Thirty-eight million people die annually from non-communicable diseases (NCDs), such as type 2 diabetes, heart disease, and hypertension, and three-quarters of these global deaths occur in low- and middle-income countries (LMICs) [1]. Although historically NCDs have afflicted affluent population, low-income populations increasingly present higher incidence, prevalence, and mortality as a result of NCDs [2, 3]. Escalation of NCDs in LMICs, and in particular among the poor in such contexts, pose not only extraordinary economic risk [4] but also unprecedented challenges to health systems already overburdened by infectious diseases, including HIV/AIDS [5].
South Africa is a country undergoing rapid health system transformation [5] that historically presented challenges for NCD care because of its great systemic inequalities [6] as well as its extraordinary burden of HIV/AIDS and tuberculosis [7, 8]. Yet, South Africa holds the second largest number of people living with type 2 diabetes in sub-Saharan Africa [3], with 2.7 million people, or 5Â % of the population affected by diabetes [9]. The largest concentration of diabetes cases in South Africa are among low-income groups [10], with recent studies estimating 13.1Â % diabetes prevalence among urban Blacks in the Cape [11] and 14.1Â % diabetes prevalence among urban Black women in Soweto [12], low-income neighborhoods in Cape Town and Johannesburg, respectively. Increases in diabetes among the poor facilitate increased clustering of diabetes with other conditions [13], including mental illnesses [10], such as depression [14], and infectious diseases [8], such as HIV and tuberculosis [7]. Co-occurring conditions pose challenges for how people experience both diabetes and diabetes care [15, 16].
This article investigates low-income Black women’s experiences with diabetes care in Soweto, South Africa. Elsewhere we have argued that low-income Black women with diabetes hold low levels of knowledge about what is diabetes, its causes, and how one treats the disease [15]. This may be a reflection of their poor access to healthcare [10], mistrust of the healthcare system [17], or impediments to effective diabetes self-care and behavior change, such as poor health literacy, a lack of self-efficacy, and perceived social support [18]. It may also be a reflection of the public healthcare delivery system, whereby 64 % of South Africans depend upon the public sector for all healthcare needs [6]. Escalation of diabetes among low-income populations, therefore, places extraordinary demand for education and diabetes care delivery upon government hospitals and clinics [10]. Effective low-cost solutions for NCD care are sorely needed that move from the clinic to the community [19].
Systematic inequalities in health care delivery have muted South Africa’s response to NCD care nationally [10] and contributed to low-utilization of healthcare for NCDs [17, 20]. There are some exemplar efforts, however, to carry out effective NCD care. For example, community based interventions for diabetes control and management, like the Kgatelopele program in Gauteng Province or the Community Health Intervention Program, deliver medication and routine services to patients’ homes [10]. Others have demonstrated that mobile phone technologies, such as SMS-messaging [21], improve NCD care. Although community health worker programs seem to be effective at improving control of diabetes, systemic factors like too few doctor visits and insufficient patient monitoring by clinic staff hinder programs’ activities [22]. Moreover, doctors express lifestyle changes as the major obstacles to diabetes care [23], placing blame on the patients as opposed to the system. This contrasts to qualitative studies with women living with diabetes who mistrust the healthcare system and find it unreliable [17].
This article qualitatively examines perceptions about diabetes care of women with diabetes enrolled in the Birth to Twenty Plus (Bt20) Cohort in Soweto. Most women sought care at a public hospital or clinic near their home. Some received public care as well as private, and others received only private healthcare (such as through their employer). For this analysis, we examine three major themes related to diabetes care, including counseling, treatment, and social support, in order to understand challenges and opportunities for enhancing diabetes care for low-income women seeking care in South Africa’s public health system. Our qualitative insight provides a window through which South African policy-makers and practitioners working with low-income populations with diabetes can envision improved diabetes care.