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  • 1. Ameh, Soter
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Klipstein-Grobusch, Kerstin
    Predictors of health care use by adults 50 years and over in a rural South African setting2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 1-11Article in journal (Refereed)
    Abstract [en]

    Background: South Africa's epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults.

    Objective: To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa.

    Design: A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables.

    Results: Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e. g. hypertension), acute conditions (27% - e. g. flu and fever), other conditions (26% - e. g. musculoskeletal pain), chronic communicable diseases (3% - e. g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR = 5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR = 2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR = 2.49, 95% CI: 1.27, 4.86) compared with those with no formal education.

    Conclusion: Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.

  • 2. Ameh, Soter
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), Accra, Ghana.
    Klipstein-Grobusch, Kerstin
    Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 229Article in journal (Refereed)
    Abstract [en]

    Background: South Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients’ and operational managers’ satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian’s theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care.

    Methods: A cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian’s theory, using unidirectional, mediation, and reciprocal pathways.

    Results: The mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs.

    Conclusion: Of the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian’s theoretical framework can be used to provide evidence of quality systems in the ICDM model.

  • 3. Ameh, Soter
    et al.
    Klipstein-Grobusch, Kerstin
    D'ambruoso, Lucia
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana.
    Gomez-Olive, Francesc Xavier
    Quality of integrated chronic disease care in rural South Africa: user and provider perspectives2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, no 2, p. 257-266Article in journal (Refereed)
    Abstract [en]

    The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients >= 18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian's structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low-and middle-income countries.

  • 4. Ameh, Soter
    et al.
    Klipstein-Grobusch, Kerstin
    Musenge, Eustasius
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Sch Publ Hlth, Fac Hlth Sci, Med Res Council,Wits Univ Rural Publ Hlth, Johannesburg, South Africa ; Int Network Demog Evaluat Populat & Their Hlth De, Accra, Ghana ; Univ Witwatersrand, Sch Publ Hlth, Fac Hlth Sci, Hlth Transit Res Unit Agincourt, Johannesburg, South Africa.
    Tollman, Stephen
    Gomez-Olive, Francesc Xavier
    Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis2017In: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 75, no 4, p. 472-479Article in journal (Refereed)
    Abstract [en]

    Background: South Africa faces a dual burden of HIV/AIDS and noncommunicable diseases. In 2011, a pilot integrated chronic disease management (ICDM) model was introduced by the National Health Department into selected primary health care (PHC) facilities. The objective of this study was to assess the effectiveness of the ICDM model in controlling patients' CD4 counts (>350 cells/mm(3)) and blood pressure [BP (<140/90 mm Hg)] in PHC facilities in the Bushbuckridge municipality, South Africa. Methods: A controlled interrupted time-series study was conducted using the data from patients' clinical records collected multiple times before and after the ICDM model was initiated in PHC facilities in Bushbuckridge. Patients >18 years were recruited by proportionate sampling from the pilot (n = 435) and comparing (n = 443) PHC facilities from 2011 to 2013. Health outcomes for patients were retrieved from facility records for 30 months. We performed controlled segmented regression to model the monthly averages of individuals' propensity scores using autoregressive moving average model at 5% significance level. Results: The pilot facilities had 6% greater likelihood of controlling patients' CD4 counts than the comparison facilities (coefficient = 0.057; 95% confidence interval: 0.056 to 0.058; P < 0.001). Compared with the comparison facilities, the pilot facilities had 1.0% greater likelihood of controlling patients' BP (coefficient = 0.010; 95% confidence interval: 0.003 to 0.016; P = 0.002). Conclusions: Application of the model had a small effect in controlling patients' CD4 counts and BP, but showed no overall clinical benefit for the patients; hence, the need to more extensively leverage the HIV program for hypertension treatment.

  • 5. Arthur, Samuelina S.
    et al.
    Nyide, Bongiwe
    Soura, Abdramane Bassiahi
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weston, Mark
    Sankoh, Osman
    Tackling malnutrition: a systematic review of 15-year research evidence from INDEPTH health and demographic surveillance systems2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-13, article id 28298Article, review/survey (Refereed)
    Abstract [en]

    Background: Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Objective: To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs). Methods: Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords 'nutrition', 'malnutrition', 'over and under nutrition', we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight paperswere identified and reviewed, and 67 were selected for this study. Results: The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition. Conclusions: Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

  • 6. Baiden, Frank
    et al.
    Bawah, Ayaga
    Biai, Sidu
    Binka, Fred
    Boerma, Ties
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Chandramohan, Daniel
    Chatterji, Somnath
    Engmann, Cyril
    Greet, Dieltiens
    Jakob, Robert
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kunii, Osamu
    Lopez, Alan D
    Murray, Christopher JL
    Nahlen, Bernard
    Rao, Chalapati
    Sankoh, Osman
    Setel, Philip W
    Shibuya, Kenji
    Soleman, Nadia
    Wright, Linda
    Yang, Gonghuan
    Setting international standards for verbal autopsy2007In: Bulletin of the World Health Organization, ISSN 0042-9686, E-ISSN 1564-0604, Vol. 85, no 8, p. 570-571Article in journal (Refereed)
  • 7. Bawah, Ayaga
    et al.
    Houle, Brian
    Alam, Nurul
    Razzaque, Abdur
    Streatfield, Peter Kim
    Debpuur, Cornelius
    Welaga, Paul
    Oduro, Abraham
    Hodgson, Abraham
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Toan, Tran Khan
    Phuc, Ho Dang
    Chuc, Nguyen Thi Kim
    Sankoh, Osman
    Clark, Samuel J.
    The Evolving Demographic and Health Transition in Four Low- and Middle-Income Countries: Evidence from Four Sites in the INDEPTH Network of Longitudinal Health and Demographic Surveillance Systems2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 6, article id e0157281Article in journal (Refereed)
    Abstract [en]

    This paper contributes evidence documenting the continued decline in all-cause mortality and changes in the cause of death distribution over time in four developing country populations in Africa and Asia. We present levels and trends in age-specific mortality (all-cause and cause-specific) from four demographic surveillance sites: Agincourt (South Africa), Navrongo (Ghana) in Africa; Filabavi (Vietnam), Matlab (Bangladesh) in Asia. We model mortality using discrete time event history analysis. This study illustrates how data from INDEPTH Network centers can provide a comparative, longitudinal examination of mortality patterns and the epidemiological transition. Health care systems need to be reconfigured to deal simultaneously with continuing challenges of communicable disease and increasing incidence of non-communicable diseases that require long-term care. In populations with endemic HIV, long-term care of HIV patients on ART will add to the chronic care needs of the community.

  • 8. Beran, David
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gbakima, Aiah
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sankoh, Osman
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Witham, Miles
    Davies, Justine
    Research capacity building-obligations for global health partners2017In: The Lancet Global Health, E-ISSN 2214-109X, Vol. 5, no 6, p. E567-E568Article in journal (Refereed)
  • 9. Bird, J.
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, University of the Witwatersrand, South Africa and University College London, United Kingdom .
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, University of the Witwatersrand, South Africa and University College London, United Kingdom .
    Mee, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, University of the Witwatersrand, South Africa and University College London, United Kingdom .
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. UCL Institute for Global Health, University College London, United Kingdom.
    A matter of life and death: practical and ethical constraints in the development of a mobile verbal autopsy tool2013In: CHI '13 Proceedings of the SIGCHI Conference on Human Factors in Computing SystemsPages 1489-1498, 2013, p. 1489-1498Conference paper (Refereed)
    Abstract [en]

    Verbal autopsy (VA) involves interviewing relatives of the deceased to identify the probable cause of death and is typically used in settings where there is no official system for recording deaths or their causes. Following the interview, physician assessment to determine probable cause can take several years to complete. The World Health Organization (WHO) recognizes that there is a pressing need for a mobile device that combines direct data capture and analysis if this technique is to become part of routine health surveillance. We conducted a field test in rural South Africa to evaluate a mobile system that we designed to meet WHO requirements (namely, simplicity, feasibility, adaptability to local contexts, cost-effectiveness and program relevance). If desired, this system can provide immediate feedback to respondents about the probable cause of death at the end of a VA interview. We assessed the ethical implications of this technological development by interviewing all the stakeholders in the VA process (respondents, fieldworkers, physicians, population scientists, data managers and community engagement managers) and highlight the issues that this community needs to debate and resolve.

  • 10. Brooks, Chloe
    et al.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kazimierczak, Karolina
    Ngobeni, Sizzy
    Twine, Rhian
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Introducing visual participatory methods to develop local knowledge on HIV in rural South Africa2017In: BMJ Global Health, E-ISSN 2059-7908, Vol. 2, no 3, article id e000231Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: South Africa is a country faced with complex health and social inequalities, in which HIV/AIDS has had devastating impacts. The study aimed to gain insights into the perspectives of rural communities on HIV-related mortality.

    METHODS: A participatory action research (PAR) process, inclusive of a visual participatory method (Photovoice), was initiated to elicit and organise local knowledge and to identify priorities for action in a rural subdistrict underpinned by the Agincourt Health and Socio-Demographic Surveillance System (HDSS). We convened three village-based discussion groups, presented HDSS data on HIV-related mortality, elicited subjective perspectives on HIV/AIDS, systematised these into collective accounts and identified priorities for action. Framework analysis was performed on narrative and visual data, and practice theory was used to interpret the findings.

