Prevalence and Psychosocial Correlates of Diabetes Mellitus in South Africa: Results from the South African National Health and Nutrition Examination Survey (SANHANES-1)

Availability and pricing of insulin and related diagnostics in South Africa

Background

In South Africa (SA), most patients rely on the government for free healthcare. Some choose to subscribe to a medical insurance scheme. If insulin is unavailable in government or otherwise unaffordable, non-adherence may occur, which can increase complications of the disease.

Methods

Data on availability and pricing of insulin and related diagnostics was collected from SA pharmacies via an online survey. Co-payments levied on insulin by the biggest medical aids were extracted from formularies. Affordability of these items was then assessed. An adapted methodology from the World Health Organization/Health Action International tool was used.

Results

There was fairly high availability of insulin in the public sector, with the exception of long-acting insulin which respondents claimed was difficult to find; however, long-acting insulin glargine was available in most private sector pharmacies. Point-of-care (POC) blood glucose testing was free in the public sector but offered in only 31.25% of pharmacies. Patients pay a minimum of USD 40.4 (over 3 days' wages for the lowest paid government worker (LPGW)) for a months' supply of the cheapest insulin, needles and test strips. Insulin in SA was cheaper than 5 other countries, except Australia.

Conclusion

Overall, there is a good availability of insulin and related diagnostics in SA. Even though insulin is cheaper than other countries, it is unaffordable to the LPGW. This highlights the importance of ensuring a constant availability of insulin in the free public sector. Whilst human insulins are cheaper than newer analogue insulins and SA faces cost constraints, important variables in favour of newer insulins, such as ease-of-use, long term outcomes and value should be considered when treatment guidelines are updated. Annual POC testing should be available and offered free to all patients to detect diabetes early.

Feasibility of Provision and Vaccine Hesitancy at a Central Hospital COVID-19 Vaccination Site in South Africa after Four Waves of the Pandemic

BACKGROUND

As mortality declined significantly during the fourth and fifth waves compared to previous waves, the question of the future role of COVID-19 vaccination arose among both experts and the public in South Africa. Turning attention away from the general public, now considered to be at very low risk of severe COVID-19 disease, a commonly held view was that the vaccination campaign should focus only on those who remain highly vulnerable to severe disease and death from COVID-19. Primary amongst this group are patients with common chronic diseases attending hospital outpatient departments. We hypothesized that providing COVID-19 vaccinations on-site at a central hospital will increase uptake for the patients with co-morbid chronic conditions who need them most in the Omicron phase of the pandemic.

AIM

Evaluate the acceptability, need, and uptake of a hospital-based vaccination site for patients attending the medical hospital outpatient departments.

OBJECTIVES

To assess vaccination uptake, coverage, and hesitancy in people attending a central hospital, to determine factors associated with and influencing vaccination uptake, and to document implementation and assess acceptability of the vaccination project among staff and persons attending the hospital.

METHODS

Mixed-methods study using quantitative and qualitative methods.

RESULTS

Of the 317 participants enrolled in the study, 229 (72%) had already received at least one dose of the COVID-19 vaccine. A total of 296 participants were eligible for a first vaccination, additional vaccination, or booster vaccination according to the South African Department of Health guidelines. Of those previously vaccinated, 65% opted for an additional dose on the day it was offered (same day). Only 13 previously unvaccinated participants (15% of vaccine naïve participants) opted for vaccination, increasing vaccine coverage with at least one dose from 72% to 76%. Approximately 24% (n = 75) of all participants refused vaccination (vaccine hesitant). Variables tested for an association with vaccination status demonstrated that age reached statistical significance. Emerging themes in the qualitative analysis included perceptions of vulnerability, vaccine safety and efficacy concerns, information gaps regarding vaccinations, the value of convenience in the decision to vaccinate, and the role of health promoters.

CONCLUSIONS

This study has shown that it is logistically acceptable to provide a vaccination site at a large hospital targeting patients attending outpatient services for chronic medical conditions. This service also benefits accompanying persons and hospital staff. Access and convenience of the vaccination site influence decision-making, increasing the opportunity to vaccinate. However, vaccine hesitancy is widespread with just under one-quarter of all those offered vaccinations remaining unvaccinated. Strengthening health education and patient-clinician engagement about the benefits of vaccination is essential to reach highly vulnerable populations routinely attending hospital outpatient departments with an appropriate vaccination program.

Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa

The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.

Antioxidative, Metabolic and Vascular Medicinal Potentials of Natural Products in the Non-Edible Wastes of Fruits Belonging to the Citrus and Prunus Genera: A Review

Diabetes mellitus and related metabolic and vascular impairments are notable health problems. Fruits and vegetables contain phenolics that are beneficial to metabolic and oxidative health and useful in preventing associated disease. Scientific evidence has shown that some bioactive phenolics are more abundant in the non-edible parts (especially the peels) of many fruits than in their respective edible tissues. Fruits belonging to the Citrus and Prunus genera are commonly consumed worldwide, including in South Africa, and their non-edible wastes (peel and seed) have been shown to have antioxidative, metabolic and vascular pharmacological potentials and medicinal phytochemistry. It is therefore imperative to evaluate the pharmacological actions and phytochemical properties of the non-edible wastes of these fruits and understand how they could potentially be of medicinal relevance in oxidative, metabolic and vascular diseases, including diabetes, oxidative stress, obesity, hypertension and related cardiovascular impairments. In the absence of a previous review that has concomitantly presented the medicinal potentials of fruits wastes from both genera, this review presents a critical analysis of previous and recent perspectives on the medicinal potential of the non-edible wastes from the selected Citrus and Prunus fruits in metabolic, vascular and oxidative health. This review further exposes the medicinal phytochemistry, while elucidating the underlying mechanisms through the fruit wastes potentiates their therapeutic effects. A literature search was carried out on "PubMed" to identify peer-reviewed published (mostly 2015 and beyond) studies reporting the antidiabetic, antioxidative, antihypertensive, anti-hyperlipidemic and anti-inflammatory properties of the non-edible parts of the selected fruits. The data of the selected studies were analyzed to understand the bioactive mechanisms, bioactive principles and toxicological profiles. The wastes (seed and peel) of the selected fruits had antioxidant, anti-obesogenic, antihypertensive, anti-inflammatory, antidiabetic and tissue protective potentials. Some phenolic acids and terpenes, as well as flavonoids and glycosides such as narirutin, nobiletin, hesperidin, naringin, naringenin, quercetin, rutin, diosmin, etc., were the possible bioactive principles. The peel and seed of the selected fruits belonging to the Citrus and Prunus genera are potential sources of bioactive compounds that could be of medicinal relevance for improving oxidative, metabolic and vascular health. However, there is a need for appropriate toxicological studies.

Advances in Psychological and Social Aetiology of Patients with Diabetes

Diabetes is a metabolic disease that is affected by internal and external factors. Its prevalence is rising, and it is characterized by a continuous increase in blood glucose levels. With the deepening understanding of diabetes, it is not only necessary to explore its physiological basis, but also to explore the complex interaction between social and psychological factors. In addition to traditional risk factors, the article also highlights the psychological and social aspects of the patient 's impact on the development of diabetes. Because diabetes is not only the result of metabolic imbalances, but also the product of broader background factors, the importance of psychosocial interventions is particularly important. By examining psychosocial dimensions, this review aims to provide a comprehensive understanding of the causes of diabetes. It deeply studies the complex relationship between psychosocial factors and diabetes, and recognizes the complexity of this metabolic disorder. In addition, the article discussed interventions designed to address the psychosocial problems of diabetes, emphasizing the need to take a holistic approach to care for patients. This review explores the impact of psychological and social factors on the incidence, progression and outcome of diabetes, complementing traditional considerations such as obesity, genetic and physiological factors. Recognizing the multifaceted nature of diabetes, this article uses a social etiology perspective to emphasize the important role of social psychological factors. In the process, it has contributed to the ongoing discussion on diabetes management by incorporating a broader social context into the understanding and treatment of this general health problem.

