and 4 while distinct share similar factors for the intervention’s implementation such as capacity building, provision of protocols and guidelines suitable for a community-based facility (such as the CHPS zones) to undertake the mandate of screening and referring individuals with hypertension to the next level of care (health centers or district hospitals) for the required treatment. Cluster 5 and 6 also highlight key health systems strengthening strategies that facilitate this community-based approach. The stress value of 0.225 reported by this study lies within the 95% confidence interval (0.205–0.365) reported by a meta-analysis of concept mapping projects which is an indication that final cluster was a representative of the stakeholders perspectives[20, 31].
A pattern match compared importance and feasibility ratings by the cluster. The cluster “availability of equipment” had a high mean rating (mean 4.80 out of 5) for importance followed by “capacity building” as well as both clusters had a high proportion of statements placed within the Go-zone. Also, the cluster “capacity building” received the high mean rating (mean 4.20 out of 5) for feasibility followed by the cluster “availability of equipment”. This is an indication that these two strategies were regarded as the most feasible and the most important strategies for the successful implementation of any community-based hypertension management program. These findings are similar to a study conducted by Blackstone et al., 2017 in the Ashanti Region of Ghana, that found that personnel training was the most feasible and important intervention component . Although important (mean 4.40 out of 5), Policy reform was rated as the least feasible strategy to address. In this study, the overall correlation between the ratings for importance and feasibility was moderately positive (r = 0.67). This is an indication that participants opinions on importance aligns with what is considered feasible. The degree of slope of the lines (in Fig. 2) between importance and feasibility demonstrate this alignment. For example, there was much alignment between importance and feasibility to implement indicators within the cluster protocol and guidelines domain. Also, participants agreed on the relative low importance and feasibility of policy reforms as a strategy required for the successful implementation of a community-based hypertension control programme like uptake TASSH.
The statements in the cluster “availability of equipment” offers a rich repository of ideas for identifying the needed logistics and immediate next steps for the successful implementation of a health system strengthening initiatives for hypertension control. Furthermore, statements in the cluster “capacity building” highlights the need to develop a capacity building curriculum that includes educational and training materials for the health workers which will be used in the task strengthening training modules. These statements were considered and combined to design the interventions and training package that reflects specific targets and contexts. Although, policy reforms had the least mean rating for both importance and feasibility, the statements in the cluster provides pragmatic implementation strategies that can be implemented within the primary care.
There are two key messages from this formative phase activity. To begin with, for a successful implementation of a community-based hypertension control programme requires multicomponent, multi-stakeholder action and cooperation. Outputs from this study signals 6 broad areas for interventions as well as specific requirements for action across the various level of care.
Secondly, our work underscores the importance of incorporating the perspectives of healthcare leadership (different stakeholder groups) in highlighting strategies that will be useful for the implementation processes of community-based task-shifting strategies for hypertension management and control. Encouragingly, some of the identified strategies mimic the Ministry of Health strategies sets out to prevent, control and manage non-communicable diseases (NCDs) including hypertension. For example, the policy document as part of its strategic areas of implementation specify health system strengthening; particularly in terms of capacity building and provision of logistics as a priority for preventing and managing NCDs at the community level. 
Strength and Limitations
Key contributions of this study are the identification of key strategies for the implementation of community-based strategies for hypertension control. The stakeholders who participated in this study work at GHS and are quite knowledgeable about the inner works of the health system in Ghana. The understand the capacity for success of an intervention and their numerous years in the field provide a keen insight that will help with the modification of a tasks strengthening intervention. The diverse group of stakeholders who hold positions at the national, regional and district level provide a varied scope of recommendations that can be targeted at each tier of the health system in Ghana when considering the scale of implementation of the intervention in the health system. Statements grouped into clusters are a useful source of information for researchers, policy makers and policy implementing agencies to select and combine to design and implement community-level strategies for hypertension control across different context and various cascade of healthcare. The statements suggested and grouped into clusters provides other implementation strategies which can be considered for future research for its effectiveness, Despite these strengths this study, the team note the following limitations. Although the study sampled and included various stakeholders across different levels of healthcare leadership, the small sample size of 22 may limit the generalizability of the study findings. Albeit this limitation, the study draws on the perspective of key individuals who formulate policy as well as implement policy across the Ghana healthcare system. Therefore, the views shared cut across the various levels of healthcare and are relevant to the existing system. Additionally, we did not include the community health officers who were going to implement the task strengthening interventions. However, the participants included leaders of these community health officers which implies that their views may not be different from the community health officers.