    FINDINGS: A range of social and health systems factors were identified as causes and contributors of HIV mortality. These included alcohol use/abuse, gender inequalities, stigma around disclosure of HIV status, problems with informal care, poor sanitation, harmful traditional practices, delays in treatment, problems with medications and problematic staff-patient relationships. To address these issues, developing youth facilities in communities, improving employment opportunities, timely treatment and extending community outreach for health education and health promotion were identified.

    DISCUSSION: Addressing social practices of blame, stigma and mistrust around HIV-related mortality may be a useful focus for policy and planning. Research that engages communities and authorities to coproduce evidence can capture these practices, improve communication and build trust.

    CONCLUSION: Actions to reduce HIV should go beyond individual agency and structural forces to focus on how social practices embody these elements. Initiating PAR inclusive of visual methods can build shared understandings of disease burdens in social and health systems contexts. This can develop shared accountability and improve staff-patient relationships, which, over time, may address the issues identified, here related to stigma and blame.

  • 11.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chandramohan, Daniel
    Clark, Samuel J.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Graham, Wendy J.
    Herbst, Abraham J.
    Hodgson, Abraham
    Hounton, Sennen
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krishnan, Anand
    Leitao, Jordana
    Odhiambo, Frank
    Sankoh, Osman A.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy (VA) is the only available approach for determining the cause of many deaths, where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHO VA instrument as a new standard, intended both as a research tool and for routine registration of deaths. Objective: A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument. Design: The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version 10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths. Results: The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration dataset from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4. Conclusions: InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration. Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data.

  • 12.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kabudula, C.
    Gómez-Olivé, F. X.
    Wagner, R.
    Ngobeni, S.
    Silaule, B.
    Mee, P.
    Coetzee, M.
    Twine, W.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    The long road to elimination: malaria mortality in a South African population cohort over 21 years2017In: Global Health, Epidemiology and Genomics, E-ISSN 2054-4200, Vol. 2, article id e11Article in journal (Refereed)
    Abstract [en]

    Background: Malaria elimination is on global agendas following successful transmission reductions. Nevertheless moving from low to zero transmission is challenging. South Africa has an elimination target of 2018, which may or may not be realised in its hypoendemic areas.

    Methods: The Agincourt Health and Demographic Surveillance System has monitored population health in north-eastern South Africa since 1992. Malaria deaths were analysed against individual factors, socioeconomic status, labour migration and weather over a 21-year period, eliciting trends over time and associations with covariates.

    Results: Of 13 251 registered deaths over 1.58 million person-years, 1.2% were attributed to malaria. Malaria mortality rates increased from 1992 to 2013, while mean daily maximum temperature rose by 1.5 °C. Travel to endemic Mozambique became easier, and malaria mortality increased in higher socioeconomic groups. Overall, malaria mortality was significantly associated with age, socioeconomic status, labour migration and employment, yearly rainfall and higher rainfall/temperature shortly before death.

    Conclusions: Malaria persists as a small but important cause of death in this semi-rural South African population. Detailed longitudinal population data were crucial for these analyses. The findings highlight practical political, socioeconomic and environmental difficulties that may also be encountered elsewhere in moving from low-transmission scenarios to malaria elimination.

  • 13.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Epidemiologi och folkhälsovetenskap.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Epidemiologi och folkhälsovetenskap.
    Dao, Lan Huong
    Berhane, Yemane
    Corrah, Tumani
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Muhe, Lulu
    Do, Duc Van
    Refining a probabilistic model for interpreting verbal autopsy data.2006In: Scandinavian journal of public health, ISSN 1403-4948, Vol. 34, no 1, p. 26-31Article in journal (Refereed)
  • 14.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; IMMPACT, Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK.
    Herbst, Kobus
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. UCL Institute for Global Health, University College London, London, UK.
    Ali, Mohamed M
    Odhiambo, Frank
    Amek, Nyaguara
    Hamel, Mary J
    Laserson, Kayla F
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kabudula, Chodziwadziwa
    Mee, Paul
    Bird, Jon
    Jakob, Robert
    Sankoh, Osman
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Comparing verbal autopsy cause of death findings as determined by physician coding and probabilistic modelling: a public health analysis of 54 000 deaths in Africa and Asia2015In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 5, no 1, p. 65-73, article id 010402Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Coverage of civil registration and vital statistics varies globally, with most deaths in Africa and Asia remaining either unregistered or registered without cause of death. One important constraint has been a lack of fit-for-purpose tools for registering deaths and assigning causes in situations where no doctor is involved. Verbal autopsy (interviewing care-givers and witnesses to deaths and interpreting their information into causes of death) is the only available solution. Automated interpretation of verbal autopsy data into cause of death information is essential for rapid, consistent and affordable processing.

    METHODS: Verbal autopsy archives covering 54 182 deaths from five African and Asian countries were sourced on the basis of their geographical, epidemiological and methodological diversity, with existing physician-coded causes of death attributed. These data were unified into the WHO 2012 verbal autopsy standard format, and processed using the InterVA-4 model. Cause-specific mortality fractions from InterVA-4 and physician codes were calculated for each of 60 WHO 2012 cause categories, by age group, sex and source. Results from the two approaches were assessed for concordance and ratios of fractions by cause category. As an alternative metric, the Wilcoxon matched-pairs signed ranks test with two one-sided tests for stochastic equivalence was used.

    FINDINGS: The overall concordance correlation coefficient between InterVA-4 and physician codes was 0.83 (95% CI 0.75 to 0.91) and this increased to 0.97 (95% CI 0.96 to 0.99) when HIV/AIDS and pulmonary TB deaths were combined into a single category. Over half (53%) of the cause category ratios between InterVA-4 and physician codes by source were not significantly different from unity at the 99% level, increasing to 62% by age group. Wilcoxon tests for stochastic equivalence also demonstrated equivalence.

    CONCLUSIONS: These findings show strong concordance between InterVA-4 and physician-coded findings over this large and diverse data set. Although these analyses cannot prove that either approach constitutes absolute truth, there was high public health equivalence between the findings. Given the urgent need for adequate cause of death data from settings where deaths currently pass unregistered, and since the WHO 2012 verbal autopsy standard and InterVA-4 tools represent relatively simple, cheap and available methods for determining cause of death on a large scale, they should be used as current tools of choice to fill gaps in cause of death data.

  • 15.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa.
    Hussain-Alkhateeb, Laith
    D'Ambruoso, Lucia
    Clark, Samuel
    Davies, Justine
    Fottrell, Edward
    Bird, Jon
    Kabudula, Chodziwadziwa
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; INDEPTH Network, Accra, Ghana.
    Schiöler, Linus
    Petzold, Max
    An integrated approach to processing WHO-2016 verbal autopsy data: the InterVA-5 model2019In: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 17, article id 102Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy is an increasingly important methodology for assigning causes to otherwise uncertified deaths, which amount to around 50% of global mortality and cause much uncertainty for health planning. The World Health Organization sets international standards for the structure of verbal autopsy interviews and for cause categories that can reasonably be derived from verbal autopsy data. In addition, computer models are needed to efficiently process large quantities of verbal autopsy interviews to assign causes of death in a standardised manner. Here, we present the InterVA-5 model, developed to align with the WHO-2016 verbal autopsy standard. This is a harmonising model that can process input data from WHO-2016, as well as earlier WHO-2012 and Tariff-2 formats, to generate standardised cause-specific mortality profiles for diverse contexts.

    The software development involved building on the earlier InterVA-4 model, and the expanded knowledge base required for InterVA-5 was informed by analyses from a training dataset drawn from the Population Health Metrics Research Collaboration verbal autopsy reference dataset, as well as expert input.

    Results: The new model was evaluated against a test dataset of 6130 cases from the Population Health Metrics Research Collaboration and 4009 cases from the Afghanistan National Mortality Survey dataset. Both of these sources contained around three quarters of the input items from the WHO-2016, WHO-2012 and Tariff-2 formats. Cause-specific mortality fractions across all applicable WHO cause categories were compared between causes assigned in participating tertiary hospitals and InterVA-5 in the test dataset, with concordance correlation coefficients of 0.92 for children and 0.86 for adults.

    The InterVA-5 model’s capacity to handle different input formats was evaluated in the Afghanistan dataset, with concordance correlation coefficients of 0.97 and 0.96 between the WHO-2016 and the WHO-2012 format for children and adults respectively, and 0.92 and 0.87 between the WHO-2016 and the Tariff-2 format respectively.

    Conclusions: Despite the inherent difficulties of determining “truth” in assigning cause of death, these findings suggest that the InterVA-5 model performs well and succeeds in harmonising across a range of input formats. As more primary data collected under WHO-2016 become available, it is likely that InterVA-5 will undergo minor re-versioning in the light of practical experience. The model is an important resource for measuring and evaluating cause-specific mortality globally.

