The Influence of Racial Differences in the Demand for Healthcare in South Africa: A Case of Public Healthcare

Strong effect of demographic changes on Tuberculosis susceptibility in South Africa

South Africa is among the world's top eight tuberculosis (TB) burden countries, and despite a focus on HIV-TB co-infection, most of the population living with TB are not HIV co-infected. The disease is endemic across the country, with 80-90% exposure by adulthood. We investigated epidemiological risk factors for (TB) in the Northern Cape Province, South Africa: an understudied TB endemic region with extreme TB incidence (926/100,000). We leveraged the population's high TB incidence and community transmission to design a case-control study with similar mechanisms of exposure between the groups. We recruited 1,126 participants with suspected TB from 12 community health clinics and generated a cohort of 774 individuals (cases = 374, controls = 400) after implementing our enrollment criteria. All participants were GeneXpert Ultra tested for active TB by a local clinic. We assessed important risk factors for active TB using logistic regression and random forest modeling. We find that factors commonly identified in other global populations tend to replicate in our study, e.g. male gender and residence in a town had significant effects on TB risk (OR: 3.02 [95% CI: 2.30-4.71]; OR: 3.20 [95% CI: 2.26-4.55]). We also tested for demographic factors that may uniquely reflect historical changes in health conditions in South Africa. We find that socioeconomic status (SES) significantly interacts with an individual's age (p = 0.0005) indicating that protective effect of higher SES changed across age cohorts. We further find that being born in a rural area and moving to a town strongly increases TB risk, while town birthplace and current rural residence is protective. These interaction effects reflect rapid demographic changes, specifically SES over recent generations and mobility, in South Africa. Our models show that such risk factors combined explain 19-21% of the variance (r2) in TB case/control status.

Independent Correlates of Glycemic Control among Adults with Diabetes in South Africa

BACKGROUND

Globally, the prevalence of diabetes is increasing, especially in low- and middle-income countries (LMICs), including those in the sub-Saharan African region. However, the independent socioeconomic correlates of glycemic control as measured by hemoglobin A1C have yet to be identified. Therefore, the aim of this analysis was to understand the independent correlates of glycemic control in South Africa.

METHODS

Data from the 2016 South Africa Demographic and Health Survey on adults with diabetes were used for this analysis. The dependent variable, glycemic control, was defined using hemoglobin A1c (HbA1c). Independent variables included: age, gender, ethnicity, marital status, region, urban/rural residence, ability to read, education, insurance, wealth, occupation, and employment in the last year. Analysis of variance was used to test for differences in mean HbA1c for each category of all independent variables, and a fully adjusted linear regression model was used to identify independent correlates of glycemic control (HbA1c).

RESULTS

Among the 772 people included in this analysis, there were significant differences in mean HbA1c by age (p < 0.001), ethnicity (p < 0.001), place of residence (p = 0.024), wealth index (p = 0.001), and employment in the last year (p = 0.008). Independent correlates of HbA1c included age, ethnicity, and wealth index.

CONCLUSIONS

This study used data from a large diverse population with a high prevalence of diabetes in sub-Saharan Africa and provides new evidence on the correlates of glycemic control and potential targets for interventions designed to lower HbA1c and improve diabetes-related health outcomes of adults in South Africa.

Who really decides? Feeding decisions 'made' by caregivers of children with cerebral palsy

BACKGROUND

 There are no definitive guidelines for clinical decisions for children with cerebral palsy (CP) requiring enteral feeds. Traditionally, medical doctors made enteral feeding decisions, while patients were essentially treated passively within a paternalistic 'doctor knows best' approach. Although a more collaborative approach to decision-making has been promoted globally as the favoured model among healthcare professionals, little is known about how these decisions are currently made practically.

OBJECTIVES

 This study aimed to identify the significant individuals, factors and views involved in the enteral feeding decision-making process for caregivers of children with CP within the South African public healthcare sector.

METHOD

 A single-case research design was used in this qualitative explorative study. Data were collected using semi-structured interviews and analysed using reflexive thematic analysis.

RESULTS

 Four primary individuals were identified by the caregivers in the decision-making process: doctors, speech therapists, caregivers' families and God. Four factors were identified as extrinsically motivating: (1) physiological factors, (2) nutritional factors, (3) financial factors and (4) environmental factors. Two views were identified as intrinsically motivating: personal beliefs regarding enteral feeding tubes, and feelings of fear and isolation.

