The timing of antenatal care access for adolescent pregnancies in Cape Town, South Africa.

BACKGROUND:  Late antenatal care (ANC)-seeking among pregnant adolescents threatens their health outcomes, and the health outcomes of their new-borns. South Africa has experienced a rapid increase in adolescent pregnancies during the COVID-19 pandemic, adding to the existing concerns around adolescent pregnancy care-seeking behaviour. AIM:  The main aim of this study was to investigate the causes and covariates of late ANC access among adolescents in the Cape Town Metropole, South Africa. SETTING:  Three public healthcare facilities in the Cape Town Metropole, 2018-2019. METHODS:  A retrospective, cross-sectional study on ANC seeking behaviour was conducted, surveying 202 adolescents. Late attendance was defined as attending ≥ 3 months. For this study, adolescents were defined as women aged 16-18 years. The sample was restricted to adolescents who used public healthcare facilities or who did not attend at all. Data were analysed using univariate, bivariate and multivariate methods. RESULTS:  A total of 50.8% (n = 99/195) of the pregnant adolescents in the sample had their first ANC visit 3 months. 14.9% (n = 29/195) did not attend at all. Major contributors to delayed care-seeking include poor pregnancy identification (n = 45/99, 45.5%), and a lack of information about ANC. Age, education, and alcohol consumption were significant predictors of delayed care-seeking. CONCLUSION:  Delayed ANC attendance contributes to negative long-term health outcomes for pregnant adolescents and their new-borns. Improving access to pregnancy tests in the public sector could benefit adolescents with earlier pregnancy identification. Adolescents need to be made aware of their care seeking options.Contribution: There is evidence of long-term health impacts of late ANC attendance by pregnant adolescents, but there is an absence of evidence on the timing and barriers of late care-seeking behaviour. In this study, late ANC attendance among adolescents was associated with late pregnancy identification and poor knowledge of care options.

Scoping review of the impact of coronavirus disease 2019 on unplanned pregnancy.

BACKGROUND:  Increased pressure on the healthcare system because of coronavirus disease 2019 (COVID-19) along with national lockdown policies had consequences on the sexual and reproductive health of women. While the pandemic has resulted in changes in pregnancy intentions, child-bearing and fertility, the direction of this relationship is unclear and is likely to be impacted by each country's socio-economic status and stage of fertility transition. Understanding the fertility trajectory and the pandemic is important in understanding population structures and ageing, which have consequences for health policies, budgeting and economic activity. AIM:  This study aimed to conduct a scoping review of the impact of COVID-19 on unplanned pregnancy. METHODS:  A rapid review of available literature using Google Scholar, PubMed and Medical Literature Analysis and Retrieval System Online (MEDLINE), SocINDEX, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Academic Search Ultimate. Articles in English from 2020 to 2021 were included. RESULTS:  Fifteen articles were included. These were mostly cross-sectional, primary data-collection surveys exploring the relationship between COVID-19 and child-bearing intentions. CONCLUSION:  Access to contraceptives, socio-economic status and uncertainty about the health impact of COVID-19 on pregnancy were major themes that emerged when considering child-bearing intentions. Evidence of changes in the number of unplanned pregnancies and abortions was not insignificant but should be explored further. Although the studies covered a range of countries, more studies are needed focusing on low- and middle-income countries where the socio-economic impact of child-bearing intention is greater. There is a need for causal analysis using country-level data and for longer studies using more robust methodologies. The pandemic will continue to influence birth rates.Contribution: This article revealed gaps in the current literature on the measurement of the quantitative and causal impact of the COVID-19 pandemic on fertility and child-bearing. Findings from our study may assist in setting the trajectory for future research.

Inequalities in successful tobacco cessation and tobacco cessation attempts: Evidence from eight Sub-Saharan African countries.

