Key result
HEARTS pilot boosts primary care medication availability to ~81% but shows poor 3-month retention.
Why the study?
Most Latin American countries have committed to adopting the PAHO HEARTS approach for managing hypertension and diabetes in national primary care health systems. This study aimed to understand and refine a HEARTS pilot for national scale-up in Guatemala.
While the HEARTS pilot in Guatemala was quantitatively feasible and acceptable, mixed-methods evaluation revealed that successful national scale-up requires addressing structural barriers such as punitive medication supply chain policies, competing staff workloads, and gaps in diabetes care and nurse-focused training.
Answers are grounded in this paper and cite their sources.
Pilot gains in medication availability and hypertension volume are hypothesis-generating; leaves open whether barriers limit retention and diabetes scale-up.
Objectives: Most countries in Latin America have committed to adopting HEARTS, PAHO's recommended approach for managing hypertension and diabetes in national primary care health systems. This study aimed to understand and refine a HEARTS pilot for scale-up in Guatemala. Methods: Team members conducted semi-structured interviews with 30 patients and health workers participating in a HEARTS pilot across 10 primary care facilities in Guatemala's Ministry of Health system. Researchers analyzed interviews using a combined inductive-deductive approach alongside the Tailored Implementation in Chronic Diseases framework and used convergent mixed methods to generate meta-inferences. Results: Despite high feasibility and acceptability scores, health workers described tensions between HEARTS and competing responsibilities. Patients described rational navigation of an unreliable system, a more fitting explanation for low retention than noncompliance. Both patients and health workers understood HEARTS as another externally funded project with uncertain sustainability. Medication availability improved during the pilot, but district and facility-level incentive structures perpetuated supply unreliability. Greater absolute treatment gains for hypertension than for diabetes likely reflected health worker comfort and preexisting access to blood pressure monitoring supplies. Both patients and health workers identified education gaps. Integration of qualitative and quantitative findings suggested concrete scale-up refinements, including simplifying treatment protocols, strengthening diabetes components, focusing training on nurses, reforming central-level pharmaceutical supply policies, and securing high-level Ministry of Health commitments. Conclusions: A HEARTS pilot trial in Guatemala met pre-specified quantitative outcomes, but qualitative and mixed-methods approaches revealed key barriers. These findings will assist in refining HEARTS in Guatemala for planned national scale-up. Trial registration: ClinicalTrials.gov (NCT06080451).
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Valley et al. (2026) studied Hypertension and/or diabetes (n=30). WHO/PAHO HEARTS primary care implementation model (standardized clinical protocols, strengthened medication supply chains, nurse task-sharing, electronic monitoring tool, and administrative quality feedback) was evaluated on Qualitative and mixed-methods implementation determinants, feasibility, and acceptability of the HEARTS pilot. The HEARTS primary care pilot improved facility medication availability from 60% to 81% and monthly hypertension treatment by 22.3 patients vs 3.5 for diabetes, though 3-month retention was 36%.
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