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Research article
A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa
Limakatso Lebina
University of the Witwatersrand Perinatal HIV Research Unit
Corresponding Author
ORCiD: https://orcid.org/0000-0001-6825-0573
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Health Services Research.
Background: Chronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model.
Methods: This was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically.
Results: The median age of participants was 36.5 (IQR: 30.8-45.5), and they had been in their roles for a median of 4.0 (IQR: 1.0 – 7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure and adequate staff, and balanced patient caseloads.
Conclusion: There are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.
Keywords
context, implementation research, ICDM model, chronic care, integrated care
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CURRENT STATUS: Published
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Posted 20 May, 2020
Published
On 06 Jul, 2020
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Reviewer #4 agreed
On 09 May, 2020
Reviewers invited
Invitations sent on 08 May, 2020
Reviewer #1 agreed
On 08 May, 2020
Reviewer #2 agreed
On 08 May, 2020
Reviewer #3 agreed
On 08 May, 2020
Editor assigned
On 07 May, 2020
Editor invited
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Submission checks complete
On 27 Feb, 2020
No comments provided
Editorial decision: Major revision
On 10 Apr, 2020
Review #9 received
Received 06 Apr, 2020
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Review #8 received
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Review #1 received
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Reviewer #10 agreed
On 27 Mar, 2020
Reviewer #8 agreed
On 26 Mar, 2020
Reviewer #9 agreed
On 26 Mar, 2020
Reviewer #7 agreed
On 25 Mar, 2020
Reviewer #6 agreed
On 25 Mar, 2020
Reviewer #3 agreed
On 23 Mar, 2020
Reviewer #4 agreed
On 23 Mar, 2020
Reviewer #5 agreed
On 23 Mar, 2020
Reviewers invited
Invitations sent on 22 Mar, 2020
Reviewer #1 agreed
On 22 Mar, 2020
Reviewer #2 agreed
On 22 Mar, 2020
Editor assigned
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This preprint is under consideration at BMC Health Services Research. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa
Limakatso Lebina
University of the Witwatersrand Perinatal HIV Research Unit
Corresponding Author
ORCiD: https://orcid.org/0000-0001-6825-0573
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 2
Posted 20 May, 2020
Published
On 06 Jul, 2020
No community comments so far
Reviewer #4 agreed
On 09 May, 2020
Reviewers invited
Invitations sent on 08 May, 2020
Reviewer #1 agreed
On 08 May, 2020
Reviewer #2 agreed
On 08 May, 2020
Reviewer #3 agreed
On 08 May, 2020
Editor assigned
On 07 May, 2020
Editor invited
On 06 May, 2020
Submission checks complete
On 27 Feb, 2020
No comments provided
Editorial decision: Major revision
On 10 Apr, 2020
Review #9 received
Received 06 Apr, 2020
Review #3 received
Received 03 Apr, 2020
Review #8 received
Received 03 Apr, 2020
Review #7 received
Received 03 Apr, 2020
Review #4 received
Received 03 Apr, 2020
Review #5 received
Received 03 Apr, 2020
Review #6 received
Received 02 Apr, 2020
Review #2 received
Received 31 Mar, 2020
Review #1 received
Received 31 Mar, 2020
Reviewer #10 agreed
On 27 Mar, 2020
Reviewer #8 agreed
On 26 Mar, 2020
Reviewer #9 agreed
On 26 Mar, 2020
Reviewer #7 agreed
On 25 Mar, 2020
Reviewer #6 agreed
On 25 Mar, 2020
Reviewer #3 agreed
On 23 Mar, 2020
Reviewer #4 agreed
On 23 Mar, 2020
Reviewer #5 agreed
On 23 Mar, 2020
Reviewers invited
Invitations sent on 22 Mar, 2020
Reviewer #1 agreed
On 22 Mar, 2020
Reviewer #2 agreed
On 22 Mar, 2020
Editor assigned
On 27 Feb, 2020
Submission checks complete
On 27 Feb, 2020
Editor invited
On 27 Feb, 2020
First submitted
On 21 Feb, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Health Services Research.
Background: Chronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model.
Methods: This was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically.
Results: The median age of participants was 36.5 (IQR: 30.8-45.5), and they had been in their roles for a median of 4.0 (IQR: 1.0 – 7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure and adequate staff, and balanced patient caseloads.
Conclusion: There are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.