Rural South Africa Research Articles

Protocol of a cost-effectiveness analysis of a combined intervention for depression and parenting compared with enhanced standard of care for perinatally depressed, HIV-positive women and their infants in rural South Africa

IntroductionPoverty, HIV and perinatal depression represent a triple threat to public health in sub-Saharan Africa because of their combined negative effects on parenting and child development. In the resource-constrained context...

The HIV Care Cascade for Older Adults in Rural South Africa: A Longitudinal Cohort Study (2014-2019).

As people with HIV grow older, stable engagement in care is essential for healthy aging. We evaluate the HIV care cascade for older adults in rural South Africa at 2 time points cross-sectionally and assess movement in the cascade over time. We evaluated the cascade stage at waves 1 (2014-2015) and 2 (2018-2019) of Health and Aging in Africa: A Longitudinal Study of an INDPETH Community in South Africa, a population-based longitudinal cohort study in Mpumalanga Province, South Africa. Biomarker screening defined cascade stages [HIV+/no antiretroviral therapy (ART); ART+/unsuppressed viral load; ART+/suppressed viral load]. Between-wave probability of death, cascade progression, regression, cascade transitions, and sociodemographic predictors were assessed with Poisson regression. The impact of death was considered using the Fine and Gray competing risk model. We observed a higher prevalence of antiretroviral therapy with viral suppression over time (50% in wave 1 vs. 70% in wave 2). Among those alive, the oldest age group (70+ years old) was most likely to have cascade progression [adjusted risk ratio for treatment initiation vs. 40-49 years old: 1.38 (95% confidence interval: 1.02 to 1.86)]. However, there was a significant risk of death and cascade regression. Death between waves reached 40% for 70+-year-olds who were ART+/unsuppressed. In competing risk models, older age was associated with equivalent or less cascade progression. Older age groups who were unsuppressed on treatment and men had poorer cascade outcomes. Improvements observed in HIV treatment coverage over time for older adults must be interpreted in the context of the high risk of death for older HIV-positive adults, especially among those failing treatment.

Estimating the Effect of COVID-19 Pandemic Restrictions on Self-reported Antiretroviral Therapy Use and Late Refill Visits Among People Living With HIV in Rural South Africa.

People living with HIV require reliable access to and adequate supply of antiretroviral therapy (ART) for viral suppression. The Deliver Health Study, a randomized trial conducted during the COVID-19 pandemic, found that home-delivered ART significantly increased viral suppression compared with clinic-based care. The effect of changing COVID-19 alert levels on self-reported ART use has not been quantified. KwaZulu-Natal, South Africa. Adults living with HIV were followed in the Deliver Health Study during October 2019-December 2020. We used difference-in-differences (DiD) to estimate the effect of changing COVID-19 alert levels during 3 distinct periods on self-reported missed ART doses (missed 0 vs. ≥1 doses in past week) for participants receiving home-delivered vs. clinic-based refills. We additionally estimated the effect of changing COVID-19 alert levels on late clinic ART refill visits (late vs. on-time). We used relative risk regression for both binary outcomes. Of 155 participants, 46% were women and the median age was 36 years. The mean number of missed weekly doses was 0.11, 0, and 0.12 in the home-delivery group and 0.09, 0.08, and 0.18 in the clinic group during periods 1, 2, and 3, respectively. There were no differences in relative risk of self-reported daily ART use between refill groups when comparing across periods [DiDperiod 2 vs. 1 = 1.05; 95% confidence interval: 0.97, 1.13 and DiDperiod 3 vs. 2 = 0.99; 95% confidence interval (CI): 0.91, 1.08]. In the clinic group, the risk of late refill visits was significantly higher during COVID-19 restrictions (vs. before alert level 5 implementation) and even after the COVID-19 alert level was downgraded to level 1 (RRperiod 2 vs. 1 = 1.83, 95% CI: 1.34, 2.51 and RRperiod 3 vs. 2 = 1.71; 95% CI: 1.43, 2.04). The COVID-19 pandemic did not differentially impact self-reported ART adherence by the method of ART refills, but the risk of late clinic refill visits was significantly higher during COVID-19 restrictions and sustained after restrictions were loosened.

