Investigating the enablers and barriers for hypertension control in Dakar: a qualitative system effectiveness study.

objectiveCardiovascular disease is the main cause of death worldwide. The leading risk factor, hypertension, is a major public health issue in Senegal, putting the health system under pressure. This qualitative study aimed to investigate how patients progress along the cascade of care of hypertension screening, diagnosis, treatment and control in Dakar, Senegal, in the context of the CARDIO4Cities initiative-a multisectoral urban population health initiative targeting cardiovascular risk factors in various cities globally. DESIGN AND

settingA qualitative case study in Dakar, Senegal, was conducted to map the cascade of hypertension care and identify enablers and barriers for patient progression across the cascade of care. PARTICIPANTS AND ANALYSIS: Twelve semistructured interviews were conducted with community and healthcare actors in three districts of the city of Dakar. A systems thinking lens and method, called process mapping, was used to guide the qualitative research and the analysis of the results.

resultsThe process analysis delineated four themes as enablers of patient progression: improved management processes in primary care for hypertension; community outreach and engagement; data generation for healthcare provider monitoring of the hypertension cascade of care; and providing access to hypertension screening, monitoring and management tools. Barriers across the cascade were patients' low socio-economic status; trivialisation and denial of the disease; systemic challenges in the health system, such as high healthcare provider turnover; traditional gender roles that influence access to healthcare; and inefficiencies of new tools hindering healthcare provider engagement and workflow integration.

conclusionsA wide range of patient, health system and contextual factors were identified as facilitating and hindering the progression of hypertension patients across the cascade of care in Dakar, Senegal. The structural determinants of health and systemic challenges in the health system were highlighted as prominent barriers, suggesting the need for upstream, system-oriented interventions for hypertension care in Dakar.