Leadership, cohesion, and stress in primary care facilities and retention in chronic care in rural northeast South Africa before and during the COVID-19 pandemic: A longitudinal study

Abstract

Background: Human immunodeficiency virus (HIV) and hypertension are major contributors to morbidity and mortality in South Africa. Effective management of these conditions is critical to population health, yet patient management and retention varies by facility for reasons that are not fully understood. We assessed whether measures of clinic leadership, cohesion, and stress were associated with retention for HIV and hypertension in a cohort of patients in northeast South Africa before and during the Coronavirus disease 2019 pandemic.

Methods: We quantified nursing capacity and service readiness within primary health care facilities in the Bushbuckridge sub-district in Mpumalanga province South Africa. We administered brief scales on facility leadership, cohesion, and stress from January to March 2019, and tested scales for individual and facility-level agreement. We extracted clinical records for patients with HIV and/or hypertension from 2019 to 2021 and quantified treatment retention by quarter. We used generalised estimating equations to assess individual and clinic factors associated with retention in each treatment programme prior to (2019-first quarter 2020) and during (second quarter 2020-2021) the pandemic.

Results: The nine facilities had a median of 12 nurses on staff and scored 0.83 out of 1.0 on basic service readiness. We collected responses to leadership, cohesion, and stress scales from 54 nurses and counsellors. Scales showed high inter-item agreement and moderate within-facility agreement. From 2019 to 2021, 19 445 individuals were treated for HIV and/or hypertension across seven participating facilities. Two-year retention was 91% for those with both conditions, 82% for those in treatment for HIV alone and 77% for those in treatment for hypertension alone, with 10-15% differences between facilities and high retention during the pandemic period. In addition to those with both conditions, women and adults aged 60-69 were more likely to be retained. Clinic factors were inconsistently associated with patient retention.

Conclusions: While measures of clinic leadership, cohesion, and stress were generally reliable at individual and facility levels, we found limited evidence supporting a link between these factors and better retention in care. Retention was stable during the Coronavirus disease 2019 pandemic. Men, the youngest and oldest adults, and those without known multimorbidity should be prioritised for retention interventions.

Figure 1

Retention in chronic care across seven PHC facilities in Agincourt HDSS study area before and during the COVID-19 pandemic. Percent of patients retained in care is shown for each condition, overall and by facility; the y-axis spans 50 to 100%. Dashed lines indicate facilities with statistically significant difference in retention from reference facility (Facility 6, largest patient volume) at P < 0.050. The start of the COVID-19 pandemic is shown in the vertical red line. HDSS – Health and Socio-Demographic Surveillance System, PHC – primary health care

Figure 2

Retention in care by demographic and clinical characteristics in Agincourt HDSS study area. Percent of patients retained in care is shown for each condition, overall and by age, sex, and comorbidity. Dashed lines indicate retention significantly lower than the reference (most highly retained group) at P < 0.050 using unadjusted GEE Poisson models with autoregressive correlation structure. HDSS – Health and Socio-Demographic Surveillance System