Self-management approaches for individuals with multiple chronic health conditions in rural South Africa

Chronic health conditions, including non-communicable diseases (NCDs), mental disorders, and certain long-term infectious diseases such as HIV/AIDS have emerged as leading causes of morbidity and mortality in low and middle-income countries including South Africa (SA). This growing burden demands an innovative response. As most of the management of chronic diseases, which includes taking medication, making lifestyle changes, or undertaking preventive action occurs in homes, communities and outpatient settings, it involves patients, their carers or both making the day-to-day decisions about what actions to take. Involvement of patients in the management of their care for chronic diseases is referred to as self-management. A prerequisite for self-management to be effective is self-monitoring which is the "ability to monitor one's condition to effect the cognitive, behavioural and emotional responses necessary to maintain a satisfactory quality of life". Self-monitoring broadly includes the monitoring of clinical parameters (such as weight, blood pressure, blood glucose and lung function), symptom measures (such as fatigue, stress and pain) and features of daily life (such as physical activities, dietary intake, and sleep patterns). Key attributes of self-monitoring are: (i) awareness of bodily symptoms, sensations, daily activities, and cognitive processes and, (ii) measurements, recordings, or observations that inform cognition and provide information for independent action or consultation with care providers. As health-related behaviours and practices are known to be distinctly different between geographical settings and between individuals within a particular setting, similarly is the case of self-monitoring of personal health. Evidence from high income settings has demonstrated that self-monitoring of personal health can improve self-management, symptom management and disease regulation, and can lead to reductions in complications, improvement in patients' coping and attitudes toward their disease, realistic goal setting and an enhanced quality of life. However, it is unknown whether, how and the extent to which the benefits of self-monitoring observed in high income settings can be realised in low and middle-income countries especially in rural settings. This project aims to assess the extent to which individuals with multiple chronic health conditions living in rural South Africa self-monitor their health, what methods they use, and the effect of different self-monitoring approaches on behaviours and health outcomes - as a basis for improving self-management among individuals with multiple chronic health conditions. The research for the project will be conducted in the Agincourt health and socio-demographic surveillance system study area in Agincourt sub-district in Mpumalanga province, in northeast South Africa. Data will be collected using questionnaires administered to patients aged 40 years and older with chronic health conditions, interviews with patients and health care professionals, and discussions with patients, care givers and community members. Our research activities are expected to contribute to efforts to effectively tackle the rising burden of multimorbidity of chronic health conditions and subsequent mortality among rural populations in South Africa and other rural settings in East and Southern Africa.

South Africans are experiencing a complex, protracted health transition characterised by ongoing burdens from epidemic infectious diseases, particularly HIV/AIDS, rapidly increasing morbidity and mortality from chronic diseases such as heart diseases, stroke, cancer and metabolic disorders and ill-prepared healthcare systems. Levels of multimorbidity, commonly defined as having two or more medical conditions are very high among older South Africans in rural areas with combinations of cardiometabolic conditions, cardiometabolic conditions and depression, HIV and anaemia and combinations of mental disorders as the most common condition groups and multimorbid profiles. As self-management is a critical aspect of the management of chronic diseases, it is important to understand the extent to which individuals with multiple chronic health conditions in South Africa, particularly in rural settings are involved in the self-management of their conditions. Evidence from high income settings shows that self-monitoring of personal health, which is a key aspect of patients' self-management of chronic illnesses, could improve self-management, symptom management and disease regulation, and could lead to reductions in complications, improved patients' coping and attitudes toward their disease, realistic goal setting and an enhanced quality of life. Using a combination of quantitative and qualitative research approaches this project will assess the extent to which individuals with multiple chronic health conditions living in rural South Africa self-monitor their health, what methods they use, and the effect of different self-monitoring approaches on behaviours and health outcomes. The research will be conducted in the Agincourt health and socio-demographic surveillance system study area in Agincourt sub-district in Mpumalanga province, in northeast South Africa.

Our project will be conducted in South Africa, an upper-middle income ODA country and will primarily address the development challenges of sustainable health and wellbeing. Our work will contribute towards ensuring good health and wellbeing (Sustainable Development Goal (SDG) 3), with particular emphasis on goal 3.4 - reducing premature mortality from non-communicable diseases. We will achieve this by generating knowledge that will inform the design of innovative interventions that will optimise the benefits of self-management of chronic health conditions and tackle the growing problem of multimorbidity affecting people in rural marginalised settings in South Africa. This will improve health, wellbeing and economic productivity of individuals, households and communities and facilitate economic development. In this way, our work will address an explicit development challenge and directly inform the wider development agenda for South Africa, as recognised by the South African National Development Plan which aims to eliminate poverty and reduce inequality by 2030. This also aligns with the UK Aid Objective 4 (tackling poverty and helping the world's most vulnerable).

The project investigators have different strengths and expertise which will be shared across the team. Therefore, the project will strengthen mutual collaboration between the investigators and improve their capacity and skills in multimorbidity research methods, data collection, processing, analysis and interpretation.

As part of the proposed research we will train local fieldworkers in Agincourt in quantitative and qualitative data collection methods. This will help build research capacity and enhance the skill set of those involved. This is likely to increase their professional standing within their peer group.

The project will also contribute to the career development of early career researchers that will be mentored by the project team's senior investigators. Further, our research will contribute to training of masters and doctoral candidates at Wits and UCL by providing data for their research projects. In addition, our research will provide a valuable data resource for advancing research capacity of other researchers beyond the named project investigators following the public release of the data.

The research work in this project will lead to an increase in knowledge regarding multimorbidity and self-management that is likely to have applicability beyond the study setting and may impact on people living in other areas in South Africa and beyond. The proposed study will form the basis for future projects on implementation and evaluation of innovative self-monitoring and self-management strategies to tackle the rising burden of multimorbidity in rural South Africa. The leading role of the Agincourt HDSS in the South African Population Research Network- a South African Government Department of Science and Innovation funded network of HDSS sites, founded on the existing rural HDSS sites in South Africa (Agincourt in Mpumalanga Province, Africa Health Research Institute in KwaZulu Natal Province and DIMAMO in Limpopo Province) and extending to one more rural site in Eastern Cape Province and three urban sites in (Gauteng, KwaZulu-Natal and Western Cape Provinces) will make it possible to expand future work to other areas in South Africa. The potential to inform future research work on self-monitoring and self-management among individuals living with multiple chronic conditions in sub-Saharan Africa is also enormous through the involvement of Agincourt HDSS in the International Network for the Demographic Evaluation of Populations and Their Health and the leading role played within the network by the MRC/Wits-Agincourt Unit researchers.