Quality of integrated chronic disease care in rural South Africa: user and provider perspectives

A framework for chronic care quality: results of a scoping review and Delphi survey

Frameworks conceptualising the quality of care abound and vary; some concentrate on specific aspects such as safety, effectiveness, others all-encompassing. However, to our knowledge, tailoring to systematically arrive at a comprehensive care for chronic conditions quality (CCCQ) framework has never been done. We conducted a scoping review and Delphi survey to produce a CCCQ framework, comprehensively delineating aims, determinants and measurable attributes. With the assumption that specific groups (people with chronic conditions, care providers, financiers, policy-makers, etc.) view quality of care differently, we analysed 48 scientific and 26 grey literature deductively and inductively using the Institute of Medicine's quality of care framework as the foundation. We produced a zero-version of the quality of chronic care framework, detailing aims, healthcare system determinants, and measurement mechanisms. This was presented in a Delphi survey to 49 experts with diverse chronic care expertise/experience around the world. Consensus was obtained after the first round, with the panel providing suggestions and justifications to expand the agreed-upon components. Through this exercise, a comprehensive CCCQ framework encompassing the journey through healthcare of people with chronic conditions was developed. The framework specifies seven CCCQ 'aims' and identifies health system determinants which can be acted upon with 'organising principles' and measured through chronic care quality 'attributes' related to structures, processes and outcomes. Tailoring quality of care based on the nature of the diseases/conditions and considering different views can be done to ensure a comprehensive offer of healthcare services, and towards better outcomes that are acceptable to both the health system and people with chronic conditions (PwCC).

Quality of care for chronic conditions: identifying specificities of quality aims based on scoping review and Delphi survey

There is a growing need to implement high quality chronic care to address the global burden of chronic conditions. However, to our knowledge, there have been no systematic attempts to define and specify aims for chronic care quality. To address this gap, we conducted a scoping review and Delphi survey to establish and validate comprehensive specifications. The Institute of Medicine's (IOM) quality of care definition and aims were used as the foundation. We purposively selected articles from the scientific (n=48) and grey literature (n=26). We sought papers that acknowledged and unpacked the plurality of quality in chronic care and proposed or utilised frameworks, studied their implementation, or investigated at least two IOM quality care aims and implementation. Articles were analysed both deductively and inductively. The findings were validated through a Delphi survey involving 49 international chronic care experts with varied knowledge of, and experience in, low-and-middle-income countries. Considering the natural history of chronic conditions and the journey of a person with a chronic condition, we defined and identified the aims of chronic care quality. The six IOM aims apply with specific meanings. We identified a seventh aim, continuity, which relates to the issue of chronicity. The group endorsed our specifications and several participants gave contextualised interpretations and concrete examples. Chronic conditions pose specific challenges underscoring the relevance of tailoring quality of care aims. The next steps require a tailored definition and specific aims to improve, measure and assure the quality of chronic care.

Service guidelines, models, and protocols for integrating rehabilitation services in primary healthcare in Brazil, Russia, India, China, and South Africa: a scoping review

PURPOSE

The WHO emphasises that rehabilitation services must be integrated into primary healthcare as an inherent part of universal health coverage. However, there is limited research on the integration of rehabilitation services in primary healthcare in low- and middle-income countries. The purpose of this paper is to identify and describe the literature on service guidelines, models, and protocols that support the integration of rehabilitation services in primary healthcare in the BRICS countries (Brazil, Russia, India, China, and South Africa).

METHODS

A scoping review guided by Arksey and O'Malley's framework was conducted. Structured database and website searches identified published and unpublished records from 2010, which were subjected to eligibility criteria. Mendeley, JBI SUMARI, and Microsoft Excel were used to extract and synthesise the data.

RESULTS

The search strategy identified 542 records. Thirty-two records met the inclusion criteria. Shared care and community-based rehabilitation were the most reported practice models, and the implementation of the models, guidelines, and protocols was mostly described in mental health services.

CONCLUSION

This review discusses BRICS countries' rehabilitation service guidelines, models, and protocols for primary healthcare integration and implementation challenges. Rehabilitation professionals should rethink, realign, and apply existing models because of the lack of primary healthcare integration directives.

User Satisfaction with Primary Health Care Rehabilitation Services in a South African Metropolitan District

Rehabilitation services are critical to improve health outcomes, particularly at community level within primary healthcare settings. As groups with an interest in the health system, rehabilitation service users' and caregivers' involvement in various aspects of health system strengthening is important for healthcare planning and evaluation. This study aimed to explore rehabilitation service users' perceptions of the rehabilitation services and their effect on their functioning in the Johannesburg Metropolitan District. A qualitative study was conducted using purposive sampling of participants attending rehabilitation at nine provincially funded clinics. Semi-structured interviews were conducted, and data were analysed using reflexive thematic analysis. The findings revealed the theme of happy with rehabilitation services and five associated categories, namely (1) service provider actions, (2) service organisation, (3) service user actions, (4) service access, and (5) service outcomes. The participants expressed overall satisfaction with their experiences of rehabilitation services, highlighting the importance of effective communication, patient-centred care, strong therapeutic relationships, and active patient engagement to achieve positive outcomes. This study provides the evidence for maintaining and extending rehabilitation at the PHC level in support of the health policy changes proposed for South Africa.

Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa

BACKGROUND

The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. This study aimed to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV in primary care clinics in Johannesburg, South Africa. Additionally, different stakeholder groups were included to identify discordant perceptions.

METHODS

Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by COM-B and the Theoretical Domains Framework were used to identify and compare determinants of hypertension care across stakeholder groups.

RESULTS

Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) and patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care.

CONCLUSIONS

The convergence of multi-stakeholder data highlight key areas for improvement, where tailored implementation strategies targeting motivations of clinic staff and capacity of patients may address challenges to hypertension screening, treatment, and management recognized across groups.

Strategies that enabled access to chronic care during the COVID-19 pandemic and beyond in South Africa

Background

The COVID-19 epidemic has revealed disturbing information about how chronic diseases are treated globally. Healthcare providers and coronavirus response teams have primarily reported on how individuals with chronic conditions sought care and treatment. However, individuals' experiences of patients are yet unknown.

Aim

This study aimed to explore those strategies that enabled patients with chronic diseases access to chronic care and treatment during and beyond the COVID-19 pandemic.

Setting

The study was conducted in the predominantly rural district of the Northwest Province, South Africa.

Methods

An explorative qualitative research design was followed. Information-rich participants were chosen using a purposive sampling technique. Individual face-to-face interviews were used to gather data. Data saturation was achieved after interviewing n = 28 people in total. The six steps of Braun and Clarke thematic data analysis were used to analyse the data.

Results

The study revealed three themes, which includes improved healthcare structural systems, shift from traditional chronic care to digital care services and medication refill and buddy system.

Conclusion

The findings of this study revealed a range of effective and noteworthy approaches that facilitated access to treatment and continuity of care. As a result, enhancing telemedicine as well as structural systems such as appointment scheduling, decanting choices, mobile and medication home delivery can improve access to care and treatment.

Contribution

The burden of disease and avoidable death will be eventually addressed by maximising the use of telemedicine and sustaining the new norm of ongoing care through digital and remote care and decanting strategies.

Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda

INTRODUCTION

Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease.

METHODS AND ANALYSIS

This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension.

ETHICS AND DISSEMINATION

The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications.

TRIAL REGISTRATION NUMBER

ISRCTN15319595.

