Burden of stroke attributable to selected lifestyle risk factors in rural South Africa

Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review

Purpose

Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa.

Methods and Materials

Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies.

Results

Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 -23% among those with recurrent strokes compared to primary strokes.

Conclusion

This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.

Clinical and demographic predictors of unilateral spatial neglect recovery after prism therapy among stroke survivors in the sub-acute phase of recovery

BACKGROUND AND AIMS: Unilateral Spatial Neglect (USN) affects the rehabilitation process and leads to poor outcomes after stroke. Factors that influence USN recovery following prism adaptation therapy have not been investigated. This study investigated predictors of USN recovery after prism therapy at the sub-acute phase of recovery. METHODS: This study was a randomized controlled trial. USN was assessed with the Behavioural Inattention Test and Catherine Bergego scale. Seventy-four patients with USN were divided into control and intervention group (prism). The prism group used 20 dioptre prism lenses for repeated aiming for 12 sessions while the control group used neutral lenses for aiming training. Regression analysis was conducted to establish clinical and sociodemographic factors that influence USN recovery. RESULTS: Gender, age, years of education, race, employment status, handedness, type of stroke, time since stroke and site of stroke (p > 0.005) showed no significant influence on USN recovery following PA treatment. Higher Cognitive function (OR  = 1.52, CI = 1.08-2.14, p =  0.016) and group allocationng (being in the prism group) (OR = 63.10, CI =  9.70-410.59, P < 0.001) were found to significantly influence USN recovery following PA treatment session. CONCLUSIONS: A significant modulating effect on general cognitive ability was found in this study. This suggests that prism adaptation therapy's effect on neural activity and spatial neglect depends on the cognitive function of stroke survivors.Trial registration: Pan African Clinical Trial Registry identifier: PACTR201903732473573.

Rehabilitation Capacity in South Africa-A Situational Analysis

Rehabilitation in South Africa (SA) operates independently of major health services and reforms, despite the increasing rehabilitation need. With the introduction of National Health Insurance (NHI), SA is facing another major health reform. Evidence is needed on the current SA rehabilitation situation, regarding shortcomings, opportunities, and priority strategic strengthening actions. We aimed to describe the current rehabilitation capacity in the SA public health sector, which serves the majority and most vulnerable South Africans. A cross-sectional survey was conducted in five provinces, using the World Health Organisation's Template for Rehabilitation Information Collection (TRIC). Participants were purposively selected for their insights and experiences of rehabilitation in specific government departments, health sectors, organisations, and/or services. TRIC responses were analysed descriptively. Participants explained how timely and effective rehabilitation produced long-term health, social, and economic benefits. Positive initiatives were reported for rehabilitation data collection, service design, and innovation. Challenges included inadequacies in human resources, the integration of rehabilitation at primary care, guidelines, and specialised long-term care facilities. The continuity of care across levels of care was sub-optimal due to inefficient referral systems. Promoting and improving rehabilitation nationally requires concerted, innovative, collaborative, and integrated efforts from multiple stakeholders within, and outside, the health system.

Views of community health workers on the integration of a physiotherapist into a ward-based outreach team

Background

Due to changes in the disease profile and lifestyle of individuals in South Africa, the limited health care facilities available have experienced congestion and overcrowding, affecting health care service delivery. Ward-based outreach team (WBOT) programmes were implemented to strengthen primary health care, improve access and alleviate the congestion occurring at these facilities. However, WBOTs have limitations in terms of medical knowledge and rehabilitative skills.

Objective

To explore the views of community health workers (CHWs) on the integration of physiotherapists into WBOTs.

Method

A qualitative research design making use of focus group discussions (FGDs) was used. Through purposive sampling, 58 CHWs who were members of WBOTs were recruited. The WBOTs were from 10 selected primary health care centres in the Tshwane district, Region 2. Six FGDs were conducted. The audio-recorded data were transcribed verbatim. The transcripts were transported into NVivo 12 for thematic analysis.

Results

The views of the CHWs were that the WBOTs can benefit from having a physiotherapist as a member of the team. The WBOTs do not have adequate skills to attend to the physiotherapy needs of communities. People in the community have challenges in accessing physiotherapy services, and physiotherapy services can enhance the performance of the WBOTs by providing training to the WBOTs and providing clinical services to community members.

Conclusion

Community-based rehabilitative services with a physiotherapist as part of the WBOTs can enhance and strengthen the services of the WBOTs, which can improve the treatment outcomes for communities.

Clinical implications

The WBOTS will be empowered to provide clinical services to the vulnerable people in the community that they serve.

