Integration of Hypertension Management Into HIV Care in Nigeria

The primary outcome is change in systolic blood pressure (SBP) from baseline to 12 months. Following the research investigators' existing TASSH protocol, the SBP reduction in patients will assessed as mean change in systolic BP from baseline to 12 months. Blood pressure will be taken with valid automated BP device from the existing TASSH protocol.

Rate of adoption of TASSH is defined as the proportion of patients who were diagnosed with HTN by the HIV nurses; received lifestyle counseling and antihypertensive treatment from HIV nurses. For this purpose, adoption will be assessed as a composite of the following measures: 1) the number of hypertensive patients diagnosed by the nurses using the WHO CVD risk assessment; 2) proportion of patients with HTN who received lifestyle counseling from the nurses; and 3) proportion of patients for whom the HIV nurses initiated treatment with antihypertensive medications. In order to assess this measure, the nurses will complete a questionnaire inquiring about the number of patients with uncontrolled HTN who received medication treatment and lifestyle counseling.

Sustainability of TASSH is defined as the maintenance of TASSH uptake at the HIV clinics at 24 months (one year after the end of the intervention). Sustainability will be assessed with a composite quantitative measure similar to adoption and qualitatively, based on interviews with nurses and clinic leadership at 24 months. For this purpose, two research coordinators will conduct the interviews with two nurses and one key leadership personnel at each primary health center (PHCs).

Implementation Climate will be assessed with the Implementation Climate Scale. It measures shared perceptions of policies, practices, procedures, and behaviors that are expected, supported, and rewarded to facilitate effective evidence-based practice (EBP) implementation. It is an 18-item questionnaire that comprises six subscales. Each item is rated on a 5-point Likert scale from 0-4; each subscale score is calculated as the mean score of the associated items; the total score is the average of the six subscale scores and ranges from 0-4. Higher scores indicate a climate that is highly supportive of implementing EBPs.

Implementation Climate will be assessed with the Implementation Climate Scale. It measures shared perceptions of policies, practices, procedures, and behaviors that are expected, supported, and rewarded to facilitate effective evidence-based practice (EBP) implementation. It is an 18-item questionnaire that comprises six subscales. Each item is rated on a 5-point Likert scale from 0-4; each subscale score is calculated as the mean score of the associated items; the total score is the average of the six subscale scores and ranges from 0-4. Higher scores indicate a climate that is highly supportive of implementing EBPs.

Implementation Leadership will be assessed with the Implementation Leadership Scale (ILS). It is a 12-item measure with four subscales: Proactive Leadership (α=.95), Knowledgeable Leadership (α=.96), Supportive Leadership (α=.95), and perseverant leadership (α=.96) and a total score (α=.98). Each item is rated on an item-specific Likert scale. Each subscale score is calculated as the mean score of the associated items; the total score is the average of the four subscale scores and ranges from 0-4. Higher scores indicate greater implementation leadership.

Implementation Leadership will be assessed with the Implementation Leadership Scale (ILS). It is a 12-item measure with four subscales: Proactive Leadership (α=.95), Knowledgeable Leadership (α=.96), Supportive Leadership (α=.95), and perseverant leadership (α=.96) and a total score (α=.98). Each item is rated on an item-specific Likert scale. Each subscale score is calculated as the mean score of the associated items; the total score is the average of the four subscale scores and ranges from 0-4. Higher scores indicate greater implementation leadership.

Proficiency will be assessed using the Organizational Culture domain of the Organizational Social Context Scale, a 15-item Proficiency subscale used to evaluate the practice capacity proficiency level of the primary health centers (PHCs). Proficient Organizational Cultures are those characterized by shared norms and expectations that the nurses are skilled service providers, and have current knowledge of the TASSH protocol. Items are completed using a 5-point rating scale ranging from 1 (never) to 5 (always) with measures such as responsiveness (e.g., 'members of my organizational unit are expected to be responsive to the needs of each patient') and competence (e.g., 'members of my organizational unit are expected to have up-to-date knowledge'). The total score is the sum of responses and ranges from 15-75; higher scores indicate more proficient organizational cultures. Alpha reliability for the proficient culture scale is .89.

Proficiency will be assessed using the Organizational Culture domain of the Organizational Social Context Scale, a 15-item Proficiency subscale used to evaluate the practice capacity proficiency level of the primary health centers (PHCs). Proficient Organizational Cultures are those characterized by shared norms and expectations that the nurses are skilled service providers, and have current knowledge of the TASSH protocol. Items are completed using a 5-point rating scale ranging from 1 (never) to 5 (always) with measures such as responsiveness (e.g., 'members of my organizational unit are expected to be responsive to the needs of each patient') and competence (e.g., 'members of my organizational unit are expected to have up-to-date knowledge'). The total score is the sum of responses and ranges from 15-75; higher scores indicate more proficient organizational cultures. Alpha reliability for the proficient culture scale is .89.

Organizational Readiness to Change - Evidence is assessed with the 12-item Evidence Scale, which evaluates the strength of the evidence for the proposed change/innovation. It will be used to evaluate intervention process measures focused on CFIR's Evidence Strength & Quality and Relative Advantage construct. Each item measures the extent to which a respondent agrees or disagrees with the item statement on a 5-point Likert- type scale (1 = strongly disagree; 5 = strongly agree) and the Cronbach α=0.74. The total score is the sum of responses and ranges from 12 to 60; higher scores indicate greater strength of the evidence for the proposed change/innovation.

Organizational Readiness to Change - Evidence is assessed with the 12-item Evidence Scale, which evaluates the strength of the evidence for the proposed change/innovation. It will be used to evaluate intervention process measures focused on CFIR's Evidence Strength & Quality and Relative Advantage construct. Each item measures the extent to which a respondent agrees or disagrees with the item statement on a 5-point Likert- type scale (1 = strongly disagree; 5 = strongly agree) and the Cronbach α=0.74. The total score is the sum of responses and ranges from 12 to 60; higher scores indicate greater strength of the evidence for the proposed change/innovation.

External change agent support is assessed using a 3-item tool that evaluates support provided by external facilitators, the expectations about performance and improvement, and the ways to achieve the goal of the project. Items are scored on a 5-point Likert scale from 1-5 and the Cronbach α=0.77. The total score is the sum of responses and ranges from 3-15; higher scores indicate greater external change agent support.

External change agent support is assessed using a 3-item tool that evaluates support provided by external facilitators, the expectations about performance and improvement, and the ways to achieve the goal of the project. Items are scored on a 5-point Likert scale from 1-5 and the Cronbach α=0.77. The total score is the sum of responses and ranges from 3-15; higher scores indicate greater external change agent support.

Organizational Readiness to Change - Facilitation is measured using the Facilitation Scale (8-items) evaluates organizational capacity to facilitate change will be used to evaluate implementation process measures focused on CFIR Engaging construct. Each item measures the extent to which a respondent agrees or disagrees with the item statement on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree). It has Cronbach α=0.95. The total score is the sum of responses and ranges from 8-40; higher scores indicate greater organizational capacity to facilitate change.

Organizational Readiness to Change - Facilitation is measured using the Facilitation Scale (8-items) evaluates organizational capacity to facilitate change will be used to evaluate implementation process measures focused on CFIR Engaging construct. Each item measures the extent to which a respondent agrees or disagrees with the item statement on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree). It has Cronbach α=0.95. The total score is the sum of responses and ranges from 8-40; higher scores indicate greater organizational capacity to facilitate change.