Dietary patterns and their socio-demographic correlates in the context of migration and urbanisation demonstrate nutrition transitions in South Africa

ABSTRACT This paper investigates the demographic and socio-economic correlates of dietary patterns in South Africa, drawing on a sample of young adults experiencing internal migration and urbanisation. We use data from the 2018 baseline survey of the Migrant Health Follow-Up Study, an original longitudinal cohort study consisting of 3,087 internal migrants and rural residents aged 18–40 nested within the Agincourt Health and socio-Demographic Surveillance System in rural northeast South Africa. We employ principal components analysis to identify dietary patterns from food frequency questionnaires and ordinary least squares regression to assess whether migration and other socio-economic characteristics correlate with specific dietary patterns at baseline. We observe five distinct dietary patterns characterised by frequent consumption of processed foods, red meat, fruits and vegetables, diverse foods, and high sugar/fat foods. We find migration to be significantly associated with more frequent consumption of both processed foods and fruits and vegetables; we also find the association between migration status and dietary patterns to be heterogenous depending on migrants’ destinations. This paper extends current understanding of changing dietary patterns in the context of nutrition transitions with attention to dynamic migration processes rather than static rural-urban differences.

Elevated stress-responsive biomarkers are associated with HIV acquisition in young women in rural South Africa: A HPTN 068 case cohort study.

Biological markers of stress have been associated with HIV progression and pathogenesis but not with HIV incidence. We sought to determine if elevated stress-responsive biomarkers would be associated with incident HIV among adolescent girls and young women (AGYW). We conducted a case-cohort study within the HIV Prevention Trials Network (HPTN) 068 study among 949 AGYW in South Africa. Cases were AGYW who tested HIV-positive during the eight-year follow-up. Unmatched controls were randomly selected from the HIV-negative population at enrollment. Dried blood spots from cases and controls were tested from enrollment (2011-2012) for C-reactive protein (CRP), herpes simplex virus type-1 (HSV-1) antibody titers, and cytomegalovirus (CMV) antibody titers. Cox proportional hazards models estimated the association between each biomarker and time to incident HIV. Compared to AGYW with the lowest CRP levels, those with medium and high CRP levels had a higher hazard ratio (HR) of incident HIV (HR: 1.45, 95% CI: 0.95, 2.21; HR: 1.50, 95% CI: 0.98,2.30, respectively), although not statistically significant. The relative hazard of incident HIV was also higher among AGYW who were CMV seropositive vs. seronegative (low antibodies HR: 2.18, 95% CI: 1.2,3.87; medium HR: 2.25, 95% CI: 1.28,3.95; high HR: 1.78, 95% CI: 0.99,3.21). Those with the highest HSV-1 antibody levels experienced an increased hazard of HIV compared to those who were HSV-1 seronegative (HR: 1.58, 95% CI: 1.03,2.44). Biological stress may increase AGYW's susceptibility to HIV acquisition through changes in immune function, viral infection, and increased biological vulnerability to disease.

Prior tuberculosis, radiographic lung abnormalities and prevalent diabetes in rural South Africa