  • 16.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kabudula, Chodziwadziwa W.
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Mee, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Ngobeni, Sizzy
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;.
    Silaule, Bernard
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;.
    Gomez-Olive, F. Xavier
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Tugendhaft, Aviva
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; PRICELESS/PEECHi, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa .
    Wagner, Ryan G.
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; .
    Twine, Rhian
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; .
    Hofman, Karen
    MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; PRICELESS/PEECHi, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    A Successful Failure: missing the MDG4 Target for Under-Five Mortality in South Africa2015In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 12, no 12, article id e1001926Article in journal (Refereed)
  • 17.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Moving from data on deaths to public health policy in Agincourt, South Africa: approaches to analysing and understanding verbal autopsy findings2010In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 7, no 8, p. e1000325-Article in journal (Refereed)
    Abstract [en]

    There were no differences between physician interpretation and probabilistic modelling that might have led to substantially different public health policy conclusions at the population level. Physician interpretation was more nuanced than the model, for example in identifying cancers at particular sites, but did not capture the uncertainty associated with individual cases. Probabilistic modelling was substantially cheaper and faster, and completely internally consistent. Both approaches characterised the rise of HIV-related mortality in this population during the period observed, and reached similar findings on other major causes of mortality. For many purposes probabilistic modelling appears to be the best available means of moving from data on deaths to public health actions. Please see later in the article for the Editors' Summary.

  • 18.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and Centre for International Health and Development, Institute of Child Health, University College London, London, UK.
    Mee, Paul
    MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Using verbal autopsy to track epidemic dynamics: the case of HIV-related mortality in South Africa.2011In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 9, p. 46-Article in journal (Refereed)
    Abstract [en]

    Background Verbal autopsy (VA) has often been used for point estimates of cause-specific mortality, but seldom to characterize long-term changes in epidemic patterns. Monitoring emerging causes of death involves practitioners' developing perceptions of diseases and demands consistent methods and practices. Here we retrospectively analyze HIV-related mortality in South Africa, using physician and modeled interpretation.

    Methods Between 1992 and 2005, 94% of 6,153 deaths which occurred in the Agincourt subdistrict had VAs completed, and coded by two physicians and the InterVA model. The physician causes of death were consolidated into a single consensus underlying cause per case, with an additional physician arbitrating where different diagnoses persisted. HIV-related mortality rates and proportions of deaths coded as HIV-related by individual physicians, physician consensus, and the InterVA model were compared over time.

    Results Approximately 20% of deaths were HIV-related, ranging from early low levels to tenfold-higher later population rates (2.5 per 1,000 person-years). Rates were higher among children under 5 years and adults 20 to 64 years. Adult mortality shifted to older ages as the epidemic progressed, with a noticeable number of HIV-related deaths in the over-65 year age group latterly. Early InterVA results suggested slightly higher initial HIV-related mortality than physician consensus found. Overall, physician consensus and InterVA results characterized the epidemic very similarly. Individual physicians showed marked interobserver variation, with consensus findings generally reflecting slightly lower proportions of HIV-related deaths. Aggregated findings for first versus second physician did not differ appreciably.

    Conclusions VA effectively detected a very significant epidemic of HIV-related mortality. Using either physicians or InterVA gave closely comparable findings regarding the epidemic. The consistency between two physician coders per case (from a pool of 14) suggests that double coding may be unnecessary, although the consensus rate of HIV-related mortality was approximately 8% lower than by individual physicians. Consistency within and between individual physicians, individual perceptions of epidemic dynamics, and the inherent consistency of models are important considerations here. The ability of the InterVA model to track a more than tenfold increase in HIV-related mortality over time suggests that finely tuned "local" versions of models for VA interpretation are not necessary.

  • 19.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The global burden of childhood coeliac disease: a neglected component of diarrhoeal mortality?2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 7, p. e22774-Article in journal (Refereed)
    Abstract [en]

    Objectives Coeliac disease has emerged as an increasingly recognised public health problem over the last half-century, and is now coming to be seen as a global phenomenon, despite a profound lack of globally representative epidemiological data. Since children with coeliac disease commonly present with chronic diarrhoea and malnutrition, diagnosis is often overlooked, particularly in poorer settings where children often fail to thrive and water-borne infectious diarrhoeas are common. This is the first attempt to make global estimates of the burden of coeliac disease in childhood.

    Methods We built a relatively crude model of childhood coeliac disease, incorporating estimates of population prevalence, probability of non-diagnosis, and likelihood of mortality among the undiagnosed across all countries from 1970 to 2010, based around the few available data. All our assumptions are stated in the paper and the model is available as a supplementary file.

    Findings Our model suggests that in 2010 there were around 2.2 million children under 5 years of age living with coeliac disease. Among these children there could be 42,000 deaths related to coeliac disease annually. In 2008, deaths related to coeliac disease probably accounted for approximately 4% of all childhood diarrhoeal mortality.

    Conclusions Although coeliac disease may only account for a small proportion of diarrhoeal mortality, these deaths are not preventable by applying normal diarrhoea treatment guidelines, which may even involve gluten-based food supplements. As other causes of diarrhoeal mortality decline, coeliac disease will become a proportionately increasing problem unless consideration is given to trying gluten-free diets for children with chronic diarrhoea and malnutrition.

  • 20. Clark, Samuel J.
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Houle, Brian
    Arteche, Adriane
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stein, Alan
    Young Children's Probability of Dying Before and After Their Mother's Death: A Rural South African Population-Based Surveillance Study2013In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 10, no 3, p. e1001409-Article in journal (Refereed)
    Abstract [en]

    Background: There is evidence that a young child's risk of dying increases following the mother's death, but little is known about the risk when the mother becomes very ill prior to her death. We hypothesized that children would be more likely to die during the period several months before their mother's death, as well as for several months after her death. Therefore we investigated the relationship between young children's likelihood of dying and the timing of their mother's death and, in particular, the existence of a critical period of increased risk. Methods and Findings: Data from a health and socio-demographic surveillance system in rural South Africa were collected on children 0-5 y of age from 1 January 1994 to 31 December 2008. Discrete time survival analysis was used to estimate children's probability of dying before and after their mother's death, accounting for moderators. 1,244 children (3% of sample) died from 1994 to 2008. The probability of child death began to rise 6-11 mo prior to the mother's death and increased markedly during the 2 mo immediately before the month of her death (odds ratio [OR] 7.1 [95% CI 3.9-12.7]), in the month of her death (OR 12.6 [6.2-25.3]), and during the 2 mo following her death (OR 7.0 [3.2-15.6]). This increase in the probability of dying was more pronounced for children whose mothers died of AIDS or tuberculosis compared to other causes of death, but the pattern remained for causes unrelated to AIDS/tuberculosis. Infants aged 0-6 mo at the time of their mother's death were nine times more likely to die than children aged 2-5 y. The limitations of the study included the lack of knowledge about precisely when a very ill mother will die, a lack of information about child nutrition and care, and the diagnosis of AIDS deaths by verbal autopsy rather than serostatus. Conclusions: Young children in lower income settings are more likely to die not only after their mother's death but also in the months before, when she is seriously ill. Interventions are urgently needed to support families both when the mother becomes very ill and after her death.

  • 21. Cohen, Adam L.
    et al.
    Hellferscee, Orienka
    Pretorius, Marthi
    Treurnicht, Florette
    Walaza, Sibongile
    Madhi, Shabir
    Groome, Michelle
    Dawood, Halima
    Variava, Ebrahim
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    Wolter, Nicole
    von Gottberg, Anne
    Tempia, Stefano
    Venter, Marietjie
    Cohen, Cheryl
    Epidemiology of Influenza Virus Types and Subtypes in South Africa, 2009-20122014In: Emerging Infectious Diseases, ISSN 1080-6040, E-ISSN 1080-6059, Vol. 20, no 7, p. 1162-1169Article in journal (Refereed)
    Abstract [en]

    To determine clinical and epidemiologic differences between influenza caused by different virus types and subtypes, we identified patients and tested specimens. Patients were children and adults hospitalized with confirmed influenza and severe acute respiratory illness (SARI) identified through active, prospective, hospital-based surveillance from 2009-2012 in South Africa. Respiratory specimens were tested, typed, and subtyped for influenza virus by PCR. Of 16,005 SARI patients tested, 1,239 (8%) were positive for influenza virus. Patient age and co-infections varied according to virus type and subtype, but disease severity did not. Case-patients with influenza B were more likely than patients with influenza A to be HIV infected. A higher proportion of case-patients infected during the first wave of the 2009 influenza pandemic were 5-24 years of age (19%) than were patients infected during the second wave (9%). Although clinical differences exist, treatment recommendations do not differ according to subtype; prevention through vaccination is recommended.

