Men’s motivations, barriers to and aspirations for their families’ health in the first 1000 days in sub-Saharan Africa: a secondary qualitative analysis

Introduction

The first 1000 days of life are a critical period of growth and development that have lasting implications for health, cognitive, educational and economic outcomes. In sub-Saharan Africa, gender and social norms are such that many men have little engagement with maternal and child health and nutrition during pregnancy and early childhood. This study explores how men perceive their role in three sites in sub-Saharan Africa.

Methods

Secondary qualitative analysis of 10 focus group discussions with 76 men in Burkina Faso, Ghana and South Africa. Data were thematically analysed to explore men’s perceptions of maternal and child health and nutrition.

Results

Men considered themselves ‘providers’ and 'advisors' within their families, particularly of finances, food and medicines. They also indicated that this advice was out of care and concern for their families’ health. There were similarities in how the men perceive their role. Differences between men living in rural and urban settings included health priorities, the advice and the manner in which it was provided. Across all settings, men wanted to be more involved with maternal and child health and nutrition. Challenges to doing so included stigma and proscribed social gender roles.

Conclusion

Men want a greater engagement in improving maternal and child health and nutrition but felt that their ability to do so was limited by culture-specified gender roles, which are more focused on providing for and advising their families. Involving both men and women in intervention development alongside policymakers, health professionals and researchers is needed to improve maternal and child health and nutrition.

Association between socio-economic status and non-communicable disease risk in young adults from Kenya, South Africa, and the United Kingdom

There is a pressing need for global health preventions to curb the escalating burden of non-communicable diseases (NCDs). Utilising multi-country study designs can improve our understanding of how socio-economic context shapes the aetiology of NCDs, and this has great potential to advance global health interventions. We examined the association between socio-economic status (SES) and NCD risk, and the potential confounding effects of smoking and alcohol intake in young adults (18-35-year-olds) from Kenya, South Africa (SA), and the United Kingdom (UK). Our study was a cross-sectional online survey that included 3000 respondents (n = 1000 per country, 50% women) conducted in April 2022. We utilised information on twelve NCDs to classify respondents as having "no condition", "one condition", and "multimorbidity" (having two or more conditions). A total household asset score was calculated and used as a proxy of SES, and subsequently categorised into quintiles (Q1-Q5; lowest-highest). Ordered logistic regression was used to test the associations between NCD risk and exposure variables. In the UK sample, we found that those in the second lowest SES quintile (Q2) had lower odds of developing NCDs than their lowest SES counterparts (Q1). In contrast, South African and Kenyan youth with a SES score between middle and highest quintiles (Q3-Q5) were more likely to develop NCDs than the lowest SES quintile group. In all countries, smoking and/or alcohol intake were associated with higher odds of developing NCDs, and showed some confounding effects on the SES-NCD relationships. Specifically, in Kenya, the risk of developing NCD was more than two times higher in those in the middle (Q3) SES group (OR 2.493; 95% CI 1.519-4.091; p < 0.001) compared to their lowest (Q1) SES counterparts. After adjusting for smoking and alcohol, the ORs of middle (Q3) SES group changed from 2.493 to 2.241 (1.360-3.721; p = 0.002). Overall, we found that the strength and direction of SES-NCD associations differed within and between countries. This study highlights how different SES contexts shape the risk of NCDs among young adults residing in countries at different levels of economic development.

A qualitative study to explore healthcare providers' perspectives on barriers and enablers to early detection of breast and cervical cancers among women attending primary healthcare clinics in Johannesburg, South Africa

Low-and-middle income countries (LMICs) contribute approximately 70% of global cancer deaths, and the cancer incidence in these countries is rapidly increasing. Sub-Saharan African (SSA) countries, including South Africa (SA), bear some of the world's highest cancer case fatality rates, largely attributed to late diagnosis. We explored contextual enablers and barriers for early detection of breast and cervical cancers according to facility managers and clinical staff at primary healthcare clinics in the Soweto neighbourhood of Johannesburg, South Africa. We conducted qualitative in-depth interviews (IDIs) between August and November 2021 amongst 13 healthcare provider nurses and doctors as well as 9 facility managers at eight public healthcare clinics in Johannesburg. IDIs were audio-recorded, transcribed verbatim, and entered into NVIVO for framework data analysis. Analysis was stratified by healthcare provider role and identified apriori around the themes of barriers and facilitators for early detection and management of breast and cervical cancers. Findings were conceptualised within the socioecological model and then explored within the capability, opportunity and motivation model of behaviour (COM-B) for pathways that potentially influence the low screening provision and uptake. The findings revealed provider perceptions of insufficient South African Department of Health (SA DOH) training support and staff rotations resulting in providers lacking knowledge and skills on cancer, screening policies and techniques. This coupled with provider perceptions of poor patient cancer and screening knowledge revealed low capacity for cancer screening. Providers also perceived opportunity for cancer screening to be undermined by the limited screening services mandated by the SA DOH, insufficient providers, inadequate facilities, supplies and barriers to accessing laboratory results. Providers perceived women to prefer to self-medicate and consult with traditional healers and access primary care for curative services only. These findings compound the low opportunity to provide and demand cancer screening services. And because the National SA Health Department is perceived by providers not to prioritize cancer nor involve primary care stakeholders in policy and performance indicator development, overworked, unwelcoming providers have little motivation to learn screening skills and provide screening services. Providers reported that patients preferred to go elsewhere and that women perceived cervical cancer screening as painful. These perceptions must be confirmed for veracity among policy and patient stakeholders. Nevertheless, cost-effective interventions can be implemented to address these perceived barriers including multistakeholder education, mobile and tent screening facilities and using existing community fieldworkers and NGO partners in providing screening services. Our results revealed provider perspectives of complex barriers to the early detection and management of breast and cervical cancers in primary health clinic settings in Greater Soweto. These barriers together appear potentially to produce compounding effects, and therefore there is a need to research the cumulative impact but also engage with stakeholder groups to verify findings and create awareness. Additionally, opportunities do exist to intervene across the cancer care continuum in South Africa to address these barriers by improving the quality and volume of provider cancer screening services, and in turn, increasing the community demand and uptake for these services.

