Comparing Cardiovascular Outcomes and Costs of Perindopril-, Enalapril- or Losartan-Based Antihypertensive Regimens in South Africa: Real-World Medical Claims Database Analysis.

INTRODUCTION: Differences in class or molecule-specific effects between renin-angiotensin-aldosterone system (RAAS) inhibitors have not been conclusively demonstrated. This study used South African data to assess clinical and cost outcomes of antihypertensive therapy with the three most common RAAS inhibitors: perindopril, losartan and enalapril. METHODS: Using a large, South African private health insurance claims database, we identified patients with a hypertension diagnosis in January 2015 receiving standard doses of perindopril, enalapril or losartan, alone or in combination with other agents. From claims over the subsequent 5 years, we calculated the risk-adjusted rate of the composite primary outcome of myocardial infarction, ischaemic heart disease, heart failure or stroke; rate of all-cause mortality; and costs per life per month (PLPM), with adjustments based on demographic characteristics, healthcare plan and comorbidity. RESULTS: Overall, 32,857 individuals received perindopril, 16,693 losartan and 13,939 enalapril. Perindopril-based regimens were associated with a significantly lower primary outcome rate (205 per 1000 patients over 5 years) versus losartan (221; P < 0.0001) or enalapril (223; P < 0.0001). The risk-adjusted all-cause mortality rate was lower with perindopril than enalapril (100 vs. 139 deaths per 1000 patients over 5 years; P = 0.007), but not losartan (100 vs. 94; P = 0.650). Mean (95% confidence interval) overall risk-adjusted cost PLPM was Rands (ZAR) 1342 (87-8973) for perindopril, ZAR 1466 (104-9365) for losartan (P = 0.0044) and ZAR 1540 (77-10,546) for enalapril (P = 0.0003). CONCLUSION: In South African individuals with private health insurance, a perindopril-based antihypertensive regimen provided better clinical and cost outcomes compared with other regimens.

Socio-Economic Inequalities in the Double Burden of Malnutrition among under-Five Children: Evidence from 10 Selected Sub-Saharan African Countries.

BACKGROUND: Africa is unlikely to end hunger and all forms of malnutrition by 2030 due to public health problems such as the double burden of malnutrition (DBM). Thus, the aim of this study is to determine the prevalence of DBM and degree of socio-economic inequality in double burden of malnutrition among children under 5 years in sub-Saharan Africa. METHODS: This study used multi-country data collected by the Demographic and Health Surveys (DHS) Program. Data for this analysis were drawn from the DHS women's questionnaire focusing on children under 5 years. The outcome variable for this study was the double burden of malnutrition (DBM). This variable was computed from four indicators: stunting, wasting, underweight and overweight. Inequalities in DBM among children under 5 years were measured using concentration indices (CI). RESULTS: The total number of children included in this analysis was 55,285. DBM was highest in Burundi (26.74%) and lowest in Senegal (8.80%). The computed adjusted Erreygers Concentration Indices showed pro-poor socio-economic child health inequalities relative to the double burden of malnutrition. The DBM pro-poor inequalities were most intense in Zimbabwe (-0.0294) and least intense in Burundi (-0.2206). CONCLUSIONS: This study has shown that across SSA, among under-five children, the poor suffer more from the DBM relative to the wealthy. If we are not to leave any child behind, we must address these socio-economic inequalities in sub-Saharan Africa.

Drivers of socioeconomic inequalities of child hunger during COVID-19 in South Africa: evidence from NIDS-CRAM Waves 1-5.