CONCLUSION

 Enteral feeding decision-making within the South African public healthcare sector is currently still dominated by a paternalistic approach, endorsed by a lack of caregiver knowledge, distinct patient-healthcare provider power imbalances and prescriptive multidisciplinary healthcare dialogues.Contribution: This study has implications for clinical practice, curriculum development at higher education training facilities, and institutional policy changes and development, thereby contributing to the current knowledge and clinical gap(s) in the area.

Linking African ancestral substructure to prostate cancer health disparities

Prostate cancer (PCa) is a significant health burden in Sub-Saharan Africa, with mortality rates loosely linked to African ancestry. Yet studies aimed at identifying contributing risk factors are lacking within the continent and as such exclude for significant ancestral diversity. Here, we investigate a series of epidemiological demographic and lifestyle risk factors for 1387 men recruited as part of the multi-ethnic Southern African Prostate Cancer Study (SAPCS). We found poverty to be a decisive factor for disease grade and age at diagnosis, with other notably significant PCa associated risk factors including sexually transmitted diseases, erectile dysfunction, gynaecomastia, and vertex or complete pattern balding. Aligned with African American data, Black ethnicity showed significant risk for PCa diagnosis (OR = 1.44, 95% CI 1.05-2.00), and aggressive disease presentation (ISUP ≥ 4: OR = 2.25, 95% CI   1.49-3.40). New to this study, we demonstrate African ancestral population substructure associated PCa disparity, observing increased risk for advanced disease for the southern African Tsonga people (ISUP ≥ 4: OR = 3.43, 95% CI   1.62-7.27). Conversely, South African Coloured were less likely to be diagnosed with aggressive disease overall (ISUP ≥ 3: OR = 0.38, 95% 0.17-0.85). Understanding the basis for PCa health disparities calls for African inclusion, however, lack of available data has limited the power to begin discussions. Here, focusing on arguably the largest study of its kind for the African continent, we draw attention to the contribution of within African ancestral diversity as a contributing factor to PCa health disparities within the genetically diverse region of southern Africa.

Strong Effect of Demographic Changes on Tuberculosis Susceptibility in South Africa

South Africa is among the world's top eight TB burden countries, and despite a focus on HIV-TB co-infection, most of the population living with TB are not HIV co-infected. The disease is endemic across the country with 80-90% exposure by adulthood. We investigated epidemiological risk factors for tuberculosis (TB) in the Northern Cape Province, South Africa: an understudied TB endemic region with extreme TB incidence (645/100,000) and the lowest provincial population density. We leveraged the population's high TB incidence and community transmission to design a case-control study with population-based controls, reflecting similar mechanisms of exposure between the groups. We recruited 1,126 participants with suspected TB from 12 community health clinics, and generated a cohort of 878 individuals (cases =374, controls =504) after implementing our enrollment criteria. All participants were GeneXpert Ultra tested for active TB by a local clinic. We assessed important risk factors for active TB using logistic regression and random forest modeling. Additionally, a subset of individuals were genotyped to determine genome-wide ancestry components. Male gender had the strongest effect on TB risk (OR: 2.87 [95% CI: 2.1-3.8]); smoking and alcohol consumption did not significantly increase TB risk. We identified two interactions: age by socioeconomic status (SES) and birthplace by residence locality on TB risk (OR = 3.05, p = 0.016) - where rural birthplace but town residence was the highest risk category. Finally, participants had a majority Khoe-San ancestry, typically greater than 50%. Epidemiological risk factors for this cohort differ from other global populations. The significant interaction effects reflect rapid changes in SES and mobility over recent generations and strongly impact TB risk in the Northern Cape of South Africa. Our models show that such risk factors combined explain 16% of the variance (r2) in case/control status.

Healthcare providers' perspectives on stigma when working with people with functional seizures

PURPOSE

This study aimed to explore healthcare providers' (HCPs) perspectives and experiences of stigma when working with people with Functional Seizures (FS). Particular focus was given to understanding HCPs' experience and knowledge of FS, discovering the attitudes held by HCPs towards working with FS as a mental health condition, and exploring HCPs' views of how their stigma manifests towards people with FS when in an occupational setting.

