Abstract:
Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist;
however, country level application is low due to lack of service readiness, uneven health worker motivation, weak
accountability of health worker performance, and poor integration of hypertension screening and management with
chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation
strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps
(cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and
iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and
management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA
interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to
the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-
HTN) will be effective as an adaptable, scalable model for broad implementation.We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension
management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include
hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical
outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional
patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted,
from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated
Framework for Implementation Research will guide qualitative evaluation of the implementation process in high- and
low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable
components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure
facility-level readiness for adopting SAIA-HTN.SAIA packages user-friendly systems engineering tools to guide decision-making by front-line health workers
to identify low-cost, contextually appropriate chronic care improvement strategies. By integrating SAIA into routine
hypertension screening and management structures, this pragmatic trial is designed to test a model for national scale-up.