Facilitators and barriers to integration of noncommunicable diseases with HIV care at primary health care in Ethiopia: a qualitative analysis using CFIR

Background

The rise in non-communicable diseases (NCD), such as hypertension and diabetes among people living with human immunodeficiency virus (PLWH), has increased the demand for integrated care due to multiple chronic care needs. However, there is a dearth of evidence on contextual factors implementing integrated hypertension and diabetes care with HIV care. This study aimed to identify facilitators and barriers that could affect the integration of hypertension and diabetes with HIV care at primary health care in Ethiopia.

Methods

Five primary health facilities from five districts of the Wolaita zone of South Ethiopia were included in the qualitative study. Fifteen key informant interviews were conducted with healthcare providers and managers from the zonal, district, and facility levels from October to November 2022. Data collection and analysis were guided by a consolidated framework of implementation research (CFIR).

Results

Ten CFIR constructs were found to influence the integration. Perceived benefit of integration to patients, healthcare providers, and organization; perceived possibilities of integration implementation; availability of NCD guidelines and strategies; a supportive policy of decentralization and integration; perceived leaders and healthcare provider commitment were found to be facilitators. Perceived increased cost, insufficient attention to NCD care needs, inadequate number of trained professionals, inadequate equipment and apparatus such as blood pressure measurement, glucometers, strips, and NCD drugs, inadequate allocation of budget and weak health financing system and poor culture of data capturing and reporting were identified as barriers to integration.

Conclusion

It is important to address contextual barriers through innovative implementation science solutions to address multiple chronic care needs of PLWH by implementing integrated hypertension and diabetes with HIV care in primary healthcare. Training and task shifting, pairing experienced professionals, and strengthening the health care financing system to implement evidence-based integration of hypertension and diabetes are recommended.

Health systems performance for hypertension control using a cascade of care approach in South Africa, 2011-2017

Hypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system's ability to manage hypertension between 2011 and 2017. We used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. In 2011, 19.6% (95%CI 14.2, 26.2) of individuals with incident hypertension were diagnosed, 15.4% (95%CI 10.8, 21.4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24.4% (95%CI 15.9, 35.4). Increases in treatment (23.3%, 95%CI 15.0, 34.3) and control (22.1%, 95%CI 14.1, 33.0) were also observed, translating to a decrease in unmet need for hypertension care from 92.9% in 2011 to 77.9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3.01 (95%CI 1.77, 5.13) times more likely to have a controlled blood pressure compared to those in 2011. Our data show that while substantial improvements in the hypertension care cascade occurred between 2011 and 2017, a large burden of unmet need remains. The greatest losses in the incident hypertension care cascades came before diagnosis. Nevertheless, whole system programming will be needed to sufficiently address significant morbidity and mortality related to having an elevated blood pressure.

Successes and challenges towards improving quality of primary health care services: a scoping review

BACKGROUND

Quality health services build communities' and patients' trust in health care. It enhances the acceptability of services and increases health service coverage. Quality primary health care is imperative for universal health coverage through expanding health institutions and increasing skilled health professionals to deliver services near to people. Evidence on the quality of health system inputs, interactions between health personnel and clients, and outcomes of health care interventions is necessary. This review summarised indicators, successes, and challenges of the quality of primary health care services.

METHODS

We used the preferred reporting items for systematic reviews and meta-analysis extensions for scoping reviews to guide the article selection process. A systematic search of literature from PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), Scopus, and Google Scholar was conducted on August 23, 2022, but the preliminary search was begun on July 5, 2022. The Donabedian's quality of care framework, consisting of structure, process and outcomes, was used to operationalise and synthesise the findings on the quality of primary health care.

RESULTS

Human resources for health, law and policy, infrastructure and facilities, and resources were the common structure indicators. Diagnosis (health assessment and/or laboratory tests) and management (health information, education, and treatment) procedures were the process indicators. Clinical outcomes (cure, mortality, treatment completion), behaviour change, and satisfaction were the common indicators of outcome. Lower cause-specific mortality and a lower rate of hospitalisation in high-income countries were successes, while high mortality due to tuberculosis and the geographical disparity in quality care were challenges in developing countries. There also exist challenges in developed countries (e.g., poor quality mental health care due to a high admission rate). Shortage of health workers was a challenge both in developed and developing countries.

CONCLUSIONS

Quality of care indicators varied according to the health care problems, which resulted in a disparity in the successes and challenges across countries around the world. Initiatives to improve the quality of primary health care services should ensure the availability of adequate health care providers, equipped health care facilities, appropriate financing mechanisms, enhance compliance with health policy and laws, as well as community and client participation. Additionally, each country should be proactive in monitoring and evaluation of performance indicators in each dimension (structure, process, and outcome) of quality of primary health care services.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Improvements in Hypertension Control in the Rural Longitudinal HAALSI Cohort of South African Adults Aged 40 and Older, From 2014 to 2019

BACKGROUND

Over half of the South African adults aged 45 years and older have hypertension but its effective management along the treatment cascade (awareness, treatment, and control) remains poorly understood.

METHODS

We compared the prevalence of all stages of the hypertension treatment cascade in the rural HAALSI cohort of older adults at baseline and after four years of follow-up using household surveys and blood pressure data. Hypertension was a mean systolic blood pressure >140 mm Hg or diastolic pressure >90 mm Hg, or current use of anti-hypertension medication. Control was a mean blood pressure <140/90 mm Hg. The effects of sex and age on the treatment cascade at follow-up were assessed. Multivariate Poisson regression models were used to estimate prevalence ratios along the treatment cascade at follow-up.

RESULTS

Prevalence along the treatment cascade increased from baseline (B) to follow-up (F): awareness (64.4% vs. 83.6%), treatment (49.7% vs. 73.9%), and control (22.8% vs. 41.3%). At both time points, women had higher levels of awareness (B: 70.5% vs. 56.3%; F: 88.1% vs. 76.7%), treatment (B: 55.9% vs. 41.55; F: 79.9% vs. 64.7%), and control (B: 26.5% vs. 17.9%; F: 44.8% vs. 35.7%). Prevalence along the cascade increased linearly with age for everyone. Predictors of awareness included being female, elderly, or visiting a primary health clinic three times in the previous 3 months, and the latter two also predicted hypertension control.

CONCLUSIONS

There were significant improvements in awareness, treatment, and control of hypertension from baseline to follow-up and women fared better at all stages, at both time points.

The impact of persistent precarity on patients' capacity to manage their treatment burden: A comparative qualitative study between urban and rural patients with multimorbidity in South Africa

Background

People living with multimorbidity in low-and middle-income countries (LMICs) experience a high workload trying to meet the demands of self-management. In an unequal society like South Africa, many people face continuous economic uncertainty, which can impact on their capacity to manage their illnesses and lead to poor health outcomes. Using precariousness - the real and perceived impact of uncertainty - as a lens, this paper aims to identify, characterise, and understand the workload and capacity associated with self-management amongst people with multimorbidity living in precarious circumstances in urban and rural South Africa.

Methods

We conducted qualitative semi-structured interviews with 30 patients with HIV and co-morbidities between February and April 2021. Patients were attending public clinics in Cape Town (Western Cape) and Bulungula (Eastern Cape). Interviews were transcribed and data analysed using qualitative framework analysis. Burden of Treatment Theory (BoTT) and the Cumulative Complexity Model (CuCoM) were used as theoretical lenses through which to conceptualise the data.

Results

People with multimorbidity in rural and urban South Africa experienced multi-faceted precariousness, including financial and housing insecurity, dangerous living circumstances and exposure to violence. Women felt unsafe in their communities and sometimes their homes, whilst men struggled with substance use and a lack of social support. Older patients relied on small income grants often shared with others, whilst younger patients struggled to find stable employment and combine self-management with family responsibilities. Precariousness impacted access to health services and information and peoples' ability to buy healthy foods and out-of-pocket medication, thus increasing their treatment burden and reducing their capacity.

