Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting

Self-management support from health care providers in Shared Medical Appointments: Didactic techniques, peer learning, group dynamics and motivation

Objective

We investigated the support of self-management by health care providers (HCP) in prenatal Shared Medical Appointments (SMA).

Methods

on an topic list, semi-structured interviews were conducted. HCP who provided prenatal care in SMA in the last five years were recruited. Thematic analysis was used.

Results

We conducted 15 interviews. Four research themes were defined: didactic techniques, peer learning, motivation and the health care providers. Self-management support in SMA is based on peer-learning and is influenced by group dynamics. HCP play a role in the creation of an effective learning climate by using practical and communication techniques. HCP motivate participants for self-management through peer learning and person centered care. HCP need certain personality traits and leadership skills.

Conclusion

Self-management support in SMA is based on peer-learning and is influenced by group dynamics. HCP create an effective learning climate using practical and communication techniques and motivate participants for self-management through peer learning and person-centered care.

Innovation

This is the first study that gives insight in self-management support in SMA. HCP and medical schools should be aware of the fact that HCP in SMA need insight in didactic techniques, peer learning, group dynamics and leadership skills.

The Influence of Patient-Provider Communication on Self-Management Among Patients With Chronic Illness: A Systematic Mixed Studies Review

AIM

To explore the influence of patient-provider communication on patient self-management of chronic illness.

DESIGN

Systematic Mixed Studies Review.

DATA SOURCES

CINAHL, Google Scholar, EMBASE and PubMed were searched until March 2024.

METHODS

Employed a result-based convergent design and the Mixed Method Appraisal Tool to evaluate studies. Narrative analysis, quantitative studies and thematic analysis for qualitative studies and overall results.

RESULTS

Thirteen articles published between 2003 and 2023 were included. Chronic illnesses studied: diabetes, heart failure, hypertension, chronic obstructive pulmonary disease and asthma. Data synthesis yielded the overarching theme: adaptive interpersonal communication. An approach that adapts communication content to each patient's unique needs, employs verbal and nonverbal communication, builds a connection and establishes patient rapport.

CONCLUSION

Available evidence suggests that patient-provider communication influences chronic illness self-management. A provider's ability to adjust and tailor their communication style is an important factor in helping patients to achieve optimal self-management. Future research should explore this phenomenon in other common chronic illnesses not included in this review. Additionally, research on the patient's role in this process could help improve patient-provider communication.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Findings from this review have significant implications for shared and participatory decision making, where patients and providers collaborate to develop plans of care for patients to achieve optimal self-management. Additionally, this review can contribute to the development of educational content and communication strategies for nurses and all healthcare professionals caring for patients with chronic illnesses.

IMPACT

This is the first mixed studies systematic review to describe the influence patient-provider communication on patient self-management of chronic illness. These findings consolidate existing evidence, providing a pathway for practical application to clinical practice and the potential to significantly impact the delivery of patient-centred care and healthcare quality.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Supported self-management in long-term conditions in an African context

Self-management is an important strategy to improve quality of life, appropriately manage long-term health conditions, and reduce the economic burden of long-term health conditions. However, equitable healthcare access remains an issue, and the focus on 'self' in self-management is problematic. Our review aims to explore the conceptualisation and evolution of supported self-management in an African context and its relevance to physiotherapy. A state-of-the-art review of the literature was undertaken by the authors. The authors knowledge of the subject area and a database search retrieved recent articles exploring patients' and healthcare providers' understanding of supported self-management in Africa. Relevant articles were read, and data summaries of included studies were extracted and tabulated. Findings were organised deductively. Sixteen studies, 11 primary research, and 5 reviews (2016-2023) undertaken in a variety of sub-Saharan countries with healthcare workers (~n = 177) and people (~n = 16 115) living with a mix of non-communicable and communicable conditions were considered in this state-of-the-art review. Self-management perceptions were drawn from Western authors spanning development research and understanding of the concepts in Western thinking. We conclude that imported concepts, such as supported self-management for long-term conditions, should be considered within local health delivery solutions. These should be embedded in an understanding of traditional African health systems.

Clinical implications

There is a need to develop locally derived African solutions. Self-management strategies for long-term health conditions should be developed, considering traditional holistic African health systems.