BACKGROUND: Child hunger has long-term and short-term consequences, as starving children are at risk of many forms of malnutrition, including wasting, stunting, obesity and micronutrient deficiencies. The purpose of this paper is to show that the child hunger and socio-economic inequality in South Africa increased during her COVID-19 pandemic due to various lockdown regulations that have affected the economic status of the population. METHODS: This paper uses the National Income Dynamics Study-Coronavirus Rapid Mobile Survey (NIDS-CRAM WAVES 1-5) collected in South Africa during the intense COVID-19 pandemic of 2020 to assess the socioeconomic impacts of child hunger rated inequalities. First, child hunger was determined by a composite index calculated by the authors. Descriptive statistics were then shown for the investigated variables in a multiple logistic regression model to identify significant risk factors of child hunger. Additionally, the decomposable Erreygers' concentration index was used to measure socioeconomic inequalities on child hunger in South Africa during the Covid-19 pandemic. RESULTS: The overall burden of child hunger rates varied among the five waves (1-5). With proportions of adult respondents indicated that a child had gone hungry in the past 7 days: wave 1 (19.00%), wave 2 (13.76%), wave 3 (18.60%), wave 4 (15, 68%), wave 5 (15.30%). Child hunger burden was highest in the first wave and lowest in the second wave. The hunger burden was highest among children living in urban areas than among children living in rural areas. Access to electricity, access to water, respondent education, respondent gender, household size, and respondent age were significant determinants of adult reported child hunger. All the concentrated indices of the adult reported child hunger across households were negative in waves 1-5, suggesting that children from poor households were hungry. The intensity of the pro-poor inequalities also increased during the study period. To better understand what drove socioeconomic inequalites, in this study we analyzed the decomposed Erreygers Normalized Concentration Indices (ENCI). Across all five waves, results showed that race, socioeconomic status and type of housing were important factors in determining the burden of hunger among children in South Africa. CONCLUSION: This study described the burden of adult reported child hunger and associated socioeconomic inequalities during the Covid-19 pandemic. The increasing prevalence of adult reported child hunger, especially among urban children, and the observed poverty inequality necessitate multisectoral pandemic shock interventions now and in the future, especially for urban households.

The path towards herd immunity: Predicting COVID-19 vaccination uptake through results from a stated choice study across six continents.

Despite unprecedented progress in developing COVID-19 vaccines, global vaccination levels needed to reach herd immunity remain a distant target, while new variants keep emerging. Obtaining near universal vaccine uptake relies on understanding and addressing vaccine resistance. Simple questions about vaccine acceptance however ignore that the vaccines being offered vary across countries and even population subgroups, and differ in terms of efficacy and side effects. By using advanced discrete choice models estimated on stated choice data collected in 18 countries/territories across six continents, we show a substantial influence of vaccine characteristics. Uptake increases if more efficacious vaccines (95% vs 60%) are offered (mean across study areas = 3.9%, range of 0.6%-8.1%) or if vaccines offer at least 12 months of protection (mean across study areas = 2.4%, range of 0.2%-5.8%), while an increase in severe side effects (from 0.001% to 0.01%) leads to reduced uptake (mean = -1.3%, range of -0.2% to -3.9%). Additionally, a large share of individuals (mean = 55.2%, range of 28%-75.8%) would delay vaccination by 3 months to obtain a more efficacious (95% vs 60%) vaccine, where this increases further if the low efficacy vaccine has a higher risk (0.01% instead of 0.001%) of severe side effects (mean = 65.9%, range of 41.4%-86.5%). Our work highlights that careful consideration of which vaccines to offer can be beneficial. In support of this, we provide an interactive tool to predict uptake in a country as a function of the vaccines being deployed, and also depending on the levels of infectiousness and severity of circulating variants of COVID-19.

Leaving No Child Behind: Decomposing Socioeconomic Inequalities in Child Health for India and South Africa.

