Background
Rates of diabetes (DM) are quickly increasing in countries with high burden of tuberculosis (TB) such as South Africa (SA). In most of these countries, service delivery for DM and TB are vertical, and therefore patients at risk of or with both diseases do not receive integrated care. In 2011, SA initiated the Integrated Chronic Disease Model to achieve integration of clinical services and respond to the growing burden of chronic diseases in the country.
Aim
This follow-up survey was administered to assess changes in patients’ knowledge and behaviors regarding TB and DM services, since implementation of a series of educational, advocacy and capacity building interventions at patient, provider, and facility level in three provinces in SA.
Method
A cross-sectional Knowledge, Attitudes, and Practices (KAP) survey was conducted among 395 and 420 patients attending TB and DM service sites respectively, in 22 public health facilities across three provinces in SA - involved in the baseline (BL) survey (results reported eslewhere). Patients participated in in-depth interviews and completed a structured questionnaire around patient’s knowledge, beliefs, health-seeking behaviors and experience of TB and DM public health services in SA in December 2016.
Results
Survey participant characteristics and demographic profiles were similar at BL and endline (EL). Among patients with DM, 81% were female; while only 39% were women at TB. Similar to the BL results, most of the survey patients listed clinic as their main source of health information (over 80% of the study population). The survey revealed improvements in patient exposure to health education, counselling and screening for comorbidities (TB for DM patients and DM for TB patients). Compared to BL, TB testing among patients with DM increased from 37% to 57% (p<.01) while DM testing among patients with TB increased from 55% to 67% (p<.01). Counselling on comorbidities was also higher in both groups: counselling was higher by 41% for patients with TB (p<.01) and by 59% for patients with DM (p<.00). Exposure to health education doubled for patients with DM from 22% at BL to 45% at EL (p<.01). Among patients with TB, exposure to health education was higher by 71% (p<.01) from BL to EL. Patients with DM demonstrated good basic knowledge of how to maintain their health. At EL, the proportion of patients with DM with knowledge on the importance of regular exercise, attending regular checkups, and taking medication as prescribed was higher compared to BL (+52%, +18%, and + 45%, respectively, p<.01; <.01; 0.02). However, the proportion of patients with DM who understood the risk of developing complications if they did not regularly take medication as prescribed was lower, from 17% at BL to 9% at EL (p<.01). The proportion of patients with DM knowing the link between DM and TB was also higher compared to BL. Among patients with DM, knowledge that DM is a risk factor for TB increased from 10% to 22% at EL (p<.01), while knowledge that TB is a risk factor for DM increased from 0% to 12% at EL (p<.01). There was a high level of general knowledge about TB among both patients groups, but little understanding on the importance of treating co-morbidities. Despite small improvements from BL to EL, patients with TB still have a low level of knowledge and understanding about DM, including symptoms, complications, and how to reduce their risk of DM. At endline, around a third of patients with TB recognize thirst, fatigue, and frequent urination as symptoms of DM. At endline, less than a quarter of patients with TB knew there is a link between TB and DM.
Discussion
While much research has been done in SA on patient KAP towards TB and HIV, and to a lesser extent towards DM, this is the first study of patient understanding of TB-DM comorbidity and experience of counselling, screening, and testing for both diseases at the facility level. Implementation of integrated care from educational, advocacy and capacity building interventions may contribute to provide overall quality care to patients with both diseases.

Endline patient knowledge, attitudes, and practices survey on diabetes and tuberculosis comorbidities in South Africa