Evaluating implementation of the FIGO Nutrition Checklist for preconception and pregnancy within the Bukhali trial in Soweto, South Africa

OBJECTIVE

To evaluate implementation of the FIGO Nutrition Checklist in a low/middle-income South African setting.

METHODS

This is a mixed-methods study. Following administration of the FIGO Nutrition Checklist by a dietitian between July 2021 and May 2022, quantitative responses from pregnant (n = 96) and nonpregnant (n = 291) participants with overweight or obesity were analyzed, using logistic regression. Qualitative data from in-depth interviews with the dietitian and a subgroup of participants (n = 15) were analyzed using reflexive thematic analysis.

RESULTS

Of 387 participants, 97.4% (n = 377) answered 'no' to at least one diet quality question on the FIGO Nutrition Checklist, indicative of an at-risk dietary practice. Food insecurity was positively associated with having more than three at-risk practices (OR 1.87; 95% CI, 1.10-3.18; P = 0.021). Themes from the dietitian interview included ease of use of the checklist; required adaptations to it, including explanation and translation; and benefits of the tool. Despite challenges to healthy nutrition, participant interviews identified that the checklist is acceptable and supported improved awareness of dietary intakes.

CONCLUSION

Considering the high incidence of at-risk dietary practices identified by the FIGO Nutrition Checklist in this population, further research into use of the tool across South African healthcare settings is warranted.

Targeted proteomics identifies potential biomarkers of dysglycaemia, beta cell function and insulin sensitivity in Black African men and women

AIMS/HYPOTHESIS

Using a targeted proteomics approach, we aimed to identify and validate circulating proteins associated with impaired glucose metabolism (IGM) and type 2 diabetes in a Black South African cohort. In addition, we assessed sex-specific associations between the validated proteins and pathophysiological pathways of type 2 diabetes.

METHODS

This cross-sectional study included Black South African men (n=380) and women (n=375) who were part of the Middle-Aged Soweto Cohort (MASC). Dual-energy x-ray absorptiometry was used to determine fat mass and visceral adipose tissue, and fasting venous blood samples were collected for analysis of glucose, insulin and C-peptide and for targeted proteomics, measuring a total of 184 pre-selected protein biomarkers. An OGTT was performed on participants without diabetes, and peripheral insulin sensitivity (Matsuda index), HOMA-IR, basal insulin clearance, insulin secretion (C-peptide index) and beta cell function (disposition index) were estimated. Participants were classified as having normal glucose tolerance (NGT; n=546), IGM (n=116) or type 2 diabetes (n=93). Proteins associated with dysglycaemia (IGM or type 2 diabetes) in the MASC were validated in the Swedish EpiHealth cohort (NGT, n=1706; impaired fasting glucose, n=550; type 2 diabetes, n=210).

RESULTS

We identified 73 proteins associated with dysglycaemia in the MASC, of which 34 were validated in the EpiHealth cohort. Among these validated proteins, 11 were associated with various measures of insulin dynamics, with the largest number of proteins being associated with HOMA-IR. In sex-specific analyses, IGF-binding protein 2 (IGFBP2) was associated with lower HOMA-IR in women (coefficient -0.35; 95% CI -0.44, -0.25) and men (coefficient -0.09; 95% CI -0.15, -0.03). Metalloproteinase inhibitor 4 (TIMP4) was associated with higher insulin secretion (coefficient 0.05; 95% CI 0.001, 0.11; p for interaction=0.025) and beta cell function (coefficient 0.06; 95% CI 0.02, 0.09; p for interaction=0.013) in women only. In contrast, a stronger positive association between IGFBP2 and insulin sensitivity determined using an OGTT (coefficient 0.38; 95% CI 0.27, 0.49) was observed in men (p for interaction=0.004). A posteriori analysis showed that the associations between TIMP4 and insulin dynamics were not mediated by adiposity. In contrast, most of the associations between IGFBP2 and insulin dynamics, except for insulin secretion, were mediated by either fat mass index or visceral adipose tissue in men and women. Fat mass index was the strongest mediator between IGFBP2 and insulin sensitivity (total effect mediated 40.7%; 95% CI 37.0, 43.6) and IGFBP2 and HOMA-IR (total effect mediated 39.1%; 95% CI 31.1, 43.5) in men.

