Barriers and enablers to improving integrated primary healthcare for non-communicable diseases and mental health conditions in Ethiopia: a mixed methods study

Abstract Background: The Ethiopian Primary Healthcare Clinical Guidelines (EPHCG) seek to improve quality for people with Non-Communicable Diseases and Mental Health Conditions (NCDs-MHCs) and provide an integrated approach to multi-morbidity. The aim of this study was to identify barriers and enablers to implementation of the EPHCG with a particular focus on NCDs-MHCs. Methods: A mixed-methods convergent-parallel design was employed from May, 2019 to January, 2020 after implementation of EPHCG in 18 health facilities across four districts and one town administration in southern Ethiopia. Semi-structured interviews were conducted with 10 primary healthcare clinicians and one healthcare administrator to identify barriers and enablers. The Organisational Readiness for Implementing Change (ORIC) questionnaire was self-completed by 124 health workers to identify facility level readiness for change. Determinants from both approaches were mapped to the Consolidated Framework for Implementation Science (CFIR) and the Theoretical Domains Framework (TDF). Expert Recommendations for Implementing Change (ERIC) were employed to select potential implementation strategies to address barriers. Results: Four thematic domains, EPHCG training and implementation, awareness and meeting patient needs (demand side), resource constraints/barriers (supply side) and care pathway bottlenecks were identified. The innovative facility-based training to implement the guidelines had a mixed response, especially in busy facilities where teams reported struggling to find protected time to meet. Key barriers to implementation of EPHCG were non-availability of resources (CFIR inner setting), such as reagents for laboratory tests and medications that undermined efforts to follow guideline-based care; the way care was structured and lack of familiarity with providing care for people with NCDs-MHCs. Substantial barriers arose because of interlinked socio-economic problems that were interlined with health but not addressable within the health system (CFIR outer setting). Several behavioural determinants influenced effective implementation of EPHCG (TDF), including low population awareness about NCDs/MHCs and unaffordable diagnostic and treatment services. Implementation strategies were identified. Survey findings indicated high scores of organisational readiness to implement the desired change but were notably more positive than the qualitative data. Conclusions: Although perceived as important and necessary, practical implementation of EPHCG was constrained by challenges across domains of internal/external context and behavioural determinants. This was especially marked in relation to expansion of care responsibilities to include NCDs-MHCs. Attention to social determinants of health outcomes, community engagement and awareness-raising are needed to maximize population impact. Key words: Barriers; enablers; clinical guidelines; NCDs-MHCs; organisational readiness; primary healthcare. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement National Institute for Health and Care Research, King's College London and Wellcome Trust. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Addis Ababa University, College of Health Sciences Institutional Review Board I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data for this manuscript is available upon reasonable request.