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Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods and analysis<\/jats:title>\n                  <jats:p>This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Ethics and dissemination<\/jats:title>\n                  <jats:p>Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Trial registration number<\/jats:title>\n                  <jats:p>\n                     <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"ISRCTN43896688\">ISRCTN43896688<\/jats:ext-link>; Pre-results.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjopen-2020-039237","type":"journal-article","created":{"date-parts":[[2020,10,8]],"date-time":"2020-10-08T04:03:55Z","timestamp":1602129835000},"page":"e039237","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":20,"title":["Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda"],"prefix":"10.1136","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0018-4060","authenticated-orcid":false,"given":"Marie-Claire","family":"Van Hout","sequence":"first","affiliation":[{"name":"Public Health Institute, Liverpool John Moores University, Liverpool, Merseyside, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1770-3506","authenticated-orcid":false,"given":"Max","family":"Bachmann","sequence":"additional","affiliation":[{"name":"Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9618-2299","authenticated-orcid":false,"given":"Jeffrey V","family":"Lazarus","sequence":"additional","affiliation":[{"name":"Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth Henry","family":"Shayo","sequence":"additional","affiliation":[{"name":"Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dominic","family":"Bukenya","sequence":"additional","affiliation":[{"name":"MRC\/UVRI\/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Camila A","family":"Picchio","sequence":"additional","affiliation":[{"name":"Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moffat","family":"Nyirenda","sequence":"additional","affiliation":[{"name":"MRC\/UVRI\/LSHTM Uganda Research Unit, Medical Research Council 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Process evaluation for public health interventions and research. An overview. In: Steckler A , Linnan L , eds. Process evaluation for public health interventions and research. 1 edn. San Francisco: Josset-Bass, 2002: 1\u201323."},{"key":"2025101813103134000_10.10.e039237.45","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2018-000945"},{"key":"2025101813103134000_10.10.e039237.46","doi-asserted-by":"crossref","DOI":"10.7448\/IAS.15.2.17357","article-title":"Effective HIV prevention: the indispensable role of social science","volume":"15","author":"Kippax","year":"2012","journal-title":"J Int AIDS Soc"},{"key":"2025101813103134000_10.10.e039237.47","doi-asserted-by":"publisher","DOI":"10.1037\/0003-066X.32.7.513"},{"key":"2025101813103134000_10.10.e039237.48","doi-asserted-by":"crossref","unstructured":"Bronfenbrenner U . The ecology of human development: experiments by nature and design. 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