The Healthy Aging Adult South Africa report card: a systematic review of the evidence between 2013 and 2020 for middle-aged South African men and women

Due to the increasing non-communicable disease burden in Africa, several strategies that target the major lifestyle and physiological risk factors have been implemented to combat such diseases. The Healthy Aging Adult South Africa report card systematically reviews national and regional prevalence data of middle-aged South African adults (45-65 years) published between 2013 and 2020 on diet, physical activity, tobacco use and alcohol consumption, obesity, hypertension, dyslipidaemia and diabetes mellitus. Each indicator was assigned two grades, (1) based on the availability of prevalence data, and (2) based on whether policies have been proposed and implemented for the respective indicators. Alcohol consumption, obesity, hypertension and diabetes received an A grade for the availability of prevalence data. Tobacco use and diet received an A grade for policy and implementation. Gaps have been identified that need to be filled by future research focusing on continued surveillance of all indicators in order to inform and implement effective policies.

Towards universal health coverage for people with stroke in South Africa: a scoping review

OBJECTIVES

To explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA).

SETTING

SA.

DESIGN

Scoping review.

SEARCH METHODS

We conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results.

RESULTS

Fifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available.

CONCLUSION

This review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.

Hypertension care cascade in the Ingwavuma rural community, uMkhanyakude District, KwaZulu-Natal province of South Africa

BACKGROUND

Treatment and control of hypertension are associated with a substantial reduction in adverse cardiovascular disease outcomes. Although South Africa aims to reduce the burden of cardiovascular diseases, there is limited evidence on the hypertension care cascade (HCC) performance in rural areas where stroke and hypertension are high. This study estimated HCC performance and identified predictors of hypertension screening among adults in the Ingwavuma community of KwaZulu-Natal, South Africa.

METHODS

This was a cross-sectional study. Data were collected using the WHO STEPwise approach to surveillance (STEPS) questionnaire from 400 adult participants, excluding pregnant women and those with physical or cognitive impairments. Three hundred and ninety-three participants had complete data, and 131 had high blood pressure. We calculated progression rates for screening, diagnosis, treatment and control of hypertension from the sub-sample of participants with high blood pressure and assessed the bivariate association between HCC stages and participant characteristics and their effect sizes. We used binary and multivariable logistic regression to identify predictors of hypertension screening.

RESULTS

Eighty-eight per cent of participants reported prior screening for hypertension. However, only 53.5% of patients under pharmacological treatment for hypertension had controlled blood pressure. In bivariate regression, employed participants were 80.3% (COR = 0.197, 95% CI [0.042-0.921]) more likely to be screened. In multivariable regression, the likelihood of hypertension screening was 82.4% (AOR = 0.176, 95% CI [0.047-0.655]) lower among participants in a cohabiting union than single participants. Similarly, employed participants were 87.4% (AOR = 0.129, 95% CI [0.017-0.952]) less likely to be screened than their unemployed counterparts.

CONCLUSIONS

The considerable attrition from the HCC across socio-demographic categories indicates a need for community-wide interventions. Empowering health care workers for community-based health promotion and hypertension management through point-of-care diagnostic tools could improve HCC performance. Efforts to improve the HCC should also focus on social determinants of health, notably gender and formal educational attainment.

'I've become so healthy that I can't live anymore': exploring 'health as balance' discourses and the construction of health and identity among young urban South African adults

Social science research on health in South Africa tends to focus on illness and how to address health problems. Qualitative empirical research focussing on lay understandings and experiences of healthiness, or health discourses, in South Africa is fairly limited. This article addresses this gap by critically exploring how young South African adults used discourses of balance to make sense of what it means to be a healthy person and highlights the implications of these discourses for identity. Foucault's concepts of 'technologies of the self' and 'techniques of discipline' are discussed as a theoretical grounding for this paper. Data were collected from 20 in-depth semi-structured interviews, and analysed using Foucauldian discourse analysis. This paper will specifically explore a key discourse identified through the analysis: 'health as balance' and 2 interrelated sub-discourses which fall within it. Through this discourse, healthiness was constructed as requiring a broad focus on improving all aspects of one's life ('health as holistic') and the avoidance of any behaviours or emotions which could be classified as extreme ('health as moderation'). Constant, careful management of the self, or 'calibration', functions to both perpetuate a cycle of 'anxiety and control' and to obscure ways in which health discourses can be harmful or problematic.