BACKGROUND: The United Nations' 2030 Agenda for Sustainable Development argues for the combating of health inequalities within and among countries, advocating for "leaving no one behind". However, child mortality in developing countries is still high and mainly driven by lack of immunization, food insecurity and nutritional deficiency. The confounding problem is the existence of socioeconomic inequalities among the richest and poorest. Thus, comparing South Africa's and India's Demographic and Health Surveys (DHS) of 2015/16, this study examines socioeconomic inequalities in under-five children's health and its associated factors using three child health indications: full immunization coverage, food insecurity and malnutrition. METHODS: Erreygers Normalized concentration indices were computed to show how immunization coverage, food insecurity and malnutrition in children varied across socioeconomic groups (household wealth). Concentration curves were plotted to show the cumulative share of immunization coverage, food insecurity and malnutrition against the cumulative share of children ranked from poorest to richest. Subsequent decomposition analysis identified vital factors underpinning the observed socioeconomic inequalities. RESULTS: The results confirm a strong socioeconomic gradient in food security and malnutrition in India and South Africa. However, while full childhood immunization in South Africa was pro-poor (-0.0236), in India, it was pro-rich (0.1640). Decomposed results reported socioeconomic status, residence, mother's education, and mother's age as primary drivers of health inequalities in full immunization, food security and nutrition among children in both countries. CONCLUSIONS: The main drivers of the socioeconomic inequalities in both countries across the child health outcomes (full immunization, food insecurity and malnutrition) are socioeconomic status, residence, mother's education, and mother's age. In conclusion, if socioeconomic inequalities in children's health especially food insecurity and malnutrition in South Africa; food insecurity, malnutrition and immunization in India are not addressed then definitely "some under-five children will be left behind".

Food insecurity and social injustice: The plight of urban poor African immigrants in South Africa during the COVID-19 crisis.

We discuss the plight of urban poor African immigrants from the perspective of the right to food (food availability, accessibility and adequacy) for everyone during the COVID-19 in South Africa. Despite their disrupted sources of livelihood, the majority of the African immigrants are without a social welfare safety net and have little hope of benefiting from the Government relief packages. Consequently, it seems that the increase in the triple burden of food insecurity, poverty and malnutrition compounded with social injustice and income inequality is inevitable for the urban poor African immigrants in South Africa. Even though the Government may not have the capacity to address food insecurity by itself, the Government should endeavour to make the limited resources to access food equally available to all with no social injustice. By working hand in hand with foreign national associations, township councillors and other stakeholders, such as the food banks and faith-based organisations, that have stepped forward to try and bridge the widening incapacity of the Government to feed the food insecure, the nexus of food insecurity and social injustice of African immigrants will be alleviated.

Socioeconomic inequalities in food insecurity and malnutrition among under-five children: within and between-group inequalities in Zimbabwe.

BACKGROUND: Food insecurity and malnutrition in children are pervasive public health concerns in Zimbabwe. Previous studies only identified determinants of food insecurity and malnutrition with very little efforts done in assessing related inequalities and decomposing the inequalities across household characteristics in Zimbabwe. This study explored socioeconomic inequalities trend in child health using regression decomposition approach to compare within and between group inequalities. METHODS: The study used Demographic Health Survey (DHS) data sets of 2010\11 and 2015. Food insecurity in under-five children was determined based on the WHO dietary diversity score. Minimum dietary diversity was defined by a cut- off point of > 4 therefore, children with at least 3 of the 13 food groups were defined as food insecure. Malnutrition was assessed using weight for age (both acute and chronic under-nutrition) Z-scores. Children whose weight-for-age Z-score below minus two standard deviations (- 2 SD) from the median were considered malnourished. Concentration curves and indices were computed to understand if malnutrition was dominant among the poor or rich. The study used the Theil index and decomposed the index by population subgroups (place of residence and socioeconomic status). RESULTS: Over the study period, malnutrition prevalence increased by 1.03 percentage points, while food insecurity prevalence decreased by 4.35 percentage points. Prevalence of malnutrition and food insecurity increased among poor rural children. Theil indices for nutrition status showed socioeconomic inequality gaps to have widened, while food security status socioeconomic inequality gaps contracted for the period under review. CONCLUSION: The study concluded that unequal distribution of household wealth and residence status play critical roles in driving socioeconomic inequalities in child food insecurity and malnutrition. Therefore, child food insecurity and malnutrition are greatly influenced by where a child lives (rural/urban) and parental wealth.