BackgroundGrowing evidence suggests that chronic inflammation caused by tuberculosis (TB) may increase the incidence of diabetes. However, the relationship between post-TB pulmonary abnormalities and diabetes has not been well characterized.MethodsWe analyzed data from a cross-sectional study in KwaZulu-Natal, South Africa, of people 15 years and older who underwent chest X-ray and diabetes screening with hemoglobin A1c testing. The analytic sample was restricted to persons with prior TB, defined by either (1) a self-reported history of TB treatment, (2) radiologist-confirmed prior TB on chest radiography, and (3) a negative sputum culture and GeneXpert. Chest X-rays of all participants were evaluated by the study radiologist to determine the presence of TB lung abnormalities. To assess the relationships between our outcome of interest, prevalent diabetes (HBA1c ≥6.5%), and our exposure of interest, chest X-ray abnormalities, we fitted logistic regression models adjusted for potential clinical and demographic confounders. In secondary analyses, we used the computer-aided detection system CAD4TB, which scores X-rays from 10 to 100 for detection of TB disease, as our exposure interest, and repeated analyses with a comparator group that had no history of TB disease.ResultsIn the analytic cohort of people with prior TB (n = 3,276), approximately two-thirds (64.9%) were women, and the average age was 50.8 years (SD 17.4). The prevalence of diabetes was 10.9%, and 53.0% of people were living with HIV. In univariate analyses, there was no association between diabetes prevalence and radiologist chest X-ray abnormalities (OR 1.23, 95%CI 0.95–1.58). In multivariate analyses, the presence of pulmonary abnormalities was associated with an 29% reduction in the odds of prevalent diabetes (aOR 0.71, 95%CI 0.53–0.97, p = 0.030). A similar inverse relationship was observed for diabetes with each 10-unit increase in the CAD4TB chest X-ray scores among people with prior TB (aOR 0.92, 95%CI 0.87–0.97; p = 0.002), but this relationship was less pronounced in the no TB comparator group (aOR 0.96, 95%CI 0.94–0.99).ConclusionsAmong people with prior TB, pulmonary abnormalities on digital chest X-ray are inversely associated with prevalent diabetes. The severity of radiographic post-TB lung disease does not appear to be a determinant of diabetes in this South African population.

Sociodemographic, mental, and physical health determinants of incident depressive symptoms among ageing men and women in rural South Africa: A longitudinal study from 2015 to 2022

We aimed to assess the associations between sociodemographic, mental, and physical health factors and incident depressive symptoms (IDS) among ageing men and women in rural South Africa over time. Data from the 7-year South African longitudinal Health and Ageing in Africa INDEPTH Community study (HAALSI: 2015–2022) were used in the analysis (study sample: n = 3 122, aged 40 and older). The proportion of IDS was in 28.2% in 2019 and 30.0% in 2022 among men, and 30.3% in 2019 and 2022 among women. Among men, the adjusted model indicated that older age, food insecurity, poor life satisfaction, physical pain, functional disability, diabetes, kidney disease, anaemia, and obesity were positively associated, and hypertension was negatively associated with IDS. Among women, food insecurity, poor life satisfaction, physical pain, and diabetes were positively associated, and current smokeless tobacco use was negatively associated with IDS. By sex, a high proportion of IDS were found, as was the prevalence of food insecurity, poor life satisfaction, physical pain, and diabetes associated with IDS. Among older men only, older age, functional disability, kidney disease, anaemia, and obesity, but not hypertension were associated with higher odds for IDS. Among older women, only current smokeless tobacco use was negatively associated with IDS. Interventions addressing the risk for depression should consider specific sex differences.

A mixed methods process evaluation: understanding the implementation and delivery of HIV prevention services integrated within sexual reproductive health (SRH) with or without peer support amongst adolescents and young adults in rural KwaZulu-Natal, South Africa

