Undiagnosed and uncontrolled hypertension in rural African adults: a scoping review of primary health care interventions and development of the CO-HEART framework

Non-communicable diseases, driven by cardiovascular conditions and hypertension, account for 75% of global deaths. Hypertension affects 36% of adults in Africa, exceeding the global average of 33%. Rural areas show lower diagnosis and control rates, increasing risks of stroke and early mortality. Evidence of primary health care (PHC) interventions for hypertension in these regions are limited. This scoping review analysed data from seven databases to examine hypertension-focused PHC interventions in rural Africa. Guided by the TIDieR checklist, interventions were mapped across the hypertension care cascade to develop an implementation framework. Thirty-two publications were included, revealing limited use of explicit programme theories, inconsistent outcome reporting and poor fidelity assessment. Only a few studies involved community members or health care providers in co-design. Decentralized PHC management featured in 41% of studies, with 79% adopting a nurse-management model supported by community health workers. Fewer than two-thirds addressed all stages of the hypertension care cascade. Findings underscore the promise of decentralized, nurse-led, team-based models for hypertension control Future interventions should embed clear programme theories, standardized outcomes, co-production, and strong monitoring and evaluation systems. This resulting framework supports PHC teams in implementing hypertension services from screening through long-term control in rural African contexts.