Conclusion

This study highlights that precariousness reduces the capacity and increases treatment burden for patients with multimorbidity in low-income settings in South Africa. Precariousness is both accumulative and cyclic, as financial insecurity impacts every aspect of peoples' daily lives. Findings emphasise that current models examining treatment burden need to be adapted to accommodate patients' experiences in low-income settings and address cumulative precariousness. Understanding treatment burden and capacity for patients in LMICs is a crucial first step to redesign health systems which aim to improve self-management and offer comprehensive person-centred care.

“A frightening experience, especially at our age”: Examining the neglect and abuse of older persons in HIV prevention and care programs

Background

As the global population ages and the HIV pandemic matures, a growing number of older persons aged ≥50 years are becoming increasingly vulnerable to acquiring HIV. Unfortunately, older persons are often neglected and left out of sexual health programs and services. This study explored the experiences of older persons living with and without HIV in accessing prevention and care services and how those experiences translate into the neglect and abuse of older persons. The study also explored older people's perspectives on community responses to HIV in older people.

Methods

This qualitative analysis used data from 37 individuals who participated in focus group discussions conducted in 2017/2018 across two communities in Durban, South Africa. Using an interview guide and thematic content analysis, salient themes regarding attitudes to HIV in older persons and factors of access to HIV prevention and cares services for older persons were analyzed.

Results

The study participant's mean age was 59.6 years. Major themes emerging from the data included factors impacting HIV prevention and transmission in older people; community responses to HIV contributing to the abuse of older people, and structural drivers of abuse in older people living with HIV (OPLHIV). Knowledge about HIV and how to protect themselves from HIV was limited among participants. Older persons were frightened to acquire HIV at an older age as they feared judgment and discrimination for getting HIV at that age. OPLHIV reported frequently experiencing community stigma and poor staff attitudes and practices at health facilities, such as a triage health delivery system that fueled community stigma. Participants also experienced neglect, verbal and emotional abuse at healthcare facilities.

Conclusion

Although there were no reports of physical and sexual abuse of older persons in this study, this study shows that despite decades of HIV programs in the country, HIV-related stigma, discrimination, and disrespect of older persons remain pervasive in the community and at health facilities. As an increasing number of people age and live longer with HIV, the neglect and outright abuse of older persons need urgent policy and program interventions.

Patient and health worker perspectives on quality of HIV care and treatment services in Haiti

BACKGROUND

Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti's national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient "ingredients" for improving quality of care.

METHODS

The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description.

RESULTS

Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their "own pockets."

CONCLUSIONS

These concerns reflected the embeddedness of patient - provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.

Self-care can be an alternative to expand access to universal health care: What policy makers, governments and implementers can consider for South Africa

As a result of collaboration amongst the various decision-makers in the field of healthcare, there has been an improvement in the access to healthcare and living conditions globally. Nonetheless, poorer communities continue to benefit the least from public investment. To bridge the gap, self-care can be a viable alternative as it allows individuals and communities to reduce their dependence on government healthcare solutions. Barriers to self-care do exist. Some of these are cost effectiveness, usability of self-care instruments, differentiated strategies and linkage to care. In identifying these obstacles, it is also worthwhile to investigate how they can be mitigated. To encourage sustained self-care in the HIV continuum, contextual factors as well as the manner in which individuals and communities engage with self-care must be considered. In South Africa, multiple variables come into play: literacy levels, cultural influences, socio-economic conditions and access to resources are some of these. Evidence demonstrates how self-care can be promoted by various stakeholders re-strategising to tweak and in some cases totally change existing structures. This paper explores some of the transformations, like at a governmental level where the supply of HIV self-testing kits is increased, at a production level where instructions for use are reformatting, in communities where sports programmes fulfil the dual purpose of developing sport skills and providing HIV education concurrently, and at an individual level where greater awareness invites greater participation in self-care. While self-care is a promising proposal, it is not a replacement for traditional health-care practices, but a complementary approach.

Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service

Purpose

Women experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap.

Design/methodology/approach

The INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints.

Findings

WLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care.

Originality/value

This study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys.

Chronic disease care integration into primary care services in sub-Saharan Africa: a 'best fit' framework synthesis and new conceptual model

OBJECTIVE

To examine the relevance of existing chronic care models to the integration of chronic disease care into primary care services in sub-Saharan Africa and determine whether additional context-specific model elements should be considered.

DESIGN

'Best fit' framework synthesis comprising two systematic reviews. First systematic review of existing chronic care conceptual models with construction of a priori framework. Second systematic review of literature on integrated HIV and diabetes care at a primary care level in sub-Saharan Africa, with thematic analysis carried out against the a priori framework. New conceptual model constructed from a priori themes and new themes. Risk of bias of included studies was assessed using CASP and MMAT.

ELIGIBILITY CRITERIA

Conceptual models eligible for inclusion in construction of a priori framework if developed for a primary care context and described a framework for long-term management of chronic disease care. Articles eligible for inclusion in second systematic review described implementation and evaluation of an intervention or programme to integrate HIV and diabetes care into primary care services in SSA.

INFORMATION SOURCES

PubMed, Embase, CINAHL Plus, Global Health and Global Index Medicus databases searched in April 2020 and September 2022.

RESULTS

Two conceptual models of chronic disease care, comprising six themes, were used to develop the a priori framework. The systematic review of primary research identified 16 articles, within which all 6 of the a priori framework themes, along with 5 new themes: Improving patient access, stigma and confidentiality, patient-provider partnerships, task-shifting, and clinical mentoring. A new conceptual model was constructed from the a priori and new themes.

CONCLUSION

The a priori framework themes confirm a need for co-ordinated, longitudinal chronic disease care integration into primary care services in sub-Saharan Africa. Analysis of the primary research suggests integrated care for HIV and diabetes at a primary care level is feasible and new themes identified a need for a contextualised chronic disease care model for sub-Saharan Africa.

Protocol: the complexity of informal caregiving for Alzheimer's disease and related dementias in rural South Africa

BACKGROUND

 With aging, many people develop Alzheimer's disease or related dementias (ADRD) as well as chronic physical health problems. The consequent care needs can be complicated, with heavy demands on families, households and communities, especially in resource-constrained settings with limited formal care services. However, research on ADRD caregiving is largely limited to primary caregivers and high-income countries. Our objectives are to analyse in a rural setting in South Africa: (1) how extended households provide care to people with ADRD; and (2) how the health and wellbeing of all caregivers are affected by care roles.

METHODS

 The study will take place at the Agincourt health and socio-demographic surveillance system site of the MRC/Wits Rural Public Health and Health Transitions Research Unit in Mpumalanga Province, northeast South Africa. We will recruit 100 index individuals predicted to currently have ADRD or cognitive impairment using data from a recent dementia survey. Quantitative surveys will be conducted with each index person's nominated primary caregiver, all other household members aged over 12, and caregiving non-resident kin and non-kin to determine how care and health are patterned across household networks. Qualitative data will be generated through participant observation and in-depth interviews with caregivers, select community health workers and key informants. Combining epidemiological, demographic and anthropological methods, we will build a rich picture of households of people with ADRD, focused on caregiving demands and capacity, and of caregiving's effects on health.

DISCUSSION

 Our goal is to identify ways to mitigate the negative impacts of long-term informal caregiving for ADRD when formal supports are largely absent. We expect our findings to inform the development of locally relevant and community-oriented interventions to improve the health of caregivers and recipients, with implications for other resource-constrained settings in both higher- and lower-income countries.