METHODS

Semi-structured individual interviews were conducted with thirteen HCPs who specialised in the diagnosis and/or treatment and management of FS. A reflexive thematic analysis was utilised to analyse the semi-structured interviews for means of identifying themes within the data.

RESULTS

Themes identified included those of contextual factors which indirectly influence stigma, inclusive of a lack of time and resources. HCPs additionally described having a general limited understanding of FS as a condition and becoming frustrated with their patients, which in turn fuelled a stigmatising culture. HCPs also pointed to the idea of diagnostic terms being inappropriate and adding to stigma. HCPs' personal stigma as well as institutionalised stigma were identified. The HCPs also reported on the negative attitudes and actions directed towards FS patients. Strategies to reduce stigma were also explored.

CONCLUSION

There are various ways in which HCPs' stigma towards individuals with FS can occur, both directly and indirectly. HCPs play a key role in supporting their FS patients and alleviating the effects of stigma; thus, it is important to understand their perspectives and experiences through further research.

Profile and outcome of multiple myeloma with and without HIV treated at a tertiary hospital in KwaZulu-Natal, South Africa

OBJECTIVES

To profile the outcome of multiple myeloma (MM) patients treated at a South African tertiary hospital in KwaZulu-Natal (KZN) and to compare MM in HIV-negative patients and MM in people living with HIV (PLWH).

METHODS

A retrospective analysis of patients with MM was conducted over 5 years (2015-2020). Patient demographics, presenting complaints, symptom duration, disease stage, molecular profile, treatment, and survival data were captured. Statistical analysis was conducted using R Statistical software of the R Core Team, 2020, version 3.6.3.

RESULTS

135 patients; 79% (n = 106) HIV-negative and 21% (n = 29) PLWH were investigated. 54% (n = 74) females and 57% (n = 76) 51-70-year-olds. The 40-50-year-old patient group had a significantly higher proportion of PLWH (p = 0.032). Pathological fractures were the commonest presenting complaint, 47% (n = 57 and 49% (n = 49) had International Staging System, stage III disease. Fluorescent in-situ hybridization (FISH) MM profiling was completed in 58% (n = 78). Positivity for del 11q22 was found in 23.7% (n = 14) with significantly more HIV-negative patients having the mutation (p = 0.027). Overall, 42.2% (n = 57) achieved 2-year overall survival (OS). There were no significant differences in treatment (p = 0.926) and 2-year survival outcome (p = 0.792) between the two groups.

CONCLUSION

The incidence of HIV in newly diagnosed MM patients in KZN was increasing. KZN patient profile differed from other reports by showing female predominance but was similar in advanced-stage presentation and bone fracture predominance. Statistically significant differences between the HIV-negative patients and PLWH were observed in age distribution and mutational landscape. Further studies are required in this area.

Prevalence and clinical profile of keratoconus in patients presenting at a provincial hospital in KwaZulu, Natal, South Africa: A case study

Keratoconus (KC) is a progressive, asymmetrical corneal disease, characterized by stromal thinning that leads to distortion, causing vision loss. The visual loss is secondary to corneal scarring, irregular astigmatism, and myopia. The prevalence of KC has been reported to differ in different parts of the world. The study aimed to determine the prevalence and profile of patients with KC presenting to a provincial hospital in KwaZulu-Natal, South Africa. A retrospective study design was used to review 412 clinical records of patients attending the McCord Provincial Eye Hospital (MPEH) during a five-year period (2016-2020). Data on age, race, refraction, clinical profile, treatment plan, and diagnosis were ascertained. The prevalence of KC in MPEH was found to be 13.7% with a mean age of 24.7±7.94 years. Black African and females had a higher frequency of KC compared to males and other ethnic groups. Most of the patients presented with a severe stage of KC and referral was the most common management. Central corneal thinning and Munson's sign were the most prevalent clinical signs. There was no statistically significant difference between the worse and better eye when comparing the clinical signs. The prevalence and clinical profile of patients with KC in this study was similar to that reported by previous studies and more in Blacks and females. Population based epidemiological studies are needed to determine the prevalence of KC in South Africa to enable early clinical interventions.

