Effectiveness of a health systems strengthening intervention to improve detection, treatment, and control of Multiple Long-Term Conditions in primary health care facilities in South Africa: type 2 hybrid cluster randomised control trial
1
School of Life Course & Population Sciences, King's College London, London, United Kingdom
2
Knowledge Translation Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
3
Chronic Disease Initiative in Africa, University of Cape Town, Cape Town, South Africa
4
Centre for Research in Health Systems, University of KwaZulu-Natal, Durban, South Africa
5
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, South Africa
6
Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa
7
SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, Wits School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
8
Department of Public Health, Norwich Medical School, University of East Anglia, Norwich, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1854
ABSTRACT
BACKGROUND:
Multiple long-term conditions (MLTCs) are a global threat. South Africa’s coinciding burdens of HIV, NCDs and mental illness strain primary care services. We tested a health systems strengthening intervention for people with MLTCs.
METHODS:
ENHANCE (EvideNce led co-created HeAlth systems interventioNs for MLTCs CarE) was a type 2 hybrid, parallel-arm cluster randomised controlled trial in 32 primary care clinics in KwaZulu-Natal and Western Cape provinces, South Africa. Clinics were randomised and stratified by province and location. Participants were adults ≥40 years with at least two of: HIV, hypertension, diabetes, asthma, depression, previous myocardial infarction or stroke. The intervention comprised: (1) integrated clinical decision support; (2) health literacy materials; (3) support from community health workers (CHWs). Implementation strategies included training for clinicians and CHWs and continuous quality improvement. Control facilities delivered usual care. The composite primary outcome was at least one of: (i) detection/initiation of treatment for new conditions, (ii) treatment intensification, and/or (iii) improved control, during 12 months follow-up.
RESULTS:
1743 participants (mean age 57.5 years, SD 9.9; 77% women) were enrolled: 883 (51%) in the ENHANCE group and 860 (49%) in the usual care group, of whom 89% and 88% respectively were followed up at 12 months. The primary outcome was attained in 664/794 (84%) of ENHANCE group and 626/788 (79%) of usual care group participants (Relative Risk (RR)=1.06; 95% confidence interval (CI) 1.01 to 1.11; p=.016; ICC 0.05) with the same benefit in both provinces. There was improved control of HIV (RR=1.15; 95% CI 0.98 to 1.36, p=0.09) and asthma (RR=1.72, 95%CI 0.67 to 4.47, p=0.259), but not hypertension, diabetes or depression. Intervention group participants reported greater satisfaction with care.
CONCLUSIONS:
Such co-produced interventions to address MLTCs in overburdened primary care clinics in low- and middle-income countries can improve clinical management, control and patients’ experience of care.
Multiple long-term conditions (MLTCs) are a global threat. South Africa’s coinciding burdens of HIV, NCDs and mental illness strain primary care services. We tested a health systems strengthening intervention for people with MLTCs.
METHODS:
ENHANCE (EvideNce led co-created HeAlth systems interventioNs for MLTCs CarE) was a type 2 hybrid, parallel-arm cluster randomised controlled trial in 32 primary care clinics in KwaZulu-Natal and Western Cape provinces, South Africa. Clinics were randomised and stratified by province and location. Participants were adults ≥40 years with at least two of: HIV, hypertension, diabetes, asthma, depression, previous myocardial infarction or stroke. The intervention comprised: (1) integrated clinical decision support; (2) health literacy materials; (3) support from community health workers (CHWs). Implementation strategies included training for clinicians and CHWs and continuous quality improvement. Control facilities delivered usual care. The composite primary outcome was at least one of: (i) detection/initiation of treatment for new conditions, (ii) treatment intensification, and/or (iii) improved control, during 12 months follow-up.
RESULTS:
1743 participants (mean age 57.5 years, SD 9.9; 77% women) were enrolled: 883 (51%) in the ENHANCE group and 860 (49%) in the usual care group, of whom 89% and 88% respectively were followed up at 12 months. The primary outcome was attained in 664/794 (84%) of ENHANCE group and 626/788 (79%) of usual care group participants (Relative Risk (RR)=1.06; 95% confidence interval (CI) 1.01 to 1.11; p=.016; ICC 0.05) with the same benefit in both provinces. There was improved control of HIV (RR=1.15; 95% CI 0.98 to 1.36, p=0.09) and asthma (RR=1.72, 95%CI 0.67 to 4.47, p=0.259), but not hypertension, diabetes or depression. Intervention group participants reported greater satisfaction with care.
CONCLUSIONS:
Such co-produced interventions to address MLTCs in overburdened primary care clinics in low- and middle-income countries can improve clinical management, control and patients’ experience of care.
| eISSN: | 2654-1459 |
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