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Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research.

ABSTRACT: Background: In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have explored the implementation processes of such interventions to inform their scale up and sustainability. Using the consolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencing the implementation of a community CVD programme led by community health workers (CHWs) in Mukono and Buikwe districts in Uganda.

Methods: This qualitative study is a process evaluation of an ongoing type II hybrid stepped wedge cluster trial guided by the CFIR. Data for this analysis were collected through regular meetings and focus group discussions (FGDs) conducted during the first cycle (6 months) of intervention implementation. A total of 20 CHWs participated in the implementation programme in 20 villages during the first cycle. Meeting reports and FGD transcripts were analysed following inductive thematic analysis with the aid of Nvivo 12.6 to generate emerging themes and sub-themes and thereafter deductive analysis was used to map themes and sub-themes onto the CFIR domains and constructs.

Results: The barriers to intervention implementation were the complexity of the intervention (complexity), compatibility with community culture (culture), the lack of an enabling environment for behaviour change (patient needs and resources) and mistrust of CHWs by community members (relative priority). In addition, the low community awareness of CVD (tension for change), competing demands (other personal attributes) and unfavourable policies (external policy and incentives) impeded intervention implementation. On the other hand, facilitators of intervention implementation were availability of inputs and protective equipment (design quality and packaging), training of CHWs (Available resources), working with community structures including leaders and groups (process-opinion leaders), frequent support supervision and engagements (process-formally appointed internal implementation leaders) and access to quality health services (process-champions).

Conclusion: Using the CFIR, we identified drivers of implementation success or failure for a community CVD prevention programme in a low-income context. These findings are key to inform the design of impactful, scalable and sustainable CHW programmes for non-communicable diseases prevention and control.

SUBMITTER: Ndejjo R

PROVIDER: S-EPMC7726905 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research.

Ndejjo Rawlance R Wanyenze Rhoda K RK Nuwaha Fred F Bastiaens Hilde H Musinguzi Geofrey G

Implementation science : IS 20201209 1

<h4>Background</h4>In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have explored the implementation processes of such interventions to inform their scale up and sustainability. Using the consolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencing the implementation of a community CVD programme led by communit ...[more]

PMID: 33298098

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Project description:BACKGROUND:Cardiovascular diseases (CVDs) are on the rise in many low-and middle-income countries where 80% of related deaths are registered. Community CVD prevention programmes utilizing self-care approaches have shown promise in contributing to population level reduction of risk factors. However, the acceptability of these programmes, which affects their uptake and effectiveness, is unknown including in the sub-Saharan Africa context. This study used the Theoretical Framework of Acceptability to explore the prospective acceptability of a community CVD prevention programme in Mukono and Buikwe districts in Uganda. METHODS:This qualitative descriptive study was conducted in March 2019 among community health workers (CHWs), who would implement the intervention and community members, the intervention recipients, using eight focus group discussions. All discussions were audio-recorded, transcribed verbatim and analysed thematically guided by the theoretical framework. RESULTS:CHWs and community members reported high eagerness to participate in the programme. Whereas CHWs had implemented similar community programmes and cited health promotion as their role, community members looked forward to health services being brought nearer to them. Although the intervention was preventive in nature, CHWs and community members expressed high interest in treatments for risk factors and were skeptical about the health system capacity to deliver them. CHWs anticipated barriers in mobilising communities who they said sometimes may not be cooperative while community members were concerned about failing to access treatment and support services after screening for risk factors. The major cost to CHWs and community members for engaging in the intervention was time that they would have dedicated to income generating activities and social events though CHWs also had the extra burden of being exemplary. CHWs were confident in their ability to deliver the intervention as prescribed if well trained, supported and supervised, and community members felt that if provided sufficient information and supported by CHWs, they could change their behaviours. CONCLUSIONS:The community CVD prevention programme was highly acceptable among CHWs and community members in Mukono and Buikwe districts of Uganda amidst a few burdens and opportunity costs. Suggestions made by study participants to improve programme effectiveness informed programme design and implementation for impact.