  • 22. Cohen, Adam L
    et al.
    Sahr, Philip K
    Treurnicht, Florette
    Walaza, Sibongile
    Groome, Michelle J
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health; INDEPTH Network, Accra, Ghana .
    Dawood, Halima
    Variava, Ebrahim
    Tempia, Stefano
    Pretorius, Marthi
    Moyes, Jocelyn
    Olorunju, Steven A S
    Malope-Kgokong, Babatyi
    Kuonza, Lazarus
    Wolter, Nicole
    von Gottberg, Anne
    Madhi, Shabir A
    Venter, Marietjie
    Cohen, Cheryl
    Parainfluenza Virus Infection Among Human Immunodeficiency Virus (HIV)-Infected and HIV-Uninfected Children and Adults Hospitalized for Severe Acute Respiratory Illness in South Africa, 2009-20142015In: Open forum infectious diseases, ISSN 2328-8957, Vol. 2, no 4Article in journal (Refereed)
    Abstract [en]

    Background. Parainfluenza virus (PIV) is a common cause of acute respiratory tract infections, but little is known about PIV infection in children and adults in Africa, especially in settings where human immunodeficiency virus (HIV) prevalence is high. Methods. We conducted active, prospective sentinel surveillance for children and adults hospitalized with severe acute respiratory illness (SARI) from 2009 to 2014 in South Africa. We enrolled controls (outpatients without febrile or respiratory illness) to calculate the attributable fraction for PIV infection. Respiratory specimens were tested by multiplex real-time reverse-transcription polymerase chain reaction assay for parainfluenza types 1, 2, and 3. Results. Of 18 282 SARI cases enrolled, 1188 (6.5%) tested positive for any PIV type: 230 (19.4%) were type 1; 168 (14.1%) were type 2; 762 (64.1%) were type 3; and 28 (2.4%) had coinfection with 2 PIV types. After adjusting for age, HIV serostatus, and respiratory viral coinfection, the attributable fraction for PIV was 65.6% (95% CI [ confidence interval], 47.1-77.7); PIV contributed to SARI among HIV-infected and -uninfected children < 5 years of age and among individuals infected with PIV types 1 and 3. The observed overall incidence of PIV-associated SARI was 38 (95% CI, 36-39) cases per 100 000 population and was highest in children < 1 year of age (925 [ 95% CI, 864-989] cases per 100 000 population). Compared with persons without HIV, persons with HIV had an increased relative risk of PIV hospitalization (9.4; 95% CI, 8.5-10.3). Conclusions. Parainfluenza virus causes substantial severe respiratory disease in South Africa among children < 5 years of age, especially those that are infected with HIV.

  • 23. Cohen, Cheryl
    et al.
    Moyes, Jocelyn
    Tempia, Stefano
    Groom, Michelle
    Walaza, Sibongile
    Pretorius, Marthi
    Dawood, Halima
    Chhagan, Meera
    Haffejee, Summaya
    Variava, Ebrahim
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tshangela, Akhona
    von Gottberg, Anne
    Wolter, Nicole
    Cohen, Adam L.
    Kgokong, Babatyi
    Venter, Marietjie
    Madhi, Shabir A.
    Severe Influenza-associated Respiratory Infection in High HIV Prevalence Setting, South Africa, 2009-20112013In: Emerging Infectious Diseases, ISSN 1080-6040, E-ISSN 1080-6059, Vol. 19, no 11, p. 1766-1774Article in journal (Refereed)
    Abstract [en]

    Data on influenza epidemiology in HIV-infected persons are limited, particularly for sub-Saharan Africa, where HIV infection is widespread. We tested respiratory and blood samples from patients with acute lower respiratory tract infections hospitalized in South Africa during 2009-2011 for viral and pneumococcal infections. Influenza was identified in 9% (1,056/11,925) of patients enrolled; among influenza case-patients, 358 (44%) of the 819 who were tested were infected with HIV. Influenza-associated acute lower respiratory tract infection incidence was 4-8 times greater for HIV-infected (186-228/100,000) than for HIV-uninfected persons (26-54/100,000). Furthermore, multivariable analysis showed HIV-infected patients were more likely to have pneumococcal co-infection; to be infected with influenza type B compared with type A; to be hospitalized for 2-7 days or >7 days; and to die from their illness. These findings indicate that HIV-infected persons are at greater risk for severe illnesses related to influenza and thus should be prioritized for influenza vaccination.

  • 24. Cohen, Cheryl
    et al.
    Moyes, Jocelyn
    Tempia, Stefano
    Groome, Michelle
    Walaza, Sibongile
    Pretorius, Marthi
    Dawood, Halima
    Chhagan, Meera
    Haffejee, Summaya
    Variava, Ebrahim
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    von Gottberg, Anne
    Wolter, Nicole
    Cohen, Adam L.
    Malope-Kgokong, Babatyi
    Venter, Marietjie
    Madhi, Shabir A.
    Mortality amongst Patients with Influenza-Associated Severe Acute Respiratory Illness, South Africa, 2009-20132015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 3, article id e0118884Article in journal (Refereed)
    Abstract [en]

    Introduction Data on the burden and risk groups for influenza-associated mortality from Africa are limited. We aimed to estimate the incidence and risk-factors for in-hospital influenza-associated severe acute respiratory illness (SARI) deaths.

    Methods Hospitalised patients with SARI were enrolled prospectively in four provinces of South Africa from 2009-2013. Using polymerase chain reaction, respiratory samples were tested for ten respiratory viruses and blood for pneumococcal DNA. The incidence of influenza-associated SARI deaths was estimated at one urban hospital with a defined catchment population.

    Results We enrolled 1376 patients with influenza-associated SARI and 3% (41 of 1358 with available outcome data) died. In patients with available HIV-status, the case-fatality proportion (CFP) was higher in HIV-infected (5%, 22/419) than HIV-uninfected individuals (2%, 13/620; p = 0.006). CFPs varied by age group, and generally increased with increasing age amongst individuals >5 years (p<0.001). On multivariable analysis, factors associated with death were age-group 45-64 years (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.01-16.3) and >= 65 years (OR 6.5, 95% CI 1.2-34.3) compared to 1-4 year age-group who had the lowest CFP, HIV-infection (OR 2.9, 95% CI 1.1-7.8), underlying medical conditions other than HIV (OR 2.9, 95% CI 1.2-7.3) and pneumococcal co-infection (OR 4.1, 95% CI 1.5-11.2). The estimated incidence of influenza-associated SARI deaths per 100,000 population was highest in children <1 year (20.1, 95% CI 12.1-31.3) and adults aged 45-64 years (10.4, 95% CI 8.4-12.9). Adjusting for age, the rate of death was 20-fold (95% CI 15.0-27.8) higher in HIV-infected individuals than HIV-uninfected individuals.

    Conclusion Influenza causes substantial mortality in urban South Africa, particularly in infants aged <1 year and HIV-infected individuals. More widespread access to antiretroviral treatment and influenza vaccination may reduce this burden.

  • 25. Cohen, Cheryl
    et al.
    Moyes, Jocelyn
    Tempia, Stefano
    Groome, Michelle
    Walaza, Sibongile
    Pretorius, Marthi
    Naby, Fathima
    Mekgoe, Omphile
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences; INDEPTH Network, Accra, Ghana.
    von Gottberg, Anne
    Wolter, Nicole
    Cohen, Adam L.
    von Mollendorf, Claire
    Venter, Marietjie
    Madhi, Shabir A.
    Epidemiology of Acute Lower Respiratory Tract Infection in HIV-Exposed Uninfected Infants2016In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 137, no 4, article id e20153272Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Increased morbidity and mortality from lower respiratory tract infection (LRTI) has been suggested in HIV-exposed uninfected (HEU) children; however, the contribution of respiratory viruses is unclear. We studied the epidemiology of LRTI hospitalization in HIV-unexposed uninfected (HUU) and HEU infants aged <6 months in South Africa. METHODS: We prospectively enrolled hospitalized infants with LRTI from 4 provinces from 2010 to 2013. Using polymerase chain reaction, nasopharyngeal aspirates were tested for 10 viruses and blood for pneumococcal DNA. Incidence for 2010-2011 was estimated at 1 site with population denominators. RESULTS: We enrolled 3537 children aged <6 months. HIV infection and exposure status were determined for 2507 (71%), of whom 211 (8%) were HIV infected, 850 (34%) were HEU, and 1446 (58%) were HUU. The annual incidence of LRTI was elevated in HEU (incidence rate ratio [IRR] 1.4; 95% confidence interval [CI] 1.3-1.5) and HIV infected (IRR 3.8; 95% CI 3.3-4.5), compared with HUU infants. Relative incidence estimates were greater in HEU than HUU, for respiratory syncytial virus (RSV; IRR 1.4; 95% CI 1.3-1.6) and human metapneumovirus-associated (IRR 1.4; 95% CI 1.1-2.0) LRTI, with a similar trend observed for influenza (IRR 1.2; 95% CI 0.8-1.8). HEU infants overall, and those with RSV-associated LRTI had greater odds (odds ratio 2.1, 95% CI 1.1-3.8, and 12.2, 95% CI 1.7-infinity, respectively) of death than HUU. CONCLUSIONS: HEU infants were more likely to be hospitalized and to die in-hospital than HUU, including specifically due to RSV. This group should be considered a high-risk group for LRTI.

