Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: an interrupted time series analysis

Abstract

We evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN).

Design

Observational cohort

Setting

Data were analysed from 11 primary healthcare clinics in northern KZN.

Participants

A total of 46 523 individuals made 89 476 clinic visits during the observation period.

Exposure of interest

We conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods.

Outcome measures

Daily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata.

Results

We found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI −16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (−7.1 visits/clinic/day, 95% CI −8.9 to 5.3), both for children aged <1 year and 1–5 years, with a gradual return to prelockdown within 3 months after the first lockdown measure. In contrast, we found no drop in clinic visitation in adults at the start of the level 5 lockdown, or related to HIV care (from 37.5 to 45.6, 8.0 visits/clinic/day, 95% CI 2.1 to 13.8).

Conclusions

In rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region.

SciScore for 10.1101/2020.05.15.20103226: (What is this?)

Please note, not all rigor criteria are appropriate for all manuscripts.

Table 1: Rigor

Institutional Review Board Statement	IRB: Ethical Approval: The protocol was reviewed and approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee under reference BE290/16 and the KwaZulu Department of Health Research Committee.
Randomization	not detected.
Blinding	not detected.
Power Analysis	not detected.
Sex as a biological variable	The region ranks among the lowest nationwide in terms of health indicators and socioeconomic status.23 Approximately 1 in 5 adult men and 2 in 5 adult women are living with HIV.24 Tuberculosis incidence is among the highest in the world, and above the national average of 577 per 100,000 individuals when last measured in 2015.25 Data Collection: Since 2000 AHRI has collected data on births, deaths, migrations through thrice annual data collection encounters across a catchment area of 20,000 households (over 100,000 resident individuals).

Table 2: Resources

No key resources detected.

Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

One key potential limitation to our study is that it is predicated on the assumption that there were no other external factors that would have caused interruptions to the health care system on or after 27th March 2020 (e.g., power outage, inclement weather).We are unaware of any such shock and believe this to be a minor risk. Our analysis should also be interpreted within the context of our study area – one with a few dozen reported cases of COVID-19 in a nation with a moderately sized epidemic (approximately 7,000 cases as of early May), but not yet in the depths of a large epidemic with established local transmission. In summary, we report resilience of the ambulatory health care system during the early COVID-19 epidemic and Level 5 lockdown period in rural South Africa. Future work should establish if these trends are maintained, and particularly monitor access to childcare and immunizations as a result of the trends reported here. Finally, in rural South Africa and similar areas, efforts to prevent nosocomial spread of COVID-19 among high-risk populations through decentralization of non-urgent care will remain a critical area of future study.

Results from TrialIdentifier: No clinical trial numbers were referenced.

Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

Results from JetFighter: We did not find any issues relating to colormaps.

Results from rtransparent:

Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
No protocol registration statement was detected.

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