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BMC Health Services Research

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Open Access 01-12-2019 | Care | Research article

Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa

Authors: Limakatso Lebina, Olufunke Alaba, Ashley Ringane, Khuthadzo Hlongwane, Pogiso Pule, Tolu Oni, Mary Kawonga

Published in: BMC Health Services Research | Issue 1/2019

Abstract

Background

The Integrated Chronic Disease Management (ICDM) model has been implemented in South Africa to enhance quality of clinical services in Primary Healthcare (PHC) clinics in a context of a high prevalence of chronic conditions and multi-morbidity. This study aimed to assess the implementation fidelity (adherence to guidelines) of the ICDM model.

Methods

A cross-sectional study in 16 PHC clinics in two health districts in South Africa: Dr. Kenneth Kaunda (DKK) and West Rand (WR). A fidelity assessment tool with 89 activities and maximum score of 158 was developed from the four interrelated ICDM model components: facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems. Value stream mapping of patient flow was conducted to analyse waiting time and identify operational inefficiencies. ICDM items were scored based on structured observations, facility document reviews and structured questionnaires completed by healthcare workers. Fidelity scores were summarized using medians and proportions and compared by facilities and districts using Chi-Square and Kruskal Wallis test.

Results

The monthly patient headcount over a six-month period in these 16 PHC clinics was a median of 2430 (IQR: 1685–2942) individuals over 20 years. The DKK district had more newly diagnosed TB patients per month [median 5.5 (IQR: 4.00–9.33) vs 2.0 (IQR: 1.67–2.92)], and fewer medical officers per clinic [median 1 (IQR: 1–1) vs 3.5 (IQR:2–4.5)] compared to WR district. The median fidelity scores in both districts for facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems were 78% [29/37, IQR: 27–31)]; 77% [30/39 (IQR: 27–34)]; 77% [30/39 (IQR: 28–34)]; and 80% [35/44 (IQR: 30–37)], respectively. The overall median implementation fidelity of the ICDM model was 79% (125/158, IQR, 117–132); WR was 80% (126/158, IQR, 123–132) while DKK was 74% (117/158, IQR, 106–130), p = 0.1409. The lowest clinic fidelity score was 66% (104/158), while the highest was 86% (136/158). A patient flow analysis showed long (2–5 h) waiting times and one stream of care for acute and chronic services.

Conclusion

There was some variability of scores on components of the ICDM model by PHC clinics. More research is needed on contextual adaptations of the model.

Available only for authorised users

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Title: Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa
Authors: Limakatso Lebina
Olufunke Alaba
Ashley Ringane
Khuthadzo Hlongwane
Pogiso Pule
Tolu Oni
Mary Kawonga
Publication date: 01-12-2019
Publisher: BioMed Central
Keyword: Care
Published in: BMC Health Services Research / Issue 1/2019
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-019-4785-7

At a glance: The STEP trials

Springer Medicine

Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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