  • 26. Cohen, Cheryl
    et al.
    Walaza, Sibongile
    Moyes, Jocelyn
    Groome, Michelle
    Tempia, Stefano
    Pretorius, Marthi
    Hellferscee, Orienka
    Dawood, Halima
    Chhagan, Meera
    Naby, Fathima
    Haffejee, Summaya
    Variava, Ebrahim
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nzenze, Susan
    Tshangela, Akhona
    von Gottberg, Anne
    Wolter, Nicole
    Cohen, Adam L.
    Kgokong, Babatyi
    Venter, Marietjie
    Madhi, Shabir A.
    Epidemiology of Viral-associated Acute Lower Respiratory Tract Infection Among Children < 5 Years of Age in a High HIV Prevalence Setting, South Africa, 2009-20122015In: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 34, no 1, p. 66-72Article in journal (Refereed)
    Abstract [en]

    Background: Data on the epidemiology of viral-associated acute lower respiratory tract infection (LRTI) from high HIV prevalence settings are limited. We aimed to describe LRTI hospitalizations among South African children aged < 5 years. Methods: We prospectively enrolled hospitalized children with physician-diagnosed LRTI from 5 sites in 4 provinces from 2009 to 2012. Using polymerase chain reaction (PCR), nasopharyngeal aspirates were tested for 10 viruses and blood for pneumococcal DNA. Incidence was estimated at 1 site with available population denominators. Results: We enrolled 8723 children aged < 5 years with LRTI, including 64% < 12 months. The case-fatality ratio was 2% (150/8512). HIV prevalence among tested children was 12% (705/5964). The overall prevalence of respiratory viruses identified was 78% (6517/8393), including 37% rhinovirus, 26% respiratory syncytial virus (RSV), 7% influenza and 5% human metapneumovirus. Four percent (253/6612) tested positive for pneumococcus. The annual incidence of LRTI hospitalization ranged from 2530 to 3173/100,000 population and was highest in infants (8446-10532/100,000). LRTI incidence was 1.1 to 3.0-fold greater in HIV-infected than HIV-uninfected children. In multivariable analysis, compared to HIV-uninfected children, HIV-infected children were more likely to require supplemental-oxygen [odds ratio (OR): 1.3, 95% confidence interval (CI): 1.1-1.7)], be hospitalized > 7 days (OR: 3.8, 95% CI: 2.8-5.0) and had a higher case-fatality ratio (OR: 4.2, 95% CI: 2.6-6.8). In multivariable analysis, HIV-infection (OR: 3.7, 95% CI: 2.2-6.1), pneumococcal coinfection (OR: 2.4, 95% CI: 1.1-5.6), mechanical ventilation (OR: 6.9, 95% CI: 2.7-17.6) and receipt of supplemental-oxygen (OR: 27.3, 95% CI: 13.2-55.9) were associated with death. Conclusions: HIV-infection was associated with an increased risk of LRTI hospitalization and death. A viral pathogen, commonly RSV, was identified in a high proportion of LRTI cases.

  • 27. Cohen, Cheryl
    et al.
    Walaza, Sibongile
    Moyes, Jocelyn
    Groome, Michelle
    Tempia, Stefano
    Pretorius, Marthi
    Hellferscee, Orienka
    Dawood, Halima
    Haffejee, Summaya
    Variava, Ebrahim
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tshangela, Akhona
    von Gottberg, Anne
    Wolter, Nicole
    Cohen, Adam L.
    Kgokong, Babatyi
    Venter, Marietjie
    Madhi, Shabir A.
    Epidemiology of Severe Acute Respiratory Illness (SARI) among Adults and Children Aged >= 5 Years in a High HIV-Prevalence Setting, 2009-20122015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 2, article id e0117716Article in journal (Refereed)
    Abstract [en]

    Objective There are few published studies describing severe acute respiratory illness ( SARI) epidemiology amongst older children and adults from high HIV-prevalence settings. We aimed to describe SARI epidemiology amongst individuals aged >= 5 years in South Africa. Methods We conducted prospective surveillance for individuals with SARI from 2009-2012. Using polymerase chain reaction, respiratory samples were tested for ten viruses, and blood for pneumococcal DNA. Cumulative annual SARI incidence was estimated at one site with population denominators. Findings We enrolled 7193 individuals, 9% (621/7067) tested positive for influenza and 9%(600/6519) for pneumococcus. HIV-prevalence was 74% (4663/6334). Among HIV-infected individuals with available data, 41% of 2629 were receiving antiretroviral therapy (ART). The annual SARI hospitalisation incidence ranged from 325-617/100,000 population. HIV-infected individuals experienced a 13-19 times greater SARI incidence than HIV-uninfected individuals (p<0.001). On multivariable analysis, compared to HIV-uninfected individuals, HIV-infected individuals were more likely to be receiving tuberculosis treatment (odds ratio (OR): 1.7; 95% CI:1.1-2.7), have pneumococcal infection (OR 2.4; 95% CI: 1.7-3.3) be hospitalised for >7 days rather than <2 days (OR1.7; 95% CI: 1.2-2.2) and had a higher case-fatality ratio (8% vs 5%; OR1.7; 95% CI: 1.2-2.3), but were less likely to be infected with influenza (OR 0.6; 95% CI: 0.5-0.8). On multivariable analysis, independent risk indicators associated with death included HIV infection (OR 1.8; 95% CI: 1.3-2.4), increasing age-group, receiving mechanical ventilation (OR 6.5; 95% CI: 1.3-32.0) and supplemental-oxygen therapy (OR 2.6; 95% CI: 2.1-3.2). Conclusion The burden of hospitalized SARI amongst individuals aged >= 5 years is high in South Africa. HIV-infected individuals are the most important risk group for SARI hospitalization and mortality in this setting.

  • 28.
    Collinson, Mark A
    et al.
    University of Witwatersrand, South Africa; Umeå universitet, Umeåpå.
    Clark, Samuel J
    University of Witwatersrand, South Africa, University of Washington, USA.
    Gerritsen, Annette M
    University of Venda, South Africa.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kahn, Kathleen
    University of Witwatersrand, South Africa.
    Tollman, Stephen
    University of Witwatersrand, South Africa.
    The dynamics of poverty and migration in a rural South African community, 2001-2005In: Article in journal (Other academic)
  • 29.
    Collinson, Mark A
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Tollman, Stephen M
    Brown University, USA.
    Kahn, Kathleen
    Brown University, USA.
    Migration, settlement change and health in post-apartheid South Africa: triangulating health and demographic surveillance with national census data.2007In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Scandinavian journal of public health. Supplement, ISSN 1403-4956, Vol. Suppl. 69, p. 77-84Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: World population growth will be increasingly concentrated in the urban areas of the developing world; however, some scholars caution against the oversimplification of African urbanization noting that there may be "counter-urbanization" and a prevailing pattern of circular rural-urban migration. The aim of the paper is to examine the ongoing urban transition in South Africa in the post-apartheid period, and to consider the health and social policy implications of prevailing migration patterns. METHODS: Two data sets were analysed, namely the South African national census of 2001 and the Agincourt health and demographic surveillance system. A settlement-type transition matrix was constructed on the national data to show how patterns of settlement have changed in a five-year period. Using the sub-district data, permanent and temporary migration was characterized, providing migration rates by age and sex, and showing the distribution of origins and destinations. FINDINGS: The comparison of national and sub-district data highlight the following features: urban population growth, particularly in metropolitan areas, resulting from permanent and temporary migration; prevailing patterns of temporary, circular migration, and a changing gender balance in this form of migration; stepwise urbanization; and return migration from urban to rural areas. CONCLUSIONS: Policy concerns include: rural poverty exacerbated by labour migration; explosive conditions for the transmission of HIV; labour migrants returning to die in rural areas; and the challenges for health information created by chronically ill migrants returning to rural areas to convalesce. Lastly, suggestions are made on how to address the dearth of relevant population information for policy-making in the fields of migration, settlement change and health.

  • 30.
    Collinson, Mark A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    White, Michael J.
    Bocquier, Philippe
    McGarvey, Stephen T.
    Afolabi, Sulaimon A.
    Clark, Samuel J.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Migration and the epidemiological transition: insights from the Agincourt sub-district of northeast South Africa2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 122-136Article in journal (Refereed)
    Abstract [en]

    Background:

    Migration and urbanization are central to sustainable development and health, but data on temporal trends in defined populations are scarce. Healthy men and women migrate because opportunities for employment and betterment are not equally distributed geographically. The disruption can result in unhealthy exposures and environments and income returns for the origin household.

    Objectives: The objectives of the paper are to describe the patterns, levels, and trends of temporary migration in rural northeast South Africa; the mortality trends by cause category over the period 2000-2011; and the associations between temporary migration and mortality by broad cause of death categories.

    Method:

    Longitudinal, Agincourt Health and Demographic Surveillance System data are used in a continuous, survival time, competing-risk model. Findings: In rural, northeast South Africa, temporary migration, which involves migrants relocating mainly for work purposes and remaining linked to the rural household, is more important than age and sex in explaining variations in mortality, whatever the cause. In this setting, the changing relationship between temporary migration and communicable disease mortality is primarily affected by reduced exposure of the migrant to unhealthy conditions. The study suggests that the changing relationship between temporary migration and non-communicable disease mortality is mainly affected by increased livelihood benefits of longer duration migration.

    Conclusion: Since temporary migration is not associated with communicable diseases only, public health policies should account for population mobility whatever the targeted health risk. There is a need to strengthen the rural health care system, because migrants tend to return to the rural households when they need health care.