BackgroundCombination prevention interventions, when integrated with community-based support, have been shown to be particularly beneficial to adolescent and young peoples’ sexual and reproductive health. Between 2020 and 2022, the Africa Health Research Institute in rural South Africa conducted a 2 × 2 randomised factorial trial among young people aged 16–29 years old (Isisekelo Sempilo) to evaluate whether integrated HIV and sexual and reproductive health (HIV/SRH) with or without peer support will optimise delivery of HIV prevention and care. Using mixed methods, we conducted a process evaluation to provide insights to and describe the implementation of a community-based peer-led HIV care and prevention intervention targeting adolescents and young people.MethodsThe process evaluation was conducted in accordance with the Medical Research Council guidelines using quantitative and qualitative approaches. Self-completed surveys and clinic and programmatic data were used to quantify the uptake of each component of the intervention and to understand intervention fidelity and reach. In-depth individual interviews were used to understand intervention experiences. Baseline sociodemographic factors were summarised for each trial arm, and proportions of participants who accepted and actively engaged in various components of the intervention as well as those who successfully linked to care were calculated. Qualitative data were thematically analysed.ResultsThe intervention was feasible and acceptable to young people and intervention implementing teams. In particular, the STI testing and SRH components of the intervention were popular. The main challenges with the peer support implementation were due to fidelity, mainly because of the COVID-19 pandemic. The study found that it was important to incorporate familial support into interventions for young people’s sexual health. Moreover, it was found that psychological and social support was an essential component to combination HIV prevention packages for young people.ConclusionThe results demonstrated that peer-led community-based care that integrates SRH services with HIV is a versatile model to decentralise health and social care. The family could be a platform to target restrictive gender and sexual norms, by challenging not only attitudes and behaviours related to gender among young people but also the gendered structures that surround them.

Exploring household water conservation methods in rural South Africa: a case of the Mbhashe and Mnquma local municipalities

Amidst the persistent drought disaster declared in 2015, the Amathole District Municipality grapples with severe water scarcity issues, particularly affecting local municipalities such as Mbhashe and Mnquma. Consequently, households in these areas confront the challenges of unreliable and contaminated water sources, prompting them to adopt water conservation measures to mitigate shortages. This study investigates the efficacy of water conservation methods among rural households in these drought-affected regions. It identifies associated challenges and potential interventions to ensure access to clean and dependable water. Employing a mixed methods approach, the study examines household water conservation practices through narrative analysis and descriptive statistics of survey data. Findings reveal that storing water in drums, containers, and tanks is the most prevalent conservation method, alongside measures like greywater reuse, lifestyle adjustments, and rainwater harvesting. With financial constraints and infrastructural limitations hindering broader adoption, the study found water conservation to be a challenge among the households as a minority (7.8%) of respondents adopted multiple water conservation strategies. In comparison, most respondents (73.6%) could only afford to practice one water conservation strategy at a time, and others (18.6%) had no conservation strategies. Drought conditions, lack of infrastructure, poverty, and attitudinal factors are primary barriers to effective water conservation. The study underscores the need for municipal-level initiatives to enhance water sources and advocates for increased investment in education, awareness campaigns, and policy interventions to address rural communities’ water scarcity challenges.

Social Dimension Factors Influencing Access to Bank-Credit for Small-Holder Livestock Farmers in Rural South Africa

This paper investigates the association between the social dimensions of rural small-holder livestock farmers and their access to bank credit facilities in a South African rural setup, taking gender into consideration. In many emerging economies, small-holder livestock farmers frequently face difficulties in accessing bank credit facilities due to the weak status of their standing in society (social dimensions) and limited access to banking services. This is a treat to their sustainability and growth. A quantitative approach was used on a sampled small-holder livestock farmers in the Limpopo Province of South Africa. Regression analysis was conducted to determine the relationships between the factors of social capital and their association with access to financial capital. The study revealed that social capital has influence in securing bank finance among the small holder livestock farmers but not gender. These findings should guide policymakers, banking institutions, and the government in addressing the challenges faced by small holder farmers in accessing capital and help to understand the gender inequality relating to the access of bank credit facilities.

