Area-level deprivation and individual-level socioeconomic correlates of the diabetes care cascade among black south africans in uMgungundlovu, KwaZulu-Natal, South Africa.

South Africa is experiencing a rapidly growing diabetes epidemic that threatens its healthcare system. Research on the determinants of diabetes in South Africa receives considerable attention due to the lifestyle changes accompanying South Africa's rapid urbanization since the fall of Apartheid. However, few studies have investigated how segments of the Black South African population, who continue to endure Apartheid's institutional discriminatory legacy, experience this transition. This paper explores the association between individual and area-level socioeconomic status and diabetes prevalence, awareness, treatment, and control within a sample of Black South Africans aged 45 years or older in three municipalities in KwaZulu-Natal. Cross-sectional data were collected on 3,685 participants from February 2017 to February 2018. Individual-level socioeconomic status was assessed with employment status and educational attainment. Area-level deprivation was measured using the most recent South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and hypertension diagnosis. The prevalence of diabetes was 23% (n = 830). Of those, 769 were aware of their diagnosis, 629 were receiving treatment, and 404 had their diabetes controlled. Compared to those with no formal education, Black South Africans with some high school education had increased diabetes prevalence, and those who had completed high school had lower prevalence of treatment receipt. Employment status was negatively associated with diabetes prevalence. Black South Africans living in more deprived wards had lower diabetes prevalence, and those residing in wards that became more deprived from 2001 to 2011 had a higher prevalence diabetes, as well as diabetic control. Results from this study can assist policymakers and practitioners in identifying modifiable risk factors for diabetes among Black South Africans to intervene on. Potential community-based interventions include those focused on patient empowerment and linkages to care. Such interventions should act in concert with policy changes, such as expanding the existing sugar-sweetened beverage tax.

Racial disparities in psychological distress in post-apartheid South Africa: results from the SANHANES-1 survey.

PURPOSE: South Africa has long endured a high prevalence of mental disorders at the national level, and its unique social and historical context could be a contributor to an increased risk of mental health problems. Our current understanding is limited regarding the relative importance of various social determinants to mental health challenges in South Africa, and how existing racial inequities may be explained by these determinants. METHODS: This study attempted to elucidate potential social determinants of mental health in South Africa using data from the nationally representative South African National Health and Nutrition Examination Survey (SANHANES-1). The main outcome of interest was psychological distress, measured with the Kessler-10 scale. Hierarchical linear regression models included covariates for demographic and socioeconomic factors, count of traumatic events, and a series of stress-related constructs. Analyses were conducted on two populations: the entire sample (n = 15,981), and the African subpopulation (n = 10,723). RESULTS: Regression models on the entire sample indicated racial disparities in psychological distress, with Africans experiencing higher distress than White and Coloured individuals. Results within the African sub-population indicated geo-spatial disparities, with Africans in formal urban settings experiencing higher psychological distress than those living in formal and informal rural locales. Across both samples, results indicated a cumulative association between count of stressors and traumatic events and distress. CONCLUSION: We found racial disparities across several mental health-related domains. Africans had greater exposure to traumatic events, social stressors, and psychological distress. This research is a necessary foundation for public health interventions and policy change to effectively reduce inequities in psychological distress.

Prevalence and associated factors of vision loss in the South African National Health and Nutrition Examination Survey (SANHANES-1).

