The findings are presented under five selected constructs of the TFA: Affective attitude, Self-efficacy, Perceived effectiveness, Ethicality, and Intervention coherence. We present the analysis within each construct as flowing sequentially from pre-mid-end-line, divided into distinct sub themes.
Affective attitude
This construct implies the perception and attitude towards the integrated service delivery model, and may range from a general feeling or satisfaction in attending the integrated clinic and how comfortable the patients are with the clinic arrangement.
Satisfaction with the integrated model
At the pre-phase, the majority of both patients and care-providers exhibited and described a positive attitude towards the integrated clinic model, i.e., patients showed their willingness to attend and receive services from the integrated clinic and healthcare providers were ready and happy to deliver services. The following are baseline testimonies: “…I would prefer PLHIV and other disease conditions to be managed by a single doctor. I think it will be much better…” (PLHIV with HT, female, hospital-urban, pre-phase. Patients with co-morbidity conditions either HIV/HT/DM or HT/DM supported the idea of integration as it was perceived to save time and costs of visiting multiple clinics. A positive reflection was also provided by health care-providers at all levels of the health facilities whether dispensary or hospital, rural or urban; “I am 100% satisfied because integration will enable PLHIV with also DM and HT to receive the services under the same roof to reduce disturbances of moving from one clinic to another. It will also increase confidentiality of their status hence reducing stigma” (Health Care Provider, hospital level, pre-phase). Health care providers were very supportive of the integration concept and recommended that existing structures in place to manage PLHIV be suitable to implement the integrated model. Their positive attitude was influenced by the belief that integration could facilitate timely provision of all appropriate services to patients: “I believe that if we can provide all services under one roof, we can reduce burden to clients by making sure that they get all services being HIV/ DM/ HT or both at a time. It can help to reduce costs and time” (Health Care Provider, pre-phase).
Despite the positive outlook regarding the integrated service delivery model, some reservations were reported by patients and health care-providers. For example, social stigma was reported by patients with HT and DM as a factor affecting acceptability: “When people see you at CTCT they start stigmatizing you…’he is cheating us that is suffering from diabetes…they point fingers at you and say…’he is suffering from HIV”, (patient with DM-HT, male, Periphery-hospital)
“The only problem for integration will be for those who are not HIV positive to be mixed with HIV positive patients. For example, mixing DM and HIV patients, they will feel bad psychologically as they are not used to receiving integrated services” (PLHIV with HT and DM, female, hospital level, urban, pre-phase).
The same concern was raised by a health care provider:
“Integration of services is a good intervention. But a big question is ‘will PL HIV consent their services to be integrated with others?’ This will depend on the strategies put in place because those living with HIV are usually managed privately. We should be careful with issues of confidentiality and privacy...” (Health Care Provider, hospital level-urban, pre-phase).
Health care providers also reported structural challenges as a barrier to deliver integrated care:
“There is a possibility for integration as human resources are available. The challenge is on the medicines and infrastructure capable to accommodate all patients with three disease conditions. Medicines for NCD are available, but patients have to pay while medicines for HIV is for free” (Health Care Provider, hospital level-urban, pre-phase).
During the mid-line, acceptability of integration increased with exposure to the integrated care model to the end-line phase. Greater acceptability was reported by all health workers delivering the services and most of the patients receiving them, with the availability of all services in a single location, cost and timesaving identified as the main factors: “For sure I am satisfied with the integrated model because, as I said before, it kills three birds at a time, it decreases disturbance of the patients and misuse of resources.” (Health Care Provider, hospital level-urban, end-line).
Satisfaction with the integrated care provision pathway
Patients were asked to provide their views on the procedures and pathways when entering the integrated clinic and whether they were happy with them. The pathway started with entering the clinic and moving from one point to another as shown in Fig. 1. The majority of the patients at mid-line and end-line phase reported satisfaction with the pathway as all services were provided in a single clinic setting, hence, restricting unnecessary movement: “It is just easy to follow the procedures. There isn't any difficulty that I faced in following the procedures directed. In the past we used to do the screening in different places” (PLHIV, female, hospital level urban, end-line).