Correction: Investigating risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000–2014

Correction: Investigating risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000–2014

Making Sense of Legitimacy Across Universities: Ecocritical Ontological Perspective

This paper reflects on research methodological considerations of how legitimacy of publicly funded universitiesoccurs. From an ecocritical ontological perspective the paper uses a metaphor and sense-making techniques to shed light into effective modalities universities use to connect with local economies. The Milky way Galactic ecosystem metaphor is used not only to make sense of the ecocritical ontological stance taken to make sense of legitimacy but is used as a metaphor to make sense of the findings. The paper asserts that the legitimacy theoretical lens is particularly appropriate to probe universities’ legitimacy and connectedness to the local communities they are embedded in. The rationale behind this assertion is that legitimacy is only conferred to the extent the actions of an entity are perceived as desirable, efficient, proper, or appropriate by the ecosystem stakeholders. The theory is thus useful for examining connectedness of publicly funded universities to its local community. The paper argues that the university system that is delinked from local economic development is like a Milky way Galaxy delinked from its Galactic ecosystem. Against this backdrop, the paper juxtaposes Mondragon University, located in a rural part of Northern Spain with two South African universities embedded in poverty stricken rural South Africa. Mondragon University is presented as a hallmark of success when it comes to local community legitimacy. The paper is centered around the following question: (1) how does university legitimacy yield impactful local community outcomes? Using the Milky way Galaxy metaphor, the findings show a considerable variety in local community connectedness depending on bureaucratic arrangements of the universities. The findings also showed that alternative income sources, outside the public purse, just like the gravitational force in the galactic ecosystem, is the key force that determines legitimacy in a university setting. The paper contributes to business research methods by fusing metaphorical as well as sense-making research techniques to bring to sharp focus permeability of the university space to enable local economic development.

Distribution of informal caregiving for older adults living with or at risk of cognitive decline within and beyond family in rural South Africa.

Aging populations in rural areas of low and middle-income countries will increasingly need care. However, formal support is severely limited and adult children are frequently unavailable due to morbidity, early mortality, employment and migration. We aimed to describe how care is shared within and between households for older adults in a rural South African setting. We conducted quantitative interviews with 1012 household members and non-household caregivers of 106 older adults living with or at risk of cognitive decline in rural Mpumalanga, South Africa. Using descriptive statistics and regression analysis, we described how care is shared, with particular attention to generational patterns of care. Informal care for older persons was spread among family, friends, and neighbours, with minimal paid support. This care was mostly provided by female relatives one or two generations younger than the recipient, and unemployed. However, a smaller number of paid caregivers, also mostly female, provided the most intensive care. Spouses commonly took on the role of primary caregiver for their partner. In our study, care mainly came from household members due to close family ties and practical considerations, with support from outside the household. This reflects shared history, reciprocal relationships, and easy access to care tasks within the household. A deeper understanding of how informal care for older adults is shared in low- and middle-income countries is essential for developing targeted interventions.

Increasing HIV testing and linkage to care among men in rural South Africa using conditional financial incentives and a decision support app: A process evaluation.

Men in sub-Saharan Africa are less likely to accept HIV testing and link to HIV care than women. We conducted a trial to investigate the impact of conditional financial incentives and a decision support application, called EPIC-HIV, on HIV testing and linkage to care. We report the findings of the trial process evaluation to explore whether the interventions were delivered as intended, identify mechanisms of impact and any contextual factors that may have impacted the trial outcomes. Between August 2018 and March 2019, we conducted in-depth interviews and focus group discussions with trial participants (n = 31) and staff (n = 14) to examine views on the implementation process, participant responses to the interventions and the external factors that may have impacted the implementation and outcomes of the study. Interviews were audio-recorded, transcribed, and translated where necessary, and thematically analyzed using ATLAS-ti and NVivo. Both interventions were perceived to be acceptable and useful by participants and implementers. EPIC-HIV proved challenging to implement as intended because it was difficult to ensure consistent use of earphones, and maintenance of privacy. Some participants struggled to navigate the EPIC-HIV app independently and select stories that appealed to them without support. Some participants stopped exploring the app before the end, resulting in an incomplete use of EPIC-HIV. While the financial incentive was implemented as intended, there were challenges with eligibility. The convenience and privacy of home testing influenced the uptake of HIV testing. Contextual barriers including fear of HIV stigma and disclosure if diagnosed with HIV, and expectations of poor treatment in clinics may have inhibited linkage to care. Financial incentives were relatively straightforward to implement and increased uptake of home-based rapid HIV testing but were not sufficient as a 'stand-alone' intervention. Barriers like fear of stigma should be addressed to facilitate linkage to care.