BACKGROUND: Vision loss is a major public health concern that significantly affects developing countries, including South Africa. Although existing literature have reported on the prevalence, causes, and impact of vision loss on the quality of life of affected individuals (children and adults) in parts of South Africa, there is no evidence of the prevalence and associated factors of vision loss in the general population. Hence, this study aimed to determine the prevalence of vision loss and its associated factors in South Africa using a population-based survey. METHODS: Secondary analyses were conducted using data from the South African National Health and Nutrition Examination Survey (SANHANES-1), a population-based national health survey conducted from 2011 to 2012. Vision loss was defined as presenting visual acuity (PVA) worse than Snellen 6/12 in the better eye. Visual acuity was assessed by clinicians and participants' subjective response to vision-related questions. Univariate and multiple logistic regression models were used to examine the association of the independent variables with vision loss. RESULTS: The analytic sample comprised 4346 individuals with a mean age of 39.1 years. Female sex accounted for 55.6% of the participants. The prevalence of vision loss among participants was 9.2% (95% CI: 7.7-10.9). Older age (45-54 years, OR = 2.99, p < 0.001; 55-64 years, OR = 5.78, p < 0.001 and ≥ 65 years, OR = 5.12, p < 0.001), female sex (OR = 1.50, p = 0.016), and previous diabetes diagnosis (OR = 2.28, p = 0.001) were significantly associated with increased odds of vision loss. Further, secondary school education (OR = 0.71, p = 0.031), white ethnicity (OR = 0.11, p = 0.007), residing in Mpumalanga province (OR = 0.12, p < 0.001) and having never had an eye examination (OR = 0.56, p = 0.003) were significantly associated with reduced odds of vision loss. CONCLUSION: Almost one in ten participants had vision loss. Adopting strategies targeted at reducing barriers to the utilization of eye care services will promote early detection and management of blinding conditions, and thereby, decrease the burden of vision loss in South Africa.

Body Image and the Double Burden of Nutrition among South Africans from Diverse Sociodemographic Backgrounds: SANHANES-1.

This study investigated the associations between underweight, obesity and body image (BI) among 15+ year-old South Africans with diverse socio-demographic backgrounds. A cross-sectional survey and the analyses of data for 6411 15+ year-old participants in the first South African National Health and Nutrition Examination Survey was undertaken. Body image was compared to body mass index (BMI) and socio-demography. Data were analyzed using SPSS versions 25. Results are in percentages, means, 95% confidence intervals, p-values, and odds ratios. Overall, participants who were obese of which majority: were females, earned ZAR 9601+, completed grade 6, were non-Black men, were married and resided in urban formal areas, were more likely to underestimate their BMI and desire to be lighter. Participants who were underweight of which majority: were males, had no form of income or education, were black men, were not married, resided in less urban and farm areas, were younger than 25 years, were more likely to overestimate their BMI and desire to be heavier. While underweight and obesity were strong determinants of BI, BI was differentiated by socio-demography. These findings have a public health implication that requires special attention to curb the irrepressible underweight and obesity in South Africa.

Implications of scaling up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis.

BACKGROUND: Cardiovascular diseases and their risk factors-particularly hypertension, dyslipidaemia, and diabetes-have become an increasing concern for middle-income countries. Using newly available, nationally representative data, we assessed how cardiovascular risk factors are distributed across subpopulations within South Africa and identified which cardiovascular treatments should be prioritised. METHODS: We created a demographically representative simulated population for South Africa and used data from 17 743 respondents aged 15 years or older of the 2012 South African National Health and Nutrition Examination Survey (SANHANES) to assign information on cardiovascular risk factors to each member of the simulated population. We created a microsimulation model to estimate the health and economic implications of two globally recognised treatment recommendations: WHO's package of essential non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines. The primary outcome was total disability-adjusted life-years (DALYs) averted through treatment of all cardiovascular disease or microvascular type 2 diabetes complications per 1000 population. We compared outcomes at the aspirational level of achieving access to treatment among 70% of the population. FINDINGS: Based on the SANHANES data, South Africans had a high prevalence of hypertension (24·8%), dyslipidaemia (17·5%), and diabetes (15·3%). Prevalence was disproportionately high and treatment low among male, black, and poor populations. Our simulated population experienced a burden of 40·0 DALYs (95% CI 29·5-52·0) per 1000 population per year from cardiovascular disease or type 2 diabetes complications at current treatment levels, which lowered to 32·9 DALYs (24·4-44·7) under WHO PEN implementation and to 32·5 (24·4-44·8) under SA PC 101 implementation. Under both guidelines, there were increases in blood pressure treatment (4·2 percentage points under WHO PEN vs 12·6 percentage points under SA PC 101), lipid treatment (16·0 vs 14·9), and glucose control medications (1·2 vs 0·6). The incremental cost-effectiveness of implementing SA PC 101 over current treatment would be a saving of US$24 902 (95% CI 14 666-62 579) per DALY averted compared with a saving of $17 587 (1840-42 589) under WHO PEN guidelines. INTERPRETATION: Cardiovascular risk factors are common and disproportionate among disadvantaged populations in South Africa. Treatment with blood pressure agents and statins might need greater prioritisation than blood glucose therapies, which contrasts with observed treatment levels despite a lower monthly cost of blood pressure or statin treatment than of sulfonylurea or insulin treatment. FUNDING: Stanford University.