CONCLUSIONS/INTERPRETATION

We validated 34 proteins that were associated with type 2 diabetes, of which 11 were associated with measures of type 2 diabetes pathophysiology such as peripheral insulin sensitivity and beta cell function. This study highlights biomarkers that are similar between cohorts of different ancestry, with different lifestyles and sociodemographic profiles. The African-specific biomarkers identified require validation in African cohorts to identify risk markers and increase our understanding of the pathophysiology of type 2 diabetes in African populations.

Determinants of anaemia among women of reproductive age in South Africa: A Healthy Life Trajectories Initiative (HeLTI)

Anaemia continues to be a persistent concern among South African women of reproductive age (WRA), yet population specific information on its determinants remains sparse. We used baseline data from the Healthy Lives Trajectory Initiative a randomised trial (n = 480) to quantify factors associated with anaemia in Soweto, South Africa aged 18-25 years. We used multivariable logistic regression to describe associations with anaemia and used structural equation modelling to assess a theoretical model, which tested three categories socioeconomic status (household asset score, education level), nutritional factors (food security, leafy green vegetable and chicken and beef consumption, iron status and vitamin A status) and biodemographic factors (parity, age at start of menarche, HIV status, contraception use, anthropometry, and inflammation status). The multiple logistic regression showed that ID (OR: 2.62, 95% CI: 1.72, 3.98), iron deficiency erythropoiesis (IDE) (OR: 1.62, 95% CI: 1.07, 2.46), and elevated CRP (OR: 1.69, 95% CI: 1.04, 2.76), increased the odds of being anaemic. SEM analysis revealed Hb was directly and positively associated with adjusted ferritin (0.0031 per mg/dL; p≤0.001), and CRP (0.015 per mg/dL; p≤0.05), and directly and negatively associated with soluble transferrin receptor sTfR (-0.042 per mg/dL; p≤0.001). While contraception use had both a direct (0.34; p≤0.05) and indirect (0.11; p≤0.01) positive association with Hb. Additionally, chicken and beef consumption had a positive indirect association with Hb concentrations (0.15; p≤0.05) through adjusted ferritin. Iron deficiency was the main anaemia risk factor in this low resource setting. However, anaemia of inflammation is present. Therefore, we suggest that in our setting, WRA anaemia control programs that include interventions to reduce ID and inflammation should be tested.

Early-life stature, preschool cognitive development, schooling attainment, and cognitive functioning in adulthood: a prospective study in four birth cohorts

BACKGROUND

Nutrition is important for growth and brain development and therefore cognitive ability. Growth faltering in early childhood, an important indicator of early adversity, is associated with poorer developmental outcomes, some into adulthood, but this association probably reflects early-life deprivation. We aimed to investigate the associations between early-life stature, child IQ, and adult IQ.

METHODS

In this cohort study, we used prospective longitudinal data collected in four birth cohorts from Brazil (born in 1993), Guatemala (born in 1969-77), the Philippines (born in 1983-84), and South Africa (born in 1990). Using multivariable linear models, we estimated the relative contributions of early-life stature, child IQ, and schooling (highest school year completed) to adult IQ, including interaction effects among the early-childhood measures and schooling.

FINDINGS

We included 2614 individuals in the analysis. Early-life stature was associated with adult IQ (range across eight site-by-sex groups -0·14 to 3·17 IQ points) and schooling (-0·05 to 0·77 years) per height-for-age Z-score. These associations were attenuated when controlling for child IQ (-0·86 to 1·72 for adult IQ and -0·5 to 0·60 for schooling). The association of early-life stature with adult IQ was further attenuated when controlling for schooling (-1·86 to 1·21). Child IQ was associated with adult IQ (range 3·91 to 10·02 points) and schooling (0·25 to 1·30 years) per SD of child IQ in all groups; these associations were unattenuated by the addition of early-life stature to the models. The interaction between schooling and child IQ, but not that between schooling and early-life stature, was positively associated with adult IQ across groups.

INTERPRETATION

The observed associations of early-life stature with adult IQ and schooling varied across cohorts and sexes and explained little variance in adult IQ beyond that explained by child IQ. These findings suggest that interventions targeted at growth for health and early development are important. Our results are consistent with the inference that improving long-term cognitive outcomes might require interventions that more specifically target early cognitive ability.

FUNDING

Bill & Melinda Gates Foundation.

'We were not allowed to gather even for Christmas.' Impact of COVID-19 on South African young people: Exploring messaging and support

COVID-19 prevention measures including lockdowns, school closures, and restricted movement disrupted young people's lives. This longitudinal qualitative study conducted in Soweto, South Africa aimed to explore young people's knowledge and perceptions of COVID-19, vaccination, and the impact of infections. A convenience sample of 30 young black people (n = 15 men; n = 15 women, aged 16-21 years) from Soweto participated in 24 focus group discussions (FGDs), conducted in six phases - each phase had four FGDs stratified by gender and age. Young people's understanding of COVID-19 deepened throughout the study, however, did not always translate into adherence (following the government's COVID-19 prevention measures). Although deemed inadequate, TV and radio were preferred over internet COVID-19 information. Parents, teachers, and schools were trusted sources of information. Vaccines and limited access to information attributed to low-risk perception, while new COVID-19 variants attributed to high-risk perception. A low-risk perception and conspiracy theories contributed to non-adherence (disregarding COVID-19 preventative measures provided by the government), particularly among young men. Accessing reliable information that considers young people's lives and their living context is important. Communities, scientists, and policymakers must learn from the COVID-19 experience and implement localised preventive strategies for education, awareness, and economic support in future emergencies.

