The cost and cost-effectiveness of a text-messaging based intervention to support management of hypertension in South Africa

This project assessed the cost and cost-effectiveness of hypertension management in South Africa within the context of a text messaging-based intervention (StAR* study) conducted in an urban public-sector clinic in Cape Town. The StAR* study is a community randomized trial that investigated the effect of adherence support via short messaging service (SMS) on treatment adherence and patient outcomes for the management of hypertension at Vanguard CHC in Cape Town (Bobrow et al. 2016). Patients received behavioral text messages as reminders for them to collect and take their medication on time. The StAR* study, consisted of three arms that ran in parallel: participants in the control arm received unrelated messages; patients in the information-only arm received one-way information messages twice a week; and patients in the interactive arm received interactive SMS-texts at the same frequency as those in the information only arm (Bobrow et al. 2016). Patients in the interactive arm could respond to the messages and trigger a response from the healthcare provider. The text messaging based intervention was shown to improve hypertension outcomes over a 12-month period in hypertension patients by improving adherence and retention in care. The study showed, in the one-way intervention arm an improvement in adherence (measured by medication refill rates) and a small reduction in systolic blood pressure (2.2mm Hg reduction over 12months) (Bobrow et al. 2016). In this study, we assessed the cost and cost effectiveness of the StAR* intervention under routine care management at Vanguard CHC. We also assessed the cost of hypertension management from the health system perspective and the cost of accessing hypertension care from the patient perspective. A combination of the ingredients approach and step-down costing was used to cost hypertension care from a health system perspective while a questionnaire was administered to 250 patients to estimate patient costs. The primary outcomes were the average cost of hypertension care and the incremental cost of the text message-based adherence intervention (StAR* intervention), compared to usual care, per millimetre of mercury (mmHg) reduction in systolic blood pressure. Results of the study show that the average health system cost for hypertension management is R262 per visit and the patient cost of accessing hypertension care is R172 per visit. The text messaging based intervention was found to have low implementation costs in this pilot phase. The monthly incremental cost of the text messaging based intervention cost was R4 per person. The incremental cost-effectiveness ratio of the intervention was R22 per mm Hg reduction. This study provides the first contemporary assessment of hypertension management costs and the cost-effectiveness of mobile-based hypertension adherence support in South Africa. Future work will seek to estimate the long-term cost-effectiveness of this intervention and the cost of scaling it to the provincial and national levels

Economic Burden of Human Immunodeficiency Virus and Hypertension Care Among MOPHADHIV Trial Participants: Patient Costs and Determinants of Out-of-Pocket Expenditure in South Africa

Background: Human immunodeficiency virus and hypertension increasingly co-occur in South Africa. Despite publicly funded care, patients with multimorbidity face high out-of-pocket costs, yet limited evidence exists from the patient perspective. Purpose: To quantify the economic burden of comorbid HIV and hypertension, assess predictors of monthly out-of-pocket costs, and explore coping mechanisms. Methods: We conducted a cross-sectional analysis using patient-level data from the Mobile Phone Text Messages to Improve Hypertension Medication Adherence in Adults with HIV (MOPHADHIV trial) [Trial number: PACTR201811878799717], a randomized controlled trial evaluating short messages services adherence support for hypertension care in people with HIV. We calculated the monthly direct non-medical, indirect, and coping costs from a patient perspective, valuing indirect costs using both actual income and minimum wage assumptions. Generalized linear models with a gamma distribution and log link were used to identify cost determinants. Catastrophic expenditure thresholds (10–40% of monthly income) were assessed. Results: Among 683 participants, mean monthly total costs were ZAR 105.81 (USD 5.72) using actual income and ZAR 182.3 (USD 9.9) when valuing indirect costs by minimum wage. These time-related productivity losses constituted the largest share of overall expenses. Regression models revealed a strong income gradient: participants in the richest quintile incurred ZAR 131.9 (95% CI: 63.6–200.1) more per month than the poorest. However, this gradient diminished or reversed under standardized wage assumptions, suggesting a heavier proportional burden on middle-income groups. Other socio-demographic factors (gender, employment, education) not significantly associated with total costs, likely reflecting the broad reach of South Africa’s primary health system. Nearly half of the participants also reported resorting to coping mechanisms such as borrowing or asset sales. Conclusions: Comorbid HIV and hypertension impose substantial patient costs, predominantly indirect. Income disparities drive variation, raising equity concerns. Strengthening integrated human immunodeficiency virus—non-communicable diseases care and targeting financial support are key to advancing South Africa’s Universal Health Coverage reforms

