Community health worker-facilitated home visits for hypertension management in urban Nepal: a mixed-methods process evaluation.

The majority of participants completed all planned home visits, indicating high intervention reach.

• 86% of participants completed all six planned home visits.
• The study was nested within a randomised cluster trial in an urban municipality in Nepal.
• Participants were surveyed at baseline (n=1252) and follow-up (n=1098).
• Home visits were observed (n=47) to assess fidelity.

Home visits were generally delivered with fidelity, with only minor adaptations made to fit participant and family contexts.

• Fidelity was assessed through routine monitoring forms completed by CHWs and direct observation of 47 home visits.
• Adaptations were described as 'minor' and made to fit participant and family contexts rather than representing major deviations.
• In-depth interviews were conducted with individuals with hypertension (n=20), spouses (n=7), adult children (n=13), CHWs (n=8), and public primary healthcare providers (n=5) to assess implementation processes.

Participants reported high satisfaction with the CHW-facilitated home visits and perceived multiple benefits.

• Perceived benefits included improved knowledge, increased family support, and uptake of self-blood pressure monitoring.
• Satisfaction and perceived benefits were captured through in-depth interviews with individuals with hypertension (n=20) and family members.
• Spouses (n=7) and adult children (n=13) were interviewed separately to capture family-level impacts.

Behavioural action plans developed during home visits often lacked specificity, limiting progress follow-up and accountability.

• The lack of specificity in action plans was identified as a barrier to effective behaviour change support.
• This finding points to the need for strengthened CHW training and mentorship to support effective behaviour change.
• The limitation was identified through qualitative data from in-depth interviews and observation of home visits.

Weak public primary care capacity, medication stockouts, and preference for higher-level or private facilities constrained care linkage.

• Public primary healthcare providers (n=5) were interviewed and contributed to understanding systemic constraints.
• Medication stockouts were identified as a specific structural barrier to hypertension management.
• Participant preference for higher-level or private facilities limited the effectiveness of referral and care linkage processes.
• These contextual factors were identified as limiting the overall impact of the CHW-facilitated intervention.

Integration of community interventions with functional primary care systems was identified as essential for sustained hypertension control in low-resource urban settings.

• The study was conducted in an urban municipality in Nepal, representing a low- and middle-income country context.
• The finding emerged from mixed-methods analysis combining quantitative survey data, monitoring forms, observations, and qualitative interviews.
• Strengthened CHW training and mentorship were identified as necessary to support effective behaviour change alongside system-level improvements.
• The trial was registered as NCT05292469, with registration date 22 March 2022.