Participants’ demographics
The median age of the thirty healthcare workers that participated in the study was 36.5 (IQR: 30.8–45.5) years, and they had been in their current roles for a median of 4.0 (IQR: 1.0–7.3) years. The majority (80%; 24/30) of the participants were females. Half (50%, 15/30) were nurses; 27% (8/30) were administrative staff and 23% (7/30) were in the “others” category (management, counsellors, pharmacy assistants).
Intervention Complexity
The interviewed staff members found that consultation of patients with TB disease in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS were the features of the ICDM model that was vague and that compromised fidelity. The guidelines were not specific about when patients with TB should be incorporated into the chronic diseases stream. The participants’ opinion was that it should be detailed that patients with TB should be incorporated in the chronic disease management stream after they had initiated TB treatment and have been assessed to no longer be infectious.
“TB patients are infectious and will infect the diabetes patients, a patient with TB must not mix with some other patients” (FI16-3; nurse)
The participants experienced the more complex elements of the ICDM model to be the highly administrative tasks and separating patients by different streams of care. The healthcare workers that were interviewed felt that this requires more staff. The current staff shortage was regarded as one of the limiting factors when implementing the recommended ICDM model with activities such as bookings, pre-packing of medication and designated stream of care for chronic patients with fidelity to the ICDM model guidelines.
Fidelity Facilitation Strategies
“The management must make sure that nurses get proper training on ICDM to avoid making small mistakes. So, with training they going to improve and know exactly what to do and understand what they are doing” (FI4-2; Data Capturer).
Participant Responsiveness
Participants mentioned compliant and empowered patients who understand their conditions as facilitating patients’ consent to different streams of care and down-referral to adherence clubs. They establish profound relationships with the healthcare workers. Other participants indicated that if patient feedback and community engagement on the services provided is considered, that would also enhance fidelity to the ICDM model and patient satisfaction.
“They feel like they are being isolated and they feel stigmatized and that other patients can see” (FI7-1; nurse).
Context
“We don't have enough staff, even now we rely on nurses doing their community service” (FI11-6; nurse)
The characteristics of the participating health facilities are summarised in Table 3. The maximum score on the level of implementation fidelity at the sixteen clinics was 158, and the study clinics ranged from 101 to 136 (min, max), with a median score of 125 (IQR: 117–132). Univariate linear regression indicated that customizing the budget for each clinic (ß = 9.50), and increasing in the number of consulting rooms (ß = 2.01), enrolled nurses (ß = 1.88), medical officers (ß = 1.18), and pharmacy assistants (ß = 2.0) are associated with an increase in the level of fidelity to the implementation of the ICDM model (Table 4). An increase in the proportion of patients over 20 years old and those consulting for diabetes and mental health correlate with a decrease in fidelity. Mean monthly total patients and nurse and medical officer patient ratios did not have a significant effect on the PHC facility’s fidelity scores in the univariate analysis, and so they were not included in the multivariate analysis. A unit increase in the number of consulting rooms and enrolled nurses was associated with an increase in fidelity during the multivariate analysis, with a 1.58 and 1.57 increase in the level of fidelity respectively.
Table 3
Characteristics of the 16 facilities that had implementation fidelity of the integrated chronic disease management model assessments
Variable | Mean (SD) |
Budget customized by clinic | 1 (1) |
Distance from the district offices in km | 40 (28) |
Facility area under roof | 657 (667) |
Number of consulting rooms | 6 (2) |
Number of Professional Nurses | 8 (4) |
Number of Enrolled Nurses | 2 (2) |
Number of Medical Officers | 2(2) |
Number of Pharmacy Assistants | 1(1) |
Nurse-Patient Ratio | 394 (205) |
Medical Officer-Patient Ratio | 2182 (1420) |
Number of total patients per month | 3241 (1193) |
Number of total patients above 20 years per month | 2352 (861) |
Number of TB Cases Diagnosed in a month | 5 (5) |
Monthly Diabetic consultations | 68 (35) |
Monthly mental health consultations | 26 (32) |
Table 4
Univariate and Multivariate Linear regression assessing the impact of facility characteristics on the implementation fidelity of the ICDM model
| Univariate | Multivariate |
Variable | ß (SE) | 95% CI | p-value | ß (SE) | 95% CI | p-value |
Budget customized by clinic | 9.50 (5.1) | -1.33–20.33 | 0.810 | | | |
Distance from the district offices | -0.76 (0.1) | -2.96–0.14 | 0.473 | 0.07 (0.1) | -0.24–0.37 | 0.637 |
Facility area under roof | 0.01 (0.0) | -0.00–0.02 | 0.140 | | | |
Number of consulting rooms | 2.01 (1.2) | -0.63–4.65 | 0.125 | 1.58 (1.6) | -2.11–5.26 | 0.358 |
Number of Professional Nurses | -0.17 (0.7) | -1.57–1.23 | 0.803 | | | |
Number of Enrolled Nurses | 1.88 (1.2) | -0.77–4.53 | 0.150 | 1.57 (1.8) | -2.59–5.73 | 0.415 |
Number of Medical Officers | 1.18 (1.9) | -2.82–5.17 | 0.539 | -1.66 (2.5) | -7.43–4.11 | 0.531 |
Number of Pharmacy Assistants | 2.00 (5.6) | -10.07–14.07 | 0.727 | | | |
Nurse-Patient Ratio | 0.01 (0.0) | -0.04–0.05 | 0.740 | | | |
Medical Officer-Patient Ratio | -0.00 (0.0) | -0.005–0.004 | 0.768 | | | |
Mean number of total patients per month | 0.00 (0.0) | -0.00–0.01 | 0.740 | | | |
Proportion of mean number of total patients above 20 years per month to total patients | -1.00 (0.4) | -1.80 – -0.21 | 0.017* | -1.13 (0.6) | -2.54–0.29 | 0.104 |
Proportion of mean monthly diabetic consultations to total patients | -2.16 (1.3) | -4.93–0.62 | 0.118 | 0.46 (1.6) | -0.88–1.79 | 0.459 |
Proportion of mean monthly mental health consultations to total patients | -4.84 (2.6) | -10.39–0.71 | 0.082 | | | |
* Statistically significant at the 0.05 level |