Table 1 (abstract P45). Barriers and enablers to the implementation of EPHCG identified using the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR)

Intervention characteristics (evidence strength and quality, relative advantage)

PHC workers found the training offered for the EPHCG useful.

The mode of workplace-based training for EPHCG was appreciated by some respondents as allowing more relevant and comprehensive discussion, but others preferred off-site training due to distractions and workplace pressures.

Strong policy directive supporting facility-based learning

Inner setting (readiness for implementation, available resources)

Critical shortage of diagnostic tests and medication which undermined efforts to follow the guideline, high patient load which made it difficult to consult the guidance and deliver comprehensive care, pressure on space and high turnover of staff.

Focus for Quality Improvement cycles

Implementation coverage

The EPHCG implementation was initiated in some primary healthcare facilities but not in others despite the conduct of cascade of training of trainers.

Strengthen supportive supervision and remove potential barriers

Outer setting (patient needs and resources)

The involvement of patients in making decisions about treatment options (person-centred care) was not commonly practiced by PHC workers.

Train PHC workers to develop competencies

Knowledge

After training, knowledge PHC workers had improved knowledge post training that was reflected in ability to detect NCDs and MHCs.

Post training, PHC workers still felt inadequately equipped to manage depression, diabetes mellitus and cardiac diseases.

Patients and the wider community had low awareness about NCDs/MHCs which meant people presented late, with more severe illness, and were less engaged in self-management.

Supplementary training in mental health conditions – WHO’s mental health Gap Action Programme

Skills

Emotional support was not sufficiently provided to patients in need due to lack of skills among PHC workers

Train PHC workers to develop competencies

Confidence

PHC workers had improved confidence post training in managing hypertension and asthma.

PHC workers felt inadequately equipped to manage depression, diabetes mellitus, and cardiac diseases

Information leaflets and community-based health extension worker detection of hypertension / awareness -raising

Intentions

Detection of NCDs and MHCs was not perceived to be a challenge. However, PHC clinicians reported that they were not proactive in managing care and monitoring adherence.

Train PHC workers to develop competencies

Follow up

Gaps in timely follow-up or tracking of patients were recognized and shortage of resources to use electronic devices for the tracking

Capacity development and mentoring support to PHC workers