Furthermore, patients explained that they were satisfied with the integrated care model clinics because they operated on the principle of ‘first come first served’ basis. This was supported in observational data which noted that recruited patients identified themselves as ‘we sit there because we are under the project’.
Despite the positive reflections, most patients observed concerns over waiting time, mostly during the mid-line phase. Such complaints diminished as they entered the end-line:
“It takes a long time, the congestion is high because the care providers are few, hence patients are forced to wait for the service for a long time” (HT patient, male, lower-level facility, mid-line); and “We take a lot of time at the laboratory while we (DM patients) must be screened faster so that we can go home to find something to eat” (Patient with DM, female, periphery hospital, mid-line).
Some patients with HT and DM from lower and periphery health facilities perceived integrated services to have breached the patients’ privacy, a concern that was also supported by care providers;
“We have a big challenge in this clinic. Patients with DM or HT do not feel good to come to a clinic where PLHIV are receiving services. The space is open, and there is no privacy. Patients respond badly that everybody who passes there and sees them can perceive them to have HIV’” (Health Care Provider, lower-level facility, mid-line).
Self-efficacy
Self-efficacy ranged from comfort with the sitting arrangements, movement from one point of care to another, freedom of discussion, fixing clinic appointments and medicine adherence. During the baseline, when patients were receiving services in their respective standalone clinics, some patients with NCD conditions reported that it was difficult to sit together with PLHIV; “I will feel bad sitting together with affected ones, how will people understand me, I am not one of them, because everyone knows this clinic is for HT, DM, and HIV, other people will wonder ‘What is wrong with this woman?’ (Patient with HT and DM, female, hospital level, pre-phase). They raised their concern over the possibility of contracting other conditions related to HIV infection such as tuberculosis.
During integration, the same waiting area was used for all patients regardless of disease conditions, and an acceptable level of comfort with the sitting arrangement was reported by patients. This was mostly reported by patients from the hospital level in the urban area for both mid-line and in end-line data collection points. Most patients reported that they were comfortable with moving from one point to another. Patients could sit anywhere in the integrated clinic, as also confirmed by the health workers. Health workers reported that they were stringent with queue observance:
“I am very free, and I do follow the arrangement planned as it assists us to get the services in a timely and proper way. If there is any patient violating the stipulated procedure by, for example, going straight to see the doctor, he/she is usually sent back by the health care-provider to join the queue” (Patient with HT and DM, male, lower-level facility, end-line);
“I have been instructed by the health care providers on where I am supposed to sit and I am satisfied with it [the arrangement]” (PLHIV/HT Patient, male, mid-line).
Patients further reported freedom in discussing their health status, how they felt, side-effects of their medication; they even reported encouraging others not to withdraw from the integrated care clinic. Care providers said that free discussion among patients helped to improve health literacy across all three conditions, and was deemed to support positive health behaviours and medicines adherence;
“We provide health education to the patients on all three disease conditions in a single clinic which has integrated all three services in one place rather than having two separate clinics. We provide education to eliminate stigma, and this helps them to come together” (Health Care Provider, mid-line).
At the mid-line when the integrated care services were initiated, healthcare providers observed difficulties in providing health education covering the three disease conditions in the same session. It was observed that patients with HT and DM and HIV received health education separately in their respective standalone clinics before engaging in the integrated clinic for other services. As the integrated care intervention progressed, they were comfortable with receiving health education from the integrated clinic, focusing on all the three disease conditions.
Despite the positive reflection, however, a few of the patients with HT and DM in the lower and periphery facilities reported dissatisfaction with the integrated clinic similar to that noted during the baseline. They persistently mentioned being uncomfortable during both the mid-line and end-line: “I hate being mixed with the HIV patients, we just sit together on the bench, when you get at the clinic you first sit down and wait for the doctor, no discussion” (Patient with DM, female, Periphery hospital, mid-line).