Social determinants of health in non-communicable diseases prevention policies in South Africa

BACKGROUND

 The South African government has developed many policies for the prevention and control of non-communicable diseases. However, non-communicable diseases remain among the major causes of morbidity and mortality in South Africa. Although these diseases are linked to interaction of multiple risk factors, many of which are modifiable, they continue to cause much suffering particularly among the marginalised and people from the lower socio-economic status.

OBJECTIVES

 The objective of this research was to explore and present the inclusion of social determinants of health in the policies meant for the prevention and control of non-communicable diseases in South Africa.

METHOD

 The qualitative document analysis approach was used to conduct policy analysis of purposefully selected policies for prevention and control of cancers, obesity and mental and behavioural disorders in South Africa.

RESULTS

 The analysis revealed that policies for prevention and control of cancers, obesity and mental and behavioural disorders included policy intervention activities that focused on five social determinants of health: (1) governance, (2) social policies, (3) public policies, (4) material circumstances and (5) health system.

CONCLUSION

 Excluding most of the important social determinants of health in the policies for prevention and control of non-communicable diseases means that these policies would continue to fail in preventing these diseases from the root causes.Contribution: This article points out weaknesses in the policies meant for prevention and control of obesity, cancers and mental and behavioural disorders. This article further suggests policy improvement strategies that may be considered to effectively address these diseases.

Demand prediction of medical services in home and community-based services for older adults in China using machine learning

Background

Home and community-based services are considered an appropriate and crucial caring method for older adults in China. However, the research examining demand for medical services in HCBS through machine learning techniques and national representative data has not yet been carried out. This study aimed to address the absence of a complete and unified demand assessment system for home and community-based services.

Methods

This was a cross-sectional study conducted on 15,312 older adults based on the Chinese Longitudinal Healthy Longevity Survey 2018. Models predicting demand were constructed using five machine-learning methods: Logistic regression, Logistic regression with LASSO regularization, Support Vector Machine, Random Forest, and Extreme Gradient Boosting (XGboost), and based on Andersen's behavioral model of health services use. Methods utilized 60% of older adults to develop the model, 20% of the samples to examine the performance of models, and the remaining 20% of cases to evaluate the robustness of the models. To investigate demand for medical services in HCBS, individual characteristics such as predisposing, enabling, need, and behavior factors constituted four combinations to determine the best model.

Results

Random Forest and XGboost models produced the best results, in which both models were over 80% at specificity and produced robust results in the validation set. Andersen's behavioral model allowed for combining odds ratio and estimating the contribution of each variable of Random Forest and XGboost models. The three most critical features that affected older adults required medical services in HCBS were self-rated health, exercise, and education.

Conclusion

Andersen's behavioral model combined with machine learning techniques successfully constructed a model with reasonable predictors to predict older adults who may have a higher demand for medical services in HCBS. Furthermore, the model captured their critical characteristics. This method predicting demands could be valuable for the community and managers in arranging limited primary medical resources to promote healthy aging.

Outcomes for children and adolescents with Juvenile idiopathic arthritis addressed by occupational therapy services in specialist rheumatology clinics in South Africa

Introduction:

International guidelines for best practice indicate specialised treatment is required for Juvenile idiopathic arthritis (JIA). While occupational therapy intervention for functional limitations in this chronic condition is conditionally recommended, the extent to which this is provided in public specialist rheumatology clinics in South Africa is unknown. The aim of this study was to determine which needs related to outcomes for occupational performance or functional status, condition-related factors and health-related quality of life, reported by children and adolescents with JIA were addressed by current occupational therapy services.

Methods:

The study used two descriptive, quantitative studies with limited samples of 37 clients with JIA attending specialist rheumatology clinics and nine occupational therapists who currently provide intervention for clients with JIA.

Results:

Functional deficits reported by 30–63% of clients with JIA were increased symptoms of active disease and difficulties with school activities. Occupational therapy services addressed condition-related factors and participation in personal management but not many related to the social, educational and psychosocial needs of clients with JIA.

Conclusion:

Occupational therapy services followed international guidelines but based on the reductionist biomedical model approach used within specialist services in tertiary hospitals, which limit context-based therapy for children and adolescents with JIA in the community.