Factors Influencing the Implementation of Remote Delivery Strategies for Non-Communicable Disease Care in Low- and Middle-Income Countries: A Narrative Review

Objectives: The COVID-19 pandemic has disrupted health care for non-communicable diseases (NCDs) and necessitated strategies to minimize contact with facilities. We aimed to examine factors influencing implementation of remote (non-facility-based) delivery approaches for people with hypertension and/or diabetes in low- and middle-income countries (LMICs), to inform NCD care delivery during health service disruption, including humanitarian crises. Methods: Our narrative review used a hermeneutic and purposive approach, including primary studies conducted in LMICs, which assessed implementation factors influencing remote NCD care delivery. Results were analyzed using the Consolidated Framework for Implementation Research. Results: Twenty-eight included studies revealed the strong influence of both internal organizational and broader contextual factors, such as community health worker policies or technological environment. Addressing patients' specific characteristics, needs and resources was important for implementation success. Conclusion: This review highlighted the multiple, complex, interdependent factors influencing implementation of remote NCD care in LMICs. Our findings may inform actors designing NCD care delivery in contexts where facility-based access is challenging. Implementation research is needed to evaluate context-adapted e-Health, community-based, and simplified clinical management strategies to facilitate remote NCD care.

Breast Cancer Survivors' Satisfaction and Information Recall of Telehealth Survivorship Care Plan Appointments During the COVID-19 Pandemic

OBJECTIVES

To examine patient satisfaction and information recall after telehealth breast cancer survivorship visits with a nurse practitioner.

SAMPLE & SETTING

Female survivors of breast cancer after their first visit with a nurse practitioner in the outpatient survivorship clinic post-treatment.

METHODS & VARIABLES

Participants included female survivors who were originally diagnosed with stage 0-III breast cancer and have since completed an initial telehealth appointment to review the survivorship care plan. Survivors were invited to complete a 20-question electronic survey about their satisfaction and recall of visit information.

RESULTS

62 participants completed the survey and indicated an overall high level of satisfaction with telehealth survivorship appointments. Most recalled key survivorship information from the visit and felt the appropriate amount of information was discussed. Overall satisfaction was significantly correlated with the length and convenience of the appointment, and the personal manner and technical skills of the nurse practitioner. Survivors' age was not associated with significant differences in overall satisfaction.

IMPLICATIONS FOR NURSING

Telehealth for initial survivorship visits demonstrated high satisfaction with telehealth and the overall visit as a low-cost intervention to treat symptoms.

Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Background

Public health sector service delivery challenges leading to poor population health outcomes have been observed in the Free State province of South Africa for the past decade. A multi-method situation appraisal of the different functional domains revealed serious health system deficiencies and operational defects, notably fragmentation of healthcare programmes and frontline services, as well as challenges related to governance, accountability and human resources for health. It was therefore necessary to develop a system-wide intervention to comprehensively address defects in the operation of the public health system and its major components.

Methods

This study describes the development of the ‘Health Systems Governance & Accountability’ (HSGA) intervention model by the Free State Department of Health (FSDoH) in collaboration with the community and other stakeholders following a participatory action approach. Documented information collected during routine management processes were reviewed for this paper. Starting in March 2013, the development of the HSGA intervention model and the concomitant application of Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool was informed by the World Health Organization’s (2007) conceptual framework for health system strengthening and reform comprised of six health system ‘building blocks.’ The multiple and overlapping processes and actions to develop the intervention are described according to the four steps in Kaplan et al.’s (2013) systems approach to health systems strengthening: (i) problem identification, (ii) description, (iii) alteration and (iv) implementation.

Results

The finalisation of the HSGA intervention model before end-2013 was a prelude to the development of the FSDoH’s Strategic Transformation Plan 2015–2030. The HSGA intervention model was used as a tool to implement and integrate the Plan’s programmes moving forward with a consistent focus on the six building blocks for health systems strengthening and the all-important linkages between them.

Conclusion

The model was developed to address fragmentation and improve public health service delivery by the provincial health department. In January 2016, the intervention model became an official departmental policy, meaning that it was approved for implementation, compliance, monitoring and reporting, and became the guiding framework for health systems strengthening and transform in the Free State.

Microfluidic Point-of-Care (POC) Devices in Early Diagnosis: A Review of Opportunities and Challenges

The early diagnosis of infectious diseases is critical because it can greatly increase recovery rates and prevent the spread of diseases such as COVID-19; however, in many areas with insufficient medical facilities, the timely detection of diseases is challenging. Conventional medical testing methods require specialized laboratory equipment and well-trained operators, limiting the applicability of these tests. Microfluidic point-of-care (POC) equipment can rapidly detect diseases at low cost. This technology could be used to detect diseases in underdeveloped areas to reduce the effects of disease and improve quality of life in these areas. This review details microfluidic POC equipment and its applications. First, the concept of microfluidic POC devices is discussed. We then describe applications of microfluidic POC devices for infectious diseases, cardiovascular diseases, tumors (cancer), and chronic diseases, and discuss the future incorporation of microfluidic POC devices into applications such as wearable devices and telemedicine. Finally, the review concludes by analyzing the present state of the microfluidic field, and suggestions are made. This review is intended to call attention to the status of disease treatment in underdeveloped areas and to encourage the researchers of microfluidics to develop standards for these devices.

Quality of care in public sector family planning services in KwaZulu-Natal, South Africa: a qualitative evaluation from community and health care provider perspectives

BACKGROUND

Quality of care is a multidimensional concept that forms an integral part of the uptake and use of modern contraceptive methods. Satisfaction with services is a significant factor in the continued use of services. While much is known about quality of care in the general public health care service, little is known about family planning specific quality of care in South Africa. This paper aims to fill the gap in the research by using the Bruce-Jain family planning quality of care framework.

METHODS

This formative qualitative study was conducted in South Africa, Zambia, and Kenya to explore the uptake of family planning and contraception. The results presented in this paper are from the South African data. Fourteen focus group discussions, twelve with community members and two with health care providers, were conducted along with eight in-depth interviews with key informants. Thematic content analysis using the Bruce-Jain Quality of Care framework was conducted to analyse this data using NVIVO 10.

RESULTS

Family planning quality of care was defined by participants as the quality of contraceptive methods, attitudes of health care providers, and outcomes of contraceptive use. The data showed that women have limited autonomy in their choice to either use contraception or the method that they might prefer. Important elements that relate to quality of care were identified and described by participants and grouped according to the structural or process components of the framework. Structure-related sub-themes identified included the lack of technically trained providers; integration of services that contributed to long waiting times and mixing of a variety of clients; and poor infrastructure. Sub-themes raised under the process category included poor interpersonal relations; lack of counselling/information exchange, fear; and time constraints. Neither providers nor users discussed follow up mechanisms which is a key aspect to ensure continuity of contraceptive use.

CONCLUSION

Using a qualitative methodology and applying the Bruce-Jain Quality of Care framework provided key insights into perceptions and challenges about family planning quality of care. Identifying which components are specific to family planning is important for improving contraceptive outcomes. In particular, autonomy in user choice of contraceptive method, integration of services, and the acceptability of overall family planning care was raised as areas of concern.

Patient perspectives on integrated healthcare for HIV, hypertension and type 2 diabetes: a scoping review

INTRODUCTION

Antiretroviral therapy has reduced mortality and led to longer life expectancy in people living with HIV. These patients are now at an increased risk of non-communicable diseases (NCDs). Integration of care for HIV and NCDs has become a focus of research and policy. In this article, we aim to review patient perspectives on integration of healthcare for HIV, type 2 diabetes and hypertension.