Fixing clinic appointments/refill and adherence to the medicine administration
At the baseline, there was reported drop out of patients, especially in the NCD clinics due to poor retention in care and because of irregularity in the medicine availability;
“Frankly speaking, I stopped from adhering to the drug regimen as I preferred taking alcohol than medicine, particularly those for diabetes and hypertension. However, due to recurrence of the symptoms especially for diabetes I decided to resume to the services”. (PLHIV with /DM/HT, male, hospital level, pre-phase).
At the mid-line, most patients declared to have adhered to their clinic appointments and medicine administration according to the advice they were given, more improvement been observed at the end-line phase. This information was also confirmed by the care-providers. Patients declared to have received satisfactory education on medicine adherence:
“Yes, we do discuss our health status, how to use the medicine, food types and we are free to do so. We also encourage each other. For example, there was one lady who wanted to drop out of the integrated clinic for fear of being mixed with patients with other conditions. She thought that if she would be seen by people who know her, they might suspect her to have other disease conditions. But finally, she did not drop out” (PLHIV with HT, lower-level facility, end-line).
At the mid-line, health care providers reported that a minority of patients with NCDs encountered challenges in achieving medicine adherence. At the end-line, however, all the patients with all disease conditions confirmed adherence to treatment regimens and attendance of regular clinic appointments:
“I do follow guidance and take my medicine on time, and I thank God that after I was screened and found to have this problem [HIV-positive] I haven't suffered from any disease that would make me hospitalised because of taking the medications on time. I usually fix my clinic appointment and attend on the date of appointment…” (PLHIV, female, periphery hospital, end-line).
This finding was also supported by health care-providers; “Integration has encouraged patients to adhere to their appointment on follow-up visits” (Health Care Provider, periphery hospital, end-line). Another said: “Yes, clients show good adherence to treatment, though am not sure about other government hospitals but here our clients are doing better; they stay in the treatment” (Health Care Provider, hospital-urban, end-line).
Perceived effectiveness
Since the integrated care intervention aimed to improve service delivery provision, perceived effectiveness focused on the quality of care in terms of the availability of medicine, diagnostic facilities, trained staff and increased awareness and health status.
Availability of the services in the integrated clinic
During the baseline, patients with either DM or HT reported insufficient services that they had received in their respective NCD clinics. However, when they entered the integrated clinic most of them reported improvement at mid-line, which significantly increased at the end-line phase. They described how the screening tools for taking vital signs including measuring of glucose level were available and that clinicians provided an enhanced prescription on the medication as per disease conditions: “I am satisfied with all the screening that are done, they fulfil the demands and are helpful that is why I am getting better” (Patient with DM/HT, female, periphery hospital, end-line). During the mid-line phase, however, delays in receiving integrated care were experienced due to the shortage of human resources. At the end-line phase, all patients confirmed the availability of health care providers in each visit and that they were provided with good advice on how to improve their health status: “They [providers] are there all the time and the service that they provide are very good. I have never missed them even a single day” (PLHIV with HT, female, hospital level-urban, end-line).
The findings from the patients were confirmed by a nurse from a hospital setting:
“We do provide all the services at once—full integration. We prefer giving services like this to prevent disturbance of patients moving from one clinic to another. The disturbance we [health care-providers] usually get in providing different services is moving from one place to another e.g., attending HIV patient here then you move to another station to attend to hypertensive or diabetic patients … we do provide education on the foods to take etc.” (Health Care Provider, hospital level-urban, end-line).
