School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
Chronic Disease Initiative for Africa, Division of Diabetes and Endocrinology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.
PLoS One. 2018 Mar 14;13(3):e0194191. doi: 10.1371/journal.pone.0194191. eCollection 2018.
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.
目前南非的慢性病管理卫生政策提出整合慢性病服务，以改善慢性病的治疗效果，这一政策是基于综合慢性病模式（ICDM）。然而，关于慢性病多重患者目前如何体验卫生服务的（重新）组织，以及为了加强对其病情的管理，他们的需求是什么，相关数据很少。
本研究在开普敦的一家社区卫生中心进行，该中心同时治疗 HIV 和糖尿病患者。本研究以 Shippee 的累积复杂性模型（CCM）为基础，探索了“患者工作量”和“患者能力”来管理慢性病。对 10 名 HIV 和 2 型糖尿病（T2D）多重患者和 6 名向这些患者提供卫生服务的卫生工作者进行了个人访谈。
本研究中的患者参与者经历了与诊所相关的工作量，例如：HIV 和 T2D 有两个分开的诊所，患者和卫生工作者之间存在感知和实际的权力不匹配。自我护理相关的工作量主要围绕营养需求、药物负担和耻辱感。由于能力因素，如积极的态度、最佳健康素养、社会支持和经济资源的可用性，患者参与者的这些需求的负担程度各不相同。参与者提到的改善连续性护理和多重疾病自我管理的策略包括整合慢性病服务、为卫生工作者制定综合指南、为患者提供教育材料、改善信息系统和为患者提供收入。
使用 CCM 来探索多重疾病，捕捉了与“患者工作量”和“患者能力”相关的大部分主题，因此是探索这一高 HIV/T2D 负担环境中多重疾病的合适框架。整合慢性病服务和解决健康的社会决定因素可能是减轻患者负担并改善他们获得和利用这些服务的第一步。需要进一步研究来探索 HIV/T2D 之外的多重疾病。