Individual perceptions of community efficacy for non-communicable disease management in twelve communities in China: cross-sectional and longitudinal analyses

OBJECTIVES

This objective of this study was to use empirical data to assess cross-sectional variation singular and changes over time in community efficacy for non-communicable diseases (NCDs) management (COEN) and to examine individual factors associated with changes in COEN.

STUDY DESIGN

This was a longitudinal observational study.

METHODS

Participants with hypertension and diabetes were randomly selected from 12 communities from three cities in eastern China, and a baseline survey and a 1-year follow-up were conducted. The COEN scale has five dimensions: community physical environment (CPE), behavioral risk factors (BRF), mental health and social relationships (MHSR), community health management (CHM), and community organisations and activities (COA). Mixed-effects models were used to investigate the change in COEN over time and the association between individual factors and changes in COEN.

RESULTS

COEN scores showed significant variation singular among the 12 communities (P < 0.001) at the baseline. In the mixed-effects model, CPE (β coefficient: 1.62, P < 0.001), BRF (0.90, P < 0.001), MHSR (0.86, P < 0.001), CHM (0.46, P < 0.001), and total scores (β = 3.57, P < 0.001) increased significantly over time. The changes in COEN were associated with individual characteristics (e.g., older, men, more educated).

CONCLUSIONS

Cross-sectional variations and changes over time in COEN demonstrated the utility of a sensitive instrument. Factors such as age, gender, marriage, education level, and employment may affect the financial and social resources assignment for NCD management. Our findings suggest that further high-quality studies are needed to better evaluate the effect of community empowerment on the prevention and control of NCDs.

What are the roles of eHealth literacy and empowerment in self-management in an eHealth care context? A cross-sectional study

AIMS

To examine the relationship among eHealth literacy, empowerment and self-management and the mediating effects of empowerment in diabetic kidney disease (DKD) patients in the eHealthcare context.

BACKGROUND

Self-management is an essential aspect of healthcare in delaying disease progression for DKD. In the eHealthcare era, health services providing self-management are transforming. The ability and confidence of patients to use eHealth services is a critical issue that impacts the effectiveness of self-management, but little is known about the role of eHealth literacy and empowerment in self-management.

DESIGN

A cross-sectional study guided by the STROBE.

METHODS

Overall, 127 Taiwanese patients were enrolled using convenience sampling. Data collection used structured questionnaires and chart reviews. Multiple regression was used to infer self-management predictors, and SPSS PROCESS macro and bootstrapping verified the mediating effects.

RESULTS

Empowerment and eHealth literacy both showed significant positive correlations with self-management. Empowerment was the main predictor of self-management and had a complete mediating effect between eHealth literacy and self-management.

CONCLUSION

Increasing patients' eHealth literacy can improve empowerment and prevent health inequality issues. Healthcare providers should consider improving patients' eHealth literacy to enhance their self-management.

RELEVANCE TO CLINICAL PRACTICE

Healthcare service systems need to create user-friendly eHealthcare environments, and healthcare professionals can provide multifaceted instructions that fit patients' eHealth literacy levels to enhance their motivation and confidence in disease care, thus cultivating positive self-management behaviours.

IMPACT

The popularity of eHealthcare services aimed at promoting self-management behaviours is increasing. However, the level of eHealth literacy is an essential factor that affects the effectiveness of self-management in the healthcare environment. In addition, empowerment is a major critical influence factor of self-management and a completely mediating variable between self-management and eHealth literacy. Consequently, healthcare providers should consider promoting patients' eHealth literacy to empower people using eHealthcare services for implementing self-management.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies in cross-sectional studies (STROBE) checklist was used to ensure comprehensive reporting.

PATIENT OR PUBLIC CONTRIBUTION

Patients were diagnosed with DKD in the study hospital. Physicians and case managers transferred patients to research assistants who screened them for the inclusion criteria and invited them to participate in this study if they met the requirements. After participants signed informed consent, the research nurse encouraged participants to respond to the research questionnaire face to face.