A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa.

BACKGROUND: Chronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model. METHODS: This was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically. RESULTS: The median age of participants was 36.5 (IQR: 30.8-45.5) years, and they had been in their roles for a median of 4.0 (IQR: 1.0-7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure, adequate staff, and balanced patient caseloads. CONCLUSION: There are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.

Food purchasing behaviour of shoppers from different South African socio-economic communities: results from grocery receipts, intercept surveys and in-supermarkets audits.

OBJECTIVE: To identify factors associated with food purchasing decisions and expenditure of South African supermarket shoppers across income levels. DESIGN: Intercept surveys were conducted, grocery receipts collated and expenditure coded into categories, with each category calculated as percentage of the total expenditure. In-supermarket food quality audit and shelf space measurements of foods such as fruits and vegetables (F&V) (healthy foods), snacks and sugar-sweetened beverages (SSB) (unhealthy foods) were also assessed. Shoppers and supermarkets were classified by high-, middle- and low-income socio-economic areas (SEA) of residential area and location, respectively. Shoppers were also classified as "out-shoppers" (persons shopping outside their residential SEA) and "in-shoppers" (persons shopping in their residential SEA). Data were analysed using descriptive analysis and ANOVA. SETTING: Supermarkets located in different SEA in urban Cape Town. PARTICIPANTS: Three hundred ninety-five shoppers from eleven purposively selected supermarkets. RESULTS: Shelf space ratio of total healthy foods v. unhealthy foods in all the supermarkets was low, with supermarkets located in high SEA having the lowest ratio but better quality of fresh F&V. The share expenditure on SSB and snacks was higher than F&V in all SEA. Food secure shoppers spent more on food, but food items purchased frequently did not differ from the food insecure shoppers. Socio-economic status and food security were associated with greater expenditure on food items in supermarkets but not with overall healthier food purchases. CONCLUSION: Urban supermarket shoppers in South Africa spent substantially more on unhealthy food items, which were also allocated greater shelf space, compared with healthier foods.

The cost and cost implications of implementing the integrated chronic disease management model in South Africa.

BACKGROUND: A cost analysis of implementation of interventions informs budgeting and economic evaluations. OBJECTIVE: To estimate the cost of implementing the integrated chronic disease management (ICDM) model in primary healthcare (PHC) clinics in South Africa. METHODS: Cost data from the provider's perspective were collected in 2019 from four PHC clinics with comparable patient caseloads (except for one). We estimated the costs of implementing the ICDM model current activities for three (facility reorganization, clinical supportive management and assisted self-management) components and additional costs of implementing with enhanced fidelity. Costs were estimated based on budget reviews, interviews with management teams, and other published data. The standard of care activities such as medication were not included in the costing. One-way sensitivity analyses were carried out for key parameters by varying patient caseloads, required infrastructure and staff. Annual ICDM model implementation costs per PHC clinic and per patient per visit are presented in 2019 US dollars. RESULTS: The overall mean annual cost of implementing the ICDM model was $148 446.00 (SD: $65 125.00) per clinic. Current ICDM model activities cost accounted for 84% ($124 345.00) of the annual mean cost, while additional costs for higher fidelity were 16% ($24 102.00). The mean cost per patient per visit was $6.00 (SD:$0.77); $4.94 (SD:0.70) for current cost and $1.06 (SD:0.33) for additional cost to enhance ICDM model fidelity. For the additional cost, 49% was for facility reorganization, 31% for adherence clubs and 20% for training of nursing staff. In the sensitivity analyses, the major cost drivers were the proportion of effort of assisted self-management staff and the number of patients with chronic diseases receiving care at the clinic. CONCLUSION: Minimal additional cost are required to implement the ICDM model with higher fidelity. Further research on the cost-effectiveness of the ICDM model in middle-income countries is required.

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme.