Psychological legacies of intergenerational trauma under South African apartheid: Prenatal stress predicts greater vulnerability to the psychological impacts of future stress exposure during late adolescence and early adulthood in Soweto, South Africa

BACKGROUND

South Africa's rates of psychiatric morbidity are among the highest in sub-Saharan Africa and are foregrounded by the country's long history of political violence during apartheid. Growing evidence suggests that in utero stress exposure is a potent developmental risk factor for future mental illness risk, yet the extent to which the psychiatric effects of prenatal stress impact the next generation are unknown. We evaluate the intergenerational effects of prenatal stress experienced during apartheid on psychiatric morbidity among children at ages 17-18 and also assess the moderating effects of maternal age, social support, and past household adversity.

METHODS

Participants come from Birth-to-Twenty, a longitudinal birth cohort study in Soweto-Johannesburg, South Africa's largest peri-urban township which was the epicentre of violent repression and resistance during the final years of the apartheid regime. Pregnant women were prospectively enrolled in 1990 and completed questionnaires assessing social experiences, and their children's psychiatric morbidity were assessed at ages 17-18.

RESULTS

Full data were available from 304 mother-child pairs in 2007-8. Maternal prenatal stress in 1990 was not directly associated greater psychiatric morbidity during at ages 17-18. Maternal age and past household adversity moderated the intergenerational mental health effects of prenatal stress such that children born to younger mothers and late adolescent/young adult children experiencing greater household adversity exhibited worse psychiatric morbidity at ages 17-18. Social support did not buffer against the long-term psychiatric impacts of prenatal stress.

CONCLUSIONS

Greater prenatal stress from apartheid predicted adverse psychiatric outcomes among children born to younger mothers and adolescents/young adults who experienced greater concurrent stress. Our findings suggest that prenatal stress may affect adolescent mental health, have stress-sensitising effects, and represent possible intergenerational effects of trauma experienced under apartheid in this sample.

Rethinking water, sanitation, and hygiene for human growth and development

Life history theory emphasises plasticity in developmental and biological programming where conditions in early life, lead to long-term consequences for health and wellbeing. Studies linking water, sanitation, and hygiene, nutrition, and child growth and development have emphasised the optimisation of linear growth as a key metric for the evaluation of intervention efficacy. Life history characteristics pertaining to human growth and phenotypic plasticity, suggest that different developmental outcomes in early childhood may be responsive to different stimuli at different ages. Energy utilisation by the human brain, from birth through childhood, accounts for a disproportionate percentage of the resting metabolic rate. Undernutrition in early life, and its relative resultant energy deficiency, may trigger adaptive physiological mechanisms prioritising brain growth at the expense of body growth. Emphasis placed on linear growth may have impeded the significance of WASH due to excluding aspects of child development beyond height/weight. We propose that incorporating evolutionary public health and life history theory perspectives, allows for the identification of age-appropriate biological outcomes and WASH indicators, while anticipating the timing and life-course suitability of the interventions being operationalised. Finally, integrating reflections regarding context allows for the development of transformative WASH interventions.

Preeclampsia prediction with blood pressure measurements: A global external validation of the ALSPAC models

OBJECTIVE

The prediction of preeclampsia in pregnancy has resulted in a plethora of prognostic models. Yet, very few make it past the development stage and most fail to influence clinical practice. The timely identification of high-risk pregnant women could deliver a tailored antenatal care regimen, particularly in low-resource settings. This study externally validated and calibrated previously published models that predicted the risk of preeclampsia, based on blood pressure (BP) at multiple time points in pregnancy, in a geographically diverse population.

METHODS

The prospective INTERBIO-21st Fetal Study included 3,391 singleton pregnancies from Brazil, Kenya, Pakistan, South Africa, Thailand and the UK, 2012-2018. Preeclampsia prediction was based on baseline characteristics, BP and deviation from the expected BP trajectory at multiple time points in pregnancy. The prediction rules from the Avon Longitudinal Study of Parents and Children (ALSPAC) were implemented in the INTERBIO-21st cohort.

RESULTS

Model discrimination was similar to the development cohort. Performance was best with baseline characteristics and a BP measurement at 34 weeks' gestation (AUC 0.85, 95 % CI 0.80-0.90). The ALSPAC models largely overestimated the true risk of preeclampsia incidence in the INTERBIO-21st cohort.

CONCLUSIONS

After recalibration, these prediction models could potentially serve as a risk stratifying tool to help identify women who might benefit from increased surveillance during pregnancy.

