Research Article: Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project

Date Published: March 14, 2018

Publisher: Public Library of Science

Author(s): Alexandra Wollum, Rose Gabert, Claire R. McNellan, Jessica M. Daly, Priscilla Reddy, Paurvi Bhatt, Miranda Bryant, Danny V. Colombara, Pamela Naidoo, Belinda Ngongo, Anam Nyembezi, Zaino Petersen, Bryan Phillips, Shelley Wilson, Emmanuela Gakidou, Herbert C. Duber, Albert Lee.


The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs).

This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach.

46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs.

In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Partial Text

Following public health successes in the prevention and treatment of communicable diseases, and combined with increasing life expectancy in most countries, non-communicable diseases (NCDs) have become the leading cause of death globally, accounting for nearly 40 million deaths in 2015.[1] The burden of NCDs has disproportionately increased in low- and middle-income countries (LMICs), which are also more likely to face challenges due to developing health systems and limited infrastructure.

To understand the burden and current response to NCDs in South Africa, we examined barriers to diagnosis, treatment, and management of NCDs. We used a continuum of care (CoC) framework to understand how an individual moves through and interacts with the health care system (Fig 1). [4]

This study aimed to quantify the continuum of care—prevalence, diagnosis, treatment, and control—for diabetes, hypertension, and hypercholesterolemia in two South African districts, Pixley ka Seme and Umgungundlovu. Simultaneously, we sought to identify key barriers within the continuum of care, thereby providing critical information on needs and targets for community-based interventions.

We identified important gaps in the diagnosis of hypercholesterolemia and hypertension, and the treatment of hypercholesterolemia, hypertension, and diabetes. Furthermore, we elucidated key barriers, both supply and demand, that can be addressed through the HealthRise community-based interventions. If South Africa is to meet the Sustainable Development Goal of reducing premature mortality due to NCDs by one third by 2030, considerable progress must be made. Working with provincial governments, local partners will utilize their vast knowledge and insight, much of it from the HIV epidemic, to develop ways to extend health services through the use of CHWs, integrate NCD care into other health services, and improve the capacity of health facilities to diagnosis and treat NCDs. Upon completion of the demonstration projects, the impact evaluation will provide important evidence regarding the potential for these interventions to be scaled up and serve as a model for future interventions, nationally and internationally.




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