BACKGROUND: Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC. METHODS: Using a cross-sectional survey across four of South Africa's nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status. RESULTS: A quarter of respondents remained uninsured, even higher among 20-29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits. CONCLUSIONS: By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country's financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

Acceptability of community-based adherence clubs among health facility staff in South Africa: a qualitative study.

BACKGROUND: Patient retention in care for HIV/AIDS is a critical challenge for antiretroviral treatment programs. Community-based adherence programs (CBAPs) as compared to health care facility-based adherence programs have been considered as one of the options to provide treatment maintenance support for groups of patients on antiretroviral therapy. Such an approach provides a way of enhancing self-management of the patient's condition. In addition, CBAPs have been implemented to support antiretroviral treatment expansion in resource-limited settings. CBAPs involve 30 patients that are allocated to a group and meet at either a facility or a community venue for less than an hour every 2 or 3 months depending on the supply of medication. Our study aimed to establish perceived challenges in moving adherence clubs from health facilities to communities. METHODS: A qualitative study was conducted in 39 clinics in Mpumalanga and Gauteng Provinces in South Africa between December 2015 and January 2016. Purposive sampling method was used to identify nurses, club managers, data capturers, pharmacists and pharmacy assistants who had been involved in facility-based treatment adherence clubs. Key-informant interviews were conducted. Also, semi-structured interviews were used and thematic content analysis was done. RESULTS: A total of 53 health care workers, 12 (22.6%) males and 41 (77.4%) females, participated in the study. Most of them 49 (92.5%) indicated that participating in community adherence clubs were a good idea. Reduction in waiting time at the health facilities, in defaulter rate, improvement in adherence to treatment as well as reduction in stigma were some of the perceived benefits. However, security of medication, storage conditions and transportation of the prepacked medication to the distribution sites were the areas of concern. CONCLUSION: Health care workers were agreeable to idea of the moving adherence clubs from health facilities to communities. Although some challenges were identified, these could be addressed by the key stakeholders. However, government and nongovernmental organizations need to exercise caution when transitioning to community-based adherence clubs.

The mediating role of self-efficacy in the relationship between premotivational cognitions and engagement in multiple health behaviors: a theory-based cross-sectional study among township residents in South Africa.

BACKGROUND: Noncommunicable diseases (NCDs) are one of the major global health challenges in developed countries and are rapidly increasing globally. Perception of self-efficacy is important for complex activities and long-term changes in health behavior. This study aimed to determine whether self-efficacy mediates the effect of individual beliefs (perceived severity, susceptibility, benefits and barriers) among informal settlement residents' health behavior in relation to the prevention and management of NCDs. METHODS: A cross-sectional survey was conducted using a closed-ended questionnaire among informal settlement residents in Diepsloot, Johannesburg. The proposed model was tested using structural equation modeling (AMOS software). RESULTS: A total of 2,277 participants were interviewed during this survey, consisting of 1,236 (54.3%) females, with the majority of them aged between 20 and 29 years. All constructs in the questionnaire had a good reliability with a Cronbach's alpha of >0.7. Perceived benefits and perceived barriers were the strongest predictors of self-efficacy, with the highest beta values of 0.14 and 0.15, respectively. Once associated with perceived self-efficacy, the direct effect of perceived susceptibility and perceived benefits on health behavior was statistically nonsignificant (P=0.0894 and P=0.2839, respectively). Perceived benefits and perceived susceptibility were totally mediated by self-efficacy. The indirect effects of perceived severity and perceived barriers (through self-efficacy) on health behavior were significant. Thus, perceived severity and perceived barriers were partially mediated by self-efficacy. CONCLUSION: Perceived susceptibility and perceived benefits did not affect health behavior unless associated with self-efficacy. In contrast, individual perception of the seriousness of NCDs and perceived barriers might still have a direct influence on health behavior even if the person does not feel able to prevent NCDs. However, this influence would be more significant when perceived severity and perceived barriers of NCDs are associated with self-efficacy.