The negative association of lower body fat mass with cardiometabolic disease risk factors is partially mediated by adiponectin

Gluteofemoral fat correlates negatively with a number of cardiometabolic disease risk factors, but the mechanisms involved in these relationships are unknown. The aim of this study was to test the hypothesis that gluteofemoral fat attenuates the risk of cardiometabolic disease by increasing blood adiponectin levels. This was a cross-sectional study in which arm, leg, gluteofemoral, abdominal s.c. and visceral fat levels were measured by dual-energy X-ray absorptiometry in 648 African females. Fasting serum adiponectin, lipid, insulin and plasma glucose levels and blood pressure were measured. Relationships between variables were analysed using multivariable linear regression and structural equation modelling. Adiponectin correlated positively (β = 0.45, P < 0.0001) with gluteofemoral fat in a multivariable regression model that included age, height, and arm, s.c. and visceral fat levels. In further regression models, there was a negative correlation of gluteofemoral fat with fasting glucose (β = -0.28; P < 0.0001) and triglyceride levels (β = -0.29; P < 0.0001) and insulin resistance (HOMA; β = -0.26; P < 0.0001). Structural equation modelling demonstrated that adiponectin mediated 20.7% (P < 0.01) of the association of gluteofemoral fat with insulin resistance and 16.1% (P < 0.01) of the association with triglyceride levels but only 6.67% (P = 0.31) of the association with glucose levels. These results demonstrate that gluteofemoral and leg fat are positively associated with adiponectin levels and that the negative association of lower body fat with insulin resistance and triglyceride levels may partially be mediated by this adipokine. Further studies are required to determine other factors that mediate the effect of lower body fat on cardiometabolic disease risk factors.

Interactions between maternal health and placental morphology on neonate body composition

Background

We aimed to examine maternal metabolic correlates of neonate body composition, and the potential mediating effect of the placenta.

Methods

Data were collected throughout pregnancy and at delivery. An oral glucose tolerance test (OGTT) was conducted in order to diagnose or rule out gestational diabetes mellitus (GDM). Maternal weight and blood pressure were taken and hypertension and gestational weight gain (GWG) were defined. Gestational age, birth weight (BW) and weight to length ration (WLR) were recorded. Photographs were taken of the placenta, and the widths and lengths were measured digitally. Body composition was analysed via air displacement plethysmography or dual-energy x-ray absorptiometry. Mediation models were conducted to determine the mediation effect of the placental variables on the relationships between maternal health variables and neonate outcomes. Next, interaction terms were added to models to determine how maternal and placental variables interacted in their effect on neonate outcomes.

Results

A total of n = 280 women were included in the analysis. Majority were overweight or obese. Fourteen percent of women developed GDM during pregnancy, 5% had hypertension during pregnancy, 32% were HIV positive, and 32% had anemia. For the birth weight outcome, coefficients of BMI were attenuated by the addition of placental variables (Model 1 β=18.66 vs Model 2 β=16.40). Similar patterns were evident for GWG and hypertension, and for the WLR outcome. In all cases the addition of the placental variables attenuated associations between maternal exposures and neonatal outcomes, yet the level of significance did not change. Inclusion of interaction terms reversed the direction of the relationships between hypertension and BW and WLR, and between GWG and WLR.

Conclusion

The placenta buffers some harmful effects of obesity, GWG, and hypertension on neonate size, and placental efficiency interacted with most maternal risk factors to either counteract, or attenuate relationships with neonate size at birth. However the placenta was unable to completely counteract the negative effect of excess nutrient supply on in utero growth.

Menopause is associated with bone loss, particularly at the distal radius, in black South African women: Findings from the Study of Women Entering and in Endocrine Transition (SWEET)

Menopause transition is associated with accelerated bone loss, though data are limited from sub-Saharan African (SSA). Our objective was to describe bone density, geometry and estimated strength in women by menopause status and to explore whether patterns differed within those living with HIV.

METHODS

Radius and tibia peripheral QCT data were collected for Black South African women (n = 430) aged 40-61 years with verified menopause and HIV status. pQCT outcomes were distal 4 % radius and tibia total cross-sectional area (CSA), total volumetric bone mineral density (vBMD), and compressive bone strength (BSIc); proximal 66 % radius and 38 % tibia cortical vBMD, total CSA, cortical thickness, and Stress-strain Index (SSI). Linear regression assessed associations between pre, peri-, and postmenopausal groups and pQCT outcomes adjusting for age, height, and weight, and then stratified by HIV status. Mean [95%CI] and tests for trend (p-trend) across menopausal groups are presented.

RESULTS

Women were mean (SD) age 49.2 (5.3) years, with a body mass index (BMI) of 32.4 (6.3) m/kg², and 18 % were living with HIV. After adjustment, later menopause stage was associated with lower 4 % radius total mean [95%CIs] vBMD (premenopause: 345.7 [335.8,355.5] vs. postmenopause: 330.1 [322.7,337.6] mg/cm³, p-trend = 0.017) and BSIc (premenopause: 0.39 [0.37,0.41] vs. postmenopause: 0.36 [0.35,0.37] g²/cm⁴; p-trend = 0.012). Similar trends were observed at the 66 % radius for cortical vBMD (premenopause: 1146.8 [1138.9,1154.6] vs. postmenopause: 1136.1 [1130.1,1142.0] mg/cm³; p-trend = 0.028) and cortical thickness (premenopause: 2.01 [1.95,2.06] vs. postmenopause: 1.93 [1.89,1.98] mm; p-trend = 0.036). After stratification by HIV status a similar patten was observed in women with HIV (cortical vBMD premenopause: 1152.9 [1128.5,1177.2] mg/cm³ vs. postmenopause: 1123.6 [1106.0,1141.2] mg/cm³, p-trend = 0.048). Total CSA varied little by menopause or HIV status at either radius sites; few differences were found at the tibia.