METHODS

The framework for scoping reviews developed by Arksey and O'Malley and updated by Peter et al was applied for this review. The databases PubMed, Web of Science and Cochrane library were searched. Broad search terms for HIV, NCDs (specifically type 2 diabetes and hypertension) and healthcare integration were used. As the review aimed to identify definitions of patient perspectives, they were not included as an independent term in the search strategy. References of included publications were searched for relevant articles. Titles and abstracts for these papers were screened by two independent reviewers. The full texts for all the publications appearing to meet the inclusion criteria were then read to make the final literature selection.

RESULTS

Of 5502 studies initially identified, 13 articles were included in this review, of which 11 had a geographical origin in sub-Saharan Africa. Nine articles were primarily focused on HIV/diabetes healthcare integration while four articles were focused on HIV/hypertension integration. Patient's experiences with integrated care were reduced HIV-related stigma, reduced travel and treatment costs and a more holistic person-centred care. Prominent concerns were long waiting times at clinics and a lack of continuity of care in some clinics due to a lack of healthcare workers. Non-integrated care was perceived as time-consuming and more expensive.

CONCLUSION

Patient perspectives and experiences on integrated care for HIV, diabetes and hypertension were mostly positive. Integrated services can save resources and allow for a more personalised approach to healthcare. There is a paucity of evidence and further longitudinal and interventional evidence from a more diverse range of healthcare systems are needed.

Hypertension Care for People With HIV in Tanzania: Provider Perspectives and Opportunities for Improvement

One in three people with HIV (PWH) has hypertension. However, most hypertensive PWH in sub-Saharan Africa are unaware of their hypertension diagnosis and are not on treatment. To better understand barriers to hypertension care faced by PWH, we interviewed 15 medical providers who care for patients with HIV and hypertension in northern Tanzania. The data revealed barriers at the patient, provider, and system level and included: stress, depression, and HIV-related stigma; lack of hypertension knowledge; insufficient hypertension training; inefficient prescribing practices; challenges with counselling; capacity limitations in hypertension care; high costs of care; and lack of routine hypertension screening and follow-up. Opportunities for improvement focused on prioritizing resources and funding towards hypertension care. System-related challenges were the underlying cause of barriers at individual levels. Strategies that focus on strengthening capacity and utilize existing HIV platforms to promote hypertension care delivery are urgently needed to improve cardiovascular outcomes among PWH.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa

In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President’s Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.

Multimorbidity in South Africa: a systematic review of prevalence studies

OBJECTIVES

To review prevalence studies of multimorbidity in South Africa to identify prevalence estimates, common disease clusters and factors associated with multimorbidity.

DESIGN

Systematic review.

SETTING

South Africa (general community and healthcare facilities).

DATA SOURCES

Articles were retrieved from electronic databases (PubMed, Web of Science, Scopus, CINAHL, Science Direct and JSTOR).

ELIGIBILITY CRITERIA

Studies addressing the prevalence of multimorbidity in South Africa were eligible for inclusion. A systematic search was done in various databases up to December 2020. A risk of bias assessment was conducted for each article using a modified checklist.

STUDY SELECTION

Two researchers independently screened titles and abstracts; assessed the risk of bias of each study and extracted data. Included studies were described using a narrative synthesis.

RESULTS

In total, 1407 titles were retrieved; of which 10 articles were included in the narrative synthesis. Six studies had a low risk of bias and three had a moderate risk of bias. One study was not assessed for risk of bias, because there was no criteria that apply to routine health information systems. Three of the included studies were population-based surveys, four were community-based cohorts and three cross-sectional studies of health facility data. The prevalence of multimorbidity was low to moderate (3%-23%) in studies that included younger people or had a wide range of selected age groups; and moderate to high (30%-87%) in studies of older adults. The common disease clusters were hypertension and diabetes, hypertension and HIV, and TB and HIV.

CONCLUSION

All studies indicated that multimorbidity is a norm in South Africa, especially among older adults. Hypertension is the main driver of multimorbidity. Research on multimorbidity in South Africa needs to be strengthened with high-quality study designs.

PROSPERO REGISTRATION NUMBER

CRD42020196895.

Task Sharing or Task Dumping: Counsellors Experiences of Delivering a Psychosocial Intervention for Mental Health Problems in South Africa

Given task-sharing mental health counselling to non-specialist providers is a recognised strategy to increase service capacity, ensuring that their training, supervision, and support needs are met is necessary to facilitate the sustainable delivery of a high-quality service. Using in-depth interviews, we qualitatively explored the experiences of 18 facility-based counsellors (FBCs) tasked with delivering a counselling intervention within chronic disease services offered within primary care facilities participating in the project MIND cluster randomised controlled trial. Findings show that project MIND training with a strong emphasis on role playing and skills rehearsal improved FBCs' confidence and competence, complemented by highly structured supervision and debriefing provided by a registered counsellor, were key strategies for supporting the implementation of task-shared mental health counselling. FBCs perceived many benefits to providing mental health counselling in primary healthcare but systemic interventions are needed for sustained implementation.

ffects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty).

CONCLUSIONS

Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations.

PROSPERO REGISTRATION NUMBER

CRD42018099314.

The comorbidity of HIV, hypertension and diabetes: a qualitative study exploring the challenges faced by healthcare providers and patients in selected urban and rural health facilities where the ICDM model is implemented in South Africa

BACKGROUND

PLWH are living longer as a result of advancement and adherence to antiretroviral therapy. As the life expectancy of PLWH increases, they are at increased risk of hypertension and diabetes. HIV chronic co-morbidities pose a serious public health concern as they are linked to increased use and need of health services, decreased overall quality of life and increased mortality. While research shows that integrated care approaches applied within primary care settings can significantly reduce hospital admissions and mortality levels among patients with comorbidities, the primary care system in South Africa continues to be challenged with issues about the delivery of quality care.

METHODS

This study applied a phenomenological qualitative research design. IDIs were conducted with 24 HCPs and adults living with the comorbidity of HIV and either hypertension or diabetes across two provinces in South Africa. The objective of the research was to understand the challenges faced by HCPs and patients in health facilities where the ICDM model is implemented. The health facilities were purposively sampled. However, the HCPs were recruited through snowballing and the patients through reviewing the facilities' clinic records for participants who met the study criteria. All participants provided informed consent. The data was collected between March and May 2020. The findings were analysed inductively using thematic content analysis.

RESULTS

The challenges experienced included lack of staff capacity, unclear guidelines on the delivery of integrated care for patients with HIV chronic comorbidities, pill burden, non-disclosure, financial burden, poor knowledge of treatments, relocation of patients and access to treatment. Lack of support and integrated chronic programmes including minimal information regarding the management of HIV chronic comorbidities were other concerns.

CONCLUSION

The outcomes of the ICDM model need to be strengthened and scaled up to meet the unique health needs and challenges of people living with HIV and other chronic conditions. Strengthening these outcomes includes providing capacity building and training on the delivery of chronic care treatment under the ICDM model, assisted self-management to improve patient responsibility of chronic disease management and strengthening activities for comorbidity health promotion.

Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

OBJECTIVES

Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.

DESIGN

A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.

SETTING

This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.

PARTICIPANTS

Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.

RESULTS

Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).

CONCLUSIONS

The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Understanding non-communicable diseases: combining health surveillance with local knowledge to improve rural primary health care in South Africa

Background: NCDs are non-infectious, long-term conditions that account for 40 million deaths per annum. 87% of premature NCD mortality occurs in low- and middle-income countries.

Objective: The aims were:develop methods to provide integrated biosocial accounts of NCD mortality; and explore the practical utility of extended mortality data for the primary health care system.

Methods: We drew on data from research programmes in the study area. Data were analysed in three steps: [a]analysis of levels, causes and circumstances of NCD mortality [n = 4,166] from routine census updates including Verbal Autopsy and of qualitative data on lived experiences of NCDs in rural villages from participatory research; [b] identifying areas of convergence and divergence between the analyses; and [c]exploration of the practical relevance of the data drawing on engagements with health systems stakeholders.