  • 31.
    Collinson, Mark A
    et al.
    University of Witwatersrand, South Africa; University of Umeå, Sweden.
    White, Michael J
    Brown University, USA.
    Short, Susan
    Brown University, USA.
    Lurie, Mark
    Brown University, SUA.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kahn, Kathleen
    University of Witwatersrand, South Africa; Umeå University, Sweden.
    Clark, Samuel J
    University of Witwatersrand, South Africa.
    Tollman, Stephen M
    University of Witwatersrand,South Africa; University of Umeå, Sweden.
    Child mortality, migration and parental presence in rural South Africa near the border with MozambiqueManuscript (preprint) (Other academic)
  • 32. Cortina, Melissa A.
    et al.
    Stein, Alan
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hlungwani, Tintswalo Mercy
    Holmes, Emily A.
    Fazel, Mina
    Cognitive styles and psychological functioning in rural South African school students: Understanding influences for risk and resilience in the face of chronic adversity2016In: Journal of Adolescence, ISSN 0140-1971, E-ISSN 1095-9254, Vol. 49, p. 38-46Article in journal (Refereed)
    Abstract [en]

    Adverse childhood experiences can show lasting effects on physical and mental health. Major questions surround how children overcome adverse circumstances to prevent negative outcomes. A key factor determining resilience is likely to be cognitive interpretation (how children interpret the world around them). The cognitive interpretations of 1025 school children aged 10-12 years in a rural, socioeconomically disadvantaged area of South Africa were examined using the Cognitive Triad Inventory for Children (CTI-C). These were examined in relation to psychological functioning and perceptions of the school environment. Those with more positive cognitive interpretations had better psychological functioning on scales of depression, anxiety, somatization and sequelae of potentially traumatic events. Children with more negative cognitions viewed the school-environment more negatively. Children living in poverty in rural South Africa experience considerable adversity and those with negative cognitions are at risk for psychological problems. Targeting children's cognitive interpretations may be a possible area for intervention.

  • 33.
    D'Ambruoso, Lucia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Twine, R
    Spies, B
    van der Merwe, M
    Gómez-Olivé, FX
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality2016In: Global Health Research and Policy, ISSN 2397-0642, Vol. 1, no 2Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy (VA) is a health surveillance technique used in low and middle-income countries to establish medical causes of death (CODs) for people who die outside hospitals and/or without registration. By virtue of the deaths it investigates, VA is also an opportunity to examine social exclusion from access to health systems. The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA.

    Methods: A short set of questions on care pathways, circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA (SF-VA). Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site (HDSS), South Africa in 2012 and 2013 where the SF-VA had been applied. InterVA and descriptive analysis were used to calculate cause-specific mortality fractions (CSMFs), and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex sub-groups.

    Results: One thousand two hundred forty-nine deaths were recorded in the Agincourt HDSS censuses in 2012–13 of which 1,196 (96 %) had complete VA data. Infectious and non-communicable conditions accounted for the majority of deaths (47 % and 39 % respectively) with smaller proportions attributed to external, neonatal and maternal causes (5 %, 2 % and 1 % respectively). 5 % of deaths were of indeterminable cause. The new indicators revealed multiple problems with access to care at the time of death: 39 % of deaths did not call for help, 36 % found care unaffordable overall, and 33 % did not go to a facility. These problems were reported consistently across age and sex sub-groups. Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility. An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting.

    Conclusions: Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning. Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.

  • 34. Draper, Catherine E.
    et al.
    Tomaz, Simone A.
    Jones, Rachel A.
    Hinkley, Trina
    Twine, Rhian
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Norris, Shane A.
    Cross-sectional associations of physical activity and gross motor proficiency with adiposity in South African children of pre-school age2019In: Public Health Nutrition, ISSN 1368-9800, E-ISSN 1475-2727, Vol. 22, no 4, p. 614-623Article in journal (Refereed)
    Abstract [en]

    Objective: The study aimed to investigate the relationship between physical activity, gross motor skills and adiposity in South African children of pm-school age.

    Design: Cross-sectional study.

    Setting: High-income urban, and low-income urban and rural settings in South Africa.

    Participants: Children (3-6 years old, n 268) were recruited from urban high-income (n 46), urban low-income (n 91) and rural low-income (n 122) settings. Height and weight were measured to calculate the main outcome variables: BMI and BMI-for-age Z-score (BAZ). Height-for-age and weight-for-age Z-scores were also calculated. Actigraph GT3X+ accelerometers were used to objectively measure physical activity; the Test of Gross Motor Development (Version 2) was used to assess gross motor skills.

    Results: More children were overweight/obese and had a higher BAZ from urban low-income settings compared with urban high-income settings and rural low-income settings. Being less physically active was associated with thinness, but not overweight/obesity. Time spent in physical activity at moderate and vigorous intensities was positively associated with BMI and BAZ. Gross motor proficiency was not associated with adiposity in this sample.

    Conclusions: The findings of this research highlight the need for obesity prevention particularly in urban low-income settings, as well as the need to take into consideration the complexity of the relationship between adiposity, physical activity and gross motor skills in South African pre-school children.

  • 35. Draper, Catherine E.
    et al.
    Tomaz, Simone A.
    Stone, Matthew
    Hinkley, Trina
    Jones, Rachel A.
    Louw, Johann
    Twine, Rhian
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Norris, Shane A.
    Developing Intervention Strategies to Optimise Body Composition in Early Childhood in South Africa2017In: BioMed Research International, ISSN 2314-6133, E-ISSN 2314-6141, article id 5283457Article in journal (Refereed)
    Abstract [en]

    Purpose. The purpose of this research was to collect data to inform intervention strategies to optimise body composition in South African preschool children. Methods. Data were collected in urban and rural settings. Weight status, physical activity, and gross motor skill assessmentswere conducted with 341 3-6-year-old children, and 55 teachers and parents/caregivers participated in focus groups. Results. Overweight and obesity were a concern in low-income urban settings (14%), but levels of physical activity and gross motor skills were adequate across all settings. Focus group findings from urban and rural settings indicated that teachers would welcome input on leading activities to promote physical activity and gross motor skill development. Teachers and parents/caregivers were also positive about young children being physically active. Recommendations for potential intervention strategies include a teacher-training component, parent/child activitymornings, and a home-based component for parents/caregivers. Conclusion. The findings suggest that an intervention focussed on increasing physical activity and improving gross motor skills per se is largely not required but that contextually relevant physical activity and gross motor skills may still be useful for promoting healthy weight and a vehicle for engaging with teachers and parents/caregivers for promoting other child outcomes, such as cognitive development.

  • 36.
    Edin, Kerstin
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/ Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Nilsson, Bo
    Umeå University, Faculty of Arts, Department of culture and media studies.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/ Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kinsman, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norris, Shane A
    Kahn, Kathleen
    Umeå University, Faculty of Arts, Department of culture and media studies. MRC/ Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Perspectives on intimate relationships among young people in rural South Africa: the logic of risk2016In: Culture, Health and Sexuality, ISSN 1369-1058, E-ISSN 1464-5351, Vol. 18, no 9, p. 1010-1024Article in journal (Refereed)
    Abstract [en]

    This paper explores how young people in rural South Africa understand gender, dating, sexuality and risk-taking in adolescence. The empirical material drawn upon consists of 20 interviews with young men and women (aged 18-19) and reflects normative gender patterns characterised by compulsory heterosexuality and dating as obligatory, and representing key symbols of normality. However, different meanings of heterosexual relationships are articulated in the interviews, for example in the recurring concept of 'passing time', and these meanings show that a relationship can be something arbitrary: a way to reduce boredom and have casual sex. Such a rationale for engaging in a relationship reflects one of several other normative gender patterns, which relate to the trivialisation of dating and sexual risk-taking, and which entail making compromises and legitimising deviations from the 'ideal' life-script and the hope of a better future. However, risks do not exclusively represent something bad, dangerous or immoral, because they are also used as excuses to avoid sex, HIV acquisition and early pregnancy. In conclusion, various interrelated issues can both undermine and/or reinforce risk awareness and subsequent risk behaviour. Recognition of this tension is essential when framing policies to support young people to reduce sexual risk-taking behaviour.

  • 37. Ezeh, Alex C
    et al.
    Izugbara, Chimaraoke O
    Kabiru, Caroline W
    Fonn, Sharon
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Manderson, Lenore
    Undieh, Ashiwel S
    Omigbodun, Akinyinka
    Thorogood, Margaret
    Building capacity for public and population health research in Africa: the consortium for advanced research training in Africa (CARTA) model2010In: Global health action, ISSN 1654-9880, Vol. 3Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Globally, sub-Saharan Africa bears the greatest burden of disease. Strengthened research capacity to understand the social determinants of health among different African populations is key to addressing the drivers of poor health and developing interventions to improve health outcomes and health systems in the region. Yet, the continent clearly lacks centers of research excellence that can generate a strong evidence base to address the region's socio-economic and health problems.

    OBJECTIVE AND PROGRAM OVERVIEW: We describe the recently launched Consortium for Advanced Research Training in Africa (CARTA), which brings together a network of nine academic and four research institutions from West, East, Central, and Southern Africa, and select northern universities and training institutes. CARTA's program of activities comprises two primary, interrelated, and mutually reinforcing objectives: to strengthen research infrastructure and capacity at African universities; and to support doctoral training through the creation of a collaborative doctoral training program in population and public health. The ultimate goal of CARTA is to build local research capacity to understand the determinants of population health and effectively intervene to improve health outcomes and health systems.

