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Implementation of Single-Pill Combination Medication for Hypertension Treatment by Nonphysician Health Care Workers at Primary Healthcare Facilities in Nigeria: An Explanatory Mixed Methods Study Cover

Implementation of Single-Pill Combination Medication for Hypertension Treatment by Nonphysician Health Care Workers at Primary Healthcare Facilities in Nigeria: An Explanatory Mixed Methods Study

Open Access
|Dec 2025

References

  1. Odili AN, Chori BS, Danladi B, Nwakile PC, Okoye IC, Abdullah U, et al. Prevalence, awareness, treatment and control of hypertension in Nigeria: data from a nationwide survey 2017. Glob Heart. 2020;15(1):47. DOI: 10.5334/gh.848
  2. Burnier M, Egan BM. Adherence in hypertension. Circ Res. 2019;124(7):11241140. DOI: 10.1161/CIRCRESAHA.118.313220
  3. Jobe M, Beye SM, Gaye ND, Ka MM, Perel P, Perkins AD, et al. Hypertension in sub-Saharan Africa: burden, barriers and priorities for improving treatment outcomes. Circ Res. 2025;137(1):106118. DOI: 10.1161/CIRCRESAHA.124.323889
  4. Seedat YK. Why is control of hypertension in sub-Saharan Africa poor? Cardiovasc J Afr. 2015;26(4):1935. DOI: 10.5830/CVJA-2015-065
  5. Du LP, Cheng ZW, Zhang YX, Li Y, Mei D. The impact of fixed-dose combination versus free-equivalent combination therapies on adherence for hypertension: a meta-analysis. J Clin Hypertens. 2018;20(5):902907. DOI: 10.1111/jch.13272
  6. Salam A, Huffman MD, Kanukula R, Prasad EH, Sharma A, Heller DJ, et al. Two-drug fixed-dose combinations of blood pressure-lowering drugs as WHO essential medicines: an overview of efficacy, safety, and cost. J Clin Hypertens. 2020;22(10):17691779. DOI: 10.1111/jch.14009
  7. Kishore SP, Salam A, Rodgers A, Jaffe MG, Frieden T. Fixed-dose combinations for hypertension. The Lancet. 2018;392(10150):819820. DOI: 10.1016/S0140-6736(18)31814-2
  8. Benjamin IJ, Kreutz R, Olsen MH, Schutte AE, Lopez-Jaramillo P, Frieden TR, et al. Fixed-dose combination antihypertensive medications. The Lancet. 2019;394(10199):637638. DOI: 10.1016/S0140-6736(19)31629-0
  9. An J, Derington CG, Luong T, Olson KL, King JB, Bress AP, et al. Fixed-dose combination medications for treating hypertension: a review of effectiveness, safety, and challenges. Curr Hypertens Rep. 2020;22:119. DOI: 10.1007/s11906-020-01109-2
  10. Webster R, Salam A, de Silva HA, Selak V, Stepien S, Rajapakse S, et al. Fixed low-dose triple combination antihypertensive medication vs usual care for blood pressure control in patients with mild to moderate hypertension in Sri Lanka: a randomized clinical trial. JAMA. 2018;320(6):566579. DOI: 10.1001/jama.2018.10359
  11. Ojji DB, Salam A, Sani MU, Ogah OS, Schutte AE, Huffman MD, et al. Low-dose triple-pill vs standard-care protocols for Hypertension Treatment in Nigeria: a randomized clinical trial. JAMA. 2024;332(13):10701079. DOI: 10.1001/jama.2024.18080
  12. Salam A, Atkins ER, Hsu B, Webster R, Patel A, Rodgers A. Efficacy and safety of triple versus dual combination blood pressure-lowering drug therapy: a systematic review and meta-analysis of randomized controlled trials. J Hypertens. 2019;37(8):15671573. DOI: 10.1097/HJH.0000000000002089
  13. Kadiri S, Arogundade F, Arije A, Omotoso A, Onwubere B, Aderibigbe A, et al. Guidelines for the management of hypertension in Nigeria 2020. Tropical Journal of Nephrology. 2020;15(1):6584.
  14. Ojji DB, Huffman MD. The place of polypill in secondary prevention of stroke. Lancet Glob Health. 2023;11(10):e1488e1489. DOI: 10.1016/S2214-109X(23)00407-2
  15. Callaghan M, Ford N, Schneider H. A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health. 2010;8(1):8. DOI: 10.1186/1478-4491-8-8
  16. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Glob Public Health. 2011;6(3):247256. DOI: 10.1080/17441692.2011.552068
  17. Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2013;16(1):18586. DOI: 10.7448/IAS.16.1.18586
  18. Adebayo MA, Adeniyi BO, Oluwasanu M, Hassan A, Ajuwon GA, Ogbuji QC, et al. Tuberculosis treatment outcomes and associated factors in two states in Nigeria. Trop Med & Int Health. 2020;25(10):12611270. DOI: 10.1111/tmi.13467
  19. Sanuade OA, Ale BM, Baldridge AS, Orji IA, Shedul GL, Ojo TM, et al. Fixed-dose combination therapy-based protocol compared with free pill combination protocol: Results of a cluster randomized trial. J Clin Hypertens. 2023;25(2):127136. DOI: 10.1111/jch.14632
  20. Orji IA, Baldridge AS, Omitiran K, Guo M, Ajisegiri WS, Ojo TM, et al. Capacity and site readiness for hypertension control program implementation in the Federal Capital Territory of Nigeria: a cross-sectional study. BMC Health Serv Res. 2021;21(1). DOI: 10.1186/s12913-021-06320-8
  21. Baldridge AS, Aluka-Omitiran K, Orji IA, Shedul GL, Ojo TM, Eze H, et al. Hypertension Treatment in Nigeria (HTN) Program: rationale and design for a type 2 hybrid, effectiveness, and implementation interrupted time series trial. Implement Sci Commun. 2022;3(1):84. DOI: 10.1186/s43058-022-00328-9
  22. National Primary Health Care Development Agency. National Standing Orders, for Community Health Officers/Community Health Extension Workers. 2020; Bill Shakespeare.
  23. Okpetu EI, Abimbola S, Koot J, Kane S. Implementing prevention interventions for non-communicable diseases within the primary health care system in the Federal Capital Territory, Nigeria. Journal Community Med Prim Health Care. 2018;30(1):118.
  24. Ojji DB, Baldridge AS, Orji IA, Shedul GL, Ojo TM, Ye J, et al. Characteristics, treatment, and control of hypertension in public primary healthcare centers in Nigeria: baseline results from the Hypertension Treatment in Nigeria Program. J Hypertens. 2022;40(5):888896. DOI: 10.1097/HJH.0000000000003089
  25. World Health Organization. Guideline for the pharmacological treatment of hypertension in adults. World Health Organization; 2021.
  26. World Health Organization. Hearts: technical package for cardiovascular disease management in primary health care. 2021. World Health Organization; 2021. Accessed May 10, 2025.
  27. Schoonenboom J, Johnson RB. How to construct a mixed methods research design. KZfSS Kölner Zeitschrift für Soziologie und Sozialpsychologie. 2017;69(S2):107131. DOI: 10.1007/s11577-017-0454-1
  28. Forman J, Heisler M, Damschroder LJ, Kaselitz E, Kerr EA. Development and application of the RE-AIM QuEST mixed methods framework for program evaluation. Prev Med Rep. 2017;6:322328. DOI: 10.1016/j.pmedr.2017.04.002
  29. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):34957. DOI: 10.1093/intqhc/mzm042
  30. Dedoose. Dedoose Version 9.0.107, cloud application for managing, analyzing, and presenting qualitative and mixed method research data. 2023 [cited 2025 March 6th]. Available from: https://www.dedoose.com/.
