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 human immunodeficiency virus (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. Whilst integrated health education and concurrent management of HIV, hypertension and diabetes is being scaled up in clinics, innovative, more efficient and cost-effective interventions which include decentralisation into the community are required to respond to increased burden of co-morbid HIV/NCD disease. Methods and analysis: This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomized trial (INTE-COMM) in Tanzania and Uganda which will compare community-based integrated care (HIV, diabetes, hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension, diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet, exercise) provided by community nurses and trained lay-workers, and the devolvement of NCD drug dispensing to community level. Based on Bronfenbrenner’s ecological systems theory, the process evaluation will use qualitative methods to investigate socio-structural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multi-stakeholder interviews (patients, community health workers/volunteers, healthcare providers, policymakers, clinical researchers, international and non-governmental organisations), focus group discussions (community leaders, members) and non-participant observations (community meetings, 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 under 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

Community and stakeholders' engagement in the prevention and management of Type 2 diabetes : a qualitative study in socioeconomically disadvantaged suburbs in region Stockholm

Background: Community-based approaches have been identified as an effective strategy to address the growing burden of noncommunicable diseases (NCDs) worldwide. However, little is known about community as a concept among people living in socioeconomically disadvantaged settings and stakeholders’ interactions and engagement in NCDs prevention and management. Objective: The aim of this study was to understand; (1) the meaning of community among people living in socioeconomically disadvantaged suburbs in Region Stockholm and (2) how communities interact and engage with stakeholders at local and regional levels for the prevention and management of type 2 diabetes (T2D). Methods: This qualitative study was conducted in three municipalities in Region Stockholm with a high proportion of migrants. Multiple data collection methods were used, including observations of community activities; interviews with community members, representatives of public authorities and NGOs; and group interviews with healthcare providers. Data were analyzed using content analysis. Results: Community was perceived as living in close proximity with shared beliefs, values and resources. Although they recognized its social and cultural diversity, community members focused more on the commonalities of living in their neighborhood and less on their differences in country of birth and languages spoken. Several mismatches between awareness of community needs and the available skills and resources among stakeholders for T2D prevention were identified. Stakeholders expressed awareness of T2D risk and interest in addressing it in a culturally appropriate manner. Conclusion: Interaction between the communities and stakeholders was limited, as was engagement in T2D prevention and management. This highlights barriers in the collaboration between community, healthcare institutions and other stakeholders which consequently affect the implementation of preventive interventions. Innovative ways to link the community to the healthcare sector and other local government institutions are needed to build the capacity of health systems for T2D prevention in socioeconomically disadvantaged communities.De 2 sista författarna delar sistaförfattarskapet.</p