Economic vulnerability and poor service delivery made it more difficult for shack-dwellers to comply with COVID-19 restrictions: The impracticability and inequitable burden of universal/unstratified public health policies.

In South Africa, demand for housing close to viable/sustained sources of employment has far outstripped supply; and the size of the population living in temporary structures/shacks (and in poorly serviced informal settlements) has continued to increase. While such dwellings and settlements pose a number of established risks to the health of their residents, the present study aimed to explore whether they might also undermine the potential impact of regulations intended to safeguard public health, such as the stringent lockdown restrictions imposed to curb the spread of COVID-19 in 2020 and 2021. Using a representative sample of 1,381 South African households surveyed in May-June 2021, the present study found that respondents in temporary structures/shacks were more likely to report non-compliance (or difficulty in complying) with lockdown restrictions when compared to those living in traditional/formal houses/flats/rooms/hostels (OR:1.61; 95%CI:1.06-2.45). However, this finding was substantially attenuated and lost precision following adjustment for preceding sociodemographic and economic determinants of housing quality (adjusted OR:1.20; 95%CI:0.78-1.87). Instead, respondents were far more likely to report non-compliance (or difficulty in complying) with COVID-19 lockdown restrictions if their dwellings lacked private/indoor toilet facilities (adjusted OR:1.56; 95%CI:1.08,2.22) or they were Black/African, young, poorly educated and under-employed (regardless of: their socioeconomic position, or whether they resided in temporary structures/shacks, respectively). Restrictions imposed to safeguard public health need to be more sensitively designed to accommodate the critical role that poverty and inadequate service delivery play in limiting the ability of residents living in temporary structures/shacks and inadequately serviced dwellings/settlements to comply. [250/250 words] Significance of the main findingsO_LISouth Africans living in temporary structures/shacks are more likely to: be poorly educated and under-employed; with fewer assets and limited access to basic household services. C_LIO_LIPoverty and inadequate service delivery were more important determinants of compliance with COVID-19 restrictions than housing quality. C_LIO_LIIn the absence of improvements in economic circumstances and the delivery of basic household services, restrictions imposed to safeguard public health need to be more sensitively designed to take account of the structural barriers to compliance experienced by households where poverty and/or inadequate service delivery limit their ability to: stay at home; maintain hygiene; and/or practice social distancing. [100/100 words] C_LI O_QD"This idea of the "humbling pandemic"1 does not hold for people whose lives depend on informal economy and movement in the face of heavy restrictions on their respective activities such as... street hustle and domestic work. Therefore, the pandemic response - which employs tactics that come to determine how lives are to be lived - can be seen as an exacerbator of inequalities, by the hands of which precarious circumstances of living are a larger threat than the risk of infection"2 Stefan Ogedengbe (2021: 94)3 C_QD

Might first-hand experience of ill-health and economic hardship during the COVID-19 pandemic strengthen public support for vaccination and the reallocation of health sector funding towards health emergency preparedness in South Africa?

AimsWe examined whether first-hand experience of ill-health and economic hardship during the COVID-19 pandemic might strengthen public support for vaccination, and for the reallocation of health sector funding towards health emergency preparedness in South Africa - a country in which high rates of vaccine hesitancy go hand in hand with widespread discontent regarding public service delivery. MethodsUsing data from 1,600 South African respondents who were surveyed during 2021 for the Eighth Round of Afrobarometer (AB-R8), discrete measures of household- and individual-level sociodemographic and economic factors were generated to permit confounder-adjusted analyses of probabilistic causal relationships between self-reported measures of: personal/household COVID-19 illness and job/income/business loss as a result of COVID-19; and the likelihood that respondents would accept a (government-approved) COVID-19 vaccine, or support the reallocation of health sector funding towards health emergency preparedness. FindingsThere was little evidence that personal/household experience of COVID-19 illness was associated with the likelihood that respondents would (or would not) accept a (government-approved) COVID-19 vaccine (OR: 0.96; 95%CI: 0.72,1.28); or that these respondents would (or would not) support the reallocation of health sector funding towards health emergency preparedness (OR: 0.95; 95%CI: 0.71,1.26), even after adjustment for individual- or household-level sociodemographic and economic covariates considered likely confounders. There was similarly little evidence that personal/household experience of job/income/business loss as a result of the COVID-19 pandemic was associated with support for the reallocation of health sector resources for emergency preparedness (OR: 1.02; 95%CI: 0.80,1.30); again, even after adjustment for potential confounders. However, respondents who reported that they or someone in their household had lost their job/income/or business as a result of the COVID-19 pandemic had only around half the odds of reporting that they would accept a (government-approved) COVID-19 vaccine (OR: 0.60; 95%CI: 0.47,0.77) - and this finding, like the others in these analyses, was largely unaffected by the inclusion/exclusion of covariates considered susceptible to change following the onset of the COVID-19 pandemic (i.e. those covariates potentially operating as colliders rather than genuine confounders). ConclusionsThese findings suggest that - despite the postulated experiential dividend of COVID-19 illness (i.e. its expected impact on vaccine hesitancy and support for the reallocation of health sector resources for health emergency preparedness) - no such dividend was observed in this broadly representative sample of South African adults. Indeed, job/income/business loss (and associated economic hardship) also had little effect on support for the reallocation of health sector resources for health emergency preparedness; yet this was somewhat paradoxically associated with a much lower odds of vaccine acceptance - paradoxically, since vaccination has been widely viewed as a pragmatic (if somewhat neoliberal) intervention to protect economic activity. However, these findings might simply reflect inadequate confounder adjustment for preceding and entrenched attitudes towards vaccination amongst those South Africans who are also most vulnerable to job/income/business loss as a result of the COVID-19 pandemic. Protecting the livelihood and health of such individuals and households is likely to remain a substantial challenge and key priority for future emergencies in which economic activity is compromised. AimThe aim of the present study was to examine whether first-hand experience of ill-health and economic hardship during the COVID-19 pandemic might have strengthened public support for vaccination, and for the reallocation of health sector funding towards health emergency preparedness in South Africa - a country in which high rates of vaccine hesitancy go hand in hand with widespread discontent regarding public service delivery. To this end we drew on data generated by the eighth round of household surveys undertaken by Afrobarometer (AB-R8) which interviewed 1,600 respondents across South Africa during 2021 - more than a year after the countrys first confirmed case of COVID-19 on 5 March 2020.