Quantifying unmet need for hypertension care in South Africa through a care cascade: evidence from the SANHANES, 2011-2012.

INTRODUCTION: Hypertension has become a major cause of morbidity and premature mortality in South Africa, but population-wide estimates of prevalence and access to care are scarce. Using data from the South African National Health and Nutrition Examination Survey (2011-2012), this analysis evaluates the national prevalence of hypertension and uses a care cascade to examine unmet need for care. METHODS: Hypertension was defined as blood pressure over 140/90 mm Hg or use of antihypertensive medication. We constructed a hypertension care cascade by decomposing the population with hypertension into five mutually exclusive and exhaustive subcategories: (1) unscreened and undiagnosed, (2) screened but undiagnosed, (3) diagnosed but untreated, (4) treated but uncontrolled and (5) treated and controlled. Multivariable logistic regression models were used to explore factors associated with hypertension prevalence and diagnosis. RESULTS: In South Africans aged 15 and above, the age standardised prevalence of hypertension was 35.1%. Among those with hypertension, 48.7% were unscreened and undiagnosed, 23.1% were screened but undiagnosed, 5.8% were diagnosed but untreated, 13.5% were treated but uncontrolled and 8.9% were controlled. The hypertension care cascade demonstrates that 49% of those with hypertension were lost at the screening stage, 50% of those who were screened never received a diagnosis, 23% of those who were diagnosed did not receive treatment and 48% of those who were treated did not reach the threshold for control. Men and older individuals had increased risks of being undiagnosed after controlling for other factors. CONCLUSIONS: There is significant unmet need for hypertension care in South Africa; 91.1% of the hypertensive population was unscreened, undiagnosed, untreated or uncontrolled. Data from this study provide insight into where patients are lost in the hypertension care continuum and serve as a benchmark for evaluating efforts to manage the rising burden of hypertension in South Africa.

The association between adolescent risk behaviours and feelings of sadness or hopelessness: a cross-sectional survey of South African secondary school learners.

Poor mental health in adolescents has shown associations with engagement in other risk behaviours. However, evidence of this association in Sub-Saharan Africa, particularly South Africa, is lacking. This study examines the associations between pertinent risk behaviours and feelings of sadness or hopelessness amongst a nationally representative sample of South African school going adolescents. Data was analysed from the South African Youth Risk Behaviour Survey 2011 (n=10,997), a cross-sectional national survey among grades 8-11 school learners. Logistic regression examined the association of demographic, substance use, violent behaviour, sexual activity and suicidal plans and attempts with the primary outcome, feelings of sadness or hopelessness. Having feelings of sadness or hopelessness was significantly associated with more senior grades, being bullied (AOR:1.67, 95% CI: 1.42-1.96), being assaulted by a partner (1.33 [1.05-1.68]), forced sex (1.78 [1.37-2.32]); gang membership (1.32 [1.06-1.65]), binge drinking (1.37 [1.14-1.65]), ever having sex (1.23 [1.02-1.47]), having ≥1 partner/s in preceding three months (1.25 [1.02-1.53]), having made a plan to attempt suicide (2.50 [1.95-3.21]) and suicide attempt (1.49 [1.21-1.85]). Adolescents in South Africa are experiencing a multiple burden of risk. Health promotion strategies targeting adolescent mental health and risk behaviours need to be developed and implemented in a timely and comprehensive manner.

