Building Capacity on Hypertension Management in Nigeria

TL;DR

This study examines how a training program improved healthcare workers' knowledge of hypertension treatment in Nigeria.

Contribution

The novelty lies in evaluating the impact of a simplified hypertension protocol training on healthcare workers in Nigeria.

Findings

Health care workers showed improved knowledge after the training program.

The study provides baseline data for future hypertension management interventions in Nigeria.

Abstract

This cross-sectional study estimates changes in health care workers’ knowledge of the simplified Nigerian hypertension treatment protocol after participating in a hypertension management training program.

Tables

Table 1.. Comparison of Knowledge of Hypertension Among the Different Categories of Health Workers (N = 236)

Workforce cadre	Participants, No. (%)	Knowledge scores, median (IQR)		Difference (95% CI)
		Pretest	Posttest
Nurses and CHEWs	102 (43.2)	6.5 (5.5-7.5)	7.0 (6.0-8.0)	0.8 (0.3-1.2)
Pharmacists	95 (40.3)	4.0 (3.0-5.5)	7.5 (6.3-8.0)	3.5 (3.0-4.0)
Physicians	39 (16.5)	6.5 (5.0-8.0)	9.0 (8.0-9.0)	2.2 (1.5-3.0)

Table 2.. Evaluation of Hypertension Workshop by Health Workers

Survey domaina	Median (IQR)	Participants, No. (%)
		Excellent	Very good	Neutral	Good	Poor
Nurses and CHEWs
Content relevance	4.0 (4.0-5.0)	32 (36.0)	40 (44.9)	1 (1.1)	16 (18.0)	0
Delivery (methodology)	4.0 (4.0-5.0)	31 (38.8)	33 (41.3)	2 (2.5)	14 (17.5)	0
Delivery (role play)	4.0 (4.0-5.0)	36 (40.0)	37 (41.1)	2 (2.2)	15 (16.7)	0
Applicability	5.0 (4.0-5.0)	26 (52.0)	18 (36.0)	1 (2.0)	5 (10.0)	0
Pharmacists
Content relevance	5.0 (5.0-5.0)	85 (78.7)	23 (21.3)	1 (0.9)	0	0
Delivery (methodology)	5.0 (5.0-5.0)	90 (84.9)	16 (15.1)	0	0	0
Delivery (role play)	5.0 (4.0-5.0)	50 (56.8)	32 (36.4)	5 (5.7)	1 (0.17)	0
Applicability	5.0 (5.0-5.0)	87 (84.5)	16 (15.5)	0	0	0
Physicians
Content relevance	5.0 (4.0-5.0)	19 (63.3)	10 (33.3)	0	0	1 (3.3)
Delivery (methodology)	5.0 (4.0-5.0)	21 (70.0)	8 (26.7)	0	0	1 (3.3)
Delivery (role play)	5.0 (4.0-5.0)	18 (60.0)	11 (36.7)	0	0	1 (3.3)
Applicability	5.0 (4.3-5.0)	22 (73.3)	7 (23.3)	0	0	1 (3.3)

Full text

Introduction

Strengthening primary care for noncommunicable disease management through task-sharing is critical to reducing premature mortality in low- and middle-income countries.^1^ Although task-shifting guidelines for hypertension exist in Nigeria,^2^ primary health care workforces remain underprepared, reflecting their long-standing focus on infectious diseases.^3^

We implemented the Hypertension Academy training program in Akwa Ibom State, Nigeria, as part of the MAP-IT study to support uptake of the simplified Nigerian hypertension treatment protocol^2^ among health workers. The primary objective was to estimate short-term changes in cadre-specific hypertension knowledge before and after training. Secondary objectives were to assess training acceptability and self-reported confidence in hypertension management.

Methods

This cross-sectional study evaluated the outcomes of 3 Hypertension Academy workshops conducted between January 16 and April 20, 2024, for nurses, community health extension workers (CHEWs), primary care physicians, and community pharmacists. The study was approved by the institutional review boards of the University of Abuja and New York University Grossman School of Medicine. All participants provided written informed consent, and analytic datasets contained no individually identifiable information. The study followed the STROBE reporting guideline for cross-sectional studies.

The Hypertension Academy targeted proximal implementation outcomes through structured, guideline-based training, focusing on short-term knowledge gains and acceptability rather than downstream clinical outcomes. Training content was based on the simplified Nigerian hypertension protocol for primary care^2^ and the World Health Organization HEARTS package.^4^ Participants completed an anonymized pretraining and posttraining knowledge assessment (eAppendix in Supplement 1) and a posttraining evaluation of content, delivery, and applicability. The knowledge assessment included 10 items covering core domains of primary care hypertension management. Pretraining and posttraining assessments were linked using unique codes for matching, and analyses were conducted on deidentified paired data. Scores ranged from 0 to 10, with higher scores indicating greater guideline-based knowledge. Training evaluations assessed content relevance, delivery, and applicability using 5-point Likert scales from 1 (poor) to 5 (excellent) and were summarized descriptively using means, SDs, and response distributions, with domain-level summaries characterizing acceptability.

Normality of pretraining and posttraining differences was assessed using the Shapiro-Wilk test.^5^ Because differences were nonnormally distributed, results were summarized using medians and IQRs. Paired comparisons were by the Wilcoxon signed rank test,^6^ with effect sizes reported as Hodges-Lehmann median differences and CIs. Bonferroni adjustment maintained a 95% family-wise confidence level. Analyses were stratified by cadre to estimate within-cadre change; multilevel models and workshop-level clustering adjustments were not applied. The analyses were conducted using R, version 4.5.1 (R Foundation).

Results

A total of 236 health workers (169 female [71.6%] and 67 male [28.4%]) participated in the training and were included in the primary analysis, including 102 nurses and CHEWs (43.2%), 95 pharmacists (40.3%), and 39 physicians (16.5%). Within-participant improvements were found in hypertension knowledge across cadres, with higher median posttest scores in each group (from 7.0 [IQR, 6.0-8.0] for nurses and CHEWS to 9.0 [IQR, 8.0-9.0) for physicians) (Table 1).

Training evaluations showed high acceptability, with median Likert scores for content relevance, delivery, and applicability ranging from 4.0 to 5.0. Participants also reported increased confidence in hypertension management and high ratings of applicability of the training to their clinical roles (Table 2).

Discussion

This cross-sectional study found short-term improvements in hypertension knowledge and high training acceptability among primary care health workers participating in the Hypertension Academy. Use of simplified, context-specific protocols^2,4^ and interactive training aligns with global recommendations for task-sharing in low- and middle-income countries.

Several limitations merit consideration. The pretraining and posttraining design without a control group limited causal inference. Identical assessments may have introduced test familiarity effects, and posttraining evaluations may have reflected social desirability bias. Response rates varied across cadres, and the single-state implementation limits generalizability. Despite these limitations, the Hypertension Academy represents a scalable approach to primary care workforce development. Future studies should assess knowledge retention, clinical outcomes, and integration into routine continuing education systems.