Browsing by Subject "Chronic diseases"

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    Open Access
    Chronic diseases and multi-morbidity - a conceptual modification to the WHO ICCC model for countries in health transition
    (BioMed Central, 2014-06-09) Oni, Tolu; McGrath, Nuala; BeLue, Rhonda; Roderick, Paul; Colagiuri, Stephen; May, Carl R; Levitt, Naomi S
    Background: The burden of non-communicable diseases is rising, particularly in low and middle-income countries undergoing rapid epidemiological transition. In sub-Saharan Africa, this is occurring against a background of infectious chronic disease epidemics, particularly HIV and tuberculosis. Consequently, multi-morbidity, the co-existence of more than one chronic condition in one person, is increasing; in particular multimorbidity due to comorbid non-communicable and infectious chronic diseases (CNCICD). Such complex multimorbidity is a major challenge to existing models of healthcare delivery and there is a need to ensure integrated care across disease pathways and across primary and secondary care. Discussion: The Innovative Care for Chronic Conditions (ICCC) Framework developed by the World Health Organization provides a health systems roadmap to meet the increasing needs of chronic disease care. This framework incorporates community, patient, healthcare and policy environment perspectives, and forms the cornerstone of South Africa’s primary health care re-engineering and strategic plan for chronic disease management integration. However, it does not significantly incorporate complexity associated with multimorbidity and CNCICD. Using South Africa as a case study for a country in transition, we identify gaps in the ICCC framework at the micro-, meso-, and macro-levels. We apply the lens of CNCICD and propose modification of the ICCC and the South African Integrated Chronic Disease Management plan. Our framework incorporates the increased complexity of treating CNCICD patients, and highlights the importance of biomedicine (biological interaction). We highlight the patient perspective using a patient experience model that proposes that treatment adherence, healthcare utilization, and health outcomes are influenced by the relationship between the workload that is delegated to patients by healthcare providers, and patients’ capacity to meet the demands of this workload. We link these issues to provider perspectives that interact with healthcare delivery and utilization. Summary: Our proposed modification to the ICCC Framework makes clear that healthcare systems must work to make sense of the complex collision between biological phenomena, clinical interpretation, beliefs and behaviours that follow from these. We emphasize the integration of these issues with the socio-economic environment to address issues of complexity, access and equity in the integrated management of chronic diseases previously considered in isolation.
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    Open Access
    Health status of primary school educators in low socio-economic areas in South Africa
    (BioMed Central, 2015-02-25) Senekal, Marjanne; Seme, Zibuyile; de Villiers, Anniza; Steyn, Nelia P
    Background: Non-communicable Diseases (NCDs) are major health concerns in South Africa. According to the life cycle approach NCD prevention strategies should target children. Educators are important external factors influencing behaviour of learners. The objective of this study was to assess the prevalence of selective NCD risk factors in educators of primary school learners. Methods: A cross-sectional design was used to assess the body mass index (BMI) and waist circumference (WC), blood glucose (BG), cholesterol (BC), blood pressure (BP), perceived health and weight, and parental NCD history of 517 educators in the Western Cape of South Africa. Results: The sample included 40% males and 60% females; 64% urban and 36% rural, 87% were mixed ancestry, 11% white and 2% black. Mean age for the total group was 52 ± 10.1 years, BMI 30 ± 1.2 kg/m2 (31% overweight, 47% obese), diastolic BP 84 ± 10.0 mmHg, systolic BP 134 ± 18.7 mmHg (46% high BP), BG 4.6 ± 2.3 mmol/L (2% high BG), BC 4.4 ± 0.9 (30.4% high BC) and WC 98 ± 14.1 cm for males (38% high WC) and 95 ± 15.3 for females (67% high WC). BMI was higher (p = 0.001) and systolic (p = 0.001) and diastolic (p = 0.005) BP lower in females. Rural educators were more obese (p = 0.001). BMI (p = 0.001) and systolic BP (p = 0.001) were lower in younger educators. Correct awareness of personal health was 65% for BP, 79.2% for BC and 53.3% for BG. Thirty-eight percent overweight/obese females and 33% males perceived their weight as normal. Conclusion: The findings of this study demonstrated a number of characteristics of educators in the two study areas that may influence their risk for developing NCDs and their potential as role models for learners. These included high levels of obesity, high blood pressure, high waist circumference, high cholesterol levels, and high levels of blood glucose. Furthermore, many educators had a wrong perception of their actual body size and a lack of awareness about personal health.
