Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: A cross-sectional study using the COACH questionnaire

Ana A. Baumann, Cole Hooley, Charles W. Goss, Vincent Mutabazi, Angela L. Brown, Kenneth B. Schechtman, Marc Twagirumukiza, Lisa De Las Fuentes, Dominic Reeds, Makeda Williams, Eugene Mutimura, Anna Bergström, Aurore Nishimwe, Cecile Ingabire, Victor G. Davila-Roman

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Importance Hypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary. Objective To study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool. Design A cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training. Setting Three tertiary care hospitals in Rwanda. Participants Healthcare professionals (n=223). Primary outcome(s) and measure(s) The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0-1 scale). Four questions surveyed training on hypertension. Results Responders (n=223, 75% women; 56% aged 20-35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care. Conclusions There is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

Original languageEnglish
Article numbere048425
JournalBMJ Open
Issue number9
StatePublished - Sep 21 2021


  • education & training (see medical education & training)
  • hypertension
  • quality in healthcare


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