Community Health

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    Chronic diseases of lifestyle: a risk assessment and health promotion framework for a rural and urban primary health care setting in the Free State province
    (University of the Free State, 2021) Van Zyl, Sanet; Kruger, W. H.; Walsh, C.
    Non-communicable diseases (NCDs), also known as chronic diseases (CD), are the leading cause of death globally. The World Health Organization (WHO) projects a significant increase in CD mortality rates, especially in developing countries. Chronic diseases of lifestyle (CDL) are chronic diseases that share similar modifiable risk factors resulting in long-term disease processes. The WHO's country-specific profile for NCDs illustrates the persistent high prevalence of modifiable risk factors in South Africa (SA) relating to CDL that place a significant burden on health systems. Shifting from an expensive hospital-centred acute-care approach to an affordable and effective primary health care (PHC) approach requires knowledge of communities' risk and disease profiles. Effective community-based PHC responses can reduce morbidity and mortality caused by CDL. However, detailed information relating to CDL and risk factors that maintain the risk cycle for CDL in rural and urban Free State (FS) communities is still limited. This study aimed to develop a framework to provide a better understanding of the CDL risk profiles and barriers and challenges experienced with regard to the effective implementation of CDL programmes in a rural and an urban PHC setting in the FS. A convergent mixed method design was applied in the study. Using the existing Assuring Health for All in the FS database, the quantitative study (PHASE I) aimed to compile a risk factor profile for the FS's rural and urban study populations. Qualitative data (PHASE II), obtained during focus group discussions, explored participants’ knowledge of CDL (patients with CDL) and related training programmes (PHC team members and medical students). Participants' attitudes and experiences of the practical implementation of CDL intervention programmes in these communities were also investigated. The quantitative part of the study found similarities and distinct differences in the CDL risk profiles between the urban and rural study communities. The qualitative part of the study provided insight into CDL-related health needs and current experiences of intervention programmes in the PHC settings. PHC team members indicated that CDL guidelines covered a range of diseases relevant to the SA context; however, several challenges and barriers to implementing the protocols and guidelines were identified. Focus group discussions with patients revealed, among others, staff shortages, high patient load leading to long waiting times, lack of supporting health care services, and transport as barriers to optimal health care at PHC facilities. Focus group discussions conducted with medical students confirmed the before-mentioned findings. In addition, medical students indicated that community-based education provided valuable opportunities to develop knowledge, skills, and attitudes relating to PHC. However, they highlighted the importance for students to have a contextualised understanding of the multi-factorial aetiology of CDL in different communities. A combination of quantitative and qualitative data was used to construct a CDL risk assessment and health promotion framework for the urban and rural settings. In Step 1 of developing the risk assessment and health promotion framework, identified CDL risk factors in each study population were prioritised to complete the risk assessment process. Step 2 identified CDL training needs for PHC teams, patient educational needs, and MBChB CDL curriculum development needs. Step 3 revealed three main barriers: resource constraints, patient noncompliance, and the lack of supporting healthcare services to the effective implementation of CDL programmes. Step 4, the final step, used the six main focus areas identified in steps 1-3 to develop a tailor-made community-based patient-centred approach to facilitate the development of focused and effective PHC programmes for CDL in these resource-constrained areas. This thesis contains details of the research study.