Educational outreach with an integrated clinical tool for nurse-led non-communicable chronic disease management in primary care in South Africa: a pragmatic cluster randomised controlled trial

Fairall, Lara R.; Folb, Naomi; Timmerman, Venessa; Lombard, Carl; Steyn, Krisela; Bachmann, Max O.; Bateman, Eric D.; Lund, Crick; Cornick, Ruth; Faris, Gill; Gaziano, Thomas; Georgeu-Pepper, Daniella; Zwarenstein, Merrick; Levitt, Naomi S.

doi:10.1371/journal.pmed.1002178

Cited by 99Nursing Roles and PracticesChronic Disease Management StrategiesHealth Policy Implementation Science

Educational outreach with an integrated clinical tool for nurse-led non-communicable chronic disease management in primary care in South Africa: a pragmatic cluster randomised controlled trial

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Fairall, Lara R., Folb, Naomi, Timmerman, Venessa, Lombard, Carl, Steyn, Krisela, Bachmann, Max O., Bateman, Eric D., Lund, Crick +6 more·2016·PLoS Medicine

DOI 10.1371/journal.pmed.1002178PMC PMC5119726

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Abstract

BACKGROUND: In many low-income countries, care for patients with non-communicable diseases (NCDs) and mental health conditions is provided by nurses. The benefits of nurse substitution and supplementation in NCD care in high-income settings are well recognised, but evidence from low- and middle-income countries is limited. Primary Care 101 (PC101) is a programme designed to support and expand nurses' role in NCD care, comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions. We evaluated the effect of the programme on primary care nurses' capacity to manage NCDs. METHODS AND FINDINGS: In a cluster randomised controlled trial design, 38 public sector primary care clinics in the Western Cape Province, South Africa, were randomised. Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an expanded range of drugs for several NCDs. Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) management tool and usual training. Patients attending these clinics with one or more of hypertension (3,227), diabetes (1,842), chronic respiratory disease (1,157) or who screened positive for depression (2,466), totalling 4,393 patients, were enrolled between 28 March 2011 and 10 November 2011. Primary outcomes were treatment intensification in the hypertension, diabetes, and chronic respiratory disease cohorts, defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo, and case detection in the depression cohort. Primary outcome data were analysed for 2,110 (97%) intervention and 2,170 (97%) control group patients. Treatment intensification rates in intervention clinics were not superior to those in the control clinics (hypertension: 44% in the intervention group versus 40% in the control group, risk ratio [RR] 1.08 [95% CI 0.94 to 1.24; p = 0.252]; diabetes: 57% versus 50%, RR 1.10 [0.97 to 1.24; p = 0.126]; chronic respiratory disease: 14% versus 12%, RR 1.08 [0.75 to 1.55; p = 0.674]), nor was case detection of depression (18% versus 24%, RR 0.76 [0.53 to 1.10; p = 0.142]). No adverse effects of the nurses' expanded scope of practice were observed. Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts, limited data on uptake of PC101 by users, reliance on process outcomes, and insufficient resources to measure important health outcomes, such as HbA1c, at follow-up. CONCLUSIONS: Educational outreach to primary care nurses to train them in the use of a management tool involving an expanded role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases. This notwithstanding, the intervention, with adjustments to improve its effectiveness, has been adopted for implementation in primary care clinics throughout South Africa. TRIAL REGISTRATION: The trial is registered with Current Controlled Trials (ISRCTN20283604).

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The authors of the South Africa trial noted that these trial findings assessing the effectiveness of complex interventions in real world settings were difficult to interpret and noted several challenges including a co-intervention, called the Chronic Disease Season, triggered by the trial, and not expanding access to antidepressant prescribing or psychological therapies.
“The authors noted that these trial findings assessing the effectiveness of complex interventions in real world settings, were difficult to interpret and noted several challenges including a co-intervention, called the Chronic Disease Season, triggered by the trial, and not expanding access to antidepressant prescribing or psychological therapies 41 68 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [41]
The chronic care model was shown not to be effective for people with depression when delivered using training of health providers alone, without resourcing the health system to expand access to anti-depressants or psychological treatments.
“But the model was shown not to be effective for people with depression when delivered using training of health providers alone, without resourcing the health system to expand access to anti-depressants or psychological treatments identified as an additional pre-requisite 41 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [41]

