The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility
| dc.contributor.advisor | Gwyther, Liz | |
| dc.contributor.advisor | Van Zyl-Smit, Richard | |
| dc.contributor.advisor | Harding, Richard | |
| dc.contributor.author | Farrant, Lindsay | |
| dc.date.accessioned | 2026-06-23T08:36:59Z | |
| dc.date.available | 2026-06-23T08:36:59Z | |
| dc.date.issued | 2026 | |
| dc.date.updated | 2026-06-23T08:34:52Z | |
| dc.description.abstract | Background: Morbidity from non-communicable diseases such as chronic lung disease is placing an increasing burden on patients, families and health systems. In low- and middle- income countries (LMIC), these patients are largely managed in primary care settings where care is often fragmented such that patients attend different clinics or providers for specific aspects of management. Chronic obstructive pulmonary disease requires spirometry for confirmation of diagnosis, however this is not commonly available in primary care settings in South Africa, and as such the term chronic lung disease is used. Patients experience multidimensional symptoms, including dyspnoea, pain, fatigue and anxiety, in addition to psychosocial and spiritual concerns. The Global Initiative for Chronic Obstructive Lung Disease recommends early palliative care integration for holistic care, symptom and quality of life management. There is uncertainty around what is required for integrated palliative care and how this can be best implemented in a South African urban primary care setting. Aim of the study was to determine the feasibility of integrating palliative care into primary health care for patients with COPD and chronic lung disease. Study one was a systematic review with narrative and thematic synthesis of the concept and application of integration of palliative care into standard care in LMICs. Seven databases were searched since inception. Fifty-nine articles were included, representing 45 LMICs. Fifty-one articles (86.4%) were studies conducted in single countries, representing a total of 18 LMICs. All levels of health care settings are represented. One article (1.7%) evaluated integration using a theoretical framework, and six (10.2%) specified a definition of integration. The clinical, professional, organisational and system components of integration and their normative and functional enablers of integration were narratively synthesised according to an international taxonomy of integrated primary care. The findings were further thematically synthesised according to a systems-oriented framework to reflect their structures, processes and outcomes required for person-centred care, according to the WHO health system building blocks. There was a lack of structural elements of normative integration related to limited health information systems and medical products and technologies. The limitation of process elements of health system financing (of palliative care) appears to limit professional integration and to therefore affect the processes for functional and normative integration. The synthesised integrated palliative care framework of structures, processes and outcomes provided a framework for the evaluation of the feasibility of the integration of palliative care into primary care for patients with COPD and chronic lung disease. Study two was a multi-methods study to explore the processes for and barriers to making the diagnosis of COPD and chronic lung disease in patients receiving care in primary care settings, and the subsequent impact on patient management and on integrating palliative care. A cross-sectional survey of 6 family physicians representing 10 primary care facilities described the context for availability of investigations at primary care level. A qualitative study included 9 healthcare professionals' experiences and approaches to diagnosis, referrals, management and palliative care for patients with chronic lung disease. Three themes from thematic analysis revealed diverse interpretations of professional roles, dilemmas faced by professionals in providing guideline concordant care and referral and co-ordination processes. Approaches to palliative care varied according to training and qualification of professionals. Clarity regarding limited gold standard COPD diagnosis and the implications for care of patients with COPD and CLD in primary care, from the start of the disease trajectory and through advanced disease with palliative care needs, provided the necessary framework to understand the patient population as well as the system limitations. Study three was a mixed methods sequential, cluster feasibility stepped wedge hybrid type II design randomised controlled trial with nested in-depth qualitative interviews. The training and mentoring intervention and Theory of Change logic model were refined through patient and family member engagement. The trial was paused after one month of recruitment, due to the COVID-19 pandemic, and restarted in 2021. Three study primary care sites were randomised to intervention delivery. One study site withdrew from intervention training. Intervention training at two sites was acceptable, however clinical on-site and on-going mentoring was considered key to supporting a change in primary care professional practice to integrate a palliative approach to