CONCLUSION

In black South African women, menopause is associated with lower bone density and strength at the distal radius, a common site of osteoporotic fracture, in addition to lower cortical density and thickness at the proximal radius. Although the sample size was small, following stratification by HIV, women living with HIV had evidence of lower cortical density across menopause stages, unlike those without HIV. These findings raise concern for the incidence of Colles' fractures in postmenopausal women in South Africa; longitudinal studies of fracture incidence and implications of living with HIV are required.

The prevalence of probable depression and probable anxiety, and associations with adverse childhood experiences and socio-demographics: A national survey in South Africa

Objective and methods

Mental health problems among adults are a growing public health concern, and middle-income countries such as South Africa are disproportionally affected. Using a large scale nationally representative weighted survey, we assessed the prevalence of probable depression, probable anxiety, and adverse childhood experiences (ACEs), and explored associations between probable depression, probable anxiety, ACEs, socio-economic status, and demographic characteristics.

Results

Nationally, 25.7, 17.8, and 23.6% of respondents, respectively, reported scores of ≥10 on the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), indicating probable depression or probable anxiety, and an ACE score of ≥4 (high exposure). Overall probable depression prevalence across South Africa varied from 14.7 to 38.8%. Both probable depression and probable anxiety were more frequently reported among adults who were: retired and older (>65 years of age), and widowed, divorced, or separated; living in metropolitan areas; and only had primary school education. In a multivariable adjusted logistic regression, the likelihood of reporting probable depression or probable anxiety was also found to increase with each standard deviation increase in the ACE score (p < 0.001), independent of other socio-demographic determinants.

Conclusion

The prevalence of probable depression among respondents in South Africa varies significantly across the nine provinces. Furthermore, higher ACE score and several socio-demographic determinants were associated with a higher likelihood of probable depression and probable anxiety. Adult mental health services are urgently needed to identify groups of the population vulnerable to mental health problems for better targeting of interventions. Given the range of probable depression prevalence across the country, provincial level plans and resources should also reflect the burden of mental health problems in that province.

Prevalence of multimorbidity in men of African descent with and without prostate cancer in Soweto, South Africa

OBJECTIVE

With increases in chronic disease, men with prostate cancer are likely to have at least one other chronic health condition. The burden and complexity of each additional chronic disease may complicate prostate cancer treatment and reduce survival. In this paper, we describe the frequency of multimorbid chronic diseases, HIV and depression among men in Soweto, South Africa (SA) with and without prostate cancer and determine whether the presence of multimorbid diseases is associated with metastatic and high-risk, non-metastatic prostate cancer.

METHODS

A population-based case-control study on prostate cancer was conducted among black men in Soweto. All participants completed a baseline survey on sociodemographics, lifestyle, and comorbid medical conditions. All participants completed a depression screening survey and HIV testing at enrolment. Blood pressure measurements and blood testing for fasting glucose, total cholesterol, and high-density lipoprotein were performed on a subset of randomly selected cases and controls. For men with prostate cancer, clinical T staging was assessed with the digital rectal examination, the diagnosis was confirmed with a biopsy and PSA levels were assessed at presentation. The metastatic staging was assessed by bone scans, and this was confirmed with PSMA PET scans, CT scans and X-rays, standard for our resource-constrained setting. Normal PSA scores were used as an inclusion criterion for controls.

RESULTS

Of the 2136 men (1095 with prostate cancer and 1041 controls) included in the analysis, 43.0% reported at least one chronic metabolic disease; 24.1% reported two metabolic diseases; 5.3% reported three metabolic diseases; and 0.3% reported four metabolic diseases. Men with prostate cancer were more likely to report a multimorbid chronic metabolic disease compared to controls (p<0.001) and more likely to test positive for HIV (p = 0.05). The majority of men (66.2%) reported at least one metabolic disease, tested negative for HIV and had a negative depression screen. The clinical characteristics of men with prostate cancer, were as follows: 396 (36.2%) had a Gleason score of 8 and above; 552 (51.3%) had a PSA score of >20ng/ml; 233 (21.7%) had confirmed metastatic prostate cancer at diagnosis. Older age was associated with metastatic prostate cancer (OR = 1.043 95% CI:1.02-1.07) and NCCN defined high-risk non-metastatic prostate cancer (OR = 1.03 95% CI:1.01-1.05), whilst being hypertensive was protective (OR = 0.63 95% CI:0.47-0.84 and OR = 0.55 95% CI:0.37-0.83) respectively for metastatic and high-risk, non-metastatic prostate cancer.

CONCLUSION

The high prevalence of multimorbid metabolic diseases and HIV among men with prostate cancer represents a public health concern in South Africa. There is a need to effectively address multiple chronic diseases among men with prostate cancer by incorporating coordinated care models.

Association of Longitudinal Nutrient Patterns with Body Composition in Black Middle-Aged South African Women: A Five-Year Follow-Up Study

This study aimed to evaluate the association of longitudinal nutrient patterns with body composition in a cohort of 132 black South African middle-aged women over five years. Nutrient patterns were identified using principal component analysis at baseline and follow-up 5 years later. Associations between nutrient patterns and repeated body composition measures were evaluated using generalized estimating equations, before and after adjusting for baseline education and repeated measures of age, socio-economic status, physical activity and employment. The animal-driven nutrient pattern was associated with increases in repeated measures of visceral adipose tissue (VAT) (β coefficient, 5.79 [95% CI, 0.01-11.57] cm²), fat mass index (FMI) (0.47 [0.01-0.93] kg·m^-2) and lean mass index (LMI) (0.50 [0.18-1.17] kg·m^-2) (p < 0.05) after adjustment. Vitamin C, sugar, and potassium-driven nutrient pattern was associated with higher FMI (0.50 [0.12-0.88] kg·m^-2) and LMI (0.58 [0.07-1.10] kg·m^-2) before and after adjustment (p < 0.05). These findings suggest that dietary interventions to curb obesity in black middle-aged South African women should focus on attenuation of nutrient patterns centred on added sugar, animal fat and animal protein.