Teenage pregnancy rates and associations with other health risk behaviours: a three-wave cross-sectional study among South African school-going adolescents.

BACKGROUND: Teenage pregnancy still remains high in low and middle-income countries (LMIC), as well as in high-income countries (HIC). It is a major contributor to maternal and child morbidity and mortality rates. Furthermore, it has social consequences, such as perpetuating the cycle of poverty including early school dropout by the pregnant adolescent, especially in sub-Saharan Africa (SSA). Few studies in SSA have investigated the trends in teenage pregnancy and the associated factors, while this is critical in fully understanding teenage pregnancy and for promotion of reproductive health among adolescents at large in SSA. METHODS: To examine the trends in teenage pregnancy and to identify associations with other health risk behaviours in South Africa (SA), a total of 31 816 South African school-going adolescents between 11 to 19 years of age were interviewed in three cross-sectional surveys. Data from the first (2002, n = 10 549), second (2008, n = 10 270) and the third (2011, n = 10 997) nationally representative South African youth risk behaviour surveys (YRBS) were used for this study. RESULTS: The overall prevalence of having ever been pregnant among the combined 3-survey sample was self-reported to be 11.0 % and stable across the three surveys. Sexual intercourse among adolescents in SA has decreased from 41.9 % in 2002 to 36.9 % in 2011. However, pregnancy among girls who ever had sex increased from 17.3 % (95 % CI: 0.16-0.19) in 2002, to 23.6 % (95 % CI: 0.21-0.26) in 2008 and decreased to 21.3 % (95 % CI: 0.19-0.23) in 2011. The odds for ever been pregnant were higher for girls who had 2 or more sexual partners (OR: 1.250, 95 % CI: 1.039-1.503), girls who ever used alcohol before sex (OR: 1.373, 95 % CI: 1.004-1.878), practised binge-drinking during the last month (OR: 0.624, 95 % CI: 0.503-0.774), and girls who used mandrax (OR: 1.968, 95 % CI: 1,243-3.117). The odds for never been pregnant were lower for those who used condoms (OR: 0.462, 95 % CI: 0.309-0.691). CONCLUSIONS: Girls continue to become pregnant at unacceptably high rates in SA. Sexual intercourse among adolescents in SA has decreased slightly. However, among those who are sexually active pregnancy prevalence rates have increased. More over, this is in the context of high prevalence of HIV and other STI. There is a need to address adolescents' sexual and reproductive health, and several health risk behaviours, including substance use, that are associated with teenage pregnancy in SA.

A decade of tobacco control: the South African case of politics, health policy, health promotion and behaviour change.

BACKGROUND: The South African (SA) government has implemented comprehensive tobacco control measures in line with the requirements of the Framework Convention on Tobacco Control. The effect of these measures on smoking prevalence and smoking-related attitudes, particularly among young people, is largely unknown. OBJECTIVE: To describe the impact of a comprehensive health promotion approach to tobacco control amongst SA school learners. METHODS: Four successive cross-sectional Global Youth Tobacco Surveys (GYTSs) were conducted in 1999, 2002, 2008 and 2011 among nationally representative samples of SA grades 8 - 10 school learners. We assessed the prevalence of current smoking (having smoked a cigarette on ≥1 day in the 30 days preceding the survey) and smoking-related attitudes and behaviours. RESULTS: Over the 12-year survey period current smoking among learners declined from 23.0% (1999) to 16.9% (2011) - a 26.5% reduction. Reductions in smoking prevalence were less pronounced amongst girls and amongst black learners. We observed an increase in smoking prevalence amongst learners between 2008 and 2011. Smoking-related attitudes and behaviours showed favourable changes over the survey period. CONCLUSION: These surveys demonstrate that the comprehensive and inter-sectorial tobacco control health promotion strategies implemented in SA have led to a gradual reduction in cigarette use amongst school learners. Of concern, however, are the smaller reductions in smoking prevalence amongst girls and black learners and an increase in smoking prevalence from 2008 to 2011. Additional efforts, especially for girls, are needed to ensure continued reduction in smoking prevalence amongst SA youth.