Epilepsy in rural South Africa: Patient experiences and healthcare challenges.

This study investigates the prevalent issues of healthcare access and the impact of antiseizure treatments among people with epilepsy (PWE) in rural Limpopo and Mpumalanga, South Africa, where healthcare facilities and affordable treatments are often inadequate. Using a cross-sectional survey, 162 PWE were selected using multistage sampling across the provinces. Data were collected via a structured questionnaire and analyzed descriptively using SPSS v27. Most of the participants experienced seizures intermittently, with 70.6% in Limpopo and 53.3% in Mpumalanga reporting occasional episodes, whereas a significant minority in both regions-20.6% and 40%, respectively-suffered from frequent seizures. A notable portion of PWE also reported recurring side effects from antiseizure drugs, which led to consequential life disruptions, including educational dropout and unemployment. The findings underscore an urgent need for enhanced educational programs and increased awareness to improve the understanding and management of epilepsy in these underserved areas. Optimizing care for PWE requires a multifaceted approach, including evaluating healthcare accessibility, affordability, and societal beliefs influencing treatment adherence. The study advocates for government and policy interventions to mitigate the quality of life deterioration caused by epilepsy and its treatment in rural communities. In Limpopo and Mpumalanga, many individuals with epilepsy experience seizures occasionally, while a significant minority have them frequently. Numerous people also suffer recurring side effects from antiseizure medications, impacting their lives severely by causing school dropouts and job losses. This underscores the urgent need for improved education and awareness programs to manage epilepsy in these provinces effectively. The study urges government action and policy reforms to enhance care and support for people with epilepsy in rural areas, aiming to improve their quality of life.

Internal migration and depressive symptoms: Exploring selection and outcomes in a South African cohort

IntroductionInvestigations of migration effects on mental health conditions, including depression are sparse in low- and middle-income countries (LMIC), yet mental health may play a role in a decision to migrate, and migration in turn can impact on mental health outcomes. MethodsThis paper uses two waves of data from the Migrant Health Follow-Up Study, a young adult cohort of 2967 internal migrants and residents of the Agincourt study site in rural northeast South Africa to explore the relationship between internal migration and depressive symptoms, as measured on the Center for Epidemiological Studies Depression (CES-D) scale. We employ logistic regression analysis to investigate selectivity of migrants in relation to depressive symptoms, and we fit generalized linear models to analyse depressive symptoms (CES-D scores) as a function of migration status and sociodemographic and health characteristics, accounting for temporal sequence. ResultsAlthough we observe systematically low reporting of depressive symptoms, average CES-D scores are lower among migrants (comprising approximately 53% of the cohort) compared to Agincourt residents at both survey timepoints. We do not find evidence of a selection effect in relation to mental health among those newly migrating between Wave 2 and 3 (n = 1393). In analyses of the CES-D score outcome, the significant influence of migration status on depressive symptoms is reduced with the inclusion of controls in the models. Consistent employment and higher levels of education are associated with lower CES-D scores, while diagnosis of a chronic condition is associated with higher scores. ConclusionThe relationship between migration and depressive symptoms is influenced by factors preceding a migration and destination-place characteristics and experiences. Further examination of the role of migration at different stages of the process, along with continuing attention to psychosocial measurement considerations for LMIC subpopulations, can improve our understanding of these complex interrelationships and contribute to evidence.

Mid-Life Household Food Insecurity and Subsequent Memory Function and Rate of Decline in Rural South Africa, 2004-2022.