Nigerian Health Care Providers and Diabetes Self-Management Support: Their Perspectives and Practices

Nigeria struggles to reframe its traditional acute-care disease approach to health care to accommodate rising needs for chronic disease care. This interpretive descriptive study explored Nigerian healthcare providers' (HCPs) perspectives, experiences, and practices related to self-management support (SMS). Observational and experiential data were gathered from 19 HCPs at two urban hospitals in Southeastern Nigeria (seven physicians, four nurses, five dietitians/nutritionists, and three health educators). There were four themes: (a) compliance-oriented medical model, (b) SMS as advice, informal counseling, and education, (c) navigating the sociocultural terrain, and (d) workarounds. Nigerian HCPs perspectives and SMS practices were characterized by attempts to foster compliance with healthcare instructions within a traditional biomedical model. Participants enhanced patient support using specific strategies to bypass structural system obstacles. These findings demonstrate the need to reevaluate the current understanding of SMS in Nigeria and its practice.

Correlation between health literacy and health‐related quality of life in patients with diabetic peripheral neuropathy: The mediating role of self‐management

AIM

The aims of the study were to analyse the current situation of health literacy (HL), self-management and health-related quality of life (HRQOL) in patients with diabetic peripheral neuropathy (DPN), to explore the correlation between the three and to verify the mediating role of self-management in HL and HRQOL.

DESIGN

A cross-sectional survey.

METHODS

The convenience sampling method was used to select 401 DPN patients attending the First Hospital of Jinzhou Medical University in Liaoning Province, China, from December 2020 to December 2021 as the study population. The research instrument included socio-demographic characteristics questionnaire, Health Literacy Management Scale (HeLMS), Summary of Diabetes Self-Care Activities (SDSCA) and Short-Form 12-item Health Survey (SF-12). SPSS 25.0 was applied to the data for descriptive analysis, Pearson correlation analysis and stratified multiple regression analysis. Mediating effects were tested using SPSS PROCESS macro 4.0 software.

RESULTS

HL and self-management of DPN patients correlated positively with HRQOL. The mediation role of self-management was significant in the relationship between HL and physical and mental HRQOL (physical component summary: β = 0.26, P < 0.01; mental component summary: β = 0.18, P < 0.01), with mediating effects accounting for 35.62% and 34.62% of the total effect.

CONCLUSIONS

There was a positive correlation between HL, self-management and HRQOL in patients with DPN. Self-management plays a partially mediating role in the relationship between HL and HRQOL in DPN patients. It means that HRQOL in this population can be improved by increasing HL and thus self-management in DPN patients.

PATIENT OR PUBLIC CONTRIBUTION

None.

Optimising care coordination strategies for physical activity referral scheme patients by Australian health professionals

Physical activity (PA) has been identified as an essential tool for the prevention and management of multi-morbidity in patients. Coordination of patients’ care through interventions like physical activity referral schemes (PARS) could foster the utilization of PA. This study explored the views of General Practitioners (GPs) and Exercise Physiologists (EPs) as key stakeholders, for optimizing patient care and efficiency of PARS. Sequential explanatory mixed methods design was used to explore the perceptions of these health professionals on PA and coordination strategies for PARS patient care. Data analyses included descriptive and inferential statistics for questionnaires and theoretical framework analysis for the semi-structured interviews. Participants demonstrated a good knowledge of PA and valued PARS. However, the findings unravelled external factors, inter-organisational mechanisms, and relational coordination obstacles that hinder efficient coordination of PARS patient care and delay/limit beneficial health outcomes for patients. Incentivising the PARS initiative and empowering patients to seek referral into the programme, are strategies that could boost PARS efficiency. Improving inter-professional relationships between GPs and EPs could lead to enhanced PARS functionality and efficient coordination of care for patients with chronic diseases.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

Retention in antiretroviral therapy (ART) services is critical to achieving positive health outcomes for individuals living with HIV, but accumulating evidence indicates that individuals are likely to miss ART appointments over time. Thus, it is important to understand why individuals miss appointments and how they re-engage in HIV care. We used in-depth interviews with 44 ART clients in Malawi who recently missed an ART appointment (> 14 days) but eventually re-engaged in care (within 60 days) to explore reasons for missed appointments and barriers and facilitators to re-engagement. We found that most individuals missed ART appointments due to unexpected life events such as funerals, work, and illness for both clients and their treatment guardians who were also unable to attend facilities. Several reasons differed by gender-work-related travel was common for men, while caring for sick family members was common for women. Barriers to re-engagement included continued travel, illness, and restricted clinic schedules and/or staff shortages that led to repeat facility visits before being able to re-engage in care. Strong internal motivation combined with social support and reminders from community health workers facilitated re-engagement in HIV care.