  31. Campbell NRC. A step in the global effort to control hypertension: fixed dose combination antihypertensive drugs. J Clin Hypertens (Greenwich). 2019;21(9):14261428. DOI: 10.1111/jch.13683
  32. Mbuthia D, Willis R, Gichagua M, Nzinga J, Mugo P, Murphy A. Acceptability of fixed-dose combination treatments for hypertension in Kenya: a qualitative study using the theoretical framework of acceptability. medRxiv. 2024:2024.02.23.24303258. DOI: 10.1101/2024.02.23.24303258
  33. Okello S, Muhihi A, Mohamed SF, Ameh S, Ochimana C, Oluwasanu AO, et al. Hypertension prevalence, awareness, treatment, and control and predicted 10-year CVD risk: a cross-sectional study of seven communities in East and West Africa (SevenCEWA). BMC Public Health. 2020;20(1):1706. DOI: 10.1186/s12889-020-09829-5
  34. Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control. Circulation. 2016;134(6):441450. DOI: 10.1161/CIRCULATIONAHA.115.018912
  35. Sorato MM, Davari M, Kebriaeezadeh A, Sarrafzadegan N, Shibru T, Fatemi B. Reasons for poor blood pressure control in Eastern sub-Saharan Africa: looking into 4P’s (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review. BMC Cardiovasc Disord. 2021;21(1):123. DOI: 10.1186/s12872-021-01934-6
  36. Brown MT, Bussell JK. Medication adherence: who cares? Mayo Clin Proc. 2011;86(4):30414. DOI: 10.4065/mcp.2010.0575
  37. Kim H, Yoon HJ, Park HS, Cho YK, Nam CW, Han S, et al. Implications of prescribing a fixed-dose combination in clinical cardiology practice: a retrospective observational study using a single medical centre database in Korea. Heart Asia. 2017;9(2):e010885. DOI: 10.1136/heartasia-2017-010885
  38. Swanlund SL. Successful cardiovascular medication management processes as perceived by community-dwelling adults over age 74. Appl Nurs Res. 2010;23(1):2229. DOI: 10.1016/j.apnr.2008.03.005
  39. Drumond N, van Riet-Nales DA, Karapinar-Çarkit F, Stegemann S. Patients’ appropriateness, acceptability, usability and preferences for pharmaceutical preparations: results from a literature review on clinical evidence. Int J Pharm. 2017;521(1):294305. DOI: 10.1016/j.ijpharm.2017.02.029
  40. Osuafor NG, Ukwe CV, Okonta M. Evaluation of availability, price, and affordability of cardiovascular, diabetes, and global medicines in Abuja, Nigeria. PLOS ONE. 2021;16(8):e0255567. DOI: 10.1371/journal.pone.0255567
  41. Ndichu ET, Ohiri K, Sekoni O, Makinde O, Schulman K. Evaluating the quality of antihypertensive drugs in Lagos State, Nigeria. PLOS One. 2019;14(2):e0211567. DOI: 10.1371/journal.pone.0211567
  42. Essa M, Ross JS, Dhruva SS, Desai NR, Spatz ES, Faridi KF. Utilization of fixed-dose combination treatment for hypertension in Medicare and Medicaid from 2016 to 2020. Circ: Cardiovasc Qual Outcomes. 2024;17(5):e010697. DOI: 10.1161/CIRCOUTCOMES.123.010697
  43. Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task shifting for non-communicable disease management in low and middle income countries—a systematic review. PLOS One. 2014;9(8):e103754. DOI: 10.1371/journal.pone.0103754
  44. Adejumo OA, Ogundele OA, Mamven M, Otubogun FM, Junaid OA, Okoye OC, et al. Physicians’ perception of task sharing with non-physician health care workers in the management of uncomplicated hypertension in Nigeria: a mixed method study. PLOS One. 2023;18(9):e0291541. DOI: 10.1371/journal.pone.0291541
  45. Adeyemo A, Tayo BO, Luke A, Ogedegbe O, Durazo-Arvizu R, Cooper R. The Nigerian antihypertensive adherence trial: a community-based randomized trial. J Hypertens. 2013;31(1):2017. DOI: 10.1097/HJH.0b013e32835b0842
  46. Morris-Paxton AA, Rheeder P, Ewing R-MG, Woods D. Detection, referral and control of diabetes and hypertension in the rural Eastern Cape Province of South Africa by community health outreach workers in the rural primary healthcare project: health in every hut. Afr J Prim Health Care Fam Med. 2018;10(1):e1e8. DOI: 10.4102/phcfm.v10i1.1610
  47. Shedul GL, Ripiye N, Jamro EL, Orji IA, Shedul GJ, Ugwuneji EN, et al. Supportive supervision visits in a large community hypertension programme in Nigeria: implementation methods and outcomes. BMJ Open Quality. 2025;14(1):e003163. DOI: 10.1136/bmjoq-2024-003163
  48. Hong SH, Wang J, Tang J. Dynamic view on affordability of fixed-dose combination antihypertensive drug therapy. Am J Hypertens. 2013;26(7):879887. DOI: 10.1093/ajh/hpt035
  49. Bramlage P, Schmidt S, Sims H. Fixed-dose vs free-dose combinations for the management of hypertension-An analysis of 81 958 patients. J Clin Hypertens (Greenwich). 2018;20(4):705715. DOI: 10.1111/jch.13240
  50. Parati G, Kjeldsen S, Coca A, Cushman WC, Wang J. Adherence to single-pill versus free-equivalent combination therapy in hypertension. Hypertension. 2021;77(2):692705. DOI: 10.1161/HYPERTENSIONAHA.120.15781
  51. Zhou X, Zhang X, Gu N, Cai W, Feng J. Barriers and facilitators of medication adherence in hypertension patients: a meta-integration of qualitative research. Journal of Patient Experience. 2024;11:23743735241241176. DOI: 10.1177/23743735241241176
  52. Harrison MA, Marfo AFA, Opare-Addo MNA, Ankrah DNA, Acheampong F, Nelson F, et al. Anti-hypertensive medication access and affordability and their association with blood pressure control at a teaching hospital in Ghana. Pan Afr Med J. 2021;39:184. DOI: 10.11604/pamj.2021.39.184.27977
  53. Edward A, Campbell B, Manase F, Appel LJ. Patient and healthcare provider perspectives on adherence with antihypertensive medications: an exploratory qualitative study in Tanzania. BMC Health Serv Res. 2021;21(1):834. DOI: 10.1186/s12913-021-06858-7
  54. Shedul G, Sanuade OA, Ugwuneji EN, Ojo TM, Vijay A, Ponzing P, et al. Stakeholder perspectives on the demand and supply factors driving substandard and falsified blood pressure lowering medications in Nigeria: a qualitative study. BMJ Open. 2022;12(12):e063433. DOI: 10.1136/bmjopen-2022-063433
  55. Jifar WW, Geneti GB, Dinssa SD. The Impact of COVID-19 on pharmaceutical shortages and supply disruptions for non-communicable diseases among public hospitals of South West, Oromia, Ethiopia. J Multidiscip Healthc. 2022;15:19331943. DOI: 10.2147/JMDH.S377319
  56. Badreldin HA, Atallah B. Global drug shortages due to COVID-19: impact on patient care and mitigation strategies. Res Social Adm Pharm. 2021;17(1):19461949. DOI: 10.1016/j.sapharm.2020.05.017
  57. Faiva E, Hashim HT, Ramadhan MA, Musa SK, Bchara J, Tuama YD, et al. Drug supply shortage in Nigeria during COVID-19: efforts and challenges. J Pharm Policy Pract. 2021;14(1):17. DOI: 10.1186/s40545-021-00302-1
  58. Ajisegiri WS, Abimbola S, Tesema AG, Odusanya OO, Peiris D, Joshi R. The organisation of primary health care service delivery for non-communicable diseases in Nigeria: a case-study analysis. PLOS Glob Public Health. 2022;2(7):e0000566. DOI: 10.1371/journal.pgph.0000566
  59. Ajisegiri WS, Abimbola S, Tesema AG, Odusanya OO, Ojji DB, Peiris D, et al. Aligning policymaking in decentralized health systems: Evaluation of strategies to prevent and control non-communicable diseases in Nigeria. PLOS Glob Public Health. 2021;1(11):e0000050. DOI: 10.1371/journal.pgph.0000050
  60. Klassen SL, Okello E, Ferrer JME, Alizadeh F, Barango P, Chillo P, et al. Decentralization and integration of advanced cardiac care for the world’s poorest billion through the PEN-Plus Strategy for severe chronic non-communicable disease. Glob Heart. 2024;19(1):33. DOI: 10.5334/gh.1313
  61. Varghese C, Prem A, Nongkynrih B, Chattu VK, Mikkelsen B. Fourth UNHLM on noncommunicable diseases 2025: an opportunity to bridge the transcending priorities for impact in global south. PLOS Glob Public Health. 2025;5(3):e0004287. DOI: 10.1371/journal.pgph.0004287
  62. Shedul GJ, Ugwuneji EN, Jamro EL, Banigbe B, Ponzing P, Okpe I, et al. Design and implementation of a drug revolving fund for hypertension treatment in primary care setting of the Federal Capital Territory, Nigeria. BMJ Global Health. 2025;10(11):e018029. DOI: 10.1136/bmjgh-2024-018029
DOI: https://doi.org/10.5334/gh.1507 | Journal eISSN: 2211-8179
Language: English
Submitted on: Jul 27, 2025
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Accepted on: Dec 4, 2025
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Published on: Dec 22, 2025
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 1 issue per year

© 2025 Emmanuel I. Okpetu, Chisom Obiezu-Umeh, Boni M. Ale, Abigail S. Baldridge, Rosemary C. B. Okoli, Grace J. Shedul, Gabriel L. Shedul, Nanna R. Ripiye, Ikechukwu A. Orji, Lisa R. Hirschhorn, Dike B. Ojji, Mark D. Huffman, on behalf of the Hypertension Treatment in Nigeria Program Investigators, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.