    CONCLUSIONS: CARTA's focus on the local production of networked and high-skilled researchers committed to working in sub-Saharan Africa, and on the concomitant increase in local research and training capacity of African universities and research institutes addresses the inability of existing programs to create a critical mass of well-trained and networked researchers across the continent. The initiative's goal of strengthening human resources and university-wide systems critical to the success and sustainability of research productivity in public and population health will rejuvenate institutional teaching, research, and administrative systems.

  • 38. Fearon, Elizabeth
    et al.
    Wiggins, Richard D.
    Pettifor, Audrey E.
    MacPhail, Catherine
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Selin, Amanda
    Gomez-Olive, F. Xavier
    Hargreaves, James R.
    Friendships Among Young South African Women, Sexual Behaviours and Connections to Sexual Partners (HPTN 068)2019In: Aids and Behavior, ISSN 1090-7165, E-ISSN 1573-3254, Vol. 23, no 6, p. 1471-1483Article in journal (Refereed)
    Abstract [en]

    Friends could be influential on young women's sexual health via influences on sexual behaviours and as connections to sexual partners, but are understudied in sub-Saharan Africa. We cross-sectionally surveyed 2326 13-20year-old young women eligible for grades 8-11 in rural South Africa about their sexual behaviour and up to three sexual partners. Participants each described five specific but unidentified friends and the relationships between them in an egocentric' network analysis design. We used logistic regression to investigate associations between friendship characteristics and participants' reports of ever having had sex (n=2326) and recent condom use (n=457). We used linear regression with random effects by participant to investigate friendship characteristics and age differences with sexual partners (n=633 participants, 1051 partners). We found that it was common for friends to introduce young women to those who later became sexual partners, and having older friends was associated with having older sexual partners, (increase of 0.37years per friend at least 1year older, 95% CI 0.21-0.52, adjusted). Young women were more likely to report ever having had sex when more friends were perceived to be sexually active (adjusted OR 1.85, 95% CI 1.72-2.01 per friend) and when they discussed sex, condoms and HIV with friends. Perception of friends' condom use was not associated with participants' reported condom use. While this study is preliminary and unique in this population and further research should be conducted, social connections between friends and sexual partners and perceptions of friend sexual behaviours could be considered in the design of sexual health interventions for young women in South Africa.

  • 39. Fearon, Elizabeth
    et al.
    Wiggins, Richard D.
    Pettifor, Audrey E.
    MacPhail, Catherine
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Selin, Amanda
    Gómez-Olivé, F. Xavier
    Delany-Moretlwe, Sinéad
    Piwowar-Manning, Estelle
    Laeyendecker, Oliver
    Hargreaves, James R.
    Associations between friendship characteristics and HIV and HSV-2 status amongst young South African women in HPTN-0682017In: Journal of the International AIDS Society, ISSN 1758-2652, E-ISSN 1758-2652, Vol. 20, article id e25029Article in journal (Refereed)
    Abstract [en]

    Introduction: Prevalence of HIV among young women in South Africa remains extremely high. Adolescent peer groups have been found to be an important influence on a range of health behaviours. The characteristics of young women's friendships might influence their sexual health and HIV risk via connections to sexual partners, norms around sexual initiation and condom use, or provision of social support. We investigated associations between young women's friendships and their Herpes Simplex Virus Type 2 (HSV-2) and HIV infection status in rural South Africa. Methods: Our study is a cross-sectional, egocentric network analysis. In 2011 to 2012, we tested 13- to 20-year-old young women for HIV and HSV-2, and collected descriptions of five friendships for each. We generated summary measures describing friend socio-demographic characteristics and the number of friends perceived to have had sex. We used logistic regression to analyse associations between friend characteristics and participant HIV and HSV-2 infection, excluding likely perinatal HIV infections. Results: There were 2326 participants included in the study sample, among whom HIV and HSV-2 prevalence were 3.3% and 4.6% respectively. Adjusted for participant and friend socio-demographic characteristics, each additional friend at least one year older than the participant was associated with raised odds of HIV (odds ratio (OR)=1.37, 95% CI 1.03 to 1.82) and HSV-2 (adjusted OR=1.41, 95% CI 1.18 to 1.69). Each additional friend perceived to have ever had sex also raised the odds of HIV (OR=1.29, 95% CI 1.03 to 1.63) and HSV-2 (OR=1.18, 95% CI 1.03 to 1.35). Discussion: We found good evidence that a greater number of older friends and friends perceived to have had sex were associated with increased risk for HSV-2 and HIV infection among young women. Conclusions: The characteristics of young women's friendships could contribute to their risk of HIV infection. The extent to which policies or programmes influence age-mixing and young women's normative environments should be considered.

  • 40.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sartorius, Benn
    Huong, Dao Lan
    Van Minh, Hoang
    Fantahun, Mesganaw
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mortality measurement in transition: proof of principle for standardised multi-country comparisons2010In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 15, no 10, p. 1256-1265Article in journal (Refereed)
    Abstract [en]

    Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit-for-purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource-poor settings.

  • 41.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Probabilistic methods for verbal autopsy interpretation: InterVA robustness in relation to variations in a priori probabilities2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 11, p. e27200-Article in journal (Refereed)
    Abstract [en]

    Background: InterVA is a probabilistic method for interpreting verbal autopsy (VA) data. It uses a priori approximations of probabilities relating to diseases and symptoms to calculate the probability of specific causes of death given reported symptoms recorded in a VA interview. The extent to which InterVA's ability to characterise a population's mortality composition might be sensitive to variations in these a priori probabilities was investigated.

    Methods: A priori InterVA probabilities were changed by 1, 2 or 3 steps on the logarithmic scale on which the original probabilities were based. These changes were made to a random selection of 25% and 50% of the original probabilities, giving six model variants. A random sample of 1,000 VAs from South Africa, were used as a basis for experimentation and were processed using the original InterVA model and 20 random instances of each of the six InterVA model variants. Rank order of cause of death and cause-specific mortality fractions (CSMFs) from the original InterVA model and the mean, maximum and minimum results from the 20 randomly modified InterVA models for each of the six variants were compared.

    Results: CSMFs were functionally similar between the original InterVA model and the models with modified a priori probabilities such that even the CSMFs based on the InterVA model with the greatest degree of variation in the a priori probabilities would not lead to substantially different public health conclusions. The rank order of causes were also similar between all versions of InterVA.

    Conclusion: InterVA is a robust model for interpreting VA data and even relatively large variations in a priori probabilities do not affect InterVA-derived results to a great degree. The original physician-derived a priori probabilities are likely to be sufficient for the global application of InterVA in settings without routine death certification.

  • 42.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Golooba-Mutebi, Frederick
    Kahn, Kathleen
    The epidemiology of 'bewitchment' as a lay-reported cause of death in rural South Africa2012In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 66, no 8, p. 704-709Article in journal (Refereed)
    Abstract [en]

    Background Cases of premature death in Africa may be attributed to witchcraft. In such settings, medical registration of causes of death is rare. To fill this gap, verbal autopsy (VA) methods record signs and symptoms of the deceased before death as well as lay opinion regarding the cause of death; this information is then interpreted to derive a medical cause of death. In the Agincourt Health and Demographic Surveillance Site, South Africa, around 6% of deaths are believed to be due to ‘bewitchment’ by VA respondents.

    Methods Using 6874 deaths from the Agincourt Health and Socio-Demographic Surveillance System, the epidemiology of deaths reported as bewitchment was explored, and using medical causes of death derived from VA, the association between perceptions of witchcraft and biomedical causes of death was investigated.

    Results The odds of having one's death reported as being due to bewitchment is significantly higher in children and reproductive-aged women (but not in men) than in older adults. Similarly, sudden deaths or those following an acute illness, deaths occurring before 2001 and those where traditional healthcare was sought are more likely to be reported as being due to bewitchment. Compared with all other deaths, deaths due to external causes are significantly less likely to be attributed to bewitchment, while maternal deaths are significantly more likely to be.

    Conclusions Understanding how societies interpret the essential factors that affect their health and how health seeking is influenced by local notions and perceived aetiologies of illness and death could better inform sustainable interventions and health promotion efforts.

  • 43. Garenne, Michel
    et al.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kabudula, Chodziwadziwa W.
    Gomez-Olive, F. Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Completeness of birth and death registration in a rural area of South Africa: the Agincourt health and demographic surveillance, 1992-20142016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 32795Article in journal (Refereed)
    Abstract [en]

    Background: Completeness of vital registration remains very low in sub-Saharan Africa, especially in rural areas.

    Objectives: To investigate trends and factors in completeness of birth and death registration in Agincourt, a rural area of South Africa covering a population of about 110,000 persons, under demographic surveillance since 1992. The population belongs to the Shangaan ethnic group and hosts a sizeable community of Mozambican refugees.

    Design: Statistical analysis of birth and death registration over time in a 22-year perspective (1992-2014). Over this period, major efforts were made by the government of South Africa to improve vital registration. Factors associated with completeness of registration were investigated using univariate and multivariate analysis.

