Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa

Chronic health conditions represent a substantial challenge to global health and by 2020 they will account for 73% of all deaths, constituting 60% of the global burden of disease [1]. In South Africa NCDs have increased over the past 15 years. They now account for an estimated 37% of all-cause mortality and 16% of disability-adjusted life years [2]. The overall level of NCD mortality is similar across all provinces in South Africa but the causes are different [3]. Most NCDs share risk factors [4], and many of them are modifiable [5] and are usually adopted early in life [3]. This provides considerable opportunities for intervention [2, 5]; however, progress in reducing NCD risk factors will only be attained if appropriate attention is given to the social and cultural contributing factors [2].

Chronic disease management (CDM) entails an integrated approach involving the patient, the family and the community as active participants over a lifetime of care [6, 7]. Effective interventions to limit the progression of the diseases or to mitigate the risk of complications are needed [8]. Most CDM interventions should be tailored to the person’s strengths and challenges in managing their care [9]. Thus, collaborative efforts on the management of people with chronic diseases in primary health care (PHC) settings plays an important role in CDM, as PHC professionals link their services to other specialised services in the communities [10]. Therefore, PHC requires a greater level of organisation that must be sustained, commonly over a patient’s lifetime [11]. Developing these interventions is a challenge in low-income and middle-income countries [11]. The aim of this study was to develop an integrated, evidence-based CDM model based on the premise that multiple-strategy interventions are consistently more effective than single-strategy interventions [12].

The research methodology for the current study was guided by the research question, which was developed in order to understand the burden of chronic disease risk factors; and to learn about the perceptions, experiences, barriers and challenges of chronic disease with respect to patients, nurses, CHWs and THPs regarding chronic disease management. This, therefore, brought about the idea of employing a mixed methods approach [13, 14] with the aim of integrating quantitative and qualitative data collection and analysis into a single study in order to develop an intervention program in a form of a model designed to improve the management of chronic diseases in a rural area. The use of this mixed-method methodology included the principle of making a decision on the priority or weight given to the quantitative and qualitative data collection and analysis in the study; the sequence of the data collection and analysis; and, the stage/stages in the research process at which the quantitative and qualitative data are connected and the results are integrated [15]. When used in combination, both quantitative and qualitative data yielded a more complete analysis and they complemented each other, bringing about an understanding of the strengths and weaknesses of quantitative and qualitative research methodologies.

Multiple data was collected using different strategies, approaches and methods [16]. The quantitative techniques used included a cross-sectional study design using the World Health Organization (WHO) STEPwise approach to surveillance of NCD risk factors (WHO STEPS) [17]. The qualitative techniques used included focus group discussions (FGDs) [18], semi-structured interviews [19] and QCs [20, 21]. The present study was developmental in nature because the first method was used sequentially to help inform the second and third methods. This was done in the form of sequential triangulation because the model or interventions were developed in phases, with results from all the phases essential for planning the model development.

A multifaceted intervention using QCs [22‐24], was developed during the month of February 2014 to improve the quality and the management of chronic diseases in Dikgale HDSS. This intervention comprised small group sessions of expertise to discuss and provide feedback on prevention, management and control of chronic diseases in rural areas. The QCs have become an important method of quality improvement (QI) in primary care [24]. The rationale behind the use of this research methodology was the fact that it involved gathering together small groups of employees doing similar or related work, who voluntary meet to identify, define, analyze and solve work-related problems or issues [25].

In the previous studies conducted as part of the bigger project in the study area, the quantitative study revealed a high prevalence of behavioural and biomedical risk factors for NCDs [31]. Approximately one in three study participants were found to be hypertensive, starting at a young age of 15 to 24 years. Approximately 90% of the participants were below the WHO recommendations for fruit and vegetable consumption, while more than half had low physical activity levels. A quarter of the participants were overweight and obese, while one in third had high total cholesterol levels. The qualitative studies [27] revealed that lack of knowledge of chronic diseases was predominant among patients, nurses, CHWs and THPs. Training on CDM was also lacking or insufficient and there was poor supervision of health facility operations by the district and provincial managers. The CHWs were not respected by nurses and their remuneration was not regularly received. A poor relationship was found to exist between THPs and clinic nurses, due to lack of formal referral system. This was primarily due to the lack of a formal structure to represent the THPs in government.

The QCs used the abovementioned findings to discuss specific needs in relation to capacities for chronic disease prevention and management in the Dikgale HDSS. The discussions were focused on the ability to integrate determinants of health approach into programme planning in order to address the root causes of chronic disease. Further discussions addressed the integration of health services in order to improve the management and prevention of chronic non-communicable diseases. Therefore, the model development followed three major steps as follows:

The integrated evidence-based chronic NCD management model developed in the current study describes changes which are needed at PHC settings in a rural area.

The main focus of our study was to develop appropriately effective intervention strategies that will facilitate change, in order to prevent and control chronic diseases within and across cultural contexts [28] in rural areas. An integrated multi-faceted approach to improving care of chronic conditions has been shown to result in better outcomes [32].

These changes are based on four interacting system components, which are health care providers; health care system; community partners; and, patients with their families. These health system changes are supported by the concept of an ideal clinic introduced into the South African health system, in order to move from a hospital-centric, curative system to preventive and promotive PHC that is cost effective and meets community needs [33]. This is also supported by the Chronic Care model developed by Wagner and colleagues, which comprises four components, which are self-management support; delivery system design; decision support; and clinical information systems [1, 34]. An important difference in the current proposed integrated model is the integration of services from nurses, CHWs and THPs. This addition to the model was mainly due to the fact that, in this rural area, health services are provided by nurses in the clinics and CHWs and THPs in the community. This study also supports the notion that patients may be the ambassadors who inform and support others, as seen in recent smoking cessation programmes [35] and also in decision making [36].

The model developed highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers. Therefore, further research will be conducted in the study area on planned community intervention programmes, which are a substantial component of the strategy to help solve prevention of NCDs [8]. Therefore, as the model development is comprehensive [37, 38] emphasis should also be placed on the complex and dynamic settings in which the delivery of nursing care occurs, as it involves social, political, economic and clinical factors [39].