Abstract
BackgroundIn 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.MethodsThis 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.ResultsThe 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).ConclusionUsing 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.
Highlights
In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD)
This study highlights the implementation of a communitybased cardiovascular disease prevention programme and how prior processes of assessing the needs of the community and implementers influenced implementation
Emerging themes from analysis of transcripts are presented under the consolidated framework for implementation research (CFIR) major domains embedding the framework constructs except for the process domain constructs that have been integrated within the others
Summary
In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). The SSA region experiences over a million cardiovascular disease (CVD) deaths annually with several risk factors on the rise [3]. In Uganda, over 25% of the adult population are hypertensive but awareness remains low [6, 7] and is the population knowledge on CVD and related risk factors [8, 9]. Broader determinants of health such as globalisation and urbanization have had influence on population lifestyles contributing to the increasing prevalence and incidence of modifiable CVD risk factors [10, 11]
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