Association between fetal abdominal growth trajectories, maternal metabolite signatures early in pregnancy, and childhood growth and adiposity: prospective observational multinational INTERBIO-21st fetal study

BACKGROUND

Obesity predominantly affects populations in high-income countries and those countries facing epidemiological transition. The risk of childhood obesity is increased among infants who had overweight or obesity at birth, but in low-resource settings one in five infants are born small for gestational age. We aimed to study the relationships between: (1) maternal metabolite signatures; (2) fetal abdominal growth; and (3) postnatal growth, adiposity, and neurodevelopment.

METHODS

In the prospective, multinational, observational INTERBIO-21st fetal study, conducted in maternity units in Pelotas (Brazil), Nairobi (Kenya), Karachi (Pakistan), Soweto (South Africa), Mae Sot (Thailand), and Oxford (UK), we enrolled women (≥18 years, with a BMI of less than 35 kg/m², natural conception, and a singleton pregnancy) who initiated antenatal care before 14 weeks' gestation. Ultrasound scans were performed every 5±1 weeks until delivery to measure fetal growth and feto-placental blood flow, and we used finite mixture models to derive growth trajectories of abdominal circumference. The infants' health, growth, and development were monitored from birth to age 2 years. Early pregnancy maternal blood and umbilical cord venous blood samples were collected for untargeted metabolomic analysis.

FINDINGS

From Feb 8, 2012, to Nov 30, 2019, we enrolled 3598 pregnant women and followed up their infants to 2 years of age. We identified four ultrasound-derived trajectories of fetal abdominal circumference growth that accelerated or decelerated within a crucial 20-25 week gestational age window: faltering growth, early accelerating growth, late accelerating growth, and median growth tracking. These distinct phenotypes had matching feto-placental blood flow patterns throughout pregnancy, and different growth, adiposity, vision, and neurodevelopment outcomes in early childhood. There were 709 maternal metabolites with positive effect for the faltering growth phenotype and 54 for the early accelerating growth phenotype; 31 maternal metabolites had a negative effect for the faltering growth phenotype and 76 for the early accelerating growth phenotype. Metabolites associated with the faltering growth phenotype had statistically significant odds ratios close to 1·5 (ie, suggesting upregulation of metabolic pathways of impaired fetal growth). The metabolites had a reciprocal relationship with the early accelerating growth phenotype, with statistically significant odds ratios close to 0.6 (ie, suggesting downregulation of fetal growth acceleration). The maternal metabolite signatures included 5-hydroxy-eicosatetraenoic acid, and 11 phosphatidylcholines linked to oxylipin or saturated fatty acid sidechains. The fungicide, chlorothalonil, was highly abundant in the early accelerating growth phenotype group.

INTERPRETATION

Early pregnancy lipid biology associated with fetal abdominal growth trajectories is an indicator of patterns of growth, adiposity, vision, and neurodevelopment up to the age of 2 years. Our findings could contribute to the earlier identification of infants at risk of obesity.

FUNDING

Bill & Melinda Gates Foundation.

Are cardiovascular health measures heritable across three generations of families in Soweto, South Africa? A cross-sectional analysis using the random family method

OBJECTIVES

Cardiovascular disease is increasing in many low and middle-income countries, including those in Africa. To inform strategies for the prevention of cardiovascular disease in South Africa, we sought to determine the broad heritability of phenotypic markers of cardiovascular risk across three generations.

DESIGN

A cross-sectional study conducted in a longitudinal family cohort.

SETTING

Research unit within a tertiary hospital in a historically disadvantaged, large urban township of South Africa.

PARTICIPANTS

195 individuals from 65 biological families with all three generations including third-generation children aged 4-10 years were recruited from the longest running intergenerational cohort study in Africa, the Birth to Twenty Plus cohort. All adults (grandparents and parents) were female while children were male or female.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was heritability of blood pressure (BP; brachial and central pressures). Secondary outcomes were heritability of arterial stiffness (pulse wave velocity), carotid intima media thickness (cIMT) and left ventricular mass indexed to body surface area (LVMI).

RESULTS

While no significant intergenerational relationships of BP or arterial stiffness were found, there were significant relationships in LVMI across all three generations (p<0.04), and in cIMT between grandparents and parents (p=0.0166). Heritability, the proportion of phenotypic trait variation attributable to genetics, was estimated from three common statistical methods and ranged from 23% to 44% for cIMT and from 21% to 39% for LVMI.

CONCLUSIONS

Structural indicators of vascular health, which are strong markers of future clinical cardiovascular outcomes, transmit between generations within African families. Identification of these markers in parents may be useful to trigger assessments of preventable risk factors for cardiovascular disease in offspring.