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Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review
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Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child)
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Pathways to Care for Patients With Type 2 Diabetes and HIV/AIDS Comorbidities in Soweto, South Africa: An Ethnographic Study
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A qualitative study on knowledge, perception, and practice related to non-communicable diseases in relation to happiness among rural and urban residents in Bhutan
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Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to care kit
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A contextualisation approach to health promotion guideline development in South Africa
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A collaborative care package for depression comorbid with chronic physical conditions in South Africa
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Nurse-led interventions for prevention and control of noncommunicable diseases in low- and middle-income countries
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RETRACTED: Revamping of Chronic Respiratory Diseases in Low- and Middle-Income Countries
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Retracted
Hypertension in Sub-Saharan Africa
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Supporting a rapid primary care response to emergent communicable disease threats with PACK (Practical Approach to Care Kit) in Florianópolis, Brazil
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Physical activity interventions implemented for older people in Sub-Saharan Africa: a scoping review
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Ethiopian primary healthcare clinical guidelines 5 years on—processes and lessons learnt from scaling up a primary healthcare initiative
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Understanding the role and organization of health workers delivering non-communicable disease management in primary care in low- and middle-income countries: a scoping review
Gupta, A., Ogundele, O. J., Rabet, R., Artyukh, I., da Trindade, T. G., Cheng, D., Darko, D., Eltigany, M., Cieza, A., Skidmore, B., et al. (2025) · BMC Family Practice · doi:10.1186/s12875-025-03033-3 · Cited by 11 · see citing works
Knowledge and Perceptions of Final-Year Nursing Students Regarding Antimicrobials, Antimicrobial Resistance, and Antimicrobial Stewardship in South Africa: Findings and Implications to Reduce Resistance
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Integrating Depression and Alcohol Use Care Into Primary Care in Low- and Middle-Income Countries: A Meta-Analysis
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A Conceptual Model to Strengthen Integrated Management of HIV and NCDs among NIMART-Trained Nurses in Limpopo Province, South Africa
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Integrated Management of HIV and NCDs within the Primary Health Care in the South African Context: A Comprehensive Literature Review
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Physical activity and ageing: The role of physiotherapy in promoting healthy ageing
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Authors: Fairall, L. R., Folb, N., Timmerman, V., Lombard, C., Steyn, K., Bachmann, M. O., Bateman, E. D., Lund, C., Cornick, R., Faris, G., Gaziano, T., Georgeu-Pepper, D., Zwarenstein, M., & Levitt, N. S.
Affiliations: University of Cape Town (ZA)
South African Medical Research Council (ZA)
University of East Anglia (GB)
Brigham and Women's Hospital (US)
Western University (CA)
Corresponding author: Fairall, Lara R.
ORCID: Fairall, Lara R.
Folb, Naomi
Timmerman, Venessa
Lombard, Carl
Bachmann, Max O.
Bateman, Eric D.
Lund, Crick
Cornick, Ruth
Faris, Gill
Gaziano, Thomas
Georgeu-Pepper, Daniella
Zwarenstein, Merrick
Levitt, Naomi S.
Venue: PLoS Medicine
Publisher: Public Library of Science (PLoS)
Published: 2016-11-22
Volume: 13
Issue: 11
Pages: e1002178
ISSN: 1549-1277 (ISSN-L)
1549-1676
DOI: 10.1371/journal.pmed.1002178
PMC: PMC5119726
OpenAlex: W2554606173
Cited by: 99
References: 61
Citations by year: 2026: 4 · 2025: 9 · 2024: 10 · 2023: 14 · 2022: 11 · 2021: 11 · 2020: 10 · 2019: 9 · 2018: 17 · 2017: 4
FWCI: 18.61
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0/ (vor)
Locations: PLoS Medicine (publishedVersion, cc-by)
Europe PMC (PubMed Central) (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
UEA Digital Repository (University of East Anglia) (acceptedVersion)
Research Portal (King's College London) (submittedVersion, cc-by)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Figshare (submittedVersion, cc-by)
Funders: National Heart, Lung, and Blood Institute (HHSN268200900030C)
United Health, USA
Department of Health of the Provincial Government of the Western Cape
Department of Medicine, University of Cape Town, South Africa
United Kingdom Department for International Development
University of Cape Town Lung Institute, South Africa
Topics: Health Sciences › Health Professions › General Health Professions › Nursing Roles and Practices
Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Keywords: nurse-led care, non-communicable diseases, chronic disease management, primary care, educational outreach, hypertension, diabetes mellitus, chronic respiratory disease, treatment intensification, low- and middle-income countries, South Africa, Western Cape, health workforce capacity building, mental health integration
MeSH terms: Adult, Chronic Disease, Depression, Diabetes Mellitus, Female, Humans, Hypertension, Male, Middle Aged, Primary Health Care, Respiratory Tract Diseases, South Africa, Cohort Studies, Disease Management, Primary Care Nursing

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Educational outreach with an integrated clinical tool for nurse-led non-communicable chronic disease management in primary care in South Africa: a pragmatic cluster randomised controlled trial

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