Association of Dietary Changes with Risk Factors of Type 2 Diabetes among Older Adults in Sharpeville, South Africa, from 2004 to 2014

This study aimed to evaluate the associations of dietary changes with risk factors of type 2 diabetes among older populations in Sharpeville, South Africa. A 24 h recall assessment, dietary diversity, and anthropometrics were measured. Blood samples were collected to assess fasting glucose and insulin. Regression analysis was performed using SPSS version 20. The mean BMI of the total of 103 participants was 30.63 kg/m2 at baseline and 29.66 kg/m2 at follow-up. Significantly higher BMI levels were reported in women than men both at baseline (p = 0.003) and follow-up (p = 0.009). Waist circumference significantly decreased from 96.20 cm to 93.16 cm (p = 0.046). The mean levels of HOMA-B significantly increased from 88.99 to 111.19 (p = 0.021). BMI was positively associated with intakes of total energy (p = 0.22), polyunsaturated fatty acids (p = 0.050), and cholesterol (p = 0.006). Waist circumference was strongly associated with total energy (p = 0.048), polyunsaturated fatty acids (p = 0.037), trans fatty acids (p = 0.039), and cholesterol (p = 0.000). HOMA-IR and HOMA-B were associated with intakes of fat (HOMA-IR: p = 0.013; HOMA-B: p = 0.040) and monounsaturated fatty acids (HOMA-IR: p = 0.003; HOMA-B: p = 0.040).

Socioeconomic inequalities in diabetes prevalence: the case of Egypt between 2008 and 2015

BACKGROUND

There is a steady increase in diabetes prevalence globally and many studies imply that high socioeconomic status (SES) is inversely related to diabetes prevalence. However, there is scarcity in literature from countries like Egypt regarding this topic.

METHODS

This study aims to investigate prevalence of diabetes in Egypt between 2008 and 2015, and the effect of SES. Diabetes prevalence -based on self-reports of past diagnosis- was measured using two datasets Egypt DHS 2008 (10,917 participants) and EHIS 2015 (16,485 participants). Logistic regression and odds ratios (ORs) with 95% confidence intervals (CIs) were applied for diabetes controlling for age, gender, educational level, employment status and place of residence. Extend of difference in diabetes prevalence between the two time points was measured by combining the two datasets using the EDHS 2008 as reference.

RESULTS

Diabetes prevalence was higher in 2015 (4.83%) compared to 2008 (3.48%). It was more in women at both time points (4.08% and 5.16% in 2008 and 2015 respectively) compared to men (2.80% and 4.43% in 2008 and 2015 respectively). Older age and living in urban areas were positively related to diabetes prevalence at both time points. Men had a significant higher chance of developing diabetes in 2015 (OR = 1.45, p-value = 0.001). Men with higher education had higher chance of developing diabetes (OR = 1.76), in contrast to women (OR = 0.59). Employment decreased the chance of developing diabetes for men (OR = .72), but had minimal effect on women (OR = 1.06).

CONCLUSION

Diabetes prevalence in Egypt has increased between the years 2008 and 2015 and evident social inequalities were found. Women had more diabetes than men and were more affected with low SES. Unlike women, highly educated men had higher chance of developing diabetes in 2015 compared to 2008. This might be attributed to behavioral and sociocultural factors.

Diabetic control and compliance using glycated haemoglobin (HbA1C) testing guidelines in public healthcare facilities of Gauteng province, South Africa

OBJECTIVE

This study aimed at evaluating diabetic control and compliance with testing guidelines, across healthcare facilities of Gauteng Province, South Africa, as well as factors associated with time to achieve control. South Africa's estimated total unmet need for care for patients with type 2 diabetes mellitus is 80%.

RESEARCH DESIGN, METHODS AND FINDINGS

The data of 511 781 patients were longitudinally evaluated. Results were reported by year, age category, race, sex, facility and test types. HbA1C of ≤7% was reported as normal, >7 - ≤9% as poor control and >9% as very poor control. The chi-squared test was used to assess the association between a first-ever HbA1C status and variables listed above. The Kaplan-Meier analysis was used to assess probability of attaining control among those who started with out-of-control HbA1C. The extended Cox regression model assessed the association between time to attaining HbA1C control from date of treatment initiation and several covariates. We reported hazard ratios, 95% confidence intervals and p-values. Data is reported for 511 781 patients with 705 597 laboratory results. Poorly controlled patients constituted 51.5%, with 29.6% classified as very poor control. Most poorly controlled patients had only one test over the entire study period. Amongst those who started with poor control status and had at least two follow-up measurements, the likelihood of achieving good control was higher in males (adjusted Hazard Ratio (aHR) = 1.16; 95% CI:1.12-1.20; p<0.001) and in those attending care at hospitals (aHR = 1.99; 95% CI:1.92-2.06; p<0.001).

CONCLUSION

This study highlights poor adherence to guidelines for diabetes monitoring.