Analysing and quantifying the effect of predictors of stroke direct costs in South Africa using quantile regression

BACKGROUND

In South Africa (SA), stroke is the second highest cause of mortality and disability. Apart from being the main killer and cause of disability, stroke is an expensive disease to live with. Stroke costs include death and medical costs. Little is known about the stroke burden, particularly the stroke direct costs in SA. Identification of stroke costs predictors using appropriate statistical methods can help formulate appropriate health programs and policies aimed at reducing the stroke burden. Analysis of stroke costs have in the main, concentrated on mean regression, yet modelling with quantile regression (QR) is more appropriate than using mean regression. This is because the QR provides flexibility to analyse the stroke costs predictors corresponding to quantiles of interest. This study aims to estimate stroke direct costs, identify and quantify its predictors through QR analysis.

METHODS

Hospital-based data from 35,730 stroke cases were retrieved from selected private and public hospitals between January 2014 and December 2018. The model used, QR provides richer information about the predictors on costs. The prevalence-based approach was used to estimate the total stroke costs. Thus, stroke direct costs were estimated by taking into account the costs of all stroke patients admitted during the study period. QR analysis was used to assess the effect of each predictor on stroke costs distribution. Quantiles of stroke direct costs, with a focus on predictors, were modelled and the impact of predictors determined. QR plots of slopes were developed to visually examine the impact of the predictors across selected quantiles.

RESULTS

Of the 35,730 stroke cases, 22,183 were diabetic. The estimated total direct costs over five years were R7.3 trillion, with R2.6 billion from inpatient care. The economic stroke burden was found to increase in people with hypertension, heart problems, and diabetes. The age group 55-75 years had a bigger effect on costs distribution at the lower than upper quantiles.

CONCLUSIONS

The identified predictors can be used to raise awareness on modifiable predictors and promote campaigns for healthy dietary choices. Modelling costs predictors using multivariate QR models could be beneficial for addressing the stroke burden in SA.

The barriers and facilitators to the telephonic application of the FAST assessment for stroke in a private emergency dispatch centre in South Africa

BACKGROUND

Stroke is one of the leading contributors to morbidity and mortality globally. The incidence of stroke is on the increase in Sub-Saharan countries such as South Africa. As stroke is a time-sensitive condition, emergency medical services (EMS) play an important role in the early recognition of stroke. The telephonic application of the FAST (Face, Arm, Speech, Time) assessment has been suggested to screen patients for stroke, but this is not applied consistently. This study aimed to identify the barriers and facilitators to the telephonic application of the FAST assessment.

METHODS

This retrospective, exploratory study sampled 20 randomly selected emergency calls to a private EMS in South Africa, with suspected stroke. After verbatim self-transcription, data were analysed using inductive content analysis to identify the barriers and facilitators to the application of the FAST assessment. Results were arranged according to themes.

RESULTS

Results indicated that in 15/20 (75%) of the calls, the FAST assessment was successfully applied. Eight barriers under three themes (practical barriers, emotionality, and knowledge and understanding) and three facilitators under one theme (clear communication) were identified. Most notably, language discordance, lack of empathy and caller frustration featured prominently as barriers while caller cooperation and clear instructions were prominent facilitators.

CONCLUSION

With the barriers known, methods to address these may be constructed. Additional training and credentialing for call-takers may be a reasonable first step. These lessons can likely be applied to other telephonic acuity and recognition algorithms.

Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review

INTRODUCTION

Stroke is the second most common cause of death after HIV/AIDS and a significant health burden in South Africa. The extent to which universal health coverage (UHC) is achieved for people with stroke in South Africa is unknown. Therefore, a scoping review to explore the opportunities and challenges within the South African health system to facilitate the achievement of UHC for people with stroke is warranted.

METHODS AND ANALYSIS

The scoping review will follow the approach recommended by Levac, Colquhoun and O'Brien, which includes five steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising and reporting the results. Health Systems Dynamics Framework and WHO Framework on integrated people-centred health services will be used to map, synthesise and analyse data thematically.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review, as it will only include published and publicly available data. The findings of this review will be published in an open-access, peer-reviewed journal and we will develop an accessible summary of the results for website posting and stakeholder meetings.

Nurses' knowledge of stroke-related oropharyngeal dysphagia in the Eastern Cape, South Africa

BACKGROUND

Early identification of stroke-related oropharyngeal dysphagia (OPD) using screening by nurses can prevent adverse patient outcomes in lower middle-income countries. Nurses are essential in the OPD management team and should ideally be able to screen and prioritise dysphagia management in stroke patients.

OBJECTIVE

The aim of this research was to describe nurses' practices related to identification and management of patients with stroke-related OPD.

METHODS

Qualified nurses from various healthcare levels in the Eastern Cape, South Africa were invited to complete a previously published hard copy survey on the signs and symptoms, complications and management of stroke-related OPD. A sample of 130 participants completed the survey.

RESULTS

The mean scores of correct responses for each section were: 8.7/13 (66.7%) for signs and symptoms, 4.7/10 (47.3%) for complications and 3.8/7 (54.2%) for management practices. Statistically, there were no differences between the levels of healthcare for the signs and symptoms section and the complications section. Regarding management of OPD, secondary-level (S) nurses demonstrated significantly better knowledge than primary-level (P) and tertiary-level (T) nurses (S-P: p = 0.022; S-T: p = 0.010). Secondary-level nurses also scored significantly higher across all three sections (S-P: p = 0.044; S-T: p = 0.025) than those at the other levels.

CONCLUSIONS

The study found that nurses across all levels of healthcare had only moderate knowledge regarding identification and management of stroke-related OPD. Interdisciplinary collaboration between nurses and speech-language therapists may improve nurses' knowledge in identification and management of stroke-related OPD in lower middle-income settings such as South Africa.

Comparison and Analysis of Epidemiologic Characteristics of Stroke in Sichuan Province, China

Previous studies have shown that there is a geographic variation in the prevalence of stroke, with a lower prevalence of stroke in Sichuan province. And a stroke transition was found during the period of economic development as well. However, as the center of Southwest China, with a greatly developed economy, whether the geographic variation remained with lower burden of stroke in Sichuan province is unknown. Therefore, in this study, we analyzed the secular stroke status in Sichuan province to help explore the potential reasons for geographic disparity. From a cross-sectional study conducted based on eight national disease surveillance points (DSPs) in Sichuan province in 2013, the epidemiologic data of stroke were collected. Data of risk factors were obtained from a cross-sectional study based on 12 national DSPs in Sichuan province in 2013. The results showed that the age-standardized prevalence, incidence, and mortality of stroke in Sichuan province were 338.6/100,000 people [95% confidence interval (CI), 267.8–409.4], 147.1/100,000 person-years (95% CI = 100.6–193.6), and 72.4/100,000 person-years (95% CI = 40.0–104.8), respectively, which were significantly lower than those determined from the contemporary data of China in 2013. The analysis of the risk factors showed that the weights of contribution of the potential risk factors to stroke were in consistency with those published reports from other areas. In conclusion, the disparity of lower stroke burden in Sichuan than the average China remained, although with the great developments in Sichuan province over all those decades. In addition to traditional modifiable factors, we suggest that unknown or intrinsic differences such as genetic factors might play an important role in geographic disparity, which should be investigated in future studies.

Acute stroke in the emergency department: A chart review at KwaZulu-Natal hospital

Background

Stroke is the second leading cause of death worldwide. There is limited literature detailing the clinical profile of stroke in developing countries’ emergency departments (EDs). The aim of this study is to describe the demographics and risk factors of patients presenting with stroke to an ED in South Africa.

Methods

This study was a retrospective chart review of all patients with a clinical diagnosis of stroke presenting to an ED of a regional hospital in rural KwaZulu-Natal from November 2018 to November 2019.

Results

A total of 362 patient charts were screened, and 136 of the charts met the inclusion criteria for the study. Seventy per cent of the patients had pre-existing hypertension, only one patient was not on treatment and two patients were not on secondary prevention. In human immunodeficiency virus–positive patients (20.5%; n = 28), 17 patients were under 50 years old. The most common finding on computer tomography was ischemic strokes (74%, n = 100). Thrombolysis was given to five patients included in the study. The overall in-hospital mortality rate was 4.06%.

Conclusion

This study adds to the limited data about stroke in South Africa. Our population represents a unique blend of infectious and lifestyle disease. More research in this setting is recommended to develop local guidelines on emergency stroke care.

Cognitive function and cardiometabolic disease risk factors in rural South Africa: baseline evidence from the HAALSI study

BACKGROUND

Evidence on cognitive function in older South Africans is limited, with few population-based studies. We aimed to estimate baseline associations between cognitive function and cardiometabolic disease risk factors in rural South Africa.

METHODS

We use baseline data from "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), a population-based study of adults aged 40 and above in rural South Africa in 2015. Cognitive function was measured using measures of time orientation, immediate and delayed recall, and numeracy adapted from the Health and Retirement Study cognitive battery (overall total cognitive score range 0-26). We used multiple linear regression to estimate associations between cardiometabolic risk factors (including BMI, hypertension, dyslipidemia, diabetes, history of stroke, alcohol frequency, and smoking status) and the overall cognitive function score, adjusted for potential confounders.

RESULTS

In multivariable-adjusted analyses (n = 3018; male = 1520; female = 1498; median age 59 (interquartile range 50-67)), cardiometabolic risk factors associated with lower cognitive function scores included: diabetes (b = - 1.11 [95% confidence interval: - 2.01, - 0.20] for controlled diabetes vs. no diabetes); underweight BMI (b = - 0.87 [CI: - 1.48, - 0.26] vs. normal BMI); and current and past smoking history compared to never smokers. Factors associated with higher cognitive function scores included: obese BMI (b = 0.74 [CI: 0.39, 1.10] vs. normal BMI); and controlled hypertension (b = 0.53 [CI: 0.11, 0.96] vs. normotensive).

CONCLUSIONS

We provide an important baseline from rural South Africa on the associations between cardiometabolic disease risk factors and cognitive function in an older, rural South African population using standardized clinical measurements and cut-offs and widely used cognitive assessments. Future studies are needed to clarify temporal associations as well as patterns between the onset and duration of cardiometabolic conditions and cognitive function. As the South African population ages, effective management of cardiometabolic risk factors may be key to lasting cognitive health.

Relative contribution of overweight and obesity to rising public hospital in-patient expenditure in South Australia

Objective Arguments to fund obesity prevention have often focused on the growing hospital costs of associated diseases. However, the relative contribution of overweight and obesity to public hospital expenditure growth is not well understood. This paper examines the effect of overweight and obesity on acute public hospital in-patient expenditure in South Australia over time compared with other expenditure drivers. Methods Annual inflation-adjusted acute public admitted expenditure attributable to a high body mass index was estimated for 2007-08 and 2011-12 and compared with other expenditure drivers. Results Expenditure attributable to overweight and obesity increased by A$45million, from 4.7% to 5.4% of total acute public in-patient expenditure. This increase accounted for 7.8% of the A$583million total expenditure growth, whereas the largest component of total growth (62.4%) was a real increase in the average cost per separation. Conclusions The relatively minor contribution of overweight and obesity to expenditure growth over the time period examined invites reflection on arguments to boost preventive spending that centre upon reducing hospital costs. These arguments may inadvertently detract attention from the considerable health and social burdens of overweight and obesity and from unrelated sources of expenditure growth that reduce opportunities for state governments to fund obesity prevention programs despite their comparative benefits to population health. What is known about the topic? Stand-alone estimates suggest that overweight and obesity are placing a considerable financial burden on the Australian public healthcare system. What does this paper add? Our findings challenge common perceptions about the relative importance of overweight and obesity in the context of rising public in-patient expenditure in Australia. What are the implications for practitioners? Consistent serial estimates of overweight- and obesity-attributable expenditure enable its tracking and comparison with other potentially controllable expenditure drivers that may also warrant attention. Explicit consideration of population health trade-offs in expenditure-related decisions, including in enterprise bargaining, would enhance transparency in priority setting.

Surviving a stroke in South Africa: outcomes of home-based care in a low-resource rural setting

Background: Little is known of stroke outcomes in low- and middle-income countries with limited formal stroke rehabilitation services and of homebased-stroke services delivered within the primary health care (PHC) context by community health workers (CHWs). Objectives: To describe and analyze the outcomes of patients with stroke from a rural PHC setting in the Western Cape, South Africa. Methods: In a longitudinal survey, 93 stroke patients, referred to home and community-based care services (HCBC) between June 2015 and December 2017, were assessed at baseline, one month and three months. Changes in function (Barthel Index (BI)), caregiver strain (Caregiver Strain Index (CSI)), impact of environmental factors and satisfaction with stroke care were measured. Results: HCBC was delayed, fragmented and brief (median session duration 20 minutes (IQR 15.0-30.0)). Although function improved significantly, dependence remained high: median BI score changed from 40.0 (IQR 15.0-70.0) to 62.5 (IQR 30.0-81.25) (p = .019). A third (33.0% (30/91)) of caregivers initially experienced strain and the median CSI score remained 3.0 (IQR 0.0-7.0) (p = .672). Overall, patient and caregiver satisfaction with HCBC was low with only 46.9% (31/66) of caregivers and 17.4% (12/69) of patients satisfied with all aspects of care. Only 47.6% of assistive product needs were met. Environmental factors negatively impacted on patient function and caregiving. Conclusions: Clinical practice pathways and referral guidelines should be developed for the HCBC platform. Specific training of CHWs, focusing on how to educate, support and train family caregivers, provide assistive devices and refer to health services is needed.

Stigma and chronic illness: A comparative study of people living with HIV and/or AIDS and people living with hypertension in Limpopo Province, South Africa

Background

Stigma among people with chronic illnesses exists, preventing many sufferers from presenting for treatment especially in South Africa.

Objectives

This study compared stigma experiences of people living with human immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV and/or AIDS) (PLWHA) and people living with hypertension (PLWHPT) in Limpopo Province of South Africa.

Method

Using a cross-sectional design, 600 participants (300 PLWHA with mean age of 31 years, standard deviation of 8.2; and 300 PLWHPT with age of 55 years, standard deviation of 8.1) were purposefully sampled at HIV and/or AIDS and hypertension outpatient clinics. The perceived stigma of AIDS scale was used to assess stigma in the HIV and/or AIDS sample while the adapted version was used to assess stigma in PLWHPT. Data were analysed using independent t-test.

Results

Results indicated that PLWHA experienced significantly higher enacted stigma (t(598) = −11.79, p < 0.001) as compared to PLWHPT. However, PLWHPT experienced significantly higher internalised stigma (t(598) = 37.56, p < 0.001) and perceived stigma (t(598) = 41.71, p < 0.001) than PLWHA.

Conclusion

Stigma among people with chronic illnesses is existent. The stigma type is, however, dependent on the nature of the illness. Stigma reduction interventions among these populations are indicated.

The associations between interpersonal violence and psychological distress among rural and urban young women in South Africa

BACKGROUND

Approximately 25% of the world's population consists of young people. The experience of violence peaks during adolescence and the early adult years. A link between personal experience of violence and mental health among young people has been demonstrated but rural-urban differences in these associations are less well known in low to middle income countries. The aim of this study was to investigate the associations between interpersonal violence and psychological distress among rural and urban young women.

METHODS

Data on experiences of violence and psychological distress were collected from a total of 926 non-pregnant young women aged between 18 and 22 years of age in rural and urban sites in South Africa. The General Health Questionnaire-28 was used to assess psychological distress as an indicator of mental health. Generalised structural equation models were employed to assess potential pathways of association between interpersonal violence and psychological distress.

RESULTS

Thirty-four percent of the urban young women (n = 161) reported psychological distress compared to 18% of rural young women (n = 81). In unadjusted analysis, exposure to interpersonal violence doubled the odds of psychological distress in the urban adolescents and increased the odds 1.6 times in the rural adolescents. In adjusted models, the relationship remained significant in the urban area only (OR 1.84, 95% CI 1.13-3.00). Rural residence seemed protective against psychological distress (OR 0.41, 95% CI 0.24-0.69). Structural equation modelling did not reveal any direct association between exposure to interpersonal violence and psychological distress among rural young women. Stressful household events were indirectly associated with psychological distress, mediated by violence among young women in the urban area.

CONCLUSION

The relationship between violence and psychological distress differs between urban and rural-residing young women in South Africa, and is influenced by individual, household and community (contextual) factors.

Rural-urban variations in age at menarche, adult height, leg-length and abdominal adiposity in black South African women in transitioning South Africa

Background: The pre-pubertal socioeconomic environment may be an important determinant of age at menarche, adult height, body proportions and adiposity: traits closely linked to adolescent and adult health.

Aims: This study explored differences in age at menarche, adult height, relative leg-length and waist circumference between rural and urban black South African young adult women, who are at different stages of the nutrition and epidemiologic transitions.

Subjects and methods: We compared 18–23 year-old black South African women, 482 urban-dwelling from Soweto and 509 from the rural Mpumalanga province. Age at menarche, obstetric history and household socio-demographic and economic information were recorded using interview-administered questionnaires. Height, sitting-height, hip and waist circumference were measured using standardised techniques.

Results: Urban and rural black South African women differed in their age at menarche (at ages 12.7 and 14.5 years, respectively). In urban women, a one-year increase in age at menarche was associated with a 0.65 cm and 0.16% increase in height and relative leg-length ratio, respectively. In both settings, earlier age at menarche and shorter relative leg-length were independently associated with an increase in waist circumference.

Conclusions: In black South African women, the earlier onset of puberty, and consequently an earlier growth cessation process, may lead to central fat mass accumulation in adulthood.

Modifiable lifestyle risk factors for stroke among a high risk hypertensive population in Greater Kampala, Uganda; a cross-sectional study

OBJECTIVE

To describe the modifiable lifestyle risk factors for stroke among a high risk population for stroke. Africa suffers from rapid population growth, adoption of harmful western diets, and increased prevalence of hypertension and obesity.

RESULTS

A total of 440 study participants were screened and 87 individuals with hypertension plus at least one other known stroke risk factor were enrolled. The prevalence of hypertension and diabetes mellitus in the screened population was 19.7 and 1.8%, respectively. Among those with hypertension only 2.3% (2/87) had ever had serum lipid assessment. Seventy-two percent (68/87) had very high serum LDL-cholesterol, while 33.3% (29/87) had low levels of HDL-cholesterol, and 67.8% had mean blood pressures greater than 160/100 mmHg and 40% (35/87) were obese, with a BMI ≥30. Targeting individuals with modifiable stroke risk factors and implementing self-management programs may be a way to reduce stroke burden in Uganda.

Evaluation of a Mass-Media Campaign to Increase the Awareness of the Need to Reduce Discretionary Salt Use in the South African Population

The South African strategic plan to reduce cardiovascular disease (CVD) includes reducing population salt intake to less than 5 g/day. A mass media campaign was undertaken to increase public awareness of the association between high salt intake, blood pressure and CVD, and focused on the reduction of discretionary salt intake. Community based surveys, before and after the campaign, were conducted in a cohort of black women aged 18–55 years. Questions on knowledge, attitudes and beliefs regarding salt use were asked. Current interest in engaging with salt reduction behaviors was assessed using the “stage of change” model. Five hundred fifty women participated in the baseline study and 477 in the follow-up survey. Most of the indicators of knowledge, attitudes and behavior change show a significant move towards considering and initiating reduced salt consumption. Post intervention, significantly more participants reported that they were taking steps to control salt intake (38% increased to 59.5%, p < 0.0001). In particular, adding salt while cooking and at the table occurred significantly less frequently. The findings suggest that mass media campaigns may be an effective tool to use as part of a strategy to reduce discretionary consumption of salt among the population along with other methods.

Disparities in Management of Cardiovascular Disease in Rural South Africa: Data From the HAALSI Study (Health and Aging in Africa: Longitudinal Studies of International Network for the Demographic Evaluation of Populations and Their Health Communities)

BACKGROUND

Optimal secondary prevention is critical for the reduction of repeated cardiovascular events, and the control of cardiovascular risk factors in this context is essential. Data on secondary prevention of cardiovascular disease (CVD) in sub-Saharan Africa are needed to inform intervention strategies with a particular focus on local disparities. The aim of this study was to assess CVD management in a rural community in northeast South Africa.

METHODS AND RESULTS

We recruited adults aged ≥40 years residing in the Agincourt subdistrict of Mpumalanga province. Data collection included socioeconomic and clinical data, anthropometric measures, blood pressure, human immunodeficiency virus status, and point-of-care glucose and lipid levels. CVD was defined as self-report of myocardial infarction and stroke or angina diagnosed by Rose Criteria. A linear regression model was built to identify variables independently associated with the number of cardiovascular risk factors controlled. Of 5059 subjects, 592 (11.7%) met CVD diagnostic criteria. Angina was reported in 77.0% of these subjects, stroke in 25.2%, and myocardial infarction in 3.7%. Percent controlled of the 5 individual risk factors assessed were as follows: tobacco 92.9%; blood pressure 51.2%; body mass index 33.8%; low-density lipoprotein 31.4%; and waist-to-hip ratio 29.7%. Only 4.4% had all 5 risk factors controlled and 42.4% had ≥3 risk factors controlled. Male sex (β coefficient=0.44; 95% confidence interval, 0.25-0.63; P<0.001), absence of physical disability (β coefficient=0.40; 95% confidence interval, 0.16-0.65; P=0.001), and socioeconomic status (β coefficient=0.10; 95% confidence interval, 0.01-0.19; P=0.035) were directly associated with the number of risk factors controlled.

CONCLUSIONS

Currently, CVD is not being optimally managed in this rural area of South Africa. There are significant disparities in control of CVD risk factors by sex, socioeconomic status, and level of disability. Efforts to improve secondary prevention in this population should be focused on females, subjects from lower socioeconomic status, and those with physical disabilities.

Hypertension management in a population of older adults in rural South Africa

OBJECTIVE

Assess awareness, treatment, and control of hypertension, as an indication of its management, in rural South Africa, especially regarding modifiers of these variables.

