Implementation of a large-scale hypertension program in primary health centres in the Federal Capital Territory, Nigeria: an explanatory, sequential mixed-methods study

Introduction To optimise hypertension care cascade, the multilevel Hypertension Treatment in Nigeria (HTN) Program, adapted from the WHO HEARTS package, was implemented within 60 primary healthcare centres (PHCs) in the Federal Capital Territory, Nigeria, from January 2020 to December 2023. Methods We conducted an explanatory sequential mixed-methods study, guided by the RE-AIM QuEST (Reach, Effectiveness, Adoption, Implementation, and Maintenance - Qualitative Evaluation for Systematic Translation) framework, to examine the factors influencing reach, effectiveness, adoption, implementation, acceptability and maintenance of the program. We conducted 13 focus group discussions in a subset of PHCs with patients (n=17), community health workers (n=35), pharmacy technicians (n=18) and PHC directors (n=5). Eighteen sites were purposively selected based on facility performance, targeting sites in the top and bottom 12% of blood pressure (BP) control at the end of the HTN Program. Qualitative data were coded, and subthemes were generated using directed content analysis. Results Program reach was facilitated by community education, peer influence and decentralisation of hypertension services. Patients perceived the program to be effective, citing successful BP control, fewer medication side effects and support for improving health behaviours. Adoption and fidelity were supported through training and supportive supervision strategies. Multiple outcomes, including reach, acceptability and maintenance, were facilitated by improved affordability of BP-lowering medication through a drug revolving fund scheme which led to minimal stockouts, although medication affordability remained a challenge for some patients. Health workers and directors identified needs for program sustainment, including maintaining their motivation and commitment, strengthening the medication supply chain and advocating for the inclusion of BP-lowering medications in the national health insurance scheme. Conclusion Our findings provide an understanding of the implementation strategies and program components that led to effective implementation of a primary care-based hypertension control program in Nigeria. These insights can support sustainment and nationwide scaling up of the program and inform similar programs in other low-income and middle-income countries.