We aimed to investigate mid-life food insecurity over time in relation to subsequent memory function and rate of decline in Agincourt, rural South Africa. Data from the longitudinal Agincourt Health and Socio-Demographic Surveillance System (Agincourt HDSS) were linked to the population-representative Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI). Food insecurity (yes vs. no) and food insecurity intensity (never/rarely/sometimes vs. often/very often) in the past month were assessed every 3 years from 2004 to 2013 in Agincourt HDSS. Cumulative exposure to each food insecurity measure was operationalized as 0, 1, and ≥2 time points. Episodic memory was assessed from 2014/15 to 2021/22 in HAALSI. Mixed-effects linear regression models were fitted to investigate the associations of each food insecurity measure with memory function and rate of decline over time. A total of 3,186 participants (mean age [SD] in 2004: 53 [12.87]; range: 30-96) were included and 1,173 (36%) participants experienced food insecurity in 2004, while this figure decreased to 490 (15%) in 2007, 489 (15%) in 2010, and 150 (5%) in 2013. Experiencing food insecurity at one time point (vs. never) from 2004 to 2013 was associated with lower baseline memory function (β = -0.095; 95% CI: -0.159 to -0.032) in 2014/15 but not rate of memory decline. Higher intensity of food insecurity at ≥2 time points (vs. never) was associated with lower baseline memory function (β = -0.154, 95% CI: -0.338 to 0.028), although the estimate was imprecise. Other frequencies of food insecurity and food insecurity intensity were not associated with memory function or decline in the fully adjusted models. In this setting, mid-life food insecurity may be a risk factor for lower later-life memory function, but not decline.

Adherence to medication, dietary and physical activity recommendations: Findings from a multicenter cross-sectional study among adults with diabetes in rural South Africa.

Diabetes is a complex health condition requiring medical therapy and lifestyle modifications to attain treatment targets. Previous studies have not fully explored factors associated with adherence to medication, diets and physical activity recommendations among individuals living with diabetes in rural South Africa. We examined the association between knowledge, health belief and adherence to medication, dietary, and physical activity recommendations and explored self-reported reasons for non-adherence. This cross-sectional study was conducted among 399 individuals living with diabetes recruited over 12 weeks from six randomly selected primary healthcare centres in rural South Africa. Sociodemographic and clinical data were obtained by self-report. Health beliefs, knowledge, and adherence were assessed using validated measures. Descriptive and inferential statistics were carried out. The majority (81.7%) of the participants were females, with a mean age of 62 ± 11 years. Only 39% reported adhering to their prescribed medication regimen, 25% reported adhering to dietary recommendations, and 32% reported adhering to physical activity recommendations. The most cited reasons for non-adherence were lack of access to (n = 64) and cost of drugs (n = 50), perceived high costs of healthy diets (n = 243), and lack of time (n = 181) for physical activity. Level of education was an independent predictor of medication adherence [odds ratio, OR = 2.02 (95% confidence interval, CI: 1.20-3.40)] while diabetes knowledge was independently associated with both medications [OR = 3.04 (95% CI: 1.78-45.12)]; and physical activity adherence [OR = 2.92 (95% CI: 1.04-2.96). Positive health belief was independently associated with adherence to medications [OR = 1.72 (95% CI: 1.15-2.57) and dietary recommendations [OR = 1.75 (95% CI: 1.04-2.96)]. Adherence to three important self-care practices, medication, diet, and physical activity, was suboptimal in this study setting. Socioeconomic reasons and access barriers were significant drivers of non-adherence, while increased knowledge and positive health beliefs were potential facilitators. Efforts to improve medication adherence and foster engagement in healthy lifestyle behaviours must consider patients' knowledge and health beliefs. Primary healthcare providers should create awareness on the importance of adherence on health outcomes for people with diabetes. Likewise, efforts to increase the availability and affordability of medications for socioeconomically disadvantaged populations should be prioritised by the key health stakeholders.