Defining an enabling environment for those with chronic disease: an integrative review

BACKGROUND

Health policies are currently being implemented to cope with the 37% of those affected by chronic disease and 63% of deaths worldwide. Among the proposals, there is accelerating support for greater autonomy for patients, which incorporates several concepts, including empowerment. To achieve this, develop an environment to increase an individual's capacity for action seems to be a fundamental step. The aim of this study is to characterize an enabling environment for patients in the context of chronic disease management.

METHODS

An integrative review design was applied. Medline, CINAHL, and Web of Science databases were searched to identify relevant literature published between 2009 and 2019. Overall, the review process was guided by the PRISMA 2020 checklist. The Mixed Methods Appraisal Tool for quality evaluation was used.

RESULTS

A total of 40 articles were analyzed, divided into 18 quantitative studies, 11 qualitative studies, two mixed studies, seven expert opinions, one theory and one conference report. The following characteristics defining an enabling environment were taken from the literature relating to those with a chronic condition: Needs assessment-adaptation of responses, supporting "take care", involvement in support, knowledge improvement, engagement with professionals, use of information and communication technologies, and organization of care. Beyond that, the interactions highlighted between these seven categories characterize an enabling environment.

CONCLUSION

This review specifies the essential elements of an enabling environment for patients with chronic conditions. It encompasses the partnership between the healthcare professional, such as the advanced practice nurse, and the individual for whom interventions and care strategies must be devised.

Australian patients' perception of the efficacy of the physical activity referral scheme (PARS)

BACKGROUND

Optimum physical activity (PA) interventions could be delivered via physical activity referral schemes (PARS) if utilised adequately. However, the evidence supporting PARS effectiveness is weak due to low uptake and non-adherence to interventions.

OBJECTIVE

Patients' experiences of PARS were explored to obtain in-depth insight into their perceived quality of care and practical ways to optimise the programme's effectiveness.

METHODS

A sequential explanatory mixed methods design was employed to probe cross-sectional quantitative survey data (n = 111) on patients' knowledge and beliefs about PA and PARS and qualitative interview data (n = 15) on their experiences of PARS. Informed by Donabedian framework of healthcare quality assessment, quantitative and qualitative findings were integrated to identify practical ways to enhance PARS effectiveness.

RESULTS

Participants displayed good PA knowledge, had positive beliefs and perceived PARS to be useful. Nonetheless, bottlenecks in the structure and process of PARS impact on patient health outcomes and hinder the programme's uptake.

CONCLUSION

Exploring other referral mechanisms into PARS such as self or nurse-initiated referrals could improve the programme's visibility and effectiveness.

PRACTICE IMPLICATIONS

Improved support, enhanced visibility of EPs, ongoing interactions between GPs and EPs and education about referral pathways would foster improved uptake, adherence and health outcomes for patients.

Patient empowerment and self-management behaviour of chronic disease patients: A moderated mediation model of self-efficacy and health locus of control

AIMS

To explore the role of self-efficacy (SE) in the effect of patient empowerment on self-management behaviours among patients with chronic illness and to investigate the moderating effect of three types of health locus of control (HLC) in this moderated mediation model.

DESIGN

Cross-sectional design.

METHODS

Data were collected in a general tertiary hospital, and a sample of 254 patients was recruited between August and October 2020. The effect of moderation and mediation was tested by the PROCESS macro (Model 4 and Model 8) for SPSS 25.0 by Hayes using 5000 bootstrap samples.

RESULTS

Self-efficacy significantly mediated the relationship between patient empowerment and self-management behaviour with a 95% confidence interval excluding zero. The chance HLC demonstrated a moderating effect, and the interaction effect on SE and self-management behaviour was significant.

CONCLUSION

Patient empowerment may improve confidence and adherence to self-management among people with chronic illness, and such benefits were conditional on the HLC of patients.