care. Prior palliative care training revealed improved awareness of palliative care and supported intervention acceptability and feasibility, but disease-specific palliative care training and mentoring was considered appropriate and necessary. Health system factors influenced perceived professional ability to integrate the intervention. Clinical mentorship and leadership were requested to support primary care healthcare professionals in providing integrated palliative care. Two hundred and forty patient participants were screened, 194 (80.83%) were eligible, 26 (13.61%) refused and 134 (70.16%) were enrolled pre-intervention delivery. Twelve (8.96%) participants were removed and 122 patients with COPD or CLD were included in analysis. After trial restart in 2021, a total of 26 participants (21.31%) were lost to follow up. One hundred patient participants (93.46%) had no COPD staging on file. The median (IQR) percentage of predicted peek expiratory flow rate was 33 (Q1-Q3=22-53). No change was observed in patient reported outcome measures. Conclusion: Integration of palliative care into primary care requires consideration of health system professional and organisational factors, in addition to patient, caregiver and contextual factors. Supporting policy, available medication and professional training increase the feasibility of integrating palliative care but are insufficient. The inherent clinical complexity of patients with advanced COPD and CLD suggest these patients would typically benefit from specialist palliative medicine and the monitoring of clinical indicators. For feasible integration of palliative care, there is a need for specialist palliative care oversight and leadership of clinical care to guide and support primary care professionals providing integrated care in primary care settings. | |
| dc.identifier.apacitation | Farrant, L. (2026). <i>The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility</i>. (). University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine. Retrieved from http://hdl.handle.net/11427/43357 | en_ZA |
| dc.identifier.chicagocitation | Farrant, Lindsay. <i>"The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility."</i> ., University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine, 2026. http://hdl.handle.net/11427/43357 | en_ZA |
| dc.identifier.citation | Farrant, L. 2026. The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility. . University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine. http://hdl.handle.net/11427/43357 | en_ZA |
| dc.identifier.ris | TY - Thesis / Dissertation AU - Farrant, Lindsay AB - Background: Morbidity from non-communicable diseases such as chronic lung disease is placing an increasing burden on patients, families and health systems. In low- and middle- income countries (LMIC), these patients are largely managed in primary care settings where care is often fragmented such that patients attend different clinics or providers for specific aspects of management. Chronic obstructive pulmonary disease requires spirometry for confirmation of diagnosis, however this is not commonly available in primary care settings in South Africa, and as such the term chronic lung disease is used. Patients experience multidimensional symptoms, including dyspnoea, pain, fatigue and anxiety, in addition to psychosocial and spiritual concerns. The Global Initiative for Chronic Obstructive Lung Disease recommends early palliative care integration for holistic care, symptom and quality of life management. There is uncertainty around what is required for integrated palliative care and how this can be best implemented in a South African urban primary care setting. Aim of the study was to determine the feasibility of integrating palliative care into primary health care for patients with COPD and chronic lung disease. Study one was a systematic review with narrative and thematic synthesis of the concept and application of integration of palliative care into standard care in LMICs. Seven databases were searched since inception. Fifty-nine articles were included, representing 45 LMICs. Fifty-one articles (86.4%) were studies conducted in single countries, representing a total of 18 LMICs. All levels of health care settings are represented. One article (1.7%) evaluated integration using a theoretical framework, and six (10.2%) specified a definition of integration. The clinical, professional, organisational and system components of integration and their normative and functional enablers of integration were narratively synthesised according to an international taxonomy of integrated primary care. The findings were further thematically synthesised according to a systems-oriented framework to reflect their structures, processes and outcomes required for person-centred care, according to the WHO health system building blocks. There was a lack of structural elements of normative integration related to limited health information systems and medical products and technologies. The limitation of process elements of health system financing (of palliative care) appears to limit professional integration and to therefore affect the processes for functional and normative integration. The synthesised integrated palliative care framework of structures, processes and outcomes provided