Low self-reported penicillin allergy in South Africa-implications for global public health response

Objectives

In high-income countries, up to 25% of inpatients have a self-reported penicillin allergy (PA). After testing, 95% of these self-reported PAs are incorrect. These incorrectly labelled PAs increase the use of broad-spectrum antibiotics, and drive bacterial resistance. The epidemiology of PA in low- and middle-income countries is unknown. We aimed to describe the epidemiology and delabelling outcomes of self-reported PA in South African (SA) inpatients.

Methods

We conducted point prevalence surveys between April 2019 and June 2021 at seven hospitals in Cape Town, South Africa. A team trained in the PEN-FAST allergy decision tool conducted in-person interviews, and reviewed patient notes to identify and risk stratify inpatients with a self-reported PA. These patients were referred to the Groote Schuur Hospital (GSH) allergy clinic for delabelling.

Results

A total of 1486 hospital inpatients were surveyed and 3.2% (n = 48) carried a PA label. Importantly, 64.6% (n = 31) were classified by PEN-FAST as low risk for true penicillin hypersensitivity. Overall, 25% of the self-reported PAs received a β-lactam antibiotic in hospital and were directly delabelled. Delabelling attrition was very high, with 6.3% (3/48) of the self-reported PAs attending the GSH allergy clinic, and only one patient proceeding to a negative oral penicillin challenge.

Conclusions

Inpatient self-reported PA was lower in South Africa hospitals compared with other upper-middle-income countries, and the majority of patients carried a low-risk PA label. Linkage for delabelling with the allergy clinic was very poor, and thus strategies to improve access and delivery of delabelling remains an urgent public health issue.

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

A South African Epidemiological Study of Fatal Drownings: 2016-2021

Drowning is a serious public health concern. Low-and-middle-income countries are the most affected by drowning, as they carry 90% of the global drowning burden. The purpose of this retrospective epidemiological study is to provide an overview of fatal drownings in South Africa between 2016 and 2021. The data used for the study were obtained from the South African Police Service. Descriptive statistics were used to summarize the data. Statistical analyses included a t-test and chi-square test. The results indicate that the average number of fatal drownings per annum is 1477 in South Africa, with an average drowning rate of 2.54 per 100,000 population for the period 2016 to 2021. The KwaZulu-Natal province had the highest incidence of drowning. The 0-4-year-age group has the highest prevalence of drowning among all the age categories. More males drowned in South Africa compared to females.

Life under lockdown for children with autism spectrum disorder: Insights from families in South Africa

BACKGROUND

Children with Autism Spectrum Disorder (ASD) remain vulnerable during the Covid-19 outbreak due to significant changes to their daily routines, social interactions and diets. In addition, these challenges may be exacerbated for children living in low- and middle-income countries (LMIC) such as South Africa where there are already barriers such as poverty, access to resources and availability of support. Understanding the impact of the Covid-19 outbreak on children with ASD is imperative in order to create awareness as well as provide equitable services and support to both children with ASD and their families.

PURPOSE

The study aimed to explore family-reported changes for children with ASD and their reactions and responses to the Covid-19 restrictions in South Africa.

METHOD

A qualitative research design was employed. Twelve families consisting of different family compositions with a total of 21 family members (mothers, fathers and grandmothers) participated in the current study using semistructured interviews. Data were transcribed and analysed using a framework method for thematic analysis.

RESULTS

Findings indicated that children with ASD present with unique challenges related to Covid-19. Negative themes such as children's obstructive reactions due to the immediate changes to their routines, increases in emotional dysregulation as well as loss of previously acquired skills as a result of lack of access to services during lockdown were reported. However, families also reported on positive changes such as improved social interactions as children became more accustomed to their new lockdown routines.

IMPLICATIONS

The Covid-19 response has had a negative impact on children with disabilities, specifically around access to services and support for both children with ASD and their families. While the future of the virus and impending lockdown measures is unknown, clinicians, providers and educators need to ensure that provisions are made for children's current adjustments as well as further adjustments to their current routines both during and after the pandemic.

