Equity in Health

Elevated blood pressure among adolescents in sub-Saharan Africa: a systematic review and meta-analysis
Chen A, Waite L, Mocumbi A, et al: The Lancet Global Health 11:8; E1238-E1248, 2023

More people from sub-Saharan Africa aged between 20 years and 60 years are affected by end-organ damage due to underlying hypertension than people in high-income countries, but we lack data on the pattern of elevated blood pressure among adolescents aged 10–19 years in sub-Saharan Africa. This study aimed to fill this gap, through systematic review and meta-analysis of studies published from Jan 2010, to Dec 2021. 36 studies comprising 37 926 participants aged 10–19 years from sub-Saharan African countries were eligible. A pooled sample of 29 696 adolescents informed meta-analyses of elevated blood pressure and 27 155 adolescents informed meta-analyses of mean blood pressure. The reported prevalence of elevated blood pressure ranged from 0·2% to 25·1% of adolescents. with 13·4% of male participants compared with 11·9% of female participants having elevated blood pressure, Although many low-income countries were not represented in the study, the findings suggest that approximately one in ten adolescents have elevated blood pressure across sub-Saharan Africa. The authors observe that there is an urgent need to improve preventive heart-health programmes in the region.

Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys
Daca CSL, San Sebastian M, Arnaldo C, et al. BMC Public Health. 23:1007 https://doi.org/10.1186/s12889-023-15988-y, 2023

Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed. This study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique. The study was based on analysis of measures from repeated cross-sectional surveys from nationally representative sample surveys. The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. The authors observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. They suggest that decision-makers target underserved populations, specifically non-educated, poor people and rural women, to address inequalities in health care coverage.

Individual and area-level socioeconomic correlates of hypertension prevalence, awareness, treatment, and control in uMgungundlovu, KwaZulu-Natal, South Africa
Madela S L M, Harriman N W, Sewpaul R et al. BMC Public Health 23:417; 1-15, 2023

This analysis explores the relationship between individual and area-level socioeconomic status and hypertension prevalence, awareness, treatment, and control within a sample of 7,303 Black South Africans in three municipalities of the uMgungundlovu district in KwaZulu-Natal province. The prevalence of hypertension in the sample was 44% (n = 3,240). Of those, 2,324 were aware of their diagnosis, 1,928 were receiving treatment, and 1,051 had their hypertension controlled. Educational attainment was negatively associated with hypertension prevalence and positively associated with its control. Employment status was negatively associated with hypertension control. Black South Africans living in more deprived wards had higher odds of being hypertensive and lower odds of having their hypertension controlled. Potential interventions proposed by the authors include community-based programs that deliver medication to households, workplaces, or community centers.

Emigration as a social and economic determinant of health in low-income urban Zimbabwe
Chigariro, TC and Mhloyi, MM:. Journal of Health, Population and Nutrition 41(49), 1-10, 2022

This study compared socio-economic characteristics, including health, of emigrants’ households with those of non-emigrants’ households in an urban setting in Harare, Zimbabwe. A cross-sectional survey and focus group discussions were used to collect quantitative and qualitative data, respectively. Concurrent and retrospective data were collected using an interviewer-administered questionnaire with 268 de facto heads of the respective households, the. majority of whom were female. Emigrants’ households were more likely to access private compared to government health care facilities, than non-emigrants’ households. Emigrants' households were also more likely to report higher incomes than non-emigrants’ households and were having more meals per day and better access to education. Emigrants' households were also more likely to report positive lifestyles than non-emigrants’ households. Only 13.8% of emigrants' households reported a negative shift in lifestyle, compared to 25.2% non-emigrants' households. Emigration was found to have a positive relationship with health seeking, income, education, and number of meals a household had. The authors argue that it is clear from the findings that emigration during the hard economic times in Zimbabwe is beneficial; it cushions households from the ravages of poverty. Yet emigration robs the nation of its professional able-bodied people. They recommend that government optimise the reported positive effects, whilst improving the economy to reverse out-migration.

Multimorbidity and its socio-economic associations in community-dwelling older adults in rural Tanzania; a cross-sectional study
Lewis E G; Gray W L; Walker R; et al: BMC Public Health 22(1918), 1-12, 2022

The authors describe the prevalence and socio-economic conditions associated with multimorbidity in 235 community-dwelling older people ( ≥ 60 years) living in rural Tanzania, using a history and focused clinical examination. Multimorbidity was defined as having two or more conditions. The median age was 74 years and 136 were women. Adjusting for frailty-weighting, the prevalence of self-reported multimorbidity was 26%, and by clinical assessment/screening was 67%. Adjusting for age, sex, education and frailty status, multimorbidity by self-report increased the odds of being financially dependent on others threefold, and of a household member reducing their paid employment nearly fourfold. Multimorbidity is prevalent in this rural lower-income African setting and is associated with evidence of household financial strain. Multimorbidity prevalence is higher when not reliant on self-reported methods, revealing that many conditions are underdiagnosed and undertreated.