BACKGROUND: Tobacco consumption is a contributing and modifiable risk factor for non-communicable diseases. In high-income countries, tobacco cessation attempts, and their success, are concentrated among the socio-economically advantaged, resulting in a skewed burden of disease. However, there is a paucity of evidence on the distribution of tobacco cessation in low- and middle-income countries. OBJECTIVE: The objective of this study is to measure and decompose wealth- and education-related inequalities in tobacco cessation in eight Sub-Saharan African countries. METHODOLOGY: The study applies Erreygers' corrected concentration indices and decomposition methods to the most recent Global Adult Tobacco Surveys in Botswana, Cameroon, Ethiopia, Kenya, Nigeria, Senegal, Tanzania, and Uganda. FINDINGS: We find that across countries, successful tobacco cessation, as well as tobacco cessation attempts, are concentrated among wealthier and better-educated individuals. Differences in socio-economic status, urban or rural residence, and not knowing or believing that tobacco consumption leads to serious illness contributes to these inequalities. CONCLUSION: Governments in our sample of countries can do more to support socio-economically disadvantaged smokers in their efforts to quit smoking, including by making an effort to align each country's smoking cessation strategy with the guidelines outlined in the World Health Organization's Framework Convention on Tobacco Control.

Modification of the ALSFRS-R for Utilization in Individuals Not Using Noninvasive Ventilation.

BACKGROUND: The Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) is widely employed in assessing functional decline in individuals with amyotrophic lateral sclerosis (ALS). A limitation of the scale is that item 12 does not directly evaluate worsening respiratory failure in ALS but rather the management thereof as a surrogate marker. We propose an alternative scale to assess respiratory function in ALS individuals who do not use noninvasive ventilation (NIV). METHODS: 85 participants were included in the study. ALSFRS-R scores were calculated and FVC measured at each clinic visit. Additional questions were asked regarding the presence of nocturnal hypoventilation symptoms, including (1) early-morning headaches, (2) excessive daytime somnolence, (3) poor concentration, and (4) decrease in appetite. A nocturnal hypoventilation item was developed using these questions in participants not using NIV. Internal consistency and validity were calculated using the nocturnal hypoventilation item as substitute for the existing item 12. The ALSFRS-R was modified by adding the alternative item 12 and named ALSFRS-Revised Modified (ALSFRS-RM). RESULTS: The ALSFRS-RM has a strong internal consistency and validity, which was calculated using Cronbach alpha and factor analysis. A Spearman correlation of 0.34 was calculated between the measured FVC and the nocturnal hypoventilation item score. In addition, a nocturnal hypoventilation item score of ≤ 3 corresponds to an FVC of ≤ 65%, with the upper 95% CI < 80%. CONCLUSIONS: Our results suggest that the addition of an alternative item 12 to the existing ALSFRS-R may be a viable option for use in individuals not receiving ventilatory support. The new nocturnal hypoventilation item may also be a reliable indicator of respiratory decline that may remove the need for FVC measurement prior to introducing NIV.

Predictors of mask-wearing during the advent of the COVID-19 pandemic: Evidence from South Africa.

BACKGROUND: In the absence of a vaccine, the global spread of COVID-19 during 2020 has necessitated non-pharmaceutical interventions to curb the rise of cases. PURPOSE: The article uses the health belief model and a novel rapid mobile survey to examine correlates of reported mask-wearing as a non-pharmaceutical intervention in South Africa between May and August 2020. METHODS: Two-way tabulations and multivariable analysis via logistic regression modeling describe correlations between reported mask-wearing and factors of interest among a sample of 7074 adults in a two-period national longitudinal survey, the National Income Dynamics Study-Coronavirus Rapid Mobile Survey (NIDS-CRAM). RESULTS: In line with the health belief model, results showed that self-efficacy, the prevalence of others' mask-wearing in the same district, and affluence were positively associated with reported mask-wearing. Those who reported staying at home were significantly less likely to report wearing a mask. There was little evidence that the expected severity of the disease if contracted, affects these decisions. Hypertension, obesity, or being overweight (measured three years earlier) did not have a significant association with mask-wearing. The prevalence of mask-wearing increased significantly from May to August 2020 as COVID-19 cases increased and lockdown restrictions were eased. Contrary to the health belief model, we found that despite having a higher mortality risk, the elderly had significantly lower odds of mask-wearing. CONCLUSION: In South Africa, the mask-wearing adherence has increased rapidly. It is concerning that the elderly had lower odds of mask-wearing. This should be examined further in future research.