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    Improving chronic disease monitoring in resource limited settings: simulation and economic evaluation approaches
    (2025) Mukonda, Elton; Lesosky, Maia Rose; Cleary, Susan
    Introduction: Chronic diseases are persistent long-term conditions causing significant premature mortality, functional impairment, and disability, often needing ongoing care and support. Management of these long-term conditions is an important, but costly element of health care which relies on clinical practice guidelines (CPGs) to standardise the provision of care. In low-and-middle-income countries (LMICs), where healthcare infrastructure and financial resources are often insufficient, CPGs need to strike a careful balance between evidence-based recommendations and the pragmatic feasibility of implementation. However, the scarcity of locally designed guidelines in LMICs has led to a reliance on guidelines from High-Income Countries (HICs) despite the substantial contextual differences between the origin of guidelines and their intended application settings. Within this terrain, there is a particular need for evidence around the impact of adhering to the adopted guidelines and exploring opportunities for improvement. A crucial, yet understudied component of CPGs that could particularly benefit from such scrutiny and evaluation is monitoring. The aim of this thesis is to generate evidence on the suitability of current guidelines, and potentially identify alternative strategies for monitoring chronic diseases, with a specific emphasis on Type-2 Diabetes Mellitus (T2D), using South Africa as a case study. Methods: A mixed-methods approach including a literature review, analytic studies, and a formal economic evaluation, was used to address the aim of the thesis. A comparative analysis of monitoring guidelines from LMIC and HIC settings was conducted to describe how monitoring guidelines for three chronic diseases: HIV/AIDS, hypertension, and T2D, are developed, summarising both the evidence and the strength of evidence used to develop the recommendations. The analytical study then utilised individual-level data on adults living with T2D in the Western and Northern Cape, South Africa to examine the relationship between adherence to current HbA1c monitoring guidelines and the achievement of glycaemic control targets, as well as longitudinal changes in HbA1c. Two properties, the retest interval, and the monitoring adherence rate were calculated and associations were derived using linear mixed effects modelling, and multistate modelling. An in-depth review of model-based studies on T2D populations in LMICs was then conducted to identify methodologies available for extrapolating insights from short-term empirical studies and projecting costs and health benefits over an individual's lifetime. Finally, a Markov simulation model was developed using methodologies identified in the afore-mentioned review to extend the short-term findings from the analytical study and assess the long-term effectiveness and cost-effectiveness of different HbA1c monitoring strategies with the aim of identifying the optimal HbA1c monitoring in patients with T2D. HbA1c monitoring strategies (three-monthly, four-monthly, six-monthly, and annual tests) were evaluated with respect to the incremental cost-effectiveness ratio (ICER) assessing each comparator against a less costly undominated alternative. Findings: Findings from the comparative analysis highlight how monitoring recommendations in LMIC guidelines closely resemble those in HIC guidelines with little to no consideration made for factors like genomics, resource availability, or socioeconomic context. Furthermore, the recommendations for monitoring HbA1c in T2D management and blood pressure in hypertension are based on expert opinion and clinical consensus. Findings from the analytical study reveal that a retest interval between 2-4 months is associated with the greatest reduction in HbA1c, while individuals with low adherence to the monitoring guidelines were the least likely to achieve glycaemic control in one year. Moreover, patients with low monitoring adherence had higher mean HbA1c levels compared to patients with moderate or high monitoring adherence. The literature review highlights an increase in the number of modelling studies investigating the long-term impact of interventions for T2D in LMICs, with most of these studies being from Asia. In addition, there is no consensus on the most appropriate modelling approach, as appropriateness is dependent on a variety of factors, including the study objective and data availability. However, a widely used approach is Markov modelling where the full spectrum of disease manifestations is characterized by mutually exclusive health states, and changes in health status over time are captured through transition probabilities between these states. Findings from the cost effectiveness analysis suggest annual and lifetime costs of managing diabetes increased with HbA1c monitoring, while increased monitoring provides higher quality-adjusted life years (QALYs) and Life Years. The ICER for six-monthly vs annual monitoring was cost-effective (USD 2,322.37 per QALY gained), whereas the ICER of moving from six-monthly to three-monthly monitoring was not cost-effective(USD 6,437.79 per QALY gained). The ICER for four-monthly vs six-monthly monitoring was extended dominated. The sensitivity analysis showed that the ICERs were most sensitive to health utilisation rates. Conclusion: Findings from the analytical studies and economic evaluation presented in this thesis provide strong evidence on the impact of HbA1c monitoring on costs and health outcomes in a LMIC and can be used as supporting evidence for current HbA1c monitoring guidelines, which are based on expert opinion and clinical consensus. Improving chronic disease monitoring in LMICs ultimately requires adapting guidelines and recommendations to the local context. Evaluating the effectiveness and cost-effectiveness of adopted CPG recommendations in LMICs is the first step to ensuring promotion of evidence-based, equitable healthcare practices.