Protocol of mixed-methods assessment of demographic, epidemiological and clinical profile of decentralised patients with cancer at Nelson Mandela Academic Hospital and Rob Ferreira Hospital, South Africa

IntroductionCancer is the second leading cause of death globally. However, cancer care services are often concentrated in urban centres. Two of South Africa’s hospitals have decentralised cancer care delivery since February 2018 and August 2019, respectively. This study aims to describe the demographic, epidemiological and clinical profile of various cancers at Nelson Mandela Academic Hospital (NMAH) and Rob Ferreira Hospital (RFH), in South Africa’s Eastern Cape and Mpumalanga provinces, respectively.Methods and analysisThis study will be conducted in the Eastern Cape and Mpumalanga provinces. A mixed-methods study design will be undertaken to gain insight on the characteristics of randomly sampled patients who are treated for cancer at NMAH and RFH between 1 March 2018 and 28 February 2022. A validated, researcher-administered survey questionnaire will be used to assess demographic characteristics, and prevalence of different cancers among patients. Concurrently, a document review will be undertaken on patients with cancer using a patient registry to ascertain the duration of diagnosis, type of cancer(s), management plan and patient survival time. STATA V.17 will be used for data analysis. The Shapiro-Wilk test will be used to explore the distribution of numerical variables. The χ2or Fisher’s exact tests will be used depending on the value of the expected frequencies to compare categorical variables. Kaplan-Meier survival estimates will be used to determine the survival time. Hazard ratios will be used to determine the predictors of death. The level of statistical significance will be set at p value ≤0.05. The 95% CI will be used for the precision of estimates.Ethics and disseminationEthics approval was obtained from the Human Research Ethics Committees of the University of the Witwatersrand (M210211) and Walter Sisulu University, South Africa (Ref: 040/2020). Findings will be reported through peer-reviewed journal(s), presentations at conferences and at partner meetings.</jats:sec

A cross-sectional study of knowledge, attitudes, barriers and practices of cervical cancer screening among nurses in selected hospitals in the Eastern Cape Province, South Africa

Abstract Background Cervical cancer is a preventable but highly prevalent cancer in many low -and middle-income countries including South Africa. Cervical cancer outcomes can be improved with improved vaccination, a well-coordinated and efficient screening programme, increased community awareness and uptake, and increased knowledge and advocacy of health professionals. This study therefore aimed to ascertain the knowledge, attitudes, practices and barriers of cervical cancer screening among nurses of selected rural hospitals in South Africa. Methods A quantitative cross-sectional study was conducted in five hospitals in the Eastern Cape Province of South Africa between October and December 2021. A self-administered questionnaire was used to assess demographic characteristics of nurses and cervical cancer knowledge, attitudes, barriers and practices. A knowledge score of 65% was deemed adequate. Data were captured in Microsoft Excel Office 2016 and exported to STATA version 17.0 for analysis. Descriptive data analyses were used to report the results. Results A total of 119 nurses participated in the study with just under two thirds (77/119, 64.7%) being professional nurses. Only 15.1% (18/119) of participants were assessed as having obtained a good knowledge score of ≥ 65%. The majority of these (16/18, 88.9%) were professional nurses. Of the participants with a good knowledge score, 61.1% (11/18) were from Nelson Mandela Academic Hospital, the only teaching hospital studied. Cervical cancer was deemed to be a disease of public health importance by 74.0% (88/119). However, only 27.7% (33/119) performed cervical cancer screening. Most of the participants (116/119, 97.5%) had an interest of attending more cervical cancer training. Conclusion The majority of nurse participants did not have adequate knowledge about cervical cancer and screening, and few performed screening tests. Despite this, there is a high level of interest in being trained. Meeting these training needs is of utmost importance to implementing a comprehensive cervical cancer screening programme in South Africa. </jats:sec