a framework for the evaluation of the feasibility of the integration of palliative care into primary care for patients with COPD and chronic lung disease. Study two was a multi-methods study to explore the processes for and barriers to making the diagnosis of COPD and chronic lung disease in patients receiving care in primary care settings, and the subsequent impact on patient management and on integrating palliative care. A cross-sectional survey of 6 family physicians representing 10 primary care facilities described the context for availability of investigations at primary care level. A qualitative study included 9 healthcare professionals' experiences and approaches to diagnosis, referrals, management and palliative care for patients with chronic lung disease. Three themes from thematic analysis revealed diverse interpretations of professional roles, dilemmas faced by professionals in providing guideline concordant care and referral and co-ordination processes. Approaches to palliative care varied according to training and qualification of professionals. Clarity regarding limited gold standard COPD diagnosis and the implications for care of patients with COPD and CLD in primary care, from the start of the disease trajectory and through advanced disease with palliative care needs, provided the necessary framework to understand the patient population as well as the system limitations. Study three was a mixed methods sequential, cluster feasibility stepped wedge hybrid type II design randomised controlled trial with nested in-depth qualitative interviews. The training and mentoring intervention and Theory of Change logic model were refined through patient and family member engagement. The trial was paused after one month of recruitment, due to the COVID-19 pandemic, and restarted in 2021. Three study primary care sites were randomised to intervention delivery. One study site withdrew from intervention training. Intervention training at two sites was acceptable, however clinical on-site and on-going mentoring was considered key to supporting a change in primary care professional practice to integrate a palliative approach to care. Prior palliative care training revealed improved awareness of palliative care and supported intervention acceptability and feasibility, but disease-specific palliative care training and mentoring was considered appropriate and necessary. Health system factors influenced perceived professional ability to integrate the intervention. Clinical mentorship and leadership were requested to support primary care healthcare professionals in providing integrated palliative care. Two hundred and forty patient participants were screened, 194 (80.83%) were eligible, 26 (13.61%) refused and 134 (70.16%) were enrolled pre-intervention delivery. Twelve (8.96%) participants were removed and 122 patients with COPD or CLD were included in analysis. After trial restart in 2021, a total of 26 participants (21.31%) were lost to follow up. One hundred patient participants (93.46%) had no COPD staging on file. The median (IQR) percentage of predicted peek expiratory flow rate was 33 (Q1-Q3=22-53). No change was observed in patient reported outcome measures. Conclusion: Integration of palliative care into primary care requires consideration of health system professional and organisational factors, in addition to patient, caregiver and contextual factors. Supporting policy, available medication and professional training increase the feasibility of integrating palliative care but are insufficient. The inherent clinical complexity of patients with advanced COPD and CLD suggest these patients would typically benefit from specialist palliative medicine and the monitoring of clinical indicators. For feasible integration of palliative care, there is a need for specialist palliative care oversight and leadership of clinical care to guide and support primary care professionals providing integrated care in primary care settings. DA - 2026 DB - OpenUCT DP - University of Cape Town KW - chronic lung disease KW - Cape Town KW - patients LK - https://open.uct.ac.za PB - University of Cape Town PY - 2026 T1 - The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility TI - The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility UR - http://hdl.handle.net/11427/43357 ER - | en_ZA |
| dc.identifier.uri | http://hdl.handle.net/11427/43357 | |
| dc.identifier.vancouvercitation | Farrant L. The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility. []. University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine, 2026 [cited yyyy month dd]. Available from: http://hdl.handle.net/11427/43357 | en_ZA |
| dc.language.iso | en | |
| dc.language.rfc3066 | eng | |
| dc.publisher.department | Department of Public Health and Family Medicine | |
| dc.publisher.faculty | Faculty of Health Sciences | |
| dc.publisher.institution | University of Cape Town | |
| dc.subject | chronic lung disease | |
| dc.subject | Cape Town | |
| dc.subject | patients | |
| dc.title | The integration of palliative care for patients with chronic lung disease in primary care settings in metropolitan Cape Town: assessment of feasibility | |
| dc.type | Thesis / Dissertation | |
| dc.type.qualificationlevel | Doctoral | |
| dc.type.qualificationlevel | PhD |