Improved awareness and health status
Provision of health education was reported to have raised awareness among patients to check frequently for other conditions. This practice was reported to prevent further risks and complications to patients. Further, patients generally reported an improved health status overall and that other disease conditions could be detected earlier that was also confirmed by health care providers;
“There have been significant benefits; patients were previously not known to be hypertensive and diabetic but now they have been identified and have started the medication. Moreover, they adhere to their medication and lifestyle modification … [As a result] HIV patients have achieved viral load suppression and are currently stable. Integrating all the services and delivering them at once does not only save time but also life in general” (Health Care Provider, lower-level facility, mid-line).
Study participants added that patients whose blood pressure was uncontrollable were reported to have benefited. Health care providers said that the effectiveness has been attributed by the preparedness efforts of the MOCCA project to ensure resources and screening tools were available. They acknowledged difficulties in ensuring sufficient medicines in stock within the current system.
These benefits notwithstanding, there were a few patients with HT and DM at the mid-line who reported that the integrated care was time consuming and that health workers lacked diagnostic and monitoring tools as well as clinical skills:
“Screening is not good as it takes long time and, sometimes, the tools are unavailable, medicine are unavailable… doctors are not good. We do not have specific doctors; any doctor can attend us. We had our own doctors from the places we came” (Patient with DM, male, periphery hospital, mid-line).
Similar responses were provided by several health care providers:
“Sometimes, Random Blood Glucose (RBG) strips are out of stock. We have few health care providers who are trained to deliver these integrated services. Sometimes you find the same care provider is needed at out-patients department and the labour ward at the same time” (Health Care Provider, lower-level facility, mid-line).
The complaints were also noted during observations soon after initial operationalisation of service integration, but most of them diminished as the integration continued.
Ethicality
Findings pertaining to ethicality focused on the patient provider relationship, privacy, confidentiality, and structuring of the integrated clinic.
Client-provider relationship
Before the integration, some patients at the NCD clinics reported being less satisfied as health workers were perceived to pay little attention to them when seeking care. However, with increasing duration in the integrated clinic, these complaints reduced. Most patients reported a good relationship with the healthcare providers. Moreover, this relationship significantly improved as they entered the end-line phase. Care-providers also confirmed this information by insisting that they provided all required services in a timely manner:
“The format we use is that when it comes to the service we will get it from one area, it means that the one [care-provider] you see for HT or DM is the same person for HIV and the tests are done in the same laboratory and when they [patients]arrive they will get all the tests at once…” (Health Care Provider, hospital level-urban, end-line).
Patients described the use of good language, provision of advice and care, and receiving health education as some of the positive attributes: “Honestly the relationship between the patient and the health providers is good because they received me well” (PLHIV, female, hospital level-urban, end-line). This positive relationship was also confirmed by health care-providers to include the use of friendly language and ensuring that only a reasonable number of patients were admitted in a single clinic visit so as to avoid congestion and long waiting time:
“At the individual level, we make sure that patients are warmly welcomed, and that good rapport is established. At the facility level, we ensure proper sitting plan in the patients’ waiting area. We encourage them and make sure that all the necessary investigations and essential medicines are available” (Health Care Provider, periphery hospital, mid-line).
“We do provide all the patients with health education every morning, consultation, laboratory investigation and dispensing medicines and advice on medicine adherence. Specifically, for HIV we do dispense anti retro viral therapy; undertake viral load testing, for hypertension; we do measure blood pressure, height, weight, dispense anti-hypertensive medicines and for diabetes; we do measure RBG and dispense metformin and Gemma 2” (Health Care Provider, lower-level facility, mid-line).
Health care providers also insisted on ensuring the availability of medicine, trained providers, and diagnostic tools before the implementation of the integrated model. Moreover, they called for building of trust for patients and ensuring friendly and conducive environment.
Privacy and confidentiality
Observational findings at the pre-phase revealed the differences between the clinics managing PLHIV (CTC) and those with HT and DM with regard to aspects of privacy and confidentiality assurances: The NCD clinics had small waiting areas with poor ventilation, the exact opposite to what was observed at the CTC. Similar sentiments emerged from interviews with the patients.
