Integrated chronic disease care delivery at a primary care level in sub-Saharan Africa: A systematic review, best fit framework synthesis, and new conceptual model

BackgroundExisting chronic care conceptual models were not designed for sub-Saharan Africa, where there is a growing burden of chronic disease. This review provides a qualitative synthesis and new conceptual model for primary care approaches to the integration of chronic communicable and non-communicable disease care in a sub-Saharan African context. MethodsA best fit framework synthesis comprising two systematic reviews, with information retrieved from PubMed, Embase, CINAHL plus, Global Health, and Global Index Medicus databases between 1st - 30th April 2020. Articles on chronic care conceptual models were included if they were developed for application in a primary care context and described a framework for long-term management of chronic disease care, and themes extracted to construct an a priori framework. A second systematic review included articles focussing on integrated HIV and diabetes care at a primary care level in sub-Saharan Africa, with thematic analysis carried out against the a priori framework. A new conceptual model was constructed from a priori themes and new themes. Risk of bias of included studies was assessed using CASP and MMAT. ResultsTwo conceptual models of chronic disease care, comprising 6 themes, were used to build the a priori framework. The systematic review of primary research identified 12 articles, with all 6 of the a priori framework themes, and 5 new themes identified. A new patient-centred conceptual model for integrated HIV and diabetes care was constructed, specific to a sub-Saharan African context. DiscussionImproving patient access to chronic disease care through implementing decentralised, integrated, affordable and efficient primary care services should be prioritised in sub-Saharan Africa. Services must be acceptable to patients, viewing them as partners, addressing their concerns, and seeking to safeguard confidentiality. Limitations of this study include potential publication bias, and impact of policy environment and economic factors in sub-Saharan Africa. SUMMARY BOXO_ST_ABSWhat is already known?C_ST_ABSO_LIThe health transition taking place in sub-Saharan Africa (SSA) towards chronic communicable and non-communicable diseases such as HIV and diabetes as the main causes of morbidity and mortality means that health systems currently orientated towards acute, episodic care, must be re-orientated towards meeting the long-term needs of patients with chronic diseases. C_LIO_LIExisting chronic care conceptual models were designed for use in high income countries rather than a SSA context. C_LI What are the new findings?O_LIAll 6 of the a priori framework themes derived from the Chronic Care Model and the ICCCF were identified within the primary research studies and therefore have relevance to the provision of chronic care in a primary care context in SSA. C_LIO_LIAn additional 5 new themes were identified from the primary research studies; improving patient access, task-shifting, clinical mentoring, stigma and confidentiality, and patient-provider partnerships. C_LI What do the new findings imply?O_LIThese findings imply that there are additional themes and delivery strategies specific to an SSA context that need to be considered in the implementation of primary care level integrated chronic disease care provision in SSA. C_LIO_LIThe new themes identified from the primary research highlight the importance of health services being accessible and acceptable to patients, of partnering with patients to improve health outcomes, and of patient confidentiality and imply a need to reconceptualise chronic care from a patient-centred viewpoint. C_LI