Health systems performance for hypertension control using a cascade of care approach in South Africa, 2011-2017

Hypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system's ability to manage hypertension between 2011 and 2017. We used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. In 2011, 19.6% (95%CI 14.2, 26.2) of individuals with incident hypertension were diagnosed, 15.4% (95%CI 10.8, 21.4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24.4% (95%CI 15.9, 35.4). Increases in treatment (23.3%, 95%CI 15.0, 34.3) and control (22.1%, 95%CI 14.1, 33.0) were also observed, translating to a decrease in unmet need for hypertension care from 92.9% in 2011 to 77.9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3.01 (95%CI 1.77, 5.13) times more likely to have a controlled blood pressure compared to those in 2011. Our data show that while substantial improvements in the hypertension care cascade occurred between 2011 and 2017, a large burden of unmet need remains. The greatest losses in the incident hypertension care cascades came before diagnosis. Nevertheless, whole system programming will be needed to sufficiently address significant morbidity and mortality related to having an elevated blood pressure.

Global benchmarking of children's exposure to television advertising of unhealthy foods and beverages across 22 countries

Restricting children's exposures to marketing of unhealthy foods and beverages is a global obesity prevention priority. Monitoring marketing exposures supports informed policymaking. This study presents a global overview of children's television advertising exposure to healthy and unhealthy products. Twenty-two countries contributed data, captured between 2008 and 2017. Advertisements were coded for the nature of foods and beverages, using the 2015 World Health Organization (WHO) Europe Nutrient Profile Model (should be permitted/not-permitted to be advertised). Peak viewing times were defined as the top five hour timeslots for children. On average, there were four times more advertisements for foods/beverages that should not be permitted than for permitted foods/beverages. The frequency of food/beverages advertisements that should not be permitted per hour was higher during peak viewing times compared with other times (P < 0.001). During peak viewing times, food and beverage advertisements that should not be permitted were higher in countries with industry self-regulatory programmes for responsible advertising compared with countries with no policies. Globally, children are exposed to a large volume of television advertisements for unhealthy foods and beverages, despite the implementation of food industry programmes. Governments should enact regulation to protect children from television advertising of unhealthy products that undermine their health.

The development of an evidence-based street food vending model within a socioecological framework: A guide for African countries

In the present global economic crisis and continued rapid urbanization, street food (SF) vending has grown into a practical source of income for people in the developing world. SF are not only appreciated for their unique flavours, convenience, and affordability they also contribute to the economy of the country, the perseverance of cultural and social heritage of society, as well as the potential for maintaining and improving the nutritional status of populations. This study aimed to develop a street food vending model (SFVM) that encompasses healthy and safe food options for consumers including hygiene and safety guidelines and viable business and operations for vendors. An evidence-based approach, i.e. “systematically collected proof”, was used to inform the development of this model. Phase 1 included two surveys, one of street food vendors (N = 831) and the other of consumers (N = 1047). These surveys obtained data regarding the vendors’ operations and food items they sold and the consumers’ purchases and their nutrition knowledge. In Phase 2, interviews and focus groups were conducted with government officials. Additionally, regulations and policies regarding street vending were reviewed to determine available regulations and policies for street food vending. In Phase 3, data from the two phases were integrated and participatory action methods involving street food vendors used to validate the findings and inform the development of a SFVM by engaging in focus group discussions with street food vendors (N = 28). The components of the proposed SFVM comprised four parts, namely a food and nutrition component, a hygiene component, a business component and a vending cart. These components serve as a guide and considers various elements of the socioecological framework, namely intrapersonal/individual and interpersonal factors, the physical environment/community as well as the policy environment. The development of this model can serve as an example to countries which have large street food vending components and wish to optimize their value by making them safe and healthy for consumers. Thus, allowing vendors to trade under optimal conditions giving due consideration to regulations and policy.

Prevalence and unmet need for diabetes care across the care continuum in a national sample of South African adults: Evidence from the SANHANES-1, 2011-2012

South Africa faces an epidemic of chronic non-communicable diseases (NCDs), yet national surveillance is limited due to the lack of recent data. We used data from the first comprehensive national survey on NCDs—the South African National Health and Nutrition Examination Survey (SANHANES-1 (2011–2012))—to evaluate the prevalence of and health system response to diabetes through a diabetes care cascade. We defined diabetes as a Hemoglobin A1c equal to or above 6.5% or currently on treatment for diabetes. We constructed a diabetes care cascade by categorizing the population with diabetes into those who were unscreened, screened but undiagnosed, diagnosed but untreated, treated but uncontrolled, and treated and controlled. We then used multivariable logistic regression models to explore factors associated with diagnosed and undiagnosed diabetes. The age-standardized prevalence of diabetes in South Africans aged 15+ was 10.1%. Prevalence rates were higher among the non-white population and among women. Among individuals with diabetes, a total of 45.4% were unscreened, 14.7% were screened but undiagnosed, 2.3% were diagnosed but untreated, 18.1% were treated but uncontrolled, and 19.4% were treated and controlled, suggesting that 80.6% of the diabetic population had unmet need for care. The diabetes care cascade revealed significant losses from lack of screening, between screening and diagnosis, and between treatment and control. These results point to significant unmet need for diabetes care in South Africa. Additionally, this analysis provides a benchmark for evaluating efforts to manage the rising burden of diabetes in South Africa.