As it was also noted in other aspects, some patients with NCDs from lower and periphery health facilities complained about a lack of privacy. The area where the integrated clinic operated was reported to be so open that anyone can observe them when entering the clinic, a complaint that also featured in the responses of care-providers. Some providers noted that there was a problem as a single room served all the clinicians, who would sit there and handle patients: “The service isn't friendly because there is no privacy since we use a single room for consultations services by all doctors” (Health Care Provider, Periphery hospital, mid-line). Healthcare providers reported this challenge to have made it difficult for a minority of patients to accept such integrated services especially those with either NCDs:
“It has been difficult to accept these integrated services by some of the patients especially those with either DM or HT. They complain a lot that the area used is for patients living with HIV. And that if they are seen by other people, they would be misconstrued to also be HIV-positive cases. Our environment isn't friendly; it’s too open there is no privacy...” (Health Care Provider, lower-level facility, mid-line).
While much improvement was noted at urban hospitals, patients reported congestion in the small patient waiting area, especially in the periphery and lower-level health facilities, a concern that was also raised by care-providers from similar setting. This finding was consistent with the observational findings at the mid-line.
Intervention coherence
At the mid-line, patients and healthcare providers were asked to indicate their understanding of the integrated model and what they expected in such a service spanning several disease conditions and how it could be optimally delivered. Most patients indicated increased understanding with the services delivered in the integrated clinic. They mentioned services they received following the pathway from file taking, registration, measuring of vital signs, health education, consultation, laboratory and collecting medicines: “I measure my weight, I see the doctor for the tests, getting medication and go back home” (DM/PLHIV patient, female, lower-level facility, mid-line). Increased understanding of the importance of integration and delivery of quality services emerged to be an added advantage for the increased acceptability of the integrated concept over time. Patients were willing to recommend to others to attend such a clinic:
“I now have a good understanding of the services provided at this integrated clinic. The service providers are good at providing services, which are also good. I am willing to continue receiving treatment at this clinic and even bringing [with me] my family members, relatives and friends for the services” (PLHIV with HT and DM, female, lower-level facility, mid-line).
Health care providers provided similar views:
“I am satisfied 100 percent. Continued provision of all the three services [at the same unit] in an integrated manner will give ample time for a patient to continue with his/her income generating activities because he/she gets all services in one day” (Health Care Provider, lower-level facility, mid-line).
Furthermore, at the end-line, patients were informed that the project had concluded and were asked whether they would like to remain in care or not. All patients were willing to continue with the integrated clinic: “Integration is good, at first I disagreed [with the concept] but now I see that it is good; I am ready to continue with the clinic and I am ready to tell other patients to attend such an integrated clinic” (Patient with HT/DM, female, periphery hospital, end-line). Also, all of them indicated that they would advise their friends and family members to join the clinic: “I am ready to continue getting services from the integration because the services are outstanding” (Patient with HT, female, hospital level-urban, end-line). Another patient said: “I am ready to remain at this clinic because I am satisfied with the services provided, and if I will be returned to the previous standalone clinic I will never attend” (PLHIV/HT, female, hospital level-urban, end-line).
The patients’ perspectives were supported by the views illustrated by a health care provider:
“If you compare before the integration and now, changes are there. Access to NCD services before the integration faced lots of challenges as patients used to attend the outpatient department with other patients who come with other diseases and would have to queue for the registration. This process used to delay from getting services on time. But now, they come directly to the clinic; they do not face delays anymore” (Health Care Provider, periphery hospital, end-line).
“Integration has reduced disturbances for people who used to come and take ARTs and be instructed to come back for other services in the next visit. Now they get all the services at once. As healthcare providers, we have benefited from trainings as for now we can offer advice according to the condition of the patient” (Health Care Provider, lower-level facility, mid-line).
All health care providers supported the continuation of such integrated health services because of the accruing benefits. Other reasons included a good relationship that had been cultivated between care-providers and their patients, cost-saving in terms of transport expenses and the availability of medicine.