Project description:The burden of chronic diseases is increasing in both low- and middle-income countries. However, healthcare systems in low-income countries are inadequately equipped to deal with the growing disease burden, which requires chronic care for patients. The aim of this study was to assess the capacity of health facilities to manage hypertension in two districts in Uganda.In a cross-sectional study conducted between June and October 2012, we surveyed 126 health facilities (6 hospitals, 4 Health Center IV (HCIV), 23 Health Center III (HCIII), 41 Health Center II (HCII) and 52 private clinics/dispensaries) in Mukono and Buikwe districts in Uganda. We assessed records, conducted structured interviews with heads of facilities, and administered questionnaires to 271 health workers. The study assessed service provision for hypertension, availability of supplies such as medicines, guidelines and equipment, in-service training for hypertension, knowledge of hypertension management, challenges and recommendations.Of the 126 health facilities, 92.9% reported managing (diagnosing/treating) patients with hypertension, and most (80.2%) were run by non-medical doctors or non-physician health workers (NPHW). Less than half (46%) of the facilities had guidelines for managing hypertension. A 10th of the facilities lacked functioning blood pressure devices and 28% did not have stethoscopes. No facilities ever calibrated their BP devices except one. About a half of the facilities had anti-hypertensive medicines in stock; mainly thiazide diuretics (46%), beta blockers (56%) and calcium channel blockers (48.4%). Alpha blockers, mixed alpha & beta blockers and angiotensin II receptor antagonists were only stocked by private clinics/dispensaries. Most HCIIs lacked anti-hypertensive medicines, including the first line thiazide diuretics. Significant knowledge gaps in classification of patients as hypertensive were noted among respondents. All health workers (except 5, 1.9%) indicated that they needed additional training in hypertension management. Several provider and patient related challenges were also observed in this study.Health facilities in this setting are inadequately equipped to provide services for management of hypertension. Diagnostic equipment, anti-hypertensive drugs and personnel present great challenges. To address the increasing burden of hypertension and other chronic diseases, measures are needed to substantially strengthen the healthcare facilities, including training of personnel in management of hypertension and other chronic diseases, and improving diagnostic and treatment supplies.

Project description:BackgroundSub-Saharan Africa (SSA) is experiencing an increasing burden of Cardiovascular Diseases (CVDs). Modifiable risk factors including hypertension, diabetes, obesity, central obesity, sedentary behaviours, smoking, poor diet (characterised by inadequate vegetable and fruit consumption), and psychosocial stress are attributable to the growing burden of CVDs. Small geographical area mapping and analysis of these risk factors for CVD is lacking in most of sub-Saharan Africa and yet such data has the potential to inform monitoring and exploration of patterns of morbidity, health-care use, and mortality, as well as the epidemiology of risk factors. In the current study, we map and describe the distribution of the CVD risk factors in 20 parishes in two neighbouring districts in Uganda.MethodsA baseline survey benchmarking a type-2 hybrid stepped wedge cluster randomised trial design was conducted in December 2018 and January 2019. A sample of 4372 adults aged 25-70?years was drawn from 3689 randomly selected households across 80 villages in 20 parishes in Mukono and Buikwe districts in Uganda. Descriptive statistics and generalized linear modelling controlled for clustering were conducted for this analysis in Stata 13.0, and a visual map showing risk factor distribution developed in QGIS.ResultsMapping the prevalence of selected CVD risk factors indicated substantial gender and small area geographic heterogeneity which was masked on aggregate analysis. Patterns and clustering were observed for hypertension, physical inactivity, smoking, alcohol consumption and risk factor combination. Prevalence of unhealthy diet was very high across all parishes with no significant observable differences across areas.ConclusionModifiable cardiovascular risk factors are common in this low-income context. Moreover, across small area geographic setting, it appears significant differences in distribution of risk factors exist. These differences suggest that underlying drivers such as sociocultural, environmental and economic determinants may be promoting or inhibiting the observed risk factor prevalences which should be further explored. In addition, the differences emphasize the value of small geographical area mapping and analysis to inform more targeted risk reduction interventions.

Project description:Background:Persons living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to and facilitators of integrating HTN screening and treatment into HIV clinics in Eastern Uganda. Methods:We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews and focus group discussions with health services managers, healthcare providers, and hypertensive PLHIV (n = 83). Interviews were transcribed verbatim. Three qualitative researchers used the deductive (CFIR-driven) method to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. Results:Barriers to HTN/HIV integration arose from six CFIR constructs: organizational incentives and rewards, available resources, access to knowledge and information, knowledge and beliefs about the intervention, self-efficacy, and planning. The barriers include lack of functional BP machines, inadequate supply of anti-hypertensive medicines, additional workload to providers for HTN services, PLHIV's inadequate knowledge about HTN care, sub-optimal knowledge, skills and self-efficacy of healthcare providers to screen and treat HTN, and inadequate planning for integrated HTN/HIV services.Relative advantage of offering HTN and HIV services in a one-stop centre, simplicity (non-complex nature) of HTN/HIV integrated care, adaptability, and compatibility of HTN care with existing HIV services are the facilitators for HTN/HIV integration. The remaining CFIR constructs were non-significant regarding influencing HTN/HIV integration. Conclusion:Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration, HTN/HIV integration is of interest to patients, healthcare providers, and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.

