Acceptability of community health worker-led hypertension care with independent prescribing in rural Lesotho: a mixed- methods study

Abstract Background Task-shifting to lay community health workers (CHWs) has been shown to extend access to hypertension care. However, in most studies prescribing authority remained with nurses or physicians. Whether lay CHWs can independently prescribe antihypertensive treatment, and whether this is acceptable to patients, remains poorly understood. Two cluster-randomised trials nested within the Community-Based chronic Care Lesotho (ComBaCaL) cohort demonstrated the safety and effectiveness of CHW-led hypertension management with independent prescribing supported by a mobile clinical decision support system (CDSS). We assessed the acceptability of this model among participants enrolled in the two trials. Methods This mixed-methods study was guided by the Theoretical Framework of Acceptability (TFA). A structured survey covering the eight TFA constructs and valued aspects, concerns, and recommendation intent regarding CHW-led hypertension management was administered to participants in the intervention arm of the trials. In-depth interviews were conducted with participants purposively sampled across different care pathways. Quantitative data were summarised descriptively, qualitative data were analysed using deductive content analysis, and findings were integrated during interpretation. Results A total of 322 participants completed the survey after a median of 576 days (IQR 531–603) of exposure to the intervention, and 20 were interviewed. The median age was 66 years (IQR 55–74); 254 (78.9%) were female. Overall, 200 participants (62.1%) received CHW-led antihypertensive prescribing throughout follow-up. Acceptability of CHW-led hypertension care was very high (97.2%, 313/322), including CHW-led prescribing (96.9%, 312/322). Interviews highlighted trust in CHWs and the convenience of home-based care. Most participants understood the intervention and were confident it had improved their hypertension management; this confidence appeared reinforced by participants' awareness of CHW training, supervision, and the digital CDSS. The main concerns were personal or family conflict with the CHW and confidentiality concerns, rather than concerns about CHW competence. Conclusions CHW-led hypertension care with independent prescribing was highly acceptable among participants in rural Lesotho. High acceptability supports the feasibility of implementing this model beyond research settings, although attention to confidentiality and interpersonal relationships will be important for successful scale-up. Trial registration: ClinicalTrials.gov NCT05684055, registration date 13 January 2023.