Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.
Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.
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DOI：
10.1093/heapol/czw118
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发表时间：
2017-03-01
影响因子：
3.2
通讯作者：
Gómez-Olivé FX
中科院分区：
文献类型：
--
作者：
Ameh S;Klipstein-Grobusch K;D'ambruoso L;Kahn K;Tollman SM;Gómez-Olivé FX
南非引入了综合慢性病管理（ICDM）模式，以应对艾滋病毒/艾滋病和非传染性疾病（NCD）的双重负担，这是非洲卫生部率先做出的此类努力之一。 ICDM 模型的目标是利用艾滋病毒项目创新来提高慢性病护理的质量。关于医疗保健提供者和用户对新型 ICDM 模型中的护理质量的看法的文献很少。本文描述了运营管理者和患者对 ICDM 模型中护理质量的看法。 2013年，我们对南非东北部阿金库尔乡村分区的七个初级卫生保健设施进行了案例研究。采用焦点小组讨论（n = 8）来获取 56 名 ≥ 18 岁患者的数据。对各设施运营管理人员和街道卫生管理人员进行了深入访谈。多纳贝迪安的服务质量评估结构、过程和结果理论支撑了本研究的概念框架。使用 MAXQDA 2 软件对定性数据进行分析，以确定 17 个护理先验维度以及分析过程中出现的意外主题。管理者和患者的叙述显示了结构上的缺陷（血压机故障和人员短缺）；过程（药品不规则预包装）；和结果（漫长的等待时间）。对于患者等待时间过长的原因，管理人员和患者之间存在分歧，管理人员将其归咎于人手短缺和错过预约，而患者则将其归咎于管理人员迟到。患者报告抗高血压药物缺货（结构）；次优违约者追踪（流程）；严格的门诊预约制度（流程）。新出现的主题表明，患者报告由于家庭护理人员的违约追踪活动而在社区中遭受艾滋病毒耻辱，而管理人员则报告传统治疗师对慢性病的治疗，并减少了与设施相关的艾滋病毒耻辱，因为艾滋病毒和非传染性疾病患者就诊于同一家诊所。在研究环境中，利用艾滋病毒项目的要素来治疗非传染性疾病，特别是高血压管理，尚未实现，部分原因是血压机故障和抗高血压药物缺货。这对于南非 ICDM 模式在全国范围内的推广以及其他低收入和中等收入国家的综合慢性病护理规划具有重要意义。
The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.