Chronic disease care in primary health care facilities in rural South African settings

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs.MT201

Key informant perceptions of vision loss in children and implications for their training

Background: The role of key informants (KIs) in identifying children with vision loss is expanding, yet there is a minimal understanding of KI perceptions of vision loss in children. The aim of the study was to understand the KI’s perception of childhood vision loss in order to design more effective training programmes.Materials and Methods: A population-based study on the prevalence and causes of childhood blindness and severe visual impairment was conducted using the KI method. KIs were selected by their communities and trained in advocacy, identifi cation and referral of children with visual impairment. Prior to the KI training, a pre-test was conducted, asking, “what is your perception of vision loss in children and how will you identify these children in your community?”.Result: The 742 KI provided 1,650 responses. There were three main methods suggested to identify children; observation of a child, vision assessment of a child, and recognition of isolation of a child.Conclusion: KI have a good understanding of the impact of vision loss on children. Training programmes should use existing knowledge of KI. Furthermore, training programmes should include the social impact of severe vision loss to help identify children needing the assessment.Keywords: Childhood blindness, key informant, Nigeria, perception, visio

Hepatitis B Virus Knowledge and Vaccination Status among Health‐care Workers in Calabar, Nigeria

Background and Objectives: The World Health Organization estimates that 2 million health‐care workers (HCWs) are at risk of occupational exposure to hepatitis B virus (HBV), with the majority (90%) of such infections arising in sub-Saharan Africa. This study aimed to determine HBV knowledge and vaccination uptake among HCWs. Materials and Method: This was a cross sectional analytical study conducted among 392 HCWs from two major health institutions in Calabar i.e. the University of Calabar Teaching Hospital (UCTH) and the General Hospital Calabar (GHC), Cross river State. Multi-staged sampling method comprising of two stages was used to recruit participants into the study. The study population comprised of doctors, nurses, laboratory scientists/technologist, and other categories of HCWs such as pharmacists, ward orderlies, and mortuary attendants. A semi-structured self-administered questionnaire was used to obtain data on the socio-demographic characteristics of HCWs, the knowledge of HCWs regarding HBV and vaccine. The analysis of data was done using the Statistical Package for Social Sciences version 20. Study Design: This was a cross-sectional, study of HCWs in Calabar. Sampling Method: Multi-staged sampling method was used to select participants from two major health institutions in Calabar, i.e., the University of Calabar Teaching Hospital (UCTH) and the General Hospital Calabar (GHC). Thereafter, through balloting, simple random sampling technique was used to recruit the participants. Study Population: Three hundred and ninety-two HCWs were recruited from UCTH and GHC under the following categories: doctors, nurses, laboratory scientists/technologist, and other categories of HCWs such as pharmacists, ward orderlies, and mortuary attendants. Data Management: A semi-structured self-administered questionnaire was used to obtain data on the socio-demographic characteristics of HCWs, the knowledge of HCWs regarding HBV and vaccine. The analysis of data was done using the Statistical Package for Social Sciences version 20. Results: Overall, 67.9% of the respondents were found to have adequate knowledge of HBV vaccination and infection. Less than half (43.4%) of HCWs admitted receiving three doses (i.e., full coverage) of the vaccine. Difficulty in accessing the vaccine (48, 23.4%) was identified as the major reason given for suboptimal vaccination. Conclusion: The knowledge of HBV infection and vaccination is quite modest among HCWs in Calabar. Despite this observation, the vaccination status among HCWs is unsatisfactory. The implication of the findings of our study for health policy and practice is to prevent further occupational exposure of HCWs to HBV infection through mandatory vaccination

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

Acknowledgement This work was supported by (i) Medical Research Council/Wits Rural Public Health and health Transitions Research Unit (Agincourt) South Africa, through the Wellcome Trust, UK (Grant Numbers 058893/Z/99/A, 069683/Z/02/Z); (ii) Fogarty International Centre of the National Institutes of Health fellowship (Grant number 1D43TW008330-01A); and (iii) African Doctoral Dissertation Research Fellowship. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health and other funders. This paper was facilitated by attending the Wits School of Public Health Thanda Ukubhala writing retreat funded by the Faculty of Health Sciences Research Office. The authors acknowledge the contributions of Chimaraoke Izugbara, Rachel Caesar, Lenore Manderson, Faith Mambulu and Latonya Wilson for writing support. Funding Funding to pay the Open Access publication charges for this article was provided by the Fogarty International Centre of the National Institutes of Health fellowship (Grant number 1D43TW008330-01A). This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] reviewedPublisher PD

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

Funding: This research conducted by SA was funded by the following: 1) The Agincourt Health and Socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN) and is supported by the National Department of Science and Innovation, the Medical Research Council and the University of the Witwatersrand, South Africa, and the Wellcome Trust, UK (grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z); 2) Fogarty International Centre of the National Institutes of Health under the award number D43 TW008330; and 3) an African Doctoral Dissertation Research Fellowship Programme award to the corresponding author. The funding for the publication of this article was provided by the Lown Scholars Program, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Peer reviewedPublisher PD

Hubungan Dukungan Tenaga Kesehatan Dengan Tingkat Kecemasan Wanita Premenopause Dalam Menghadapi Sindrom Menopause

: Menopause is a transition period in a woman\u27s life, which is characterized by the cessation of menstruation or menstruation. Menopausal women need support to deal with feelings of anxiety and stress as a result of the changes - changes that happened. Health personnel can provide support prevention and education, business and labor to hold the condition - stress condition will be more effective and dihargai.Penelitian aims to determine the relationship between the support of health workers with the anxiety levels in premenopausal women facing menopause syndrome. The study took place from May 27 to June 7, 2015. This type of research is descriptive correlative and using cross sectional design of the study, subjects of the study was premenopausal women who reside in the Village of East Kedungwuni as many as 176 people with techniques clutser sample. Data were analyzed using chi square test obtained value ρ = 0.001 so the conclusion: there is a relationship between support health workers with the level of anxiety in the face syndrome premenopausal women

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

Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Background: 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.This study was funded by the Joint Health Systems Research Initiative from Department for International Development/MRC/Welcome Trust/Economic and Social Research Council (MR/N005597/1 and MR/P014844/1). The work was nested within the South African Medical Research Council / Wits University Rural Public Health and Health Transitions Research Unit, supported by the University of the Witwatersrand and Medical Research Council, South Africa. The Agincourt Health and Socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN), is supported by the National Department of Science and Innovation.https://doi.org/10.1080/16549716.2020.1852781pubpu

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