A Thematic Analysis of Key Informant Interviews on the Implementation Experience of the HEARTS Hypertension Program in Nigeria

Study setting

The NCHI hypertension management program serves as a model for HEARTS implementation, offering structured guidance on lifestyle counseling, standardized treatment, essential medicines, team-based care, and monitoring. It aims to expand hypertension care through a team-based approach that empowers nurses and community health workers. Nigeria’s HEARTS protocol follows a structured regimen, starting with amlodipine 5 mg daily and progressing to combinations with losartan and hydrochlorothiazide as needed. Generic medications are available at public facilities to ensure access. The initiative has been piloted in 104 primary health centers in Kano and Ogun, enrolling about 35,000 patients, with 60 additional clinics in Abuja FCT participating in a University of Abuja hypertension outcomes study.

Key informant interviews and thematic analysis

The interview guide was developed specifically for this study by the research team, was structured around four HEARTS/NHCI implementation domains—service delivery, medication procurement and availability, task shifting, and broader program operations—and was not adapted from a pre-existing validated instrument. Eleven open-ended questions were posed across these four domains (Table 1). The study followed the Standards for Reporting Qualitative Research (SRQR) framework (6).

Fifteen key informants were purposively selected, one from each NHCI/HEARTS-participating primary care facility: five in the Abuja Federal Capital Territory (FCT), five in Kano State, and five in Ogun State. At each facility, the respondent was the Health Facility Officer-in-Charge or the designated hypertension/non-communicable disease focal person. These respondents had direct frontline management or clinical coordination responsibilities for HEARTS/NHCI implementation in their facilities and were therefore positioned to comment on service delivery, medication procurement and availability, task shifting, and broader program operations. Where relevant, respondents corroborated answers by consulting other facility staff responsible for specific operational tasks, such as drug supply or data reporting. Interviews were conducted face-to-face by the principal investigator between February and April 2024 and lasted approximately one hour each.

Following Naeem et al. (2023) (7), we conducted a structured, multi-step thematic analysis. The principal investigator (PI) conducted in-person interviews with key informants, each lasting about an hour. Responses were manually transcribed into Microsoft Excel and organized by facility and question. During initial coding, the PI and lead author independently reviewed transcripts, highlighted key excerpts, and assigned concise response codes. These were grouped into broader themes by identifying recurring concepts, with Microsoft Copilot assisting in generating an initial list. All authors collaboratively refined and named the themes to ensure clarity and alignment with the data. Final themes and codes were then applied to interpret implementation experiences across facilities. The counts presented in Table 2 reflect the number of key informants whose responses contributed to each code; codes are not mutually exclusive, and counts are descriptive within this purposive sample rather than prevalence estimates.

Service delivery

Respondents reported improved hypertension service delivery under the HEARTS protocol compared to usual care. In Abuja, four of five respondents noted enhanced competence and capacity in hypertension management, and four of five reported improved access to quality-assured, affordable medicines. In Kano, improvements in detection and management capacity were reported by four of five respondents, with four of five also noting improved capacity for tracking loss to follow-up patients. In Ogun, three of five respondents noted improved hypertension management capacity using the standardized HEARTS protocol. Despite these gains, challenges remain. In Abuja, four of five facilities reported patient dropouts after user fees were introduced following an initial period of free medication. One facility cited inefficiencies due to underutilized health workers who had not been trained or empowered to provide services. Respondents also emphasized the need for periodic retraining and timely equipment maintenance. In Ogun, two facilities reported increased data collection burdens on healthcare workers, potentially affecting service efficiency.

Medication procurement and availability

The medications supply chain presented varying challenges across different states. Three of five Abuja respondents reported no difficulty securing medication supply, with one Abuja facility flagging staffing constraints that limited refill trips and another noting initial-period stockouts. All Kano respondents and four of five Ogun respondents reported no significant supply difficulties. One Ogun facility reported a current losartan stockout. Despite these site-specific issues, there was a general sense of satisfaction with the HEARTS protocol across all three states (12 of 15 facilities expressed satisfaction). The consistent application of the protocol contributed to the perceived improved healthcare outcomes and positive feedback from the healthcare providers, underscoring the importance of reliable medication supply chains.

Task shifting

Task shifting was widely seen as a positive development within the HEARTS program. Improved service delivery as a result of task shifting was reported across nearly all sites (13 of 15 facilities). It enabled more efficient task allocation, allowing nurses and community health workers to take on responsibilities typically handled by doctors, such as enrollment counseling, screening, and treatment. Two of five Abuja respondents specifically noted a confidence boost among lower-cadre health workers as an additional benefit. However, the need for comprehensive training was highlighted by respondents in one Abuja facility, underscoring the importance of equipping staff with the skills and knowledge to carry out these delegated tasks. Thorough training is essential to maintain high standards of care and maximize the benefits of task shifting.

Program integration and support needs

Several additional aspects were highlighted that could further enhance the HEARTS program’s effectiveness. Integrating diabetes care into Nigeria’s HEARTS framework was suggested by respondents from three of five health facilities in Abuja to support a more holistic approach to chronic disease management. To address logistical challenges and improve medication affordability, decentralizing sourcing was recommended by one Abuja facility. Medication access and affordability issues were also noted by one facility in Abuja, two in Kano, and two in Ogun. In Ogun, there was also a call for increased training and support for health workers at one facility, and equipment maintenance at another—emphasizing the need for ongoing investment in healthcare infrastructure and workforce development.