Forensic autopsy-confirmed thrombosis-related deaths: the danger in the bones

Thrombosis is a potentially life-threatening condition related to roughly a quarter of all deaths globally. Many of these deaths occur inside healthcare facilities due to possibly preventable causes. Therefore, understanding the etiological factors involved in excessive thrombosis may significantly contribute to the successful identification, management and education of people who have an increased risk of thrombosis. We performed a retrospective file-audit of all forensic autopsy reports conducted at the Free State Forensic Pathology Mortuary in Bloemfontein, South Africa, over 10 years. We collected the age at death, gender and ethnicity of each person included in the study. The presence and location of the thrombosis and any underlying disorder or disease were noted. The overall prevalence of thrombosis for the total study population was 0.97%. Pulmonary embolisms (PE's) were much more common than coronary thromboses. Most PE's had known contributory risk factors, where coronary thrombosis-related deaths occurred suddenly without known risk factors. Bone fractures were the most prominent risk factor associated with PE's. Females of African descent had a consistently high prevalence of thrombosis after the age of 30 years. Males of European descent showed an unexpected peak in prevalence during the 4th decade. Since most deaths occurred in patients with conditions known to contribute to venous thrombosis, we conclude that intensified public awareness efforts are required in our region to assist the general public in identifying risk factors for thrombosis, thereby decreasing the burden this potentially preventable disorder places on society.

‘All of a sudden, you know, you can’t go to these services, because of the risk of infection’: Audiological service considerations at residential care homes for older persons during COVID-19

Background

Residential care homes for older persons were especially affected during the coronavirus disease 2019 (COVID-19) pandemic lockdowns which resulted in limited social interactions and service provision. Communication became challenging due to the prophylactic use of masks and social distancing.

Objectives

This qualitative research study set out to explore audiological service considerations in residential care homes for older persons during the COVID-19 restrictions.

Method

Through purposive sampling, nine managers from residential care homes for older persons in Johannesburg participated in semi-structured, online interviews. The transcriptions of these recorded interviews underwent thematic analysis.

Results

Managers employed various strategies to attend to residents’ audiological needs, audiological health, hearing aid use, and hearing aid provision. Furthermore, it transpired that other health related services were prioritised over audiological services in general, but especially during the pandemic lockdowns. Managers reported that staff had to use various communication strategies due to COVID-19 precautions and that masks and social distancing made communication more challenging for residents with hearing loss. Moreover, isolation and modified service provision were extremely taxing on residents.

Conclusion

This study highlights the need for continued audiological services at residential care homes, but also the need to balance audiological needs with other health needs because these seem to be prioritised over hearing loss, especially in this population who may have limited agency and choice in the health care options available to them. Furthermore, adapted strategies need to be considered to support communication considering COVID-19 precautions so that communicative difficulties do not exacerbate lockdown isolation.

The intersection of age, sex, race and socioeconomic status in COVID-19 hospital admissions and deaths in South Africa

Older age, male sex, and non-white race have been reported to be risk factors for COVID-19 mortality. Few studies have explored how these intersecting factors contribute to COVID-19 outcomes. This study aimed to compare demographic characteristics and trends in SARS-CoV-2 admissions and the health care they received. Hospital admission data were collected through DATCOV, an active national COVID-19 surveillance programme. Descriptive analysis was used to compare admissions and deaths by age, sex, race, and health sector as a proxy for socio-economic status. COVID-19 mortality and healthcare utilisation were compared by race using random effect multivariable logistic regression models. On multivariable analysis, black African patients (adjusted OR [aOR] 1.3, 95% confidence interval [CI] 1.2, 1.3), coloured patients (aOR 1.2, 95% CI 1.1, 1.3), and patients of Indian descent (aOR 1.2, 95% CI 1.2, 1.3) had increased risk of in-hospital COVID-19 mortality compared to white patients; and admission in the public health sector (aOR 1.5, 95% CI 1.5, 1.6) was associated with increased risk of mortality compared to those in the private sector. There were higher percentages of COVID-19 hospitalised individuals treated in ICU, ventilated, and treated with supplemental oxygen in the private compared to the public sector. There were increased odds of non-white patients being treated in ICU or ventilated in the private sector, but decreased odds of black African patients being treated in ICU (aOR 0.5; 95% CI 0.4, 0.5) or ventilated (aOR 0.5; 95% CI 0.4, 0.6) compared to white patients in the public sector. These findings demonstrate the importance of collecting and analysing data on race and socio-economic status to ensure that disease control measures address the most vulnerable populations affected by COVID-19.

