Determinants of scaling a systems-level hypertension intervention from the District Supervisors' perspectives in Mozambique

Abstract

In Mozambique, an estimated 39% of individuals have hypertension; however, only 14.5% are aware of their condition (compared to 44% globally), and only half of those aware receive care. The Systems Analysis and Improvement Approach (SAIA) is an implementation strategy designed to improve clinic performance and optimize care. The SCALE-SAIA-HTN (hypertension) trial aims to determine whether SAIA is sustainable when scaled using state-level employees as SAIA coaches. This sub-analysis uses an explanatory sequential analysis to determine facilitators and barriers to SCALE-SAIA-HTN from the district supervisors' perspectives in Maputo Province, Mozambique. Quantitative fidelity scores were calculated to create a high-to-low district fidelity ranking. Thirteen in-depth interviews with district supervisors across implementation waves and study phases were analyzed using embedded directed content analysis informed by CFIR 1.0. Quantitative results indicated that fidelity scores were not impacted by study implementation waves, though scores decreased from intensive to maintenance phases. Six key themes were identified. Facilitators included leadership engagement, provider incentives, and an understanding of hypertension care/treatment and SAIA components. Barriers included overly complex SAIA action plans, external events, and resource constraints. There were no significant differences between high and low fidelity districts, indicating consistency of facilitators and barriers across districts regardless of fidelity score.