Project description:BackgroundAlthough children's intake of fruit and vegetables has seen a recent rise, almost half of adolescents do not eat even one piece of fruit or vegetables per day. One way to address this problem is through interventions that provide fruit and vegetables directly to children in kindergartens and schools. For such interventions to meet their intended goals, what is important to consider in addition to impact is implementation. Our objective is to systematically review qualitative results reporting on the determinants (barriers and facilitators) to implementation of interventions that entail direct provision of fruit and vegetables in kindergarten and school settings and conduct a framework analysis of those results using the Consolidated Framework for Implementation Research (CFIR).MethodsA systematic search was designed and run in November 2019 for: MEDLINE (Ovid), Embase (Ovid), PsychINFO (Ovid), ERIC (Ovid), Cochrane Library Reviews and Cochrane Library Trials. A keyword search of the journal Implementation Science was completed. Screening of titles and abstracts (n = 5427) and full texts (n = 227), led to 14 included articles. Coding and analysis were done using the framework method and CFIR.ResultsThe following CFIR constructs were found relevant: 1) intervention characteristics domain: 'design quality and packaging', 'adaptability' 'cost'; 2) outer setting: 'cosmopolitanism', 'external policy and incentives' 'patients' needs and resources'; 3) inner setting: 'implementation climate', 'readiness for implementation' and 'structural characteristics'; 4) characteristics of individuals: 'individual stage of change', 'knowledge and beliefs about the intervention' 5) process: 'engaging', 'executing' and 'reflecting and evaluating'. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention, which could have implications for the design and implementation of future fruit and vegetables interventions. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies, and should be taken into consideration in future design efforts.ConclusionsCFIR offers a systematic way to identify and organize barriers and facilitators to implementation of interventions in the kindergarten and school setting. Revisions are encouraged to allow adequate space for perceptions of various implementation actors and the target group.Prospero registrationCRD42020167697.

Project description:BackgroundScreening, brief intervention, and referral (SBIR) is an evidence-based, comprehensive health promotion approach commonly implemented to reduce alcohol and substance use. Implementation research on SBIR demonstrate that patients find it acceptable, reduces hospital costs, and it is effective. However, SBIR implementation in hospital settings for multiple risk factors (fruit and vegetable consumption, physical activity, alcohol and tobacco use) is still emergent. More evidence is needed to guide SBIR implementation for multiple risk factors in hospital settings.ObjectiveTo explore the facilitators and barriers of SBIR implementation in a rural hospital using the Consolidated Framework for Implementation Research (CFIR).MethodsWe conducted a descriptive qualitative investigation consisting of both inductive and deductive analyses. We conducted virtual, semi-structured interviews, guided by the CFIR framework. All interviews were audio-recorded, and transcribed verbatim. NVivo 12 Pro was used to organize and code the raw data.ResultsA total of six key informant semi-structured interviews, ranging from 45 to 60 min, were carried out with members of the implementation support team and clinical implementers. Implementation support members reported that collaborating with health departments facilitated SBIR implementation by helping (a) align health promotion risk factors with existing guidelines; (b) develop training and educational resources for clinicians and patients; and (c) foster leadership buy-in. Conversely, clinical implementers reported several barriers to SBIR implementation including, increased and disrupted workflow due to SBIR-related documentation, a lack of knowledge on patients' readiness and motivation to change, as well as perceived patient stigma in relation to SBIR risk factors.ConclusionThe CFIR provided a comprehensive framework to gauge facilitators and barriers relating to SBIR implementation. Our pilot investigation revealed that future SBIR implementation must address organizational, clinical implementer, and patient readiness to implement SBIR at all phases of the implementation process in a hospital.

Project description:Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge.The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success.This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients.Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers' beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies.The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR's strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions.Clinicaltrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6cWeqN1uY).

Project description:BackgroundAlcohol screening and brief intervention (SBI) is recommended to be implemented in primary care settings to intervene against hazardous/harmful drinking. However, studies showed that the uptake rate was low in many regions/countries. This systematic review presented current findings on the facilitators and barriers of SBI implemented by health professionals in primary care settings using the Consolidated Framework for Implementation Research (CFIR).MethodsWe included qualitative, quantitative, and mixed-method studies identified through four electronic databases (PubMed, MEDLINE, PsycInfo, and Web of Science) from inception to June 2020. Included articles had to address barriers and facilitators of SBI implementation and provide sufficient details that the CFIR domains could be identified and data were abstracted using a standardized extraction form.ResultsA total of 74 studies published from 1985 to 2019 were finally analysed and summarized. The most common facilitators were knowledge and positive beliefs about SBI (characteristics of the individuals) and available resources (inner setting). In contrast, the most common barriers were cost related to implementing SBI (intervention characteristics), negative beliefs about SBI (characteristics of the individuals), and lack of self-efficacy in implementing SBI (characteristics of the individuals). It could be observed that factors related to the inner setting and characteristics of individuals were extensively studied whilst the process received the least attention.ConclusionsMost of the facilitators and barriers are modifiable. Additionally, most literature focused on various kinds of available assets to implement SBI. To promote the spread of SBI implementation, more high-quality studies on the implementation process are needed. This systematic review could serve as a reference framework for health authorities to devise strategies for improving the implementation of SBI in primary care settings.Trial registrationThis systematic review was registered in PROSPERO ( CRD42021258833 ).

Dataset Information

Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research.

Publications

Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research.

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