Self-reported diabetes during pregnancy in the South African National Health and Nutrition Examination Survey: extent and social determinants

BACKGROUND

Diabetes is a serious and growing public health concern in South Africa, but its prevalence and distribution in pregnant women is not well known. Women diagnosed with diabetes during pregnancy have a substantially greater risk of adverse health outcomes for both mother and child. This study aims to determine the prevalence and social determinants of diabetes during pregnancy in South Africa.

METHODS

Data used in this study were from the 2012 South African National Nutrition and Health Examination Survey; a nationally representative cross-sectional household survey. The analysis was restricted to girls and women between the ages of 15 to 49 years who self-reported ever being pregnant (n = 4261) Logistic regression models were constructed to analyse the relationship between diabetes during pregnancy and several indicators including race, family history of diabetes, household income, area of residence and obesity.

RESULTS

The prevalence of diabetes during pregnancy in South Africa was 3% (144 women) of all women who reported ever being pregnant. The majority of the women who had ever had diabetes were African (70%), 51% were unemployed and 76% lived in rural areas. Factors strongly associated with diabetes during pregnancy were age (1.04 [Odds Ratio], 0.01 [Standard Error]), family history of diabetes (3.04; 0.8) and race (1.91; 0.53).

CONCLUSION

The analysis will contribute to an understanding of the prevalence of diabetes during pregnancy and its social determinants. This will help in the development of effective interventions targeted at improving maternal and child health for mothers at high risk.

Nutritional contribution of street foods to the diet of people in developing countries: a systematic review

OBJECTIVE

To review studies examining the nutritional value of street foods and their contribution to the diet of consumers in developing countries.

DESIGN

The electronic databases PubMed/MEDLINE, Web of Science, Cochrane Library, Proquest Health and Science Direct were searched for articles on street foods in developing countries that included findings on nutritional value.

RESULTS

From a total of 639 articles, twenty-three studies were retained since they met the inclusion criteria. In summary, daily energy intake from street foods in adults ranged from 13 % to 50 % of energy and in children from 13 % to 40 % of energy. Although the amounts differed from place to place, even at the lowest values of the percentage of energy intake range, energy from street foods made a significant contribution to the diet. Furthermore, the majority of studies suggest that street foods contributed significantly to the daily intake of protein, often at 50 % of the RDA. The data on fat and carbohydrate intakes are of some concern because of the assumed high contribution of street foods to the total intakes of fat, trans-fat, salt and sugar in numerous studies and their possible role in the development of obesity and non-communicable diseases. Few studies have provided data on the intake of micronutrients, but these tended to be high for Fe and vitamin A while low for Ca and thiamin.

CONCLUSIONS

Street foods make a significant contribution to energy and protein intakes of people in developing countries and their use should be encouraged if they are healthy traditional foods.

Dietitians in South Africa require more competencies in public health nutrition and management to address the nutritional needs of South Africans

The aim of this study was to determine whether dietitians in South Africa are competent to meet the requirements of working in a health care setting during a compulsory one-year community service (CS) program immediately after receiving their degree. A national survey was conducted using questionnaires to illicit information from dietitians on their training and competencies. In 2009, data were collected from both community service dietitians (CSDs) participating in community service programs in primary, secondary and tertiary health care centers in all provinces of South Africa, as well as from their provincial managers (nutrition coordinators). Sixteen (100% response) nutrition coordinators and 134 (80% response) dietitians participated in the quantitative survey. The majority of the CSDs reported that, overall, their academic training had prepared them for most aspects of nutrition service delivery. However, some recommended that academic programs include more training on community-based nutrition programs and in delivering optimal services to under-resourced communities as they believed that their competencies in these two areas were weakest. Furthermore, many CSDs were required to establish dietetics departments where none had previously existed; consequently, their capacity in management and administration needed improvement. In conclusion, academic training institutions should align their programs to the transformation of the health sector in South Africa by ensuring that dietitians are empowered to provide optimal public health nutrition services in under-resourced communities.