Results: NCDs constituted a significant proportion of mortality in this setting [36%]. VA data revealed multiple barriers to access in end-of-life care. Many deaths were attributed to problems with resources and health systems [21%;19% respectively]. The qualitative research provided rich complementary detail on the processes through which risk originates, accumulates and is expressed in access to end-of-life care, related to chronic poverty and perceptions of poor quality care in clinics. The exploration of practical relevance revealed chronic under-funding for NCD services, and an acute need for robust, timely data on the NCD burden.

Conclusions: VA data allowed a significant burden of NCD mortality to be quantified and revealed barriers to access at and around the time of death. Qualitative research contextualised these barriers, providing explanations of how and why they exist and persist. Health systems analysis revealed shortages of resources allocated to NCDs and a need for robust research to provide locally relevant evidence to organise and deliver care. Pragmatic interdisciplinary and mixed method analysis provides relevant renditions of complex problems to inform more effective responses.

Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study

BACKGROUND

Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to HeAlth System StrEngThening in Sub-Saharan Africa (ASSET)-a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, person-centred care.

METHODS

Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains.

RESULTS

Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, with limited integration of TB with other conditions, and policy focused on treatment adherence contributed to staff stress and limited consideration of patients' psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care.

CONCLUSIONS

Delayed diagnosis, limited psychosocial support for patients and staff, patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants. TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem, supporting interventions which strengthen case detection, infection control and treatment, and also promote person-centred support for healthcare professionals and patients.

Pathways to Care for Patients With Type 2 Diabetes and HIV/AIDS Comorbidities in Soweto, South Africa: An Ethnographic Study

Patients with type 2 diabetes are referred to tertiary hospitals in Soweto although their care could be managed at primary health care clinics. Primary health care needs to be strengthened by addressing health systemic challenges to provide integrated care for comorbid type 2 diabetes and HIV/AIDS.

Background:

South Africa is experiencing colliding epidemics of HIV/AIDS and noncommunicable diseases. In response, the National Department of Health has implemented integrated chronic disease management aimed at strengthening primary health care (PHC) facilities to manage chronic illnesses. However, chronic care is still fragmented. This study explored how the health system functions to care for patients with comorbid type 2 diabetes (T2DM) and HIV/AIDS at a tertiary hospital in Soweto, South Africa.

Methods:

We employed ethnographic methods encompassing clinical observations and qualitative interviews with health care providers at the hospital (n=30). Data were transcribed verbatim and thematically analyzed using QSR NVivo 12 software.

Findings:

Health systemic challenges such as the lack of medication, untrained nurses, and a limited number of doctors at PHC clinics necessitated patient referrals to a tertiary hospital. At the hospital, patients with T2DM were managed first at the medical outpatient clinic before they were referred to a specialty clinic. Those with comorbidities attended different clinics at the hospital partly due to the structure of the tertiary hospital that offers specialized care. In addition, little to no collaboration occurred among health care providers due to poor communication, noncentralized patient information, and staff shortage. As a result, patients experienced disjointed care.

Conclusion:

PHC clinics in Soweto need to be strengthened by training nurses to diagnose and manage patients with T2DM and also by ensuring adequate medical supplies. We recommend that the medical outpatient clinic at a tertiary hospital should also be strengthened to offer integrated and collaborative care to patients with T2DM and other comorbidities. Addressing key systemic challenges such as staff shortages and noncentralized patient information will create a patient-centered as opposed to disease-specific approach to care.

User - provider perspectives to overcome the challenges of TB/HIV service integration at Mulago National Referral Hospital _ Kampala

BACKGROUND

Tuberculosis and Human Immunodeficiency Virus epidemics in sub-Saharan Africa have been closely related and persistent, proving a considerable burden for healthcare provision. This has complicated utilization of services, with noted opinions on the integration of these services from both users and providers of the services.

OBJECTIVES

To establish the users and the provider's perspectives in overcoming the challenges of TB/HIV services integration at Mulago National Referral Hospital.

METHODS

Descriptive cross-sectional design, with predominantly qualitative methods was used. Qualitative aspect adopted phenomenological design. Participants were randomly selected for FGDs and Key informants. An observation checklist collected quantitative data from the patients to measure level of services integration.

FINDINGS

Level of service integration of TB/HIV services was at 68% (below the acceptable 100% level). Opinions from the users pointed to; increasing number of work-days for TB/HIV service provision, strengthening sensitisation and health education and integrating other services like reproductive health services, among others. Health care providers opinions pointed to increasing trainings for health workers, increasing staffing and need for more support from Ministry of Health.

CONCLUSION

Opinions from both users and providers were similar. These ranged from increasing awareness to the users and healthcare providers about the integration of services.

A qualitative inquiry of access to and quality of primary healthcare in seven communities in East and West Africa (SevenCEWA): perspectives of stakeholders, healthcare providers and users

BACKGROUND

Universal health coverage is one of the Sustainable Development Goal targets known to improve population health and reduce financial burden. There is little qualitative data on access to and quality of primary healthcare in East and West Africa. The aim of this study was to describe the viewpoints of healthcare users, healthcare providers and other stakeholders on health-seeking behaviour, access to and quality of healthcare in seven communities in East and West Africa.

METHODS

A qualitative study was conducted in four communities in Nigeria and one community each in Kenya, Uganda and Tanzania in 2018. Purposive sampling was used to recruit: 155 respondents (mostly healthcare users) for 24 focus group discussions, 25 healthcare users, healthcare providers and stakeholders for in-depth interviews and 11 healthcare providers and stakeholders for key informant interviews. The conceptual framework in this study combined elements of the Health Belief Model, Health Care Utilisation Model, four 'As' of access to care, and pathway model to better understand the a priori themes on access to and quality of primary healthcare as well as health-seeking behaviours of the study respondents. A content analysis of the data was done using MAXQDA 2018 qualitative software to identify these a priori themes and emerging themes.

RESULTS

Access to primary healthcare in the seven communities was limited, especially use of health insurance. Quality of care was perceived to be unacceptable in public facilities whereas cost of care was unaffordable in private facilities. Health providers and users as well as stakeholders highlighted shortage of equipment, frequent drug stock-outs and long waiting times as major issues, but had varying opinions on satisfaction with care. Use of herbal medicines and other traditional treatments delayed or deterred seeking modern healthcare in the Nigerian sites.

CONCLUSIONS

There was a substantial gap in primary healthcare coverage and quality in the selected communities in rural and urban East and West Africa. Alternative models of healthcare delivery that address social and health inequities, through affordable health insurance, can be used to fill this gap and facilitate achieving universal health coverage.

Evaluation of an integrated HIV and hypertension management model in rural south africa: a mixed methods approach

Background: A summary of Soter Ameh's PhD thesis titled, 'An integrated HIV and hypertension management model in rural South Africa: A mixed methods approach' is presented here. In responding to the dual high burden of non-communicable diseases (NCDs) and HIV in South Africa, the national government initiated an integrated chronic disease management (ICDM) model in health facilities as a pilot programme. The aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs to improve the quality of care and health outcomes of adult patients.Objectives: The specific objectives of this study were to: (1) determine the quality of care provided in the integrated model in 2013, (2) describe patients' and operational managers' perceptions of quality of care in the integrated model in 2013, and (3) assess effectiveness of the integrated model in controlling CD4 counts (>350 cells/mm3) and blood pressure (<140/90 mmHg) of patients from 2011 to 2013.Methods: A combination of quantitative and qualitative methods was used to assess and describe the quality of care in the model. Effectiveness of the model in controlling patients' blood pressure (BP) and CD4 counts was assessed in selected PHC facilities in the Bushbuckridge municipality in Mpumalanga province, South Africa.Results: The findings showed the suboptimal quality of care in five of the eight priority dimensions of care used as leverage for the NCD programme. The ICDM model had a small but significant effect on BP control for hypertension patients receiving treatment.Conclusions: The HIV programme needs to be more extensively leveraged for hypertension treatment to achieve an optimal BP control in the study area. These findings could have policy relevance for low- and middle-income countries currently undertaking proof of concept studies to demonstrate the feasibility of implementing an integrated chronic disease care model.

