Understanding Readiness with COM-B: Barriers and Enablers for Hypertension and Diabetes Screening in Primary Health Care in Addis Ababa, Ethiopia

Hypertension and diabetes are leading contributors to morbidity and mortality in Ethiopia. Although primary healthcare (PHC) facilities serve as the main entry points for prevention and early detection, their readiness to deliver screening and management services remains suboptimal. This study assessed the readiness of PHC facilities in Addis Ababa to deliver hypertension and diabetes care and explored barriers and facilitators influencing screening practices.

A mixed-methods study was conducted in ten primary health centers across six sub-cities of Addis Ababa, serving catchment populations ranging from 26,733 to 101,733. The quantitative component used a tool adapted from the WHO Service Availability and Readiness Assessment (SARA) to evaluate staffing, infrastructure, equipment, laboratory capacity, and medication availability. The qualitative component included in-depth interviews with 21 clinical staff (physicians, nurses, and health officers), analyzed thematically using the Capability, Opportunity, Motivation–Behavior (COM-B) model and the Theoretical Domains Framework (TDF).

All centers offered hypertension and diabetes management, as well as lifestyle counseling. None conducted universal glucose screening because of insufficient glucometer test strips, though routine blood pressure measurement was standard. Eight centers had all antihypertensive medications available, while Hydralazine and Enalapril were missing in two.

A total of 814 staff were reported across all facilities, including 549 key clinical staff (39 physicians, 319 nurses, 191 health officers). The overall staff-to-patient ratio ranged from 6.7 to 50.0 per 1,000 patients (mean = 16.5), while key clinical staff density ranged from 4.4 to 26.0 per 1,000. Only 4.6% of all key clinical staff had received NCD-related training, although 73.5% of designated NCD staff (n = 34) had received training. The mean equipment adequacy score was 79.1%, with common gaps in BP cuffs and glucometer strips. Laboratory services were functional in all centers, though 70% had HbA1c testing, and all reported intermittent reagent stockouts.

Qualitative findings identified barriers related to capability (limited NCD-specific training, reliance on age- or symptom-based screening), opportunity (supply interruptions, infrastructure gaps, and documentation burden), and motivation (burnout, limited incentives, and confidentiality concerns). Facilitators included community-based insurance, NGO support, leadership engagement, and staff commitment.

Primary health care facilities in Addis Ababa exhibit basic readiness for non-communicable disease care; however, staff training, equipment availability, and laboratory reliability are inadequate. Improving hypertension and diabetes screening and management in Ethiopia requires strengthening workforce capacity, ensuring consistent diagnostic and medication supplies, and implementing supportive staff policies.

Given that uncontrolled hypertension and diabetes are the leading precursors of chronic kidney disease, enhancing PHC readiness for early detection and management directly contributes to CKD prevention and better kidney health outcomes. Integrating kidney health indicators within existing NCD programs, expanding access to renal function testing, and fostering interlinkages between hypertension, diabetes, and CKD care at the primary level could significantly reduce the long-term burden of kidney disease in Ethiopia.