IMPACT

This study addresses the relationship between patient empowerment and self-management behaviour in patients with different personality characteristics. This result indicated that classifying the type of HLC may enable the identification of subgroups of patients who may subsequently benefit from patient empowerment. In a patient-centred programme, nurses and other healthcare professionals correctly identifying patients' HLC type and understanding the implications and then providing appropriate health care plans for patients with different health beliefs may be useful to tailor the decision-making process.

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Despite positive NCD policies in recent years, majority of Sub-Saharan African (SSA) health systems are inadequately prepared to deliver comprehensive first-line care for NCDs. Primary health care (PHC) settings in countries like Malawi and Zambia could be a doorway to effectively manage NCDs by moving away from delivering only episodic care to providing an integrated approach over time. As part of a collaborative health system strengthening project, we assessed and compared the preparedness and operational capacity of two target networks of public PHC settings in Lilongwe (Malawi) and Lusaka (Zambia) to integrate NCD services within routine service delivery. Data was collected and analyzed using validated health facility survey tools. These baseline assessments conducted between August 2018 and March 2019, also included interviews with 20 on-site health personnel and focal persons, who described existing barriers in delivering NCD services. In both countries, policy directives to decentralize disease-specific NCD services to the primary care level were initiated to meet increased demand but lacked operational guidance. In general, the assessed PHC sites were inadequately prepared to integrate NCDs into various service delivery domains, thus requiring further support. In spite of existing multi-faceted limitations, there was motivation among healthcare staff to provide NCD services.

An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study

This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.

Ways of coping mediate the relationship between self-efficacy for managing HIV and acceptance of illness among people living with HIV

AIM

The purpose of this study was to examine the relationship between self-efficacy for managing HIV and acceptance of illness and to identify the potential mediation effect of active coping and passive coping on this relationship.

DESIGN

The study used a cross-sectional survey.

METHODS

A sample of 555 people living with HIV were recruited from September-December 2018 in the HIV clinic of a tertiary general hospital in Changsha, China. Survey data were collected through face-to-face interviews that included measures of sociodemographic and HIV-related clinical characteristics, Acceptance of Illness Scale, the Simplified Coping Style Questionnaire and the Self-efficacy for Managing Chronic Disease Scale. Step-by-step linear regression models combined with bootstrap testing were used to test the relationships when controlling for gender and HIV diagnosis duration.

RESULTS

Self-efficacy was positively related to acceptance of illness and this relationship was partially mediated by both active coping and passive coping. Acceptance of illness increased by 0.175 for every point increase in self-efficacy indirectly through active coping, while acceptance of illness decreased by 0.034 for every point increase in self-efficacy via passive coping.

CONCLUSION

The findings highlighted the importance of self-efficacy for managing HIV and ways of coping, especially active coping, for illness acceptance.

IMPACT

The findings suggested that interventions that improve confidence in managing HIV and active coping may enhance the illness acceptance of people living with HIV.

Patient perspectives on interpersonal aspects of healthcare and patient-centeredness at primary health facilities: A mixed methods study in rural Eastern Uganda

INTRODUCTION

Patient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda.

METHODS

A mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients' health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care.

RESULTS

Patient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient's health and illness experience, and the quality of the relationship between patient and health worker (range 62.1-78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes.

DISCUSSION AND CONCLUSION

Our findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients' expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients' responsibilities and patient's rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC.

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

BACKGROUND

With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level.

METHODS

A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo.

RESULTS

Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems.

CONCLUSION

In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting

AIM

To explore how provision of self-management support to chronically-ill patients in resource-limited settings contributes to patient empowerment in chronic care.

DESIGN

Concurrent descriptive mixed methods research.

METHODS

A survey of 140 patients with chronic conditions administered at four time-points in 12 months. We conducted 14 interviews and four focus-group discussions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient-support group meetings. Data were collected between April 2016 - May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data.

RESULTS

Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self-management guidance. Information exchanged during patient-provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non-physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from volunteer-led community home-based care programmes. HIV support-groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self-mangement competence and proactiveness in health care.

CONCLUSION

For optimal self-management, reforms at inter-personal and organizational level are needed including; mutual patient-provider collaboration, diversifying access to self-management support resources and restructuring patient support-groups to cater to diverse chronic conditions.

IMPACT

Our study provides insights and framing of self-management support and empowerment for patients in long-term care in sub-Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions.