At the Heart of the Problem: Health in Johannesburg's Inner-City

Leveraging data science and machine learning for urban climate adaptation in two major African cities: a HE2AT Center study protocol

INTRODUCTION

African cities, particularly Abidjan and Johannesburg, face challenges of rapid urban growth, informality and strained health services, compounded by increasing temperatures due to climate change. This study aims to understand the complexities of heat-related health impacts in these cities. The objectives are: (1) mapping intraurban heat risk and exposure using health, socioeconomic, climate and satellite imagery data; (2) creating a stratified heat-health forecast model to predict adverse health outcomes; and (3) establishing an early warning system for timely heatwave alerts. The ultimate goal is to foster climate-resilient African cities, protecting disproportionately affected populations from heat hazards.

METHODS AND ANALYSIS

The research will acquire health-related datasets from eligible adult clinical trials or cohort studies conducted in Johannesburg and Abidjan between 2000 and 2022. Additional data will be collected, including socioeconomic, climate datasets and satellite imagery. These resources will aid in mapping heat hazards and quantifying heat-health exposure, the extent of elevated risk and morbidity. Outcomes will be determined using advanced data analysis methods, including statistical evaluation, machine learning and deep learning techniques.

ETHICS AND DISSEMINATION

The study has been approved by the Wits Human Research Ethics Committee (reference no: 220606). Data management will follow approved procedures. The results will be disseminated through workshops, community forums, conferences and publications. Data deposition and curation plans will be established in line with ethical and safety considerations.

Do black women's lives matter? A study of the hidden impact of the barriers to access maternal healthcare for migrant women in South Africa

Background

Studies on the barriers migrant women face when trying to access healthcare services in South Africa have emphasized economic factors, fear of deportation, lack of documentation, language barriers, xenophobia, and discrimination in society and in healthcare institutions as factors explaining migrants' reluctance to seek healthcare. Our study aims to visualize some of the outcome effects of these barriers by analyzing data on maternal death and comparing the local population and black African migrant women from the South African Development Countries (SADC) living in South Africa. The heightened maternal mortality of black migrant women in South Africa can be associated with the hidden costs of barriers migrants face, including xenophobic attitudes experienced at public healthcare institutions.

Methods

Our analysis is based on data on reported causes of death (COD) from the South African Department of Home Affairs (DHA). Statistics South Africa (Stats SA) processed the data further and coded the cause of death (COD) according to the WHO classification of disease, ICD10. The dataset is available on the StatsSA website (http://nesstar.statssa.gov.za:8282/webview/) for research and statistical purposes. The entire dataset consists of over 10 million records and about 50 variables of registered deaths that occurred in the country between 1997 and 2018. For our analysis, we have used data from 2002 to 2015, the years for which information on citizenship is reliably included on the death certificate. Corresponding benchmark data, in which nationality is recorded, exists only for a 10% sample from the population and housing census of 2011. Mid-year population estimates (MYPE) also exist but are not disaggregated by nationality. For this reason, certain estimates of death proportions by nationality will be relative and will not correspond to crude death rates.

Results

The total number of female deaths recorded from the years 2002 to 2015 in the country was 3740.761. Of these, 99.09% (n = 3,707,003) were deaths of South Africans and 0.91% (n = 33,758) were deaths of SADC women citizens. For maternal mortality, we considered the total number of deaths recorded for women between the ages of 15 and 49 years of age and were 1,530,495 deaths. Of these, deaths due to pregnancy-related causes contributed to approximately 1% of deaths. South African women contributed to 17,228 maternal deaths and SADC women to 467 maternal deaths during the period under study. The odds ratio for this comparison was 2.02. In other words, our findings show the odds of a black migrant woman from a SADC country dying of a maternal death were more than twice that of a South African woman. This result is statistically significant as this odds ratio, 2.02, falls within the 95% confidence interval (1.82-2.22).

Conclusion

The study is the first to examine and compare maternal death among two groups of women, women from SADC countries and South Africa, based on Stats SA data available for the years 2002-2015. This analysis allows for a better understanding of the differential impact that social determinants of health have on mortality among black migrant women in South Africa and considers access to healthcare as a determinant of health. As we examined maternal death, we inferred that the heightened mortality among black migrant women in South Africa was associated with various determinants of health, such as xenophobic attitudes of healthcare workers toward foreigners during the study period. The negative attitudes of healthcare workers toward migrants have been reported in the literature and the media. Yet, until now, its long-term impact on the health of the foreign population has not been gaged. While a direct association between the heightened death of migrant populations and xenophobia cannot be established in this study, we hope to offer evidence that supports the need to focus on the heightened vulnerability of black migrant women in South Africa. As we argued here, the heightened maternal mortality among migrant women can be considered hidden barriers in which health inequality and the pervasive effects of xenophobia perpetuate the health disparity of SADC migrants in South Africa.

High prevalence of SARS-CoV-2 antibodies in pregnant women after the second wave of infections in the inner-city of Johannesburg, Gauteng Province, South Africa

OBJECTIVES

After South Africa's second wave of COVID-19, this study estimated the SARS-CoV-2 seroprevalence among pregnant women in inner-city Johannesburg, South Africa.

METHODS

In this cross-sectional survey, 500 pregnant women who were non-COVID-19-vaccinated (aged ≥12 years) were enrolled, and demographic and clinical data were collected. Serum samples were tested using the Wantai SARS-CoV-2 spike antibody enzyme-linked immunosorbent assay and Roche Elecsys® anti-SARS-CoV-2 nucleocapsid antibody assays. Seropositivity was defined as SARS-CoV-2 antibodies on either (primary) or both (secondary) assays. Univariate Poisson regression assessed risk factors associated with seropositivity.

RESULTS

The median age was 27.4 years, and HIV prevalence was 26.7%. SARS-CoV-2 seroprevalence was 64.0% (95% confidence interval [CI]: 59.6-68.2%) on the primary and 54% (95% CI: 49.5-58.4%) on the secondary measure. Most (96.6%) women who were SARS-CoV-2-seropositive reported no symptoms. On the Roche assay, we detected lower seroprevalence among women living with HIV than women without HIV (48.9% vs 61.7%, P-value = 0.018), and especially low levels among women living with HIV with a clusters of differentiation 4 <350 cells/ml compared with women without immune suppression (22.2% vs 56.4%, prevalence rate ratio = 0.4; 95% CI: 0.2-0.9; P-value = 0.046).

CONCLUSION

Pregnant women attending routine antenatal care had a high SARS-CoV-2 seroprevalence after the second wave in South Africa, and most had asymptomatic infections. Seroprevalence surveys in pregnant women present a feasible method of monitoring the course of the pandemic over time.

Experiences in receiving financial incentives to access HIV care in Johannesburg, South Africa

Background

Financial incentivisation has been used to improve all steps of the HIV cascade with varying results. Most studies conducted on the matter are of a quantitative nature, not giving enough space for in-depth understanding as to why financial incentives work or do not work.

Objectives

To describe experiences with, and opinions on, the use of financial incentives to promote linkage to and retention in care from the perspective of people living with HIV.

Method

We performed a qualitative cross-sectional study. In-depth interviews were conducted with adult men and women with HIV accessing health services or research study visits. After codebook development, NVivo 12 software was used to code and analyse the data.

Results

Through the provision of financial incentives, participants were able to cover basic needs. However, some deemed financial incentives as a form of income rather than a nudge to spark interest in changing their health behaviour. Participants communicated that a need for some type of incentive exists and recommended food vouchers as the best possible solution.

Conclusion

Financial incentivisation can facilitate engagement in the HIV care continuum through providing support to people living with HIV.

What this study adds

This study complements the body of research that explores the feasibility of using incentives and which of them may be most beneficial in encouraging patients with HIV to enter into and sustain HIV care.

Characteristics of chiropractic patients treated at the University of Johannesburg chiropractic student clinic and relevance to the educational process

OBJECTIVE

This study aimed to analyze the demographic and descriptive information of new patients presenting to an educational institution-based chiropractic student clinic in South Africa that could then be used to draw comparisons to other international chiropractic student clinics and local practices.

METHODS

We conducted a retrospective descriptive study of all new patient files from January 1, 2016, to July 31, 2016. The variables extracted were age, health profiles, number of musculoskeletal complaints, treatment protocol, and number of treatments that patients received for the initial complaint. Data were analyzed using cross-tabulations and multidimensional χ2 tests.

RESULTS

There were 865 files reviewed. Most patients were aged between 20 and 24 years. Lumbar and pelvic complaints were most common (42.2%), followed by the cervical spine (28%). Lumbar (18.8%) and cervical (16.8%) biomechanical conditions, followed by lumbar myofascial pain syndrome (7.6%), were the most common problems. Musculoskeletal conditions were reported in 99% of cases. The majority (80%) of patients received 9 or fewer treatments for their initial complaint. Manipulation was used in 93.9% of cases, followed by mobilization (8.8%), interferential current (23.5%), and dry needling (19.1%).

CONCLUSIONS

Data gathered suggest that there are some general similarities with international training institutions. There are also differences between the study sample and international institutions and South African private chiropractic practice. The dissimilarities were a younger patient population, a lower number of treatment visits, and low exposure to nonmusculoskeletal conditions. These differences may affect the breadth of student education and require further investigation.

Narrative sexual histories and perceptions of HIV risk among young women taking PrEP in southern Africa: Findings from a novel participatory method

Pre-exposure prophylaxis (PrEP) is an important HIV prevention method for adolescent girls and young women (AGYW) in Africa, who are at heightened risk of HIV infection. HIV risk perception is generally a powerful motivator for adoption of HIV prevention behaviours, including PrEP use. While HIV risk perceptions have been evaluated using quantitative measures, these seldom capture how individuals conceptualize and understand risk within local frameworks of meaning. More nuanced understanding may come from qualitative approaches that map these perceptions across the trajectory of sexual histories. Between 2016 and 2018, we implemented a novel participatory method to investigate risk perceptions in interviews with 32 participants in HPTN 082, a study of AGYW's use of PrEP in South Africa and Zimbabwe. Timelines were used to record narrative sexual histories and perceived HIV risk for each relationship. We found that women assessed HIV risk primarily based on their partners' personal qualities and behaviour (especially relating to infidelity); their subjective experience of being treated respectfully; and the practice of perceived 'risk reduction', including younger partners and condoms, even if used inconsistently. A narrative timeline approach grounded in an understanding of young women's sexual histories may increase critical reflection about HIV risks and facilitate risk-reduction counselling with this group.

Performance of the Swede score to predict cervical intraepithelial neoplasia in women with HIV-1 in Johannesburg, South Africa

OBJECTIVE

To evaluate the performance of the Swede score to detect cervical intraepithelial neoplasia (CIN) in women with HIV-1 in Johannesburg, South Africa.

METHODS

A cross-sectional study using secondary data analysis from the HPV in Africa Research Partnership (HARP) study that compared the performance of three different screening tests to detect CIN. Colposcopy was performed on any woman who screened positive and findings were recorded using the Swede score. A biopsy of any lesion and a four-quadrant biopsy was taken. The score was evaluated against a histological diagnosis of >CIN1. The sensistivity, specificity, PPV and NPV for each score was calculated.

RESULTS

Median age and CD4+ count of the 576 women eligible from the Johannesburg cohort was 34 years (IQR, 30-39) and 427 cells/mm³ (IQR, 323-579), respectively. Almost two-thirds (64%) were on ART and about 21% had CIN 2+ on histology. A Swede score of 5 or greater had the best combination of sensitivity and specificity for CIN 2+ with an AUC of 0.72 (95% CI, 0.68-0.76) corresponding to a sensitivity of 72.1 (95% CI, 63.5-79.6) and specificity of 71.8 (95% CI, 67.4-75.9).

CONCLUSION

The Swede score can assist in determining whether women with HIV/AIDS should have treatment at the first colposcopy visit versus those who may be followed up, thereby individualizing treatment.

The Mobile Alliance for Maternal Action Text Message-Based mHealth Intervention for Maternal Care in South Africa: Qualitative User Study

Background

Using mobile technology to support health care (mobile health [mHealth]) has been shown to improve health outcomes across a multitude of health specialties and across the world. Exploring mHealth user experiences can aid in understanding how and why an intervention was successful. The Mobile Alliance for Maternal Action (MAMA) was a free maternal mHealth SMS text messaging service that was offered to pregnant women in Johannesburg, South Africa, with the goal of improving maternal, fetal, and infant health outcomes. We conducted focus group discussions with MAMA users to learn about their experiences with the program.

Objective

The aim of this qualitative study was to gather opinions of participants of the MAMA maternal mHealth service regarding health care atmosphere, intervention use, and intervention feedback.

Methods

Prenatal and postnatal women (N=15) from public antenatal and postnatal care sites in central Johannesburg who were receiving free maternal health text messages (MAMA) participated in 3 focus group discussions. Predefined discussion topics included personal background, health care system experiences, MAMA program recruitment, acceptability, participant experiences, and feedback.

Results

The feedback regarding experiences with the health system were comprised of a few reports of positive experiences and many more reports of negative experiences such as long wait times, understaffed facilities, and poor service. Overall acceptability for the maternal text message intervention was high. Participants reflected that the messages were timely, written clearly, and felt supportive. Participants also reported sharing messages with friends and family.

Conclusions

These findings suggest that maternal mHealth interventions delivered through text messages can provide timely, relevant, useful, and supportive information to pregnant women and new mothers especially in settings where there may be mistrust of the health care system.

The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study

OBJECTIVE

To assess whether decentralising colposcopy services to a primary care facility in inner-city Johannesburg, South Africa raises access to colposcopy.

DESIGN

Before-after study comparing 2 years before and 2 years after decentralisation, using clinical records and laboratory data on cervical cytology and histology.

PRIMARY OUTCOME

The proportion of all women attending Hillbrow Community Health Centre (HCHC) with an abnormal Papanikolaou (Pap) smear who had a colposcopy post-decentralisation.

SETTING

Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) has provided colposcopy services for several decades. HCHC, located about 3 km away, began colposcopy services in 2014.

PARTICIPANTS

Women, aged above 18 years, who had a colposcopy for diagnosis and treatment of precancerous cervical lesions following a Pap smear, from 2012 to 2016 at CMJAH or HCHC.

RESULTS

Pre-decentralisation at CMJAH, 910 women had colposcopy (2012-2014). Post-decentralisation (2014-2016), 721 had colposcopy at CMJAH and 399 at HCHC, the decentralised facility. The number who had a Pap smear at HCHC and then a colposcopy rose threefold post-decentralisation (114 vs 350). Post-decentralisation, 43 women at HCHC were referred to CMJAH for colposcopy, compared with 114 pre-decentralisation. Post-decentralisation, 47.3% of women at CMJAH waited >6 months for colposcopy, while 35.5% did at HCHC (p<0.001). Across all three groups, 26.9%-30.3% of women had cervical intraepithelial neoplasia III lesions or carcinoma on colposcopy. The proportion of invalid specimens was similar at CMJAH and HCHC (1.8%-2.8%). Of 401 women who had an abnormal Pap smear at HCHC post-decentralisation, 267 had colposcopy (66.6%).

CONCLUSION

Decentralisation can decrease the time to colposcopy and reduce the workload of tertiary hospitals. Overall, more women accessed services. Colposcopy coverage at HCHC is higher than other sites, but could be further improved. Decentralisation did not appear to undermine the quality of services and this model could be extended to similar settings in South Africa and elsewhere.

Climate change adaptation in South Africa: a case study on the role of the health sector

BACKGROUND

Globally, the response to climate change is gradually gaining momentum as the impacts of climate change unfold. In South Africa, it is increasingly apparent that delays in responding to climate change over the past decades have jeopardized human life and livelihoods. While slow progress with mitigation, especially in the energy sector, has garnered much attention, focus is now shifting to developing plans and systems to adapt to the impacts of climate change.

METHODS

We applied systematic review methods to assess progress with climate change adaptation in the health sector in South Africa. This case study provides useful lessons which could be applied in other countries in the African region, or globally. We reviewed the literature indexed in PubMed and Web of Science, together with relevant grey literature. We included articles describing adaptation interventions to reduce the impact of climate change on health in South Africa. All study designs were eligible. Data from included articles and grey literature were summed thematically.

RESULTS

Of the 820 publications screened, 21 were included, together with an additional xx papers. Very few studies presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country's preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers.

CONCLUSIONS

Overall, the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. More effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as predominately a health issue, one necessitating an urgent, adequately-resourced response. Such a shift in South Africa, but also beyond the country, may play a key role in accelerating climate change adaptation and mitigation.

Integrating Cervical Cancer Screening Into Safer Conception Services to Improve Women's Health Outcomes: A Pilot Study at a Primary Care Clinic in South Africa

BACKGROUND

Sub-optimal cervical cancer screening in low- and middle-income countries contributes to preventable cervical cancer deaths, particularly among human immunodeficiency virus (HIV)-positive women. We assessed feasibility and outcomes of integrating cervical cancer screening into safer conception services for HIV-affected women.

METHODS

At a safer conception service in Johannesburg, South Africa, HIV-affected women desiring pregnancy received a standard package of care designed to minimize HIV transmission risks while optimizing prepregnancy health. All eligible women were offered Papanicolaou smear, and those with significant pathology were referred for colposcopy before attempting pregnancy. Multivariable analyses identified associations between patient characteristics and abnormal pathology.

RESULTS

In total, 454 women were enrolled between June 2015 and April 2017. At enrolment, 91% were HIV-positive, 92% were on antiretroviral therapy (ART) and 82% virally suppressed. Eighty-three percent (376 of 454) of clients were eligible for cervical cancer screening and 85% (321 of 376) of these completed screening. More than half had abnormal cervical pathology (185 of 321) and 20% required colposcopy for possible high-grade or persistently atypical lesions (64 of 321). Compared with HIV-negative women, abnormal pathology was more likely among HIV-positive women, both those on ART <2 years (adjusted prevalence ratio, 2.5; 95% confidence interval, 1.2-5.0) and those on ART 2 years or longer (adjusted prevalence ratio, 2.1; 95% confidence interval, 1.0-4.2).

CONCLUSIONS

Integrating cervical cancer screening into safer conception care was feasible with high coverage, including for HIV-positive women. Significant pathology, requiring colposcopy, was common, even among healthy women on ART. Safer conception services present an opportunity for integration of cervical cancer screening to avert preventable cancer-related deaths among HIV-affected women planning pregnancy.

Impacts of Climate Change on Health and Wellbeing in South Africa

Given its associated burden of disease, climate change in South Africa could be reframed as predominately a health issue, one necessitating an urgent health-sector response. The growing impact of climate change has major implications for South Africa, especially for the numerous vulnerable groups in the country. We systematically reviewed the literature by searching PubMed and Web of Science. Of the 820 papers screened, 34 were identified that assessed the impacts of climate change on health in the country. Most papers covered effects of heat on health or on infectious diseases (20/34; 59%). We found that extreme weather events are the most noticeable effects to date, especially droughts in the Western Cape, but rises in vector-borne diseases are gaining prominence. Climate aberration is also linked in myriad ways with outbreaks of food and waterborne diseases, and possibly with the recent Listeria epidemic. The potential impacts of climate change on mental health may compound the multiple social stressors that already beset the populace. Climate change heightens the pre-existing vulnerabilities of women, fishing communities, rural subsistence farmers and those living in informal settlements. Further gender disparities, eco-migration and social disruptions may undermine the prevention-but also treatment-of HIV. Our findings suggest that focused research and effective use of surveillance data are required to monitor climate change's impacts; traditional strengths of the country's health sector. The health sector, hitherto a fringe player, should assume a greater leadership role in promoting policies that protect the public's health, address inequities and advance the country's commitments to climate change accords.

High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa

Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.

CD4 cell count variability with repeat testing in South Africa: Should reporting include both absolute counts and ranges of plausible values?

Although eligibility for antiretroviral treatment is no longer based on CD4 thresholds, CD4 testing remains important. Variation in CD4 cell count complicates initiation of antibiotic prophylaxis, differential diagnoses and assessments of immunological recovery. Five hundred and fifty-three HIV-positive antiretroviral-naïve adults, recruited from inner-city clinics, had three serial CD4 cell count tests. Test 1 was mostly done in a laboratory network supporting primary care clinics, while Tests 2 and 3 were performed in a tertiary-level laboratory. Reproducibility was assessed through Bland-Altman limits of agreement and coefficients of variation. Participants, a mean age of 34 years and mostly female (57%), had a median 203 CD4 cells/μL (Test 1). Seventeen per cent classified as having advanced HIV disease (CD4 cell count  < 200 cells/µL) on Test 1 had a CD4 cell count > 200 cells/µL on Tests 2 and 3. Mean differences between tests were <10 cells/µL for all comparisons. Limits of agreement for Tests 1 and 2 were -106.9 to 112.7 and coefficient of variation 15. Corresponding figures for Tests 2 and 3 were -88.2 to 103.4, and 13. Means of tests were similar, suggesting no systematic measurement differences, despite testing being done at different times. Variations were, however, considerable in many instances, though smaller in testing done in the same laboratory. CD4 cut-offs must not be applied rigidly, but rather constitute one amongst many factors used to guide patient care. Moreover, given the difficulties in determining whether CD4 changes are due to HIV disease, or other biological and laboratory factors, CD4 laboratory reports should include a range of plausible values, not only the absolute count.