Testing an Incentive-Based and Community Health Worker Package Intervention to Improve Maternal Health and Nutrition Outcomes: A Pilot Randomized Controlled Trial.

OBJECTIVES: In order to address South Africa's maternal and infant mortality and morbidity rates, patient and community-level preventable factors need to be identified and addressed. However, there are few rigorously implemented and tested studies in low- and middle-income countries that evaluate the impact of community-level interventions on maternal and infant health outcomes. This study examined the impact of a package intervention, consisting of an incentive called the Thula Baba Box (TBB) and a community health worker (CHW) programme, on maternal depressive symptoms, maternal nutrition and intention to exclusively breastfeed. METHOD: The intervention was tested using a pilot randomised controlled trial consisting of 72 (39 treatment and 33 control) adult women, implemented in a low-income, peri-urban area in Cape Town, South Africa. Data was collected using a baseline questionnaire conducted shortly after recruitment, and an end line questionnaire conducted a week after giving birth. RESULTS: The intervention resulted in a 0.928-point drop in the maternal depressive symptom scale (which ranges from 1 to 8). We find no evidence that the intervention has either a sizeable or precisely estimated impact on maternal nutrition, measured using middle-upper arm circumference. While the intervention has almost no effect on the infant feeding intention of women who own refrigerators, it has a very large positive effect of 3.349-points (on a scale ranging from 1 to 8) for women without refrigerators. CONCLUSION: A package intervention consisting of psycho-social support, additional tailored health information, and an incentive to utilise public antenatal care services has the potential to increase exclusive breastfeeding intention and reduce maternal depressive symptoms among the economically vulnerable.

Who is more likely to return for TB test results? A survey at three high-burden primary healthcare facilities in Cape Town, South Africa.

BACKGROUND: In low- and middle-income countries with a high burden of tuberculosis (TB), a large proportion of people who are tested for TB do not return to the health facility to collect their test results and initiate treatment, thus putting themselves at increased risk of adverse outcomes. METHODS: This prospective study aimed to identify predictors of returning to the primary health care (PHC) facility to collect TB test results. From 15 August to 15 December 2017, 1105 people who tested for pulmonary TB at three Cape Town PHC facilities were surveyed. Using multi-variate logistic regressions on an analysis sample of 1097 people, three groups of predictors were considered: (i) demographics, health and socio-economic status; (ii) costs and benefits; and (iii) behavioural factors. RESULTS: Forty-four percent of people tested returned to the PHC facility to collect their test results within the stipulated 2 days, and 68% returned before the end of the study period. Return was strongly and positively correlated with expecting a TB-positive result, cognitive avoidance and postponement behaviour. CONCLUSION: Interventions to improve pre-treatment loss to follow-up should target patients who think they do not have TB, and those with a history of postponement behaviour and cognitive avoidance.

Socioeconomic status and tobacco consumption: Analyzing inequalities in China, Ghana, India, Mexico, the Russian Federation and South Africa.