Model of delivery of cancer care in South Africa’s Eastern Cape and Mpumalanga provinces: a situational analysis protocol

IntroductionCancer contributes to a significant proportion of morbidity and mortality globally. Low-income and middle-income countries such as South Africa tend to be characterised by poor and inequitable access to cancer services. Cancer resources are more likely to be found in urban areas, tertiary centres and quaternary hospitals. However, little is known about the linkages to care, continuity of care and packages of cancer care in rural South African settings. This study describes cancer service delivery for South Africa’s Eastern Cape and Mpumalanga provinces.Methods and analysisA mixed-methods qualitative and quantitative research methods of three substudies which include semistructured interviews with patients, focus group discussions with health providers and a quantitative record review that will be carried out at both Rob Ferreira hospital, Witbank hospital and Nelson Mandela Academic hospital in Mpumalanga and Eastern Cape province, respectively. Instruments assess demographic characteristics, explore packages of cancer care, explore challenges experienced by health professionals, and maps out the referral pathway of patients with a cancer diagnosis in the study sites. Numerical, quantitative data will be explored for normality using the Shapiro-Wilk test and reported using either the mean, SD and range or the median and IQR depending on the normality of the distribution. Qualitative data will be analysed using the phenomenological approach.Ethics and disseminationEthics approval was obtained from the Human Research Ethics Committee of Walter Sisulu University (040/2020) and the University of the Witwatersrand (M210211), South Africa. To the research team’s knowledge, this is the first study presenting the model of cancer delivery in South Africa’s Eastern Cape and Mpumalanga province. This will thus provide better understanding of cancer service delivery systems, packages of cancer care from primary care to quaternary care.</jats:sec

Protocol for Exploring Effective Clinical Governance Strategies in South Africa’s Eastern Cape and Mpumalanga Provinces

Abstract Background: Hospitals are an integral part of the national health system. They provide a hub for health services that cannot be provided in the primary care setting, provide facilities for advanced investigation, diagnosis, and treatment, and constitute the platform for training and development of health professionals. However, when inspections were done at public sector facilities in preparation for the implementation of the NHI, the lowest average performance score was in leadership and corporate governance. This study aims to assess the effectiveness of clinical governance interventions in selected public hospitals in South Africa’s Eastern Cape and Mpumalanga provinces. Methods: This will be a cluster randomised study where there will be two intervention sites (a tertiary hospital and a regional hospital) and control sites (non-intervention central and regional hospitals). The intervention will comprise a focused implementation of clinical governance protocols (through training and coaching of hospital management and frontline health workers). There will be a pre-intervention baseline assessment; an assessment immediately at the end of the 12 months long intervention and an assessment at 36 months post-intervention. This builds on existing policy initiatives, quality improvement initiatives and tools. Information will be sourced through six sub-studies – three qualitative and three quantitative. Ethical clearance with reference number: 040/21 has been granted by the Research Ethics Committee of the Faculty of Health Sciences at Walter Sisulu University. Approvals to access the research sites with refence numbers: EC_202106_019 and MP_202106_009 have been granted by the Eastern Cape and Mpumalanga Provincial Health Research Committees respectively.Discussion: There is a need for a deeper understanding of how tertiary and regional hospitals operate, how these hospitals ensure provision of safe high-quality patient-centred clinical care and factors enabling them or hindering them from achieving higher performance. In addition, it is necessary to explore if the performance of the hospitals improves where there is a focused implementation of clinical governance protocols.</jats:p