Patient-reported outcomes for diabetes and hypertension care in low- and middle-income countries: A scoping review

INTRODUCTION

Patient-reported outcome measures (PROMs) assess patients' perspectives on their health status, providing opportunities to improve the quality of care. While PROMs are increasingly used in high-income settings, limited data are available on PROMs use for diabetes and hypertension in low-and middle-income countries (LMICs). This scoping review aimed to determine how PROMs are employed for diabetes and hypertension care in LMICs.

METHODS

We searched PubMed, EMBASE, and ClinicalTrials.gov for English-language studies published between August 2009 and August 2019 that measured at least one PROM related to diabetes or hypertension in LMICs. Full texts of included studies were examined to assess study characteristics, target population, outcome focus, PROMs used, and methods for data collection and reporting.

RESULTS

Sixty-eight studies met the inclusion criteria and reported on PROMs for people diagnosed with hypertension and/or diabetes and receiving care in health facilities. Thirty-nine (57%) reported on upper-middle-income countries, 19 (28%) reported on lower-middle-income countries, 4 (6%) reported on low-income countries, and 6 (9%) were multi-country. Most focused on diabetes (60/68, 88%), while 4 studies focused on hypertension and 4 focused on diabetes/hypertension comorbidity. Outcomes of interest varied; most common were glycemic or blood pressure control (38), health literacy and treatment adherence (27), and acute complications (22). Collectively the studies deployed 55 unique tools to measure patient outcomes. Most common were the Morisky Medication Adherence Scale (7) and EuroQoL-5D-3L (7).

CONCLUSION

PROMs are deployed in LMICs around the world, with greatest reported use in LMICs with an upper-middle-income classification. Diabetes PROMs were more widely deployed in LMICs than hypertension PROMs, suggesting an opportunity to adapt PROMs for hypertension. Future research focusing on standardization and simplification could improve future comparability and adaptability across LMIC contexts. Incorporation into national health information systems would best establish PROMs as a means to reveal the effectiveness of person-centered diabetes and hypertension care.

Medicines Availability among Hypertensive Patients in Primary Health Care Facilities in a Rural Province in South Africa: Findings and Implications

Objective:

Controlling blood pressure (BP) in hypertensive patients is a challenge, with the lack of antihypertensive medicines negatively impacting on BP control. Consequently, we assessed the availability of prescribed antihypertensives among patients with chronic hypertension attending primary health care (PHC) facilities in a rural province of South Africa and explored any association between medicines availability, the number of prescribed antihypertensive medicines and BP control.

Methods:

Secondary data that included patients' demographics, BP, and data on medicines availability of the intervention group from a 3 months' operational study conducted in rural PHC facilities in South Africa were analyzed. The association between medicines availability, the number of antihypertensive medicines, and BP control was explored.

Findings:

Fifty-five African patients (89.1% females) with a mean age of 61.3 years were included. Two-thirds (67.2%) received all their medicines during their monthly visits, 25.5% received some, and for 7.3%, there was no record of whether medicines were dispensed or not. Patients with controlled BP (60.0%) were more likely to have been prescribed only one antihypertensive medicine compared to patients with uncontrolled BP (20.7%) (P = 0.017; odds ratio: 5.75; 95% confidence interval: 1.46, 22.61).

Conclusion:

It is concerning that one-third of patients went home without all of their antihypertensive medicines from PHC facilities in this Province of South Africa where there is evidence of use of herbal medicines and uncontrolled BP contributing to high morbidity and mortality from cardiovascular diseases. Additional studies are needed to fully explore the association between medicines availability, their use, and BP control among patients.

Multilevel predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in rural South Africa: a panel study

OBJECTIVE

In 2011, The National Department of Health introduced the Integrated Chronic Disease Management (ICDM) model as a pilot programme in selected primary healthcare facilities in South Africa. The objective of this study was to determine individual-level and facility-level predictors of controlled CD4 count and blood pressure (BP) in patients receiving treatment for HIV and hypertension, respectively.

DESIGN

A panel study.

SETTING AND PARTICIPANTS

This study was conducted in the Bushbuckridge Municipality, South Africa from 2011 to 2013. Facility records of patients aged ≥18 years were retrieved from the integrated chronic disease management (ICDM) pilot (n=435) and comparison facilities (n=443) using a three-step probability sampling process. CD4 count and BP control are defined as CD4 count >350 cells/mm³ and BP <140/90 mm Hg. A multilevel Least Absolute Shrinkage and Selection Operator binary logistic regression analysis was done at a 5% significance level using STATA V.16.

PRIMARY OUTCOME MEASURES

CD4 (cells/mm³) count and BP (mm Hg).

RESULTS

Compared with the comparison facilities, patients receiving treatment in the pilot facilities had increased odds of controlling their CD4 count (OR=5.84, 95% CI 3.21-8.22) and BP (OR=1.22, 95% CI 1.04-2.14). Patients aged 50-59 (OR=6.12, 95% CI 2.14-7.21) and ≥60 (OR=7.59, 95% CI 4.75-11.82) years had increased odds of controlling their CD4 counts compared with those aged 18-29 years. Likewise, patients aged 40-49 (OR=5.73, 95% CI 1.98-8.43), 50-59 (OR=7.28, 95% CI 4.33-9.27) and ≥60 (OR=9.31, 95% CI 5.12-13.68) years had increased odds of controlling their BP. In contrast, men had decreased odds of controlling their CD4 count (OR=0.12, 95% CI 0.10-0.46) and BP (OR=0.21, 95% CI 0.19-0.47) than women.

CONCLUSION

The ICDM model had a small but significant effect on BP control, hence, the need to more effectively leverage the HIV programme for optimal BP control in the setting.

Assessment of Patient Satisfaction in a Military and Public Hospital: A Comparative Study

BACKGROUND

In recent times, the assessment of patient satisfaction has become an essential tool for measuring the effectiveness of healthcare delivery. However, not a lot of work has been done in Pakistan, even less so in comparing it across different hospital systems in the country. This research aims to fill that gap and be the first to compare satisfaction levels in a military and public hospital.

OBJECTIVE

To assess patient satisfaction in different hospital systems of Pakistan and compare their outcomes.

METHODS

A cross-sectional study was undertaken between October 2019 and April 2020 among 376 patients; 193 from Combined Military Hospital, Lahore (CMH) and 183 from Jinnah Hospital, Lahore. The questionnaire used for the study was the Short-Form Patient Satisfaction Questionnaire - 18, and convenience sampling was used to select participants. Data was entered and analysed on Statistical Product and Service Solutions (SPSS) version 21 (IBM Corp., Armonk, NY).

RESULTS

The majority of participants were male (71.2%), entitled to free healthcare (58.4%), and employed (59.7%). It was found that CMH Lahore scored better in all seven domains of patient satisfaction (p<0.03 individually), with significant differences in six: general satisfaction, interpersonal manner, communication, financial aspects, time spent with the doctors, and accessibility and convenience. Overall, waiting times and entitlement to free healthcare were established to be major determinants of satisfaction, with CMH having shorter waiting times and providing free treatment to a larger number of patients. The mode waiting time in CMH was 1 - 15 minutes (44.9%) as compared to 15 - 30 minutes (50.9%) in Jinnah Hospital. Additionally, 78.2% of patients were entitled to free healthcare in CMH, compared to 35.5% in Jinnah Hospital.  Conclusion: Patient satisfaction was found to be significantly better in CMH in six out of seven domains studied. Further work needs to be done in its assessment, as well as in its role in healthcare policies.

Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: Viewpoints of service users and providers

BACKGROUND

An integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa.

MATERIALS AND METHODS

A content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software.

RESULTS

The emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives.

CONCLUSIONS

Although the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.

Care and management of a double burden of chronic diseases: Experiences of patients and perceptions of their healthcare providers

AIM

The increasing burden of comorbid HIV infection and hypertension necessitates a focus on healthcare services providing care for chronic multi-morbidities. The aim of this study was to evaluate the perceptions and experiences of 1) people living with HIV infection and comorbid hypertension, and 2) their healthcare providers, related to their diagnoses and interactions with chronic healthcare services in South Africa.

METHODS

This study comprised quantitative and qualitative arms with a multi-layered approach. We randomly selected 17 public healthcare facilities providing HIV care across Cape Town and surrounding rural municipalities.

RESULTS

Interviews were conducted with clinicians (n = 11), specialised nursing professionals (n = 10), lay counsellors (n = 12), six patients focus groups (n = 35) and 20 in-depth individual patient interviews. There were mixed views on being treated at integrated vs. separate chronic care facilities regarding quality of care and privacy/anonymity. Specialised clinics offered better care for HIV infection while hypertension and other non-communicable diseases were neglected. Privacy about HIV status maybe better maintained in integrated clinics but not if status was disclosed by having the green-coloured HIV treatment card. A single appointment date was considered advantageous as it saved time and money leading to greater compliance; however, waiting times at clinics were longer with perhaps fewer patients seen.

CONCLUSIONS

The mixed reactions elicited to the integration of healthcare services for HIV, hypertension and other non-communicable diseases highlights the complexities involved in implementing such services. Greater human resources with retraining and reskilling of healthcare staff is required for the optimal management of chronic multi-morbidities.

A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa

Background

Chronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model.

Methods

This was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically.

Results

The median age of participants was 36.5 (IQR: 30.8–45.5) years, and they had been in their roles for a median of 4.0 (IQR: 1.0–7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure, adequate staff, and balanced patient caseloads.

Conclusion

There are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.

Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa

BACKGROUND

Epidemiological transition in high HIV-burden settings is resulting in a rise in HIV/NCD multimorbidity. The majority of NCD risk behaviours start during adolescence, making this an important target group for NCD prevention and multimorbidity prevention in adolescents with a chronic condition such as HIV. However, there is data paucity on NCD risk and prevention in adolescents with HIV in high HIV-burden settings. The aim of this study was to investigate the extent to which NCD comorbidity (prevention, diagnosis, and management) is incorporated within existing adolescent HIV primary healthcare services in Cape Town, South Africa.

METHODS

We reviewed medical records of 491 adolescents and youth living with HIV (AYLHIV) aged 10-24 years across nine primary care facilities in Cape Town from November 2018-March 2019. Folders were systematically sampled from a master list of all AYLHIV per facility and information on HIV management and care, NCDs, NCD risk and NCD-related health promotion extracted.

RESULTS

The median age was 20 years (IQR: 14-23); median age at ART initiation 18 years (IQR: 6-21) and median duration on ART 3 years (IQR: 1.1-8.9). Fifty five percent of participants had a documented comorbidity, of which 11% had an NCD diagnosis with chronic respiratory diseases (60%) and mental disorders (37%) most common. Of those with documented anthropometrics (62%), 48% were overweight or obese. Fifty nine percent of participants had a documented blood pressure, of which 27% were abnormal. Twenty-six percent had a documented health promoting intervention, 42% of which were NCD-related; ranging from alcohol or substance abuse (13%); smoking (9%); healthy weight or diet (9%) and mental health counselling (10%).

CONCLUSIONS

Our study demonstrates limited NCD screening and health promotion in AYLHIV accessing healthcare services. Where documented, our data demonstrates existing NCD comorbidity and NCD risk factors highlighting a missed opportunity for multimorbidity prevention through NCD screening and health promotion. Addressing this missed opportunity requires an integrated health system and intersectoral action on upstream NCD determinants to turn the tide on the rising NCD and multimorbidity epidemic.

Level of adult client satisfaction with clinic flow time and services of an integrated non-communicable disease-HIV testing services clinic in Soweto, South Africa: a cross-sectional study

BACKGROUND

While HIV Testing Services (HTS) have increased, many South Africans have not been tested. Non-communicable diseases (NCDs) are the top cause of death worldwide. Integrated NCD-HTS could be a strategy to control both epidemics. Healthcare service strategies depends partially on positive user experience. We investigated client satisfaction of services and clinic flow time of an integrated NCD-HTS clinic.

METHODS

This prospective, cross-sectional study evaluated HTS client satisfaction with an HTS clinic at two phases. Phase 1 (February-June 2018) utilised standard HTS services: counsellor-led height/weight/blood pressure measurements, HIV rapid testing, and symptoms screening for sexually transmitted infections/Tuberculosis. Phase 2 (June 2018-March 2019) further integrated counsellor-led obesity screening (body mass index/abdominal circumference measurements), rapid cholesterol/glucose testing; and nurse-led Chlamydia and human papilloma virus (HPV)/cervical cancer screening. Socio-demographics, proportion of repeat clients, clinic flow time, and client survey data (open/closed-ended questions using five-point Likert scale) are reported. Fisher's exact test, chi-square analysis, and Kruskal Wallis test conducted comparisons. Multiple linear regression determined predictors associated with clinic time. Content thematic analysis was conducted for free response data.

RESULTS

Two hundred eighty-four and three hundred thirty-three participants were from Phase 1 and 2, respectively (N = 617). Phase 1 participants were significantly older (median age 36.5 (28.0-43.0) years vs. 31.0 (25.0-40.0) years; p = 0.0003), divorced/widowed (6.7%, [n = 19/282] vs. 2.4%, [n = 8/332]; p = 0.0091); had tertiary education (27.9%, [n = 79/283] vs. 20.1%, [n = 67/333]; p = 0.0234); and less female (53.9%, [n = 153/284] vs 67.6%, [n = 225/333]; p = 0.0005), compared to Phase 2. Phase 2 had 10.2% repeat clients (n = 34/333), and 97.9% (n = 320/327) were 'very satisfied' with integrated NCD-HTS, despite standard HTS having significantly shorter median time for counsellor-led HTS (36.5, interquartile range [IQR]: 31.0-45.0 vs. 41.5, IQR: 35.0-51.0; p < 0.0001). Phase 2 associations with longer clinic time were clients living together/married (est = 6.548; p = 0.0467), more tests conducted (est = 3.922; p < 0.0001), higher overall satisfaction score (est = 1.210; p = 0.0201). Those who matriculated experienced less clinic time (est = - 7.250; p = 0.0253).

CONCLUSIONS

It is possible to integrate counsellor-led NCD rapid testing into standard HTS within historical HTS timeframes, yielding client satisfaction. Rapid cholesterol/glucose testing should be integrated into standard HTS. Research is required on the impact of cervical cancer/HPV screenings to HTS clinic flow to determine if it could be scaled up within the public sector.

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi

OBJECTIVES

As HIV-positive individuals' life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using 'integrated care' if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017.

RESULTS

Only half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)-mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all.

CONCLUSIONS

Individuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries:a scoping review

BACKGROUND

Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs.

METHODS

Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results.

RESULTS

198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%).

CONCLUSION

Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.