INTRODUCTION: Globally, there has been a rapid rise in non-communicable diseases driven by changing lifestyle choices and health behaviors. Different lifestyle choices threaten to exacerbate existing health inequalities, yet evidence monitoring the extent of this impact in emerging economies is lacking. The article sets out to measure the level of wealth-related inequality and its drivers in one of these lifestyle choices, tobacco consumption, among populations aged ≥50 years in six Low- and Middle-Income Countries. METHODS: The study provides empirical evidence of the inequality in tobacco consumption across wealth groups in China, Ghana, India, Mexico, the Russian Federation and South Africa using the Erreygers' corrected concentration indices. These inequalities are then decomposed to gain a deeper understanding of the factors and broader social forces driving inequality. The WHO SAGE data set, collected between 2008 and 2010, is used for the analysis. RESULTS: Current tobacco consumption is concentrated among the poor in China, Ghana, India, and South Africa, and among the wealthy in the Russian Federation and Mexico. The inequalities widen when we focus solely on the male population. Although the results differ by country, the major drivers of inequality include wealth, locality, and gender. CONCLUSIONS: The focus on tobacco consumption in this age group is key to curbing rising healthcare costs and ensuring longevity. Policies aimed at reducing wealth-related inequalities should especially target high tobacco consumption rates among males, while simultaneously pre-empting and curbing rising rates among women.

Understanding Period Poverty: Socio-Economic Inequalities in Menstrual Hygiene Management in Eight Low- and Middle-Income Countries.

Menstrual hygiene management and health is increasingly gaining policy importance in a bid to promote dignity, gender equality and reproductive health. Effective and adequate menstrual hygiene management requires women and girls to have access to their menstrual health materials and products of choice, but also extends into having private, clean and safe spaces for using these materials. The paper provides empirical evidence of the inequality in menstrual hygiene management in Kinshasa (DRC), Ethiopia, Ghana, Kenya, Rajasthan (India), Indonesia, Nigeria and Uganda using concentration indices and decomposition methods. There is consistent evidence of wealth-related inequality in the conditions of menstrual hygiene management spaces as well as access to sanitary pads across all countries. Wealth, education, the rural-urban divide and infrastructural limitations of the household are major contributors to these inequalities. While wealth is identified as one of the key drivers of unequal access to menstrual hygiene management, other socio-economic, environmental and household factors require urgent policy attention. This specifically includes the lack of safe MHM spaces which threaten the health and dignity of women and girls.

The Economic Cost of Smoking in South Africa, 2016.

INTRODUCTION: Chronic, noncommunicable diseases are on the rise globally, with tobacco consumption being an important contributing risk factor. These increases result in significant economic costs due to increased healthcare costs, productive lives lost, and productive days lost due to illness. Estimates of these economic costs are scarce in low- and middle-income countries. METHODS: Drawing on a diverse range of data sources, direct healthcare costs, and productivity losses due to illness and premature deaths were estimated using the cost-of-illness approach. The present value of lifetime earnings was used to estimate productivity losses from premature deaths. RESULTS: We estimate that 25 708 deaths among persons aged 35-74 in 2016 are smoking-attributable. The economic cost of smoking was R42 billion (US$2.88 billion), of which R14.48 billion was for healthcare costs (hospitalization and outpatient department visits). The economic cost of smoking amounted to 0.97% of the South African GDP in 2016, while the healthcare cost of smoking-related diseases was 4.1% of total South African health expenditure. The costs are lower for women because of their lower smoking prevalence. CONCLUSION: The economic burden of smoking calls for a further scaling-up of tobacco-control interventions in South Africa. IMPLICATIONS: This article addresses the paucity of research on the detailed economic costs of smoking in low-and middle-income countries, including South Africa. Our calculations, based on an extensive range of recent data, provide the most detailed estimate to date and include quantification of the direct and indirect costs of smoking in South Africa. We found that the magnitude of the costs related to smoking in South Africa is larger than in the previous estimates and that for every Rand received in the form of cigarette tax, society loses 3.43 Rands. This article provides an economic case for evidence-based tobacco control in South Africa.

Key factors in achieving increased tobacco taxation: Experience from the island of Saint Helena.

