A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes co-morbidity

Health systems' strengthening is essential in South Africa in an era of the convergence of communicable and non-communicable diseases. Whilst TB is ranked first in all-cause mortality, non-communicable diseases which include cerebrovascular disease and diabetes mellitus follow; with HIV/AIDS in fourth place. In the Western Cape, diabetes mellitus and HIV are the top two causes of death accounting for 6.8% and 5.8% respectively (StatsSA, 2015b). As the burden of non-communicable disease continues to increase significantly due to more South Africans presenting these co-morbid conditions, the complexity of managing these chronic conditions has increased. The reorganisation of primary health services to better cater for patients with multiple chronic conditions has become an imperative in South Africa but still in its infancy. However, how chronic patients with multi-morbidities experience the current services and what their perceived needs are in order to enhance the management of their conditions both at point of healthcare and in their daily lives is not widely understood. Below, is an outline of the three parts presented in this dissertation. Part A is the study protocol, which gives a background of the intersection of communicable and noncommunicable diseases in South Africa, focusing on HIV and type two diabetes (hereafter HIV/T2D) co-morbidity. A qualitative design was employed. In-depth interviews were conducted with ten patients living with HIV/T2D co-morbidity and six health workers who interacted with these patients. Ethical considerations such as potential risks and benefits; confidentiality, autonomy and informed consent are also highlighted in the protocol. Part B is the structured literature review on chronic care in low and middle-income countries (LMICs). Two sub-sections are presented with the first focusing on LMICs excluding South Africa; and the second for South Africa only. Theoretical frameworks, which were applied to managing chronic conditions and empirical studies on HIV/T2D in these LMICs, are reviewed. Reference to the Cumulative Complexity Model (CCM), will also provide an indepth understanding of the prospects of strengthening the primary healthcare system in South Africa to address chronic conditions more effectively. Part C is the journal-ready manuscript of the data collected in the qualitative study. It consists of the background, methods, results, discussion and conclusions. Findings describe patients' experiences of the primary healthcare services and the daily challenges of living with and managing HIV and T2D among a sample of ten patients attending a clinic in Cape Town. Health worker perspectives on managing HIV/T2D co-morbidity are also presented. Both patients and healthworkers also shared strategies on how health interventions could be more responsive to HIV/T2D co-morbidity. Hence, further contributions are made in the knowledge base of strengthening chronic conditions. However, further research with different subsets of patients living with not only HIV/T2D but also other co-morbid or multi-morbid conditions is important for improvements in health policy-making in South Africa

A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes multimorbidity.

BACKGROUND: Current South African health policy for chronic disease management proposes integration of chronic services for better outcomes for chronic conditions; that is based on the Integrated Chronic Disease Model (ICDM). However, scant data exist on how patients with chronic multimorbidities currently experience the (re)-organisation of health services and what their perceived needs are in order to enhance the management of their conditions. METHODS: A qualitative study was conducted in a community health centre treating both HIV and diabetes patients in Cape Town. The study was grounded in the Shippee's Cumulative Complexity Model (CCM) and explored "patient workload" and "patient capacity" to manage chronic conditions. Individual interviews were conducted with 10 adult patient-participants with HIV and type two diabetes (T2D) multimorbidity and 6 healthcare workers who provided health services to these patient-participants. RESULTS: Patient-participants in this study experienced clinic-related workload such as: two separate clinics for HIV and T2D and perceived and experienced power mismatch between patients and healthcare workers. Self-care related workloads were largely around nutritional requirements, pill burden, and stigma. Burden of these demands varied in difficulty among patient-participants due to capacity factors such as: positive attitudes, optimal health literacy, social support and availability of economic resources. Strategies mentioned by participants for improved continuity of care and self-management of multi-morbidities included integration of chronic services, consolidated guidelines for healthcare workers, educational materials for patients, improved information systems and income for patients. CONCLUSION: Using the CCM to explore multimorbidity captured most of the themes around "patient workload" and "patient capacity", and was thus a suitable framework to explore multimorbidity in this high HIV/T2D burden setting. Integration of chronic services and addressing social determinants of health may be the first steps towards alleviating patient burden and improving their access and utilisation of these services. Further studies are necessary to explore multimorbidity beyond the context of HIV/T2D

A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes multimorbidity

Current South African health policy for chronic disease management proposes integration of chronic services for better outcomes for chronic conditions; that is based on the Integrated Chronic Disease Model (ICDM). However, scant data exist on how patients with chronic multimorbidities currently experience the (re)-organisation of health services and what their perceived needs are in order to enhance the management of their conditions.A qualitative study was conducted in a community health centre treating both HIV and diabetes patients in Cape Town. The study was grounded in the Shippee's Cumulative Complexity Model (CCM) and explored "patient workload" and "patient capacity" to manage chronic conditions. Individual interviews were conducted with 10 adult patient-participants with HIV and type two diabetes (T2D) multimorbidity and 6 healthcare workers who provided health services to these patient-participants.Patient-participants in this study experienced clinic-related workload such as: two separate clinics for HIV and T2D and perceived and experienced power mismatch between patients and healthcare workers. Self-care related workloads were largely around nutritional requirements, pill burden, and stigma. Burden of these demands varied in difficulty among patient-participants due to capacity factors such as: positive attitudes, optimal health literacy, social support and availability of economic resources. Strategies mentioned by participants for improved continuity of care and self-management of multi-morbidities included integration of chronic services, consolidated guidelines for healthcare workers, educational materials for patients, improved information systems and income for patients.Using the CCM to explore multimorbidity captured most of the themes around "patient workload" and "patient capacity", and was thus a suitable framework to explore multimorbidity in this high HIV/T2D burden setting. Integration of chronic services and addressing social determinants of health may be the first steps towards alleviating patient burden and improving their access and utilisation of these services. Further studies are necessary to explore multimorbidity beyond the context of HIV/T2D