METHODS

A population-representative sample of adults aged at least 40 years residing in the rural Agincourt subdistrict (Mpumalanga Province) covered by a long-term health and sociodemographic surveillance system was recruited. In-person interviews, physical exams, and dried blood spots were collected. Hypertension awareness, treatment, and control rates were assessed. A regression model was built to identify predictors of those outcomes.

RESULTS

The mean age of the 2884 hypertensive participants was 64.1 ± 12.7 years. Hypertension awareness rate was 64.4%, treatment among those aware was 89.3 and 45.8% of those treated were controlled. Considering aware and unaware hypertensives, treatment rate was 49.7% and control 22.8%. In the multivariable regression model, awareness was predicted by female sex, age at least 60 years, higher social economic status, prior cardiovascular disease (CVD), nonimmigrant status, literacy, and physical limitation. Improved control among those treated was predicted by age at least 60 years. Blood pressure control among all hypertensive study participants was predicted by female sex, being HIV-negative, age at least 60 years, nonimmigrant status, and prior CVD.

CONCLUSION

High rates of awareness and treatment of hypertension as well as good levels of control were found in this population, probably explained by the long-term surveillance program conducted in the area. Considering the predictors of hypertension management, particular attention should be given to men, residents younger than 60 years, immigrants, and study participants without CVD as these characteristics were predictors of poor outcome.

Estimation of the Disease Burden Attributable to 11 Risk Factors in Hubei Province, China: A Comparative Risk Assessment

In order to estimate the health losses caused by common risk factors in the Hubei province, China, we calculated the deaths and disability-adjusted life years (DALYs) attributable to 11 risk factors. We estimated the exposure distributions of risk factors in Hubei Province in 2013 from the monitoring system on chronic disease and related risk factors, combined with relative risk (RR) in order to calculate the population attributable fraction. Deaths and DALYs attributed to the selected risk factors were then estimated together with cause-specific deaths and DALYs. In total, 53.39% of the total deaths and 36.23% of the total DALYs in Hubei were a result of the 11 selected risk factors. The top five risk factors were high blood pressure, smoking, high body mass index, diet low in fruits and alcohol use, accounting for 14.68%, 12.57%, 6.03%, 3.90% and 3.19% of total deaths, respectively, and 9.41%, 7.22%, 4.42%, 2.51% and 2.44% of total DALYs, respectively. These risk factors, especially high blood pressure, smoking and high body mass index, significantly influenced quality of life, causing a large number of deaths and DALYs. The burden of chronic disease could be substantially reduced if these risk factors were effectively controlled, which would allow people to enjoy healthier lives.

Post stroke health-related quality of life, stroke severity and function: A longitudinal cohort study

Background

Health related quality of life (HRQoL) is a determinant of physical, social and emotional well-being post-stroke.

Objectives

This study aimed to correlate self-reported HRQoL with activities of daily living (ADL) and stroke severity.

Method

A longitudinal observational study was conducted at a rehabilitation centre in the Western Cape, South Africa. Stroke inpatients were sampled over 6 months. The Euro-QoL Five Dimensions instrument (EQ5D-3L) for self-reported HRQoL, Barthel Index (BI) for function and independence in ADL, and modified Rankin Scale (mRS) for stroke severity were administered on admission and discharge. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 25.

Results

Of the 54 potential participants, 49 met inclusion criteria and 41 completed reassessments (median age 48 years [interquartile range {IQR} 39–60]; median length of stay 53 days [IQR 46–60]). Most participants had infarctions (89.90%); with hypertension or diabetes risk factors (73.47% and 28.57%, respectively). The BI and mRS scores improved significantly (p < 0.001) with very strong correlation between scores (rs = -0.874, p < 0.001); indicating a trend of decreased stroke severity as function improved. The EQ5D Visual Analog Scale (VAS) scores (p < 0.001) and domains mobility, self-care, usual activities (p < 0.001) and pain/discomfort (p = 0.034) improved significantly. The anxiety/depression domain showed a non-significant change (p = 0.378). A weak negative significant correlation existed between EQ5D VAS and mRS scores (rs = -0.362; p = 0.02); indicating a trend that HRQoL was not improving to the degree stroke severity decreased. A weak positive significant correlation was seen between EQ5D VAS and BI scores (rs = 0.329; p = 0.036).

Conclusion

Although an improvement was noted in HRQoL, EQ5D VAS scores tended not to improve as strongly, despite significant improvements in function and stroke severity. These findings demonstrate the need for psychological support and pain management interventions for adjustment post-stroke.