Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial
Abstract Background Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up ‘one-stop’ integrated care clinics for HIV-infection, diabetes and hypertension at sel...
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| Format: | Article |
| Language: | English |
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BMC
2023-06-01
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| Series: | BMC Health Services Research |
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| Online Access: | https://doi.org/10.1186/s12913-023-09534-0 |
| _version_ | 1797811541720956928 |
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| author | Marie Claire Van Hout Flavia Zalwango Mathias Akugizibwe Moreen Namulundu Chaka Josephine Birungi Joseph Okebe Shabbar Jaffar Max Bachmann Jamie Murdoch |
| author_facet | Marie Claire Van Hout Flavia Zalwango Mathias Akugizibwe Moreen Namulundu Chaka Josephine Birungi Joseph Okebe Shabbar Jaffar Max Bachmann Jamie Murdoch |
| author_sort | Marie Claire Van Hout |
| collection | DOAJ |
| description | Abstract Background Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up ‘one-stop’ integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. Methods The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner’s ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). Results Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. Conclusions Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. Trial registration number ISRCTN43896688. |
| first_indexed | 2024-03-13T07:25:17Z |
| format | Article |
| id | doaj.art-560b046061bb4009a7200685c177e96e |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-03-13T07:25:17Z |
| publishDate | 2023-06-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-560b046061bb4009a7200685c177e96e2023-06-04T11:24:34ZengBMCBMC Health Services Research1472-69632023-06-0123111410.1186/s12913-023-09534-0Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trialMarie Claire Van Hout0Flavia Zalwango1Mathias Akugizibwe2Moreen Namulundu Chaka3Josephine Birungi4Joseph Okebe5Shabbar Jaffar6Max Bachmann7Jamie Murdoch8Public Health Institute, Liverpool John Moores UniversityMRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTMMRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTMMRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTMMRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTMUniversity College LondonUniversity College LondonUniversity of East AngliaKings College LondonAbstract Background Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up ‘one-stop’ integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. Methods The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner’s ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). Results Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. Conclusions Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. Trial registration number ISRCTN43896688.https://doi.org/10.1186/s12913-023-09534-0HIVNon-communicable diseaseDiabetesHypertensionIntegrated careUganda |
| spellingShingle | Marie Claire Van Hout Flavia Zalwango Mathias Akugizibwe Moreen Namulundu Chaka Josephine Birungi Joseph Okebe Shabbar Jaffar Max Bachmann Jamie Murdoch Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial BMC Health Services Research HIV Non-communicable disease Diabetes Hypertension Integrated care Uganda |
| title | Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial |
| title_full | Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial |
| title_fullStr | Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial |
| title_full_unstemmed | Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial |
| title_short | Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial |
| title_sort | implementing integrated care clinics for hiv infection diabetes and hypertension in uganda inte africa process evaluation of a cluster randomised controlled trial |
| topic | HIV Non-communicable disease Diabetes Hypertension Integrated care Uganda |
| url | https://doi.org/10.1186/s12913-023-09534-0 |
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