Subclinical tuberculosis linkage to care and completion of treatment following community-based screening in rural South Africa

BackgroundTuberculosis (TB), a leading cause of infectious death, is curable when patients complete a course of multi-drug treatment. Because entry into the TB treatment cascade usually relies on symptomatic individuals seeking care, little is known about linkage to care and completion of treatment in people with subclinical TB identified through community-based screening.MethodsParticipants of the Vukuzazi study, a community-based survey that provided TB screening in the rural uMkhanyakude district of KwaZulu-Natal from May 2018 – March 2020, who had a positive sputum (GeneXpert or Mtb culture, microbiologically-confirmed TB) or a chest x-ray consistent with active TB (radiologically-suggested TB) were referred to the public health system. Telephonic follow-up surveys were conducted from May 2021 – January 2023 to assess linkage to care and treatment status. Linked electronic TB register data was accessed. We analyzed the effect of baseline HIV and symptom status (by WHO 4-symptom screen) on the TB treatment cascade.ResultsSeventy percent (122/174) of people with microbiologically-confirmed TB completed the telephonic survey. In this group, 84% (103/122) were asymptomatic and 46% (56/122) were people living with HIV (PLWH). By self-report, 98% (119/122) attended a healthcare facility after screening, 94% (115/122) started TB treatment and 93% (113/122) completed treatment. Analysis of electronic TB register data confirmed that 67% (116/174) of eligible individuals started TB treatment. Neither symptom status nor HIV status affected linkage to care. Among people with radiologically-suggested TB, 48% (153/318) completed the telephonic survey, of which 80% (122/153) were asymptomatic and 52% (79/153) were PLWH. By self-report, 75% (114/153) attended a healthcare facility after screening, 16% (24/153) started TB treatment and 14% (22/153) completed treatment. Nine percent (28/318) of eligible individuals had TB register data confirming that they started treatment.ConclusionsDespite high rates of subclinical TB, most people diagnosed with microbiologically-confirmed TB after community-based screening were willing to link to care and complete TB treatment. Lower rates of linkage to care in people with radiologically-suggested TB highlight the importance of streamlined care pathways for this group. Clearer guidelines for the management of people who screen positive during community-based TB screening are needed.

Life After Plastic-Wrapped Bodies: COVID, the State and the Crisis of Social Reproduction in Rural South Africa

ABSTRACT: This article explores the impact and implications of the South African state’s adoption of a tough militarized, bio-medical, and essentially neo-colonial approach to the management of the COVID pandemic in the rural former Bantustans (“native reserves”) of the country. It argues that, while the “war on COVID” produced new national legislation for all citizens, those living “with custom” in former homelands were said to possess cultural attributes that amplified the risk of infection and death. The paper focuses on how the state constructed measures for these spaces and managed social interaction and burials in the migrant heartlands. The paper suggests that families “living with custom” in the former homelands were treated differently from other citizens, existing in what Giorgio Agamben (2004) might call a “state of (greater) exception.” Villagers used the metaphor of the gate closing on them (ukuvala isango) to describe their experience and exclusion during lockdown as customary practices were banned, local health facilities closed for deep cleaning, and bodies sealed in plastic at state hospitals and mortuaries. The latter measures disturbed rural families much more than police violence or the closure of government clinics because it presented a serious threat to social reproduction. The paper provides evidence of how families fought to restore conviviality by exhuming the bodies wrapped in plastic to allow them to communicate with kin and ancestors. It also shows how, after lockdown, vaccination was often treated as a family matter not an individual choice, and how families moved quickly to fix the spiritual insecurities wrought by COVID. The paper concludes with a harrowing account of the new epidemic of hunger and malnutrition that is stalking these landscapes as conviviality is not enough to secure survival. The paper highlights the limits of narrow bio-medical and individual rights-based approaches in dealing with health, livelihoods, and well-being in communities devastated by COVID in rural southern Africa.