COVID-19 hospitalization and mortality and hospitalization-related utilization and expenditure: Analysis of a South African private health insured population

Background

Evidence on the risk factors for COVID-19 hospitalization, mortality, hospital stay and cost of treatment in the African context is limited. This study aims to quantify the impact of known risk factors on these outcomes in a large South African private health insured population.

Methods and findings

This is a cross sectional analytic study based on the analysis of the records of members belonging to health insurances administered by Discovery Health (PTY) Ltd. Demographic data for 188,292 members who tested COVID-19 positive over the period 1 March 2020–28 February 2021 and the hospitalization data for these members up until 30 June 2021 were extracted. Logistic regression models were used for hospitalization and death outcomes, while length of hospital stay and (log) cost per patient were modelled by negative binominal and linear regression models. We accounted for potential differences in the population served and the quality of care within different geographic health regions by including the health district as a random effect. Overall hospitalization and mortality risk was 18.8% and 3.3% respectively. Those aged 65+ years, those with 3 or more comorbidities and males had the highest hospitalization and mortality risks and the longest and costliest hospital stays. Hospitalization and mortality risks were higher in wave 2 than in wave 1. Hospital and mortality risk varied across provinces, even after controlling for important predictors. Hospitalization and mortality risks were the highest for diabetes alone or in combination with hypertension, hypercholesterolemia and ischemic heart disease.

Conclusions

These findings can assist in developing better risk mitigation and management strategies. It can also allow for better resource allocation and prioritization planning as health systems struggle to meet the increased care demands resulting from the pandemic while having to deal with these in an ever-more resource constrained environment.

The Role of Artificial Intelligence and Machine Learning Amid the COVID-19 Pandemic: What Lessons Are We Learning on 4IR and the Sustainable Development Goals

The COVID-19 pandemic came with disruptions in every aspect of human existence, with all the sectors of the economies of the world affected greatly. In the health sector, the pandemic halted and reversed progress in health and subsequently shortened life expectancy, especially in developing and underdeveloped nations. On the other hand, machine learning and artificial intelligence contributed a great deal to the handling of the pandemic globally. Therefore, the current study aimed to assess the role played by artificial intelligence and machine learning in addressing the dangers posed by the COVID-19 pandemic, as well as extrapolate the lessons on the fourth industrial revolution and sustainable development goals. Using qualitative content analysis, the results indicated that artificial intelligence and machine learning played an important role in the response to the challenges posed by the COVID-19 pandemic. Artificial intelligence, machine learning, and various digital communication tools through telehealth performed meaningful roles in scaling customer communications, provided a platform for understanding how COVID-19 spreads, and sped up research and treatment of COVID-19, among other notable achievements. The lessons we draw from this is that, despite the disruptions and the rise in the number of unintended consequences of technology in the fourth industrial revolution, the role played by artificial intelligence and machine learning motivates us to conclude that governments must build trust in these technologies, to address health problems going forward, to ensure that the sustainable development goals related to good health and wellbeing are achieved.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

Effects of race on the outcome of COVID-19 in hospitalized patients

BACKGROUND AND AIMS

Recent reports indicate that African Americans have higher mortality rates from SARS-CoV-2 coronavirus disease 19 (COVID-19) compared to Caucasians, with more marked differences in the Midwest region of the US. This study was performed to study differences in COVID-19 related mortality and hospital length of stay (LOS) between African Americans and Caucasians in Midwest setting, and identify factors associated with mortality and LOS.

METHODS

Data were collected from the electronic health records (EHR) of patients admitted to hospitals in Midwest region of the US. EHR of 471 COVID-19 patients were reviewed.

RESULTS

Approximately 63% were African Americans and 34% Caucasians. One hundred sixteen variables were tested. There was no significant difference in hospital mortality between African Americans and Caucasians (OR 1, 95% CI 0.48-1.94). Older age, Chronic kidney disease, mental status change, mechanical ventilation, vasopressor support, high neutrophil count, elevated AST and ALT, high lung involvement severity score and elevated CRP were associated with mortality in a univariate analysis (P < 0.05). Multivariable modeling indicated that mechanical ventilation was the only factor that predicted mortality (OR 6, 95% CI: 2.94-12.48). The LOS did not differ in African Americans and Caucasians. The use of oxygen via high flow nasal cannula (Survival Estimate 1.6, 95% CI: 1.20-2.26), low estimated glomerular filtration rate (Survival Estimate 1.4, 95% CI: 1.05-1.82) and mechanical ventilation (Survival Estimate 3.5, 95% CI: 2.72-4.37) were predictors of LOS.

