Stakeholder Engagement in the Translation of a Hypertension Control Program to Guatemala’s Public Primary Health Care System: Lessons Learned, Challenges, and Opportunities

Abstract

Background: There is an urgent need to define appropriate intervention strategies to control blood pressure in low-and middle-income countries. In 2018, a program proven effective in Argentina was translated to Guatemala's public primary health care system in rural and primarily indigenous communities.Objectives: This paper describes the stakeholder engagement process used to adapt the program to the Guatemalan rural context prior to implementing a type II hybrid effectiveness-implementation trial and shares lessons learned.Methods: We identified key differences in the 2 contexts that are relevant to translating the intervention to the Guatemalan context. Alongside interviews and focus group discussions, we conducted consultation workshops in July and August 2018, applying a participatory translation process involving patients, family members, community members, health care providers, and Ministry of Health officials. The process consisted of multiple meetings in Guatemala City, as well as meetings in each of the 5 departments where the study will be implemented, and 1 district per department. During the workshops, we presented the evidence-based experience from Argentina and then focused on the challenges and recommended solutions that the participants identified for each of the intervention's 6 components. The process concluded with a meeting in which the research team and Ministry of Health officials defined specific details of the intervention.Results: The outcome of the process is an adapted approach appropriate to integrate into Guatemala's public primary health care system in the trial phase. The approach considers the challenges and recommended strategies for each of the 6 intervention components.

Evaluating a multicomponent program to improve hypertension control in Guatemala: study protocol for an effectiveness-implementation cluster randomized trial

“…4), which are defined as methods to enhance the adoption, implementation, and sustainment of the core intervention [21]. The core intervention and implementation strategies were previously adapted to the rural Guatemalan context by the study team and stakeholders from the Ministry of Health and local communities [13]. Physicians and nurses working at intervention health centers and auxiliary nurses working at health posts are responsible for delivering the intervention.…”

“…Hypertension guidelines recommend antihypertensive medications and individualized lifestyle changes, which include weight loss, physical activity, reduced alcohol and sodium intake, and a diet rich in fruits and vegetables and in low-fat dairy products with reduced saturated and total fat (Dietary Approaches to Stop Hypertension, DASH) [7][8][9][10][11][12]. Our formative needs assessment documented several limitations related to hypertension management in Guatemala, including a limited health budget for the treatment of non-communicable diseases, fragmented governance and service delivery, inadequate training of the healthcare workforce, and shortage of essential hypertensive medications and basic equipment, particularly at frontline facilities [13]. In addition, an overarching challenge is the prioritization of infectious diseases and maternal and child health over non-communicable diseases [13].…”

“…Our formative needs assessment documented several limitations related to hypertension management in Guatemala, including a limited health budget for the treatment of non-communicable diseases, fragmented governance and service delivery, inadequate training of the healthcare workforce, and shortage of essential hypertensive medications and basic equipment, particularly at frontline facilities [13]. In addition, an overarching challenge is the prioritization of infectious diseases and maternal and child health over non-communicable diseases [13]. In other countries, barriers for implementing hypertension treatment guidelines at the primary care level include organizational-level obstacles, communication problems between the primary and secondary levels of care, multiple competing demands on physicians' time, and lack of reimbursement for preventive counseling [14,15].…”

“…This study is an implementation-effectiveness, hybrid, type 2, cluster randomized control trial that will evaluate a multilevel and multicomponent hypertension control program within the Guatemalan primary care system [17]. Through a formative mixed-methods assessment and adaptation workshops, we have adapted the effective Hypertensive Control Program in Argentina (HCPIA) and other implementation strategies to the Guatemalan context [13]. The multicomponent program includes a protocol-based hypertension treatment and five implementation strategies: team-based collaborative care, health provider education, health coaching sessions, home blood pressure monitoring, and blood pressure audit and feedback.…”

Stakeholder Engagement in Late-Stage Translation Research and Implementation Science: Perspectives From the National Heart, Lung, and Blood Institute

“…Stakeholders include community health officers, administrators, policymakers from the Ghana Health Services, researchers, and community health officers in communitybased regional health planning services [20,21]. In Guatemala, patients, family members, community members, health care providers, and Ministry of Health officials from 5 districts in Guatemala City are being engaged to help define details of the planned evidence-based interventions to be studied [16]. In Vietnam, the study team has engaged leaders of provincial Departments of Health, physicians, nurses, community health workers, and patients and gained support for a storytelling intervention to help control hypertension, which is adaptable to local cultural needs [15].…”