Concerted efforts by government officials and technical assistance from the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Secretariat Knowledge Hub on Tobacco Taxation and Illicit Trade, resulted in an increase in tobacco taxation in Saint Helena during 2019. This formed part of a broader package of Tobacco Control measures to reduce the burden of noncommunicable diseases (NCD) on the island. We elaborate on key contextual and contributing factors that resulted in positive policy change in a relatively short period of time. These included political support for a strategic approach to address prevalent NCD in the context of an ageing population, high overseas health care costs and Overseas Development Aid dependency. Previous experience of impact from sugar-sweetened beverage taxation when combined with wider system measures, and the similar accompaniment of the tobacco taxation proposals with wider measures, encouraged policymakers to use tobacco taxation to curb cigarette consumption. These factors created readiness, and tailored technical assistance from an international, donor-funded partner and specifically modelling to provide evidence-based predictions of impact augmented confidence of policy benefit and enabled passage. This experience may serve as a point of reference for other countries that wish to implement similar policy changes.

Impact of tax increases on illicit cigarette trade in Mongolia.

BACKGROUND: The Mongolian government increased import tobacco tax by 30% in May 2017 and excise tobacco tax by 10% in January 2018. To assess the impact of these tax increases on illicit cigarette trade, we estimate illicit trade before and after tax increases. METHODS: Discarded cigarette packs were collected in the capital city and in two provinces near China, the Russian Federation and Kazakhstan. Tax increases occurred between all three rounds (April 2017, August/September 2017, May/June 2018). Cigarette packs are identified as illicit if there is evidence that tax was not paid. This is deduced from the absence of the Mongolian excise tax stamp, or the absence of traces of a tax stamp (glue residue). Data are weighted to represent the areas sampled. RESULTS: In round 1, 15.4% (95% CI 14.6% to 16.2%) of the 7494 collected packs were illicit. This estimate decreased to 13.6% (95% CI 12.7% to 14.5%) in round 2 (5852 collected packs) and to 6.3% (95% CI 5.7% to 6.9%) in round 3 (6258 collected packs). Illicit cigarettes originated primarily from the Republic of Korea and Ukraine, but some were manufactured in Mongolia. While the majority of illicit products are supplied by global companies (Korea Tobacco & Ginseng, Imperial Tobacco and Philip Morris Kazakhstan), one local company, Mongol Tobacco SO, is also implicated. CONCLUSIONS: The share of illicit cigarettes declined between rounds 1 and 2 despite the import tax increase, and this trend continued in round 3 despite the excise tax increase.

An Incentive-Based and Community Health Worker Package Intervention to Improve Early Utilization of Antenatal Care: Evidence from a Pilot Randomised Controlled Trial.

Objectives One of the factors linked to South Africa's relatively high maternal mortality ratio is late utilization of antenatal care (ANC). Early utilization is especially important in South Africa due to the high HIV prevalence amongst pregnant women. This study examined the impact of a package intervention, consisting of an incentive called the Thula Baba Box (TBB) and a community health worker (CHW) programme, on early utilization of ANC. Methods A pilot randomised controlled trial consisting of 72 women aged 18 and older was conducted in an urban area in South Africa to evaluate the impact of the package intervention. Women were recruited and randomised into either intervention (n = 39) or control group (n = 33). The intervention group received both the TBB and monthly CHW visits, while the control group followed standard clinical practice. Both groups were interviewed at recruitment and once again after giving birth. The outcomes measured are the timing of first ANC visit and whether they attended more than four times. It is anticipated that the box will also have a beneficial impact on infant health outcomes, but these fall out of the scope of this study. Results Women in the intervention groups sought care on average 1.35 months earlier than the control group. They were also significantly more likely to attend at least four antenatal clinic visits. Conclusions for practice Given the South African context and the importance of early care-seeking behaviour to improve health outcomes of HIV-positive pregnant women, the intervention can help to improve maternal and neonatal health outcomes. Further research is needed to investigate the impact of the two interventions separately, and to see if these findings hold in other communities.