CONCLUSION

This study performed in Midwest setting in the US showed that race did not affect in-hospital mortality and LOS. Our analysis demonstrated new predictors of LOS.

Accessing HIV care may lead to earlier ascertainment of comorbidities in health care clients in Khayelitsha, Cape Town

Successful antiretroviral rollout in South Africa has greatly increased the health of the HIV-positive population, and morbidity and mortality in PLHIV can increasingly be attributed to comorbidities rather than HIV/AIDS directly. Understanding this disease burden can inform health care planning for a growing population of ageing PLHIV. Anonymized routine administrative health data were analysed for all adults who accessed public health care in 2016-2017 in Khayelitsha subdistrict (Cape Town, South Africa). Selected comorbidities and age of ascertainment for comorbidities were described for all HIV-positive and HIV-negative healthcare clients, as well as for a subset of women who accessed maternal care. There were 172 937 adult individuals with a median age of 37 (IQR:30-48) years in the virtual cohort, of whom 48% (83 162) were HIV-positive. Median age of ascertainment for each comorbidity was lower in HIV-positive compared to HIV-negative healthcare clients, except in the case of tuberculosis. A subset of women who previously accessed maternal care, however, showed much smaller differences in the median age of comorbidity ascertainment between the group of HIV-positive and HIV-negative health care clients, except in the case of chronic kidney disease (CKD). Both HIV-positive individuals and women who link to maternal care undergo routine point-of-care screening for common diseases at younger ages, and this analysis suggests that this may lead to earlier diagnosis of common comorbidities in these groups. Exceptions include CKD, in which age of ascertainment appears lower in PLHIV than HIV-negative groups in all analyses suggesting that age of disease onset may indeed be earlier; and tuberculosis for which age of incidence has previously been shown to vary according to HIV status.

Engendering a Sense of Belonging to Support Student Well-Being during COVID-19: A Focus on Sustainable Development Goals 3 and 4

The COVID-19 pandemic has exposed a plethora of inequalities in South Africa. These inequalities have had a direct impact on the 2030 Agenda for Sustainable Development Goals (SDGs). SDG 3 (good health and well-being) and SDG 4 (quality education) were the focus of this article. This article investigated how students enrolled at a South African residential university perceived the impact of the COVID-19 pandemic on their well-being, their success in completing their studies and their future career prospects. A quantitative survey research design was followed. Data were collected by means of a questionnaire from 537 students in a South African university. Statistical Package for Social Sciences software version 27 was used to analyze the data. The results indicated direct influences on student well-being from concerns that arose from COVID-19 about future job concerns, degree completion, social support and belonging. The relationship between concerns about degree completion was moderated by a sense of belonging (social identification) but not by social support. The study has significant implications for how higher education institution governors and academics might consider reconceptualizing notions of student support, beyond the narrow, technical and basic curriculum support for degree completion, towards the affective and social as it relates to creating conditions for students to identify with and experience a profound sense of belonging.

Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

OBJECTIVES

Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.

DESIGN

A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.

SETTING

This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.

PARTICIPANTS

Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.

RESULTS

Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).

CONCLUSIONS

The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

A Dynamic Analysis of the Demand for Health Care in Post-Apartheid South Africa

The study aimed to investigate the drivers of demand for healthcare in South Africa 26 years after democracy. The pattern healthcare demand by households in South Africa is that most households use public healthcare services particularly public clinics compared to private and traditional healthcare facilities. Using conditional probability models, the logit model to be more specific, the results revealed that households head who is unemployed, households who do not have a business, households who were not receiving pension money, had a greater probability of demand for public healthcare institutions. On the other hand, being male, being White, Indian and Coloured, being a property owner and being not a grant beneficiary, reduces the probability of demand for public healthcare facilities in South Africa. As a result, the study recommends more investment in public healthcare but more in public clinics in South Africa due to the high percentage of households using these services. Also, the government must consider investing more in the maintenance and improvement of the welfare of nurses in the country considering the huge role they play in the delivery of healthcare to the citizens.