Applying the Behavior Change Wheel to develop strategies to integrate hypertension and HIV care in South African urban primary care clinics.

Long clinic wait times were identified as a priority barrier to hypertension care integration in South African HIV clinics.

• Barriers were identified through patient interviews (n=46), manager interviews (n=7), and clinical staff focus group discussions (nine groups; n=44 total participants).
• Barriers were subsequently ranked by a Community Advisory Board (CAB) to inform implementation strategy development.
• Long wait times were among four priority barriers identified across data sources.

Limited clinician training was identified as a priority barrier to integrating hypertension care into HIV services.

• This barrier emerged from patient interviews, manager interviews, and staff focus group discussions across urban clinics in Johannesburg.
• Limited training was one of four prioritized barriers ranked by the CAB.
• The barrier informed the development of a clinician training implementation strategy.

Poor patient understanding of hypertension was identified as a priority barrier to hypertension care integration.

• This finding emerged from qualitative data collection with 46 patients, 7 managers, and 44 clinical staff participants.
• Poor patient understanding was one of the four top-ranked barriers identified by the Community Advisory Board.
• This barrier directly informed the development of a structured patient education strategy.

Weak information management systems were identified as a priority barrier to hypertension and HIV care integration.

• This barrier was identified across multiple data sources including patient interviews, manager interviews, and staff focus groups.
• It was ranked as a high-priority barrier by the Community Advisory Board.
• The barrier informed strategies to revise clinic workflows and record systems.

The CAB identified six feasible, high-priority implementation strategies to address barriers to hypertension care integration.

• Strategies included structured patient education, clinician training, use of care champions, providing audit and feedback, revising clinic workflows and record systems, and adding resources to support routine blood pressure checks.
• Strategies were identified and specified through virtual meetings and workshops with CAB members, surveys, and qualitative feedback from clinic managers.
• Strategy development was guided by mapping intervention functions and behavior change techniques to prioritized barriers using the Behavior Change Wheel (BCW).

The Behavior Change Wheel framework was applied to systematically map barriers to intervention functions and behavior change techniques in a South African primary care context.

• The BCW was used to link prioritized barriers to intervention functions and behavior change techniques.
• Community engagement—including CAB workshops, surveys, and manager feedback—was embedded within the BCW process.
• This formative study demonstrates the utility of the BCW to guide community-informed implementation strategy design.

The resulting implementation strategies are planned to be tested in a type 2 hybrid effectiveness-implementation trial.

• The trial will assess impact on both clinical and implementation outcomes.
• The hybrid trial design will allow simultaneous evaluation of effectiveness and implementation.
• This next step was specified as a direct output of the BCW-guided formative strategy development process.

Hypertension is described as a leading comorbidity among people with HIV in South Africa, yet integration of hypertension screening and treatment into HIV care remains limited.

• The study was situated in urban primary care clinics in Johannesburg, South Africa.
• The gap in integration was described as persistent, motivating the use of context-specific, implementation science-grounded strategies.
• This context established the rationale for the formative strategy development study.