Community and health staff perceptions on non-communicable disease management in primary care in El Salvador: a qualitative study

Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability, with a rising burdenin low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, imply the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This analysis explores community perceptions related to the management of NCDs in this health system. During three fieldwork periods in 2018, three complementary qualitative data collection methods were deployed. First, we used illness narrative methodology to document the life histories of people living with a chronic disease and being treated in second and third level health facilities. Second, through social mapping, we analysed support-resources that NCD patients used throughout the process of their illness. Third, semi-structured interviews were conducted with both chronic patients and health personnel working at different levels of the primary health care setting. Participants were recruited through purposive sampling, and a deductive approach was implemented for coding during the analysis phase. After grouping codes into potential themes, a thematic framework was elaborated for each method through a reflexive approach and triangulation of the data. This innovative approach of combining three well-defined qualitative analysis frameworks identified key implications for the implementation of a comprehensive first line approach to NCDs management in resource-poor settings. Following dimensionsare identified: social risk factors, barriers to care, patient resources and pathways to care, trust in community social connections, and strategies for community health promotion and prevention of NCDs. The Salvadoran public health system has been able to strengthen its comprehensive approach to NCDs, combining a clinical approach – including long term follow-up – with a preventive community-based strategy. The structural collaboration between the health system and the (self)organized community has been key to identify failings, discuss tensions and work out adapted solutions.