An international analysis of the price and affordability of beer.

AIMS: To apply methods for measuring the affordability of beer in a large cross section of countries, and to investigate trends in affordability of beer over time. METHODS: We use the Relative Income Price (RIP), which uses per capita GDP, to measure the affordability of beer in up to 92 countries from 1990 to 2016 (69 countries were included in 1990, however the survey has since grown to include 92 countries). In addition to affordability, we also investigate trends in the price of beer. RESULTS: While beer is, on average, similarly priced in high-income (HICs) and low- and middle-income countries (LMICs), it is significantly more affordable in HICs. There is significant variation in both price and affordability in HICs and in LMICs. Beer has become cheaper in real terms in 49% (18/37) of HICs and 43% (20/46) of LMICs. Beer became more affordable in most HICs (RIP: 30/37 or 81%) and LMICs (RIP: 42/44 or 95%). CONCLUSIONS: The increased affordability over time of beer in most countries raises concerns about public health. Governments need to increase taxes on beer so that it becomes less affordable over time, in an effort to improve public health.

Poor Health Reporting? Using Anchoring Vignettes to Uncover Health Disparities by Wealth and Race.

In spite of the wide disparities in wealth and in objective health measures like mortality, observed inequality by wealth in self-reported health appears to be nearly nonexistent in low- to middle-income settings. To determine the extent to which this is driven by reporting tendencies, we use anchoring vignettes to test and correct for reporting heterogeneity in health among elderly South Africans. Significant reporting differences across wealth groups are detected. Poorer individuals rate the same health state description more positively than richer individuals. Only after we correct for these differences does a significant and substantial health disadvantage of the poor emerge. We also find that health inequality and reporting heterogeneity are confounded by race. Within race groups-especially among black Africans and to a lesser degree among whites-heterogeneous reporting leads to an underestimation of health inequalities between richest and poorest. More surprisingly, we also show that the correction may go in the opposite direction: the apparent black African (vs. white) health disadvantage within the top wealth quintile almost disappears after we correct for reporting tendencies. Such large shifts and even reversals of health gradients have not been documented in previous studies on reporting bias in health inequalities. The evidence for South Africa, with its history of racial segregation and socioeconomic inequality, highlights that correction for reporting matters greatly when using self-reported health measures in countries with such wide disparities.

A comparable yardstick: adjusting for education bias in South African health system responsiveness ratings.

Health-system responsiveness (HSR) measures the experience of health-system users in terms of the non-clinical aspects of the health system. This has been operationalized as a measurable construct in multiple surveys and studies. According to the literature, reporting behaviour may vary systematically across socio-demographic characteristics. In this study we explore the association between education levels and reporting behaviour in terms of HSR in South Africa using data from the World Health Organization Study on Global Ageing and Adult Health for South Africa (WHO SAGE) conducted in 2007 and 2008. We consider the reporting behaviour of 1499 adults aged 50 and older in terms of the reported HSR for their most recent outpatient provider visit during the preceding 12 months. More specifically, we explore whether there are systematic biases in reporting behaviour by education levels and other socio-economic covariates through the use of data from anchoring vignettes. These are questions depicting hypothetical HSR scenarios which provide a fixed benchmark for comparing individuals' own HSR ratings and identifying potential reporting biases. Using a hierarchical-ordered probit model in regression analysis, we found large differences in HSR ratings between the lowest and highest education groups after adjusting for reporting bias using the anchoring vignettes. This finding holds across all seven HSR domains captured in the WHO SAGE dataset. In the most extreme case, individuals with no education are likely to underreport poor HSR by between 2.6 and 9.4% percentage points compared with individuals with secondary schooling or higher. Policy-makers need to take cognizance of potential reporting biases in HSR ratings and make the necessary adjustments to obtain data that are as true and accurate as possible. The need for this is especially acute in a country such as South Africa with large socio-economic inequalities and disparities in access to healthcare.