Community health worker-facilitated home visits for hypertension management in urban Nepal: a mixed-methods process evaluation

Objectives Hypertension remains poorly controlled globally, highlighting the need for scalable community-based strategies. Although community health worker (CHW)-facilitated interventions show promise, implementation evidence from low- and middle-income countries remains limited. This study assessed the implementation processes, mechanisms of impact and contextual factors influencing a CHW-facilitated home visit intervention for hypertension management.Design Mixed-methods process evaluation nested within a randomised cluster trial.Setting An urban municipality in Nepal.Participants Individuals with hypertension were surveyed at baseline (n=1252) and follow-up (n=1098). CHWs completed routine monitoring forms and home visits were observed (n=47). In-depth interviews were conducted with individuals with hypertension (n=20), spouses (n=7), adult children (n=13), CHWs (n=8) and public primary healthcare providers (n=5).Results Overall, 86% of participants completed all six planned home visits. Visits were generally delivered with fidelity, with minor adaptations to fit participant and family contexts. Participants reported high satisfaction and perceived benefits, including improved knowledge, family support and uptake of self-blood pressure monitoring. However, developed behavioural action plans often lacked specificity, limiting progress follow-up and accountability. Weak public primary care capacity, medication stockouts and preference for higher-level or private facilities constrained care linkage.Conclusion CHW-facilitated home visits addressed key individual and family-level barriers to hypertension management, but impact was limited by uneven behaviour uptake and constrained public primary healthcare capacity for medication supply and titration. Strengthened CHW training and mentorship are needed to support effective behaviour change. Integration of community interventions with functional primary care systems is essential for sustained hypertension control in low-resource urban settings.Trial Registration number NCT05292469; date of registration: 22 March 2022; URL: https://clinicaltrials.gov/ct2/show/NCT05292469?cntry=NP&draw=2&rank=6.