Impact of COVID-19 primary healthcare service restrictions on patients with chronic obstructive pulmonary disease in Cape Town, South Africa.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) typically experience multidimensional symptoms throughout the course of their disease, with burdensome physical symptoms, social isolation, and additional psychological suffering. COVID-19 lockdown resulted in restrictions on chronic care delivery at primary healthcare (PHC) facilities, and it is not known what the care experiences of patients with COPD were during this time. OBJECTIVES: To describe patient experiences of the impact of the lockdown on their needs and their experiences of the primary care received for their COPD. METHODS: The data reported in this paper are from a cohort of 49 patients with COPD receiving primary care, recruited in February and March 2020, before recruitment was paused for COVID-19 lockdown, for a feasibility stepped-wedge hybrid type II design randomised controlled trial of integrated person-centred palliative care in primary care for patients with COPD in Cape Town, South Africa. Data are open-text responses from participants who responded to a single question on a validated measure of primary care consultation empathy (CARE), and describe patient experiences of the impact of the lockdown on the primary care received for their COPD, prior to crossover to trial intervention. RESULTS: Thirty-two patients with COPD gave between 1 and 9 responses each to the open-ended question between March and December 2020. The average age of the participants was 58.6 years, and 53.1% (n=17) were female. Inductive analysis of the open-text data identified four main themes. Participants described decreased access to chronic care and a desire for more person-centred care in interactions with healthcare professionals. The socioeconomic ramifications of the COVID-19 lockdown added to the burden they experienced. CONCLUSION: The COVID-19 lockdown PHC service restrictions caused a disruption to the continuity of care for patients with COPD, with associated worry, anxiety and disappointment. Medication access was largely supported by the home delivery of chronic medication. We suggest that there are opportunities for providing more sustained support for patients with COPD through referrals to community health workers, and also through telephonic patient follow-up by primary care teams.

The Development and Evaluation of Online Home Palliative Training During COVID-19 Pandemic in South Africa

Background/aims: COVID-19 has compounded the lack of access to palliative care described in the Lancet Commission. COVID-19 patients and their families report distressing multidimensional symptoms and concerns. South Africa faced a high burden of COVID-19, and due to restrictions in facility access there was need for upskilling of healthcare professionals to deliver home palliative care irrespective of diagnosis. Aim: To develop and evaluate online training of palliative home care. Methods: We developed: 1) guidelines for health care professionals and family caregivers using a multidisciplinary team of stakeholders from across South Africa, 2) online training covering palliative care management of COVID-19 and non-COVID-19 patients at home, completed over 4 weeks and 3) training evaluation using an online questionnaire and qualitative interviews. Results: Between March and May 2021, n=950 participants were registered for online asynchronous training. Of these, n=247 engaged with the training materials, n=141 completed assessments, receiving a certificate of completion with CPD accreditation for professionals. Survey data were collected from 53 participants: n=27 health professionals (n=13 nurses, n=5 doctors, n=3 social workers, n=3 counsellors;n=2 rehabilitation sciences, and n=1 emergency medicine), and n=26 non-professionals. Thirty-one (58.9%) had no previous palliative care training;n=22 (41.5%) had no previous experience in providing palliative care. Implementation outcome measurement: agreement with being able to apply the training clinically was 4/5 for 27 (51.0%) and 5/5 for 19 (35.8%) on a 5-point Likert scale;and 34 (64.2%) completely agreed (5/5) to welcoming the opportunity to develop palliative care knowledge and skills. Conclusions: The interest shown in the guidelines and training reflect an awareness of the importance of these skills, and the delivery method offers enormous potential to builds skills and knowledge in an accessible format.

Impact of COVID-19 Lockdown on Chronic Lung Disease Patient Experiences of Primary Health Care Services in Cape Town, South Africa

Background/aims: Chronic Obstruction Pulmonary Disease (COPD) is currently the third leading cause of death globally. COPD and chronic lung disease patients experience multidimensional symptoms throughout the disease course. Research shows palliative care alongside usual care for people living with COPD can reduce breathlessness and improve quality of life. Access to palliative care for these patients is limited, particularly in LMICs. In addition, the COVID-19 lockdown resulted in restrictions on chronic care delivery at primary care facilities. Aims: To describe the impact of the COVID-19 lockdown on patient experiences of primary care. Methods: The data reported is from a cohort of 49 chronic lung disease patients recruited for a feasibility stepped wedge hybrid type II design RCT trial of integrated person-centred palliative care in primary care in Cape Town, South Africa. Data are open-text responses to a single question on a validated measure of primary care consultation empathy (CARE). These describe patient experiences of the impact of the lockdown on the primary care received, prior to crossover to trial intervention. Results: Thirty two patients responded to the question at least once between March and December 2020. Seventeen participants were female (53.1%) and the mean age was 58.6 years. Inductive analysis of the open-text data identified four main themes. Despite home delivery of chronic medication, participants described decreased access to chronic care and a desire for more person-centred care. The socio-economic ramifications of the lockdown added to the burden experienced. Conclusions: The COVID-19 lockdown primary health care service restrictions caused a disruption to the continuity of care for patients, with associated worry, anxiety and disappointment. There are opportunities for providing more sustained person-centred care through referrals to community health workers and through telephonic patient support.

Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage

Y Background. South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis. Objectives. To develop and test an Ethics Framework for use in the SA context for health priority-setting. Methods. The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval. Results. This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs. Conclusions. The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.