Under-five mortality in the Democratic Republic of the Congo: secondary analyses of survey and conflict data by province
Schedwin M; Furaha A B; Kapend R; Akilimali P; et al: Bulletin of the World Health Organisation 100(7), 422–435, 2022

This study compared coverage of key child health policy indicators across provinces and to explore their association with under-five mortality and level of conflict in the Democratic Republic of the Congo. A secondary analysis of nationally representative data was implemented from 1380 health facilities and 20 792 households in 2017–2018 was done. All grouped coverage scores demonstrated large ranges across the 26 provinces: newborn health: 20% to 61%; pneumonia: 26% to 86%; diarrhoea: 25% to 63%; malaria: 22% to 53%; and safe environment: 4% to 53%. The diarrhoea score demonstrated the strongest association with under-five mortality. Child mortality and the odds of coverage were higher in conflict-affected provinces for 13 out of 23 indicators. However, the authors also noted that children in unaffected provinces should not be neglected while addressing the needs of the most vulnerable in conflict settings. They notes that prevent, protect and treat strategies for diarrhoeal disease could help improve equity in child survival.

Tackling health inequities in indigenous communities
World Health Organisation: WHO, Geneva, 2022

There are currently 476 million indigenous people globally who experience structural racial and ethnicity-based discrimination, higher rates of health risks and poorer health outcomes. Their leadership and participation in public health is argued to be central to understand and address their health issues. In May 2022, WHO hosted a side event at the 21st session of the UN Permanent Forum under the theme “indigenous peoples, business, autonomy and the human rights principles of due diligence including free, prior and informed consent." The session explored the ‘causes of the causes’ of these health inequities and considered measures to tackle them, with members of indigenous communities speaking out on health systems strengthening, restorative justice, racism and discrimination, traditional medicine and health practices, access to water and social determinants of health like housing and education.

Assessing the impact of Covid-19 on older people in the African Region
WHO Regional Office for Africa: WHO, Brazzaville, 2021

The COVID-19 pandemic has had a significant impact on older persons globally and in the African region. Although overall the region’s population is younger relative to many other world regions, the WHO AFRO region has a population just over 62 million older people and is ageing rapidly, with the number of older people expected to triple in the next three decades. This desktop review, complemented with regional and national stakeholder interviews for six country case studies assessed the impact of COVID-19 on older people. The six case study countries were South Africa, Ghana, Rwanda, Mozambique, Senegal and Mauritius. The findings indicated impacts on falling incomes, rising poverty and food insecurity in older people, particularly in the face of weak social protection systems. Older people faced increasing isolation and challenges in accessing resources and services, and barriers to online systems. Long-term care services for older people were heavily impacted by COVID-19 and the authors point to 'ageism' in ignoring older people's needs and roles in recovery policies and plans. The authors recommend member states in the region expedite policy implementation in the context of the Decade of Healthy Ageing 2021-2030 to address these challenges through strengthened health care systems, community-based associations and networks of older people, age friendly environments and social protection mechanisms.

Inequality kills: The unparalleled action needed to combat unprecedented inequality in the wake of COVID-19
OXFAM International:: Policy Papers, Oxfam, 2022

This report observes that the wealth of the world’s 10 richest men has doubled since the pandemic began, while the incomes of the majority of the global population has fallen due to COVID-19, with widening economic, gender, and racial inequalities within countries and inequality between countries. The report explores the structural causes in policy choices that are made for the richest and most powerful people. Inequality is reported to contribute to the death of at least one person every four seconds. The authors recommend a radical redesign of economies to be centered on equality, clawing back extreme wealth through progressive taxation; investments in powerful, proven inequality-busting public measures; and bold shifts in power in economies and society.

SARS-CoV-2 infection in Africa: A systematic review and meta-analysis of standardised seroprevalence studies, from January 2020 to December 2021
Lewis HC; Ware H; Whelan M; et al.medRxiv 02.14.22270934; doi: https://doi.org/10.1101/2022.02.14.22270934, 2022

This preprint article presents a meta-analysis of population-based seroprevalence studies conducted in Africa published 01-01-2020 to 30-12-2021 to estimate SARS-CoV-2 seroprevalence in Africa. The authors aim to inform evidence-based decision making on Public Health and Social Measures (PHSM) and vaccine strategy. From 54 full texts or early results, reporting 151 distinct seroprevalence studies in Africa, 63% had a low/moderate risk of bias. SARS-CoV-2 seroprevalence rose from 3% in Q2 2020 to 65% in Q3 2021. The ratios of seroprevalence from infection to cumulative incidence of confirmed cases was large (overall: 97:1, ranging from 10:1 to 958:1) and steady over time. Seroprevalence was highly heterogeneous both within countries - urban vs. rural (lower seroprevalence for rural geographic areas), children vs. adults (children aged 0-9 years had the lowest seroprevalence) - and between countries and African sub-regions (Middle, Western and Eastern Africa associated with higher seroprevalence).The high seroprevalence in Africa suggests greater population exposure to SARS-CoV-2 and protection against COVID-19 disease than indicated by surveillance data.