Context Matters-Child Growth within a Constrained Socio-Economic Environment

Communities in major cities in developing countries may experience economic vulnerability, which has detrimental consequences for maternal and child health. This study investigated individual-, household-, and community-level factors associated with child growth and resilience of early-grade learners aged 6 to 8 years. Demographic characteristics, depression scale, child wellbeing, and anthropometric measurements were collected on a sample of 162 caregiver-child pairs (children 46% female) who receive the child support grant (cash transfer programme) from five low-income urban communities in the City of Johannesburg, South Africa. Height and weight were converted to z-scores using the WHO Anthroplus software. Multiple linear regression was used to assess factors associated with child health outcomes and multi-level regression to account for community-level factors. Higher income vulnerability was associated with lower weight- and height-for-age z-scores (WAZ and HAZ). Not completing secondary schooling and higher household size were associated with lower HAZ but higher BAZ. Child male sex and caregiver with depression were associated with lower child resilience. Caregiver's level of schooling and household size remained independent predictors of child growth, while the caregiver's mental health status independently predicted child resilience. Thus, notwithstanding systemic constraints, there may be modifiable drivers that can help in developing targeted intervention.

Obesity, hypertension, and tobacco use associated with left ventricular remodeling and hypertrophy in South African women: Birth to Twenty Plus Cohort

Background

Left ventricular hypertrophy (LVH) is a marker of increased risk in developing future life-threatening cardiovascular disease (CVD), however, it is unclear how CVD risk factors, such as obesity, blood pressure (BP), and tobacco use, are associated with left ventricular (LV) remodeling and LVH in urban African populations. Therefore, we aimed to identify the prevalence of LVH as well as the health factors associated with LV remodeling and LVH, within black South African adult women and their pre-pubescent children.

Methods

Black female adults (n = 123; age: 29–68 years) and their children (n = 64; age: 4–10; 55% female) were recruited from the Birth to Twenty Plus Cohort in Soweto, South Africa. Tobacco and alcohol use, physical activity, presence of diabetes mellitus, heart disease, and medication were self-reported. Height, weight, and blood pressure were measured in triplicate to determine the prevalence of obesity and hypertension respectively. Echocardiography was used to assess LV mass at end-diastole, based on linear measurements, and indexed to body surface area to determine LVH.

Results

Hypertension and obesity prevalences were 35.8% and 59.3% for adults and 45.3% and 6.3% for children. Self-reported tobacco use in adults was 22.8%. LVH prevalence was 35.8% in adults (75% eccentric: 25% concentric), and 6.3% in children. Concentric remodeling was observed in 15.4% of adults, however, concentric remodeling was only found in one child. In adults, obesity [OR: 2.54 (1.07–6.02; p = 0.02)] and hypertension [3.39 (1.08–10.62; p = 0.04)] significantly increased the odds of LVH, specifically eccentric LVH, while concentric LVH was associated with self-reported tobacco use [OR: 4.58 (1.18–17.73; p = 0.03)]. Although no logistic regression was run within children, of the four children LVH, three had elevated blood pressure and the child with normal blood pressure was overweight.

Conclusions

The association between obesity, hypertension, tobacco use, and LVH in adults, and the 6% prevalence of LVH in children, calls for stronger public health efforts to control risk factors and monitor children who are at risk.

A protocol for monitoring fidelity of a preconception-life course intervention in a middle-income setting: the Healthy Life Trajectories Initiative (HeLTI), South Africa

Introduction

Despite the importance of intervention fidelity in interpreting the outcomes of complex public health interventions, there is a lack of both reporting fidelity trial protocols and uniformity. In evaluating complex, adaptable/pragmatic interventions in resource-strapped settings with systemic issues, unique challenges to intervention adherence and monitoring are introduced, increasing the importance of a fidelity protocol. We aim to describe the intervention fidelity and monitoring protocol for the Healthy Life Trajectories Initiative (HeLTI) South Africa, a complex four-phase intervention set in urban Soweto, starting preconceptionally and continuing through to pregnancy, infancy, and early childhood to improve the health of young women and reduce the intergenerational risk of obesity.

Methods

The HeLTI SA fidelity protocol was based on the NIH Behaviour Change Consortium (NIH BCC) Treatment Fidelity Framework, outlining the following components of intervention fidelity: study design, provider training, intervention delivery, intervention receipt, and intervention enactment. Context-specific fidelity challenges were identified. The intervention fidelity components and associated monitoring strategies were developed to align with HeLTI SA. Strategies for fidelity monitoring include, amongst others, qualitative process evaluation methods, reviewing observed and recorded intervention sessions, monitoring of activity logs, standardized training, and intervention session checklists. Possible challenges to fidelity and fidelity monitoring include high provider turnover, lack of qualification amongst providers, difficulty tracing participants for follow-up sessions, participant health literacy levels, and the need to prioritize participants’ non-health-related challenges. Solutions proposed include adapting intervention delivery methods, recruitment methods, and provider training methods.

Discussion

The NIH BCC Treatment Fidelity Framework provided a solid foundation for reporting intervention fidelity across settings to improve intervention validity, ability to assess intervention effectiveness, and transparency. However, context-specific challenges to fidelity (monitoring) were identified, and transparency around such challenges and possible solutions in low- and middle-income settings could help foster solutions to improve adherence, reporting, and monitoring of intervention fidelity in this setting.

Trial registration

Pan African Clinical Trials Registry PACTR201903750173871. Registered on 27 March 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06696-w.