    Results: Birth registration was very incomplete at onset (7.8% in 1992) and reached high values at end point (90.5% in 2014). Likewise, death registration was low at onset (51.4% in 1992), also reaching high values at end point (97.1% in 2014). For births, the main factors were mother's age (much lower completeness among births to adolescent mothers), refugee status, and household wealth. For deaths, the major factors were age at death (lower completeness among under-five children), refugee status, and household wealth. Completeness increased for all demographic and socioeconomic categories studied and is likely to approach 100% in the future if trends continue at this speed.

    Conclusion: Reaching high values in the completeness of birth and death registration was achieved by excellent organization of the civil registration and vital statistics, a variety of financial incentives, strong involvement of health personnel, and wide-scale information and advocacy campaigns by the South African government.

  • 44. Garenne, Michel
    et al.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Fac Hlth Sci, Sch Publ Hlth, MRC Wits Rural Publ Hlth & Hlth Transit Res Unit, Johannesburg, South Africa. Inst Pasteur, Epidemiol Malad Emergentes, Paris, France.
    Kabudula, Chodziwadziwa W.
    Gomez-Olive, F. Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Fac Hlth Sci, Sch Publ Hlth, MRC Wits Rural Publ Hlth & Hlth Transit Res Unit, Johannesburg, South Africa. INDEPTH Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Fac Hlth Sci, Sch Publ Hlth, MRC Wits Rural Publ Hlth & Hlth Transit Res Unit, Johannesburg, South Africa. INDEPTH Network, Accra, Ghana.
    Improving completeness of birth and death registration in rural Africa2016In: The Lancet Global Health, E-ISSN 2214-109X, Vol. 4, no 9, p. E604-E605Article in journal (Refereed)
  • 45. Garenne, Michel
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gómez-Olivé, F Xavier
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Maternal mortality in rural South Africa: the impact of case definition on levels and trends.2013In: International Journal of Women's Health, ISSN 1179-1411, E-ISSN 1179-1411, Vol. 5, p. 457-463Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Uncertainty in the levels of global maternal mortality reflects data deficiencies, as well as differences in methods and definitions. This study presents levels and trends in maternal mortality in Agincourt, a rural subdistrict of South Africa, under long-term health and sociodemographic surveillance.

    METHODS: All deaths of women aged 15 years-49 years occurring in the study area between 1992 and 2010 were investigated, and causes of death were assessed by verbal autopsy. Two case definitions were used: "obstetrical" (direct) causes, defined as deaths caused by conditions listed under O00-O95 in International Classification of Diseases-10; and "pregnancy-related deaths", defined as any death occurring during the maternal risk period (pregnancy, delivery, 6 weeks postpartum), irrespective of cause.

    RESULTS: The case definition had a major impact on levels and trends in maternal mortality. The obstetric mortality ratio averaged 185 per 100,000 live births over the period (60 deaths), whereas the pregnancy-related mortality ratio averaged 423 per 100,000 live births (137 deaths). Results from both calculations increased over the period, with a peak around 2006, followed by a decline coincident with the national roll-out of Prevention of Mother-to-Child Transmission of HIV and antiretroviral treatment programs. Mortality increase from direct causes was mainly due to hypertension or sepsis. Mortality increase from other causes was primarily due to the rise in deaths from HIV/AIDS and pulmonary tuberculosis.

    CONCLUSION: These trends underline the major fluctuations induced by emerging infectious diseases in South Africa, a country undergoing rapid and complex health transitions. Findings also pose questions about the most appropriate case definition for maternal mortality and emphasize the need for a consistent definition in order to better monitor and compare trends over time and across settings.

  • 46. Garenne, Michel
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gomez-Olive, Xavier
    Tollman, Stephen
    Protective Effect of Pregnancy in Rural South Africa: Questioning the Concept of "Indirect Cause'' of Maternal Death2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 5, p. e64414-Article in journal (Refereed)
    Abstract [en]

    Background: Measurement of the level and composition of maternal mortality depends on the definition used, with inconsistencies leading to inflated rates and invalid comparisons across settings. This study investigates the differences in risk of death for women in their reproductive years during and outside the maternal risk period (pregnancy, delivery, puerperium), focusing on specific causes of infectious, non-communicable and external causes of death after separating out direct obstetrical causes. Methods: Data on all deaths of women aged 15-49 years that occurred in the Agincourt sub-district between 1992 and 2010 were obtained from the Agincourt health and socio-demographic surveillance system (HDSS) located in rural South Africa. Causes of death were assessed using a validated verbal autopsy instrument. Analysis included 2170 deaths, of which 137 occurred during the maternal risk period. Findings: Overall, women had significantly lower mortality during the maternal risk period than outside it (age-standardized RR = 0.75; 95% CI = 0.63-0.89). This was true in most age groups with the exception of adolescents aged 15-19 years where the risk of death was higher. Mortality from most causes, other than obstetric causes, was lower during the maternal risk period except for malaria, cardiovascular diseases and violence where there were no differences. Lower mortality was significant for HIV/AIDS (RR = 0.29, P<0.0001), cancers (RR = 0.10, P<0.023), and accidents (RR = 0, P<0.0001). Interpretation: In this rural setting typical of much of Southern Africa, pregnancy was largely protective against the risk of death, most likely because of a strong selection effect amongst those women who conceived successfully. The concept of indirect cause of maternal death needs to be re-examined.

  • 47. Garenne, Michel L
    et al.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Fertility trends and net reproduction in Agincourt, rural South Africa: 1992-20042007In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 35, no Suppl. 69, p. 68-76Article in journal (Refereed)
  • 48. Gaziano, Thomas A.
    et al.
    Abrahams-Gessel, Shafika
    Gomez-Olive, F. Xavier
    Wade, Alisha
    Crowther, Nigel J.
    Alam, Sartaj
    Manne-Goehler, Jennifer
    Kabudula, Chodziwadziwa W.
    Wagner, Ryan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana ; Africa Wits-INDEPTH Genomic Studies of Cardiovascular Disease, University of the Witwatersrand.
    Rohr, Julia
    Montana, Livia
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana ; Africa Wits-INDEPTH Genomic Studies of Cardiovascular Disease, University of the Witwatersrand.
    Baernighausen, Till W.
    Berkman, Lisa F.
    Tollman, Stephen
    Cardiometabolic risk in a population of older adults with multiple co-morbidities in rural south africa: the HAALSI (Health and Aging in Africa: longitudinal studies of INDEPTH communities) study2017In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 17, article id 206Article in journal (Refereed)
    Abstract [en]

    Background: A consequence of the widespread uptake of anti-retroviral therapy (ART) is that the older South African population will experience an increase in life expectancy, increasing their risk for cardiometabolic diseases (CMD), and its risk factors. The long-term interactions between HIV infection, treatment, and CMD remain to be elucidated in the African population. The HAALSI cohort was established to investigate the impact of these interactions on CMD morbidity and mortality among middle-aged and older adults. Methods: We recruited randomly selected adults aged 40 or older residing in the rural Agincourt sub-district in Mpumalanga Province. In-person interviews were conducted to collect baseline household and socioeconomic data, self-reported health, anthropometric measures, blood pressure, high-sensitivity C-reactive protein (hsCRP), HbA1c, HIV-status, and point-of-care glucose and lipid levels. Results: Five thousand fifty nine persons (46.4% male) were enrolled with a mean age of 61.7 +/- 13.06 years. Waist-to- hip ratio was high for men and women (0.92 +/- 0.08 vs. 0.89 +/- 0.08), with 70% of women and 44% of men being overweight or obese. Blood pressure was similar for men and women with a combined hypertension prevalence of 58.4% and statistically significant increases were observed with increasing age. High total cholesterol prevalence in women was twice that observed for men (8.5 vs. 4.1%). The prevalence of self-reported CMD conditions was higher among women, except for myocardial infarction, and women had a statistically significantly higher prevalence of angina (10.82 vs. 6.97%) using Rose Criteria. The HIV- persons were significantly more likely to have hypertension, diabetes, or be overweight or obese than HIV+ persons. Approximately 56% of the cohort had at least 2 measured or self-reported clinical co-morbidities, with HIV+ persons having a consistently lower prevalence of co-morbidities compared to those without HIV. Absolute 10-year risk cardiovascular risk scores ranged from 7.7-9.7% for women and from 12.5-15.3% for men, depending on the risk score equations used. Conclusions: This cohort has high CMD risk based on both traditional risk factors and novel markers like hsCRP. Longitudinal follow-up of the cohort will allow us to determine the long-term impact of increased lifespan in a population with both high HIV infection and CMD risk.

  • 49. Geary, Rebecca Sally
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norris, Shane Anthony
    Barriers to and facilitators of the provision of a youth-friendly health services programme in rural South Africa2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 259-Article in journal (Refereed)
    Abstract [en]

    Background: Youth-friendly health services are a key strategy for improving young people's health. This is the first study investigating provision of the Youth Friendly Services programme in South Africa since the national Department of Health took over its management in 2006. In a rural area of South Africa, we aimed to describe the characteristics of the publicly-funded primary healthcare facilities, investigate the proportion of facilities that provided the Youth Friendly Services programme and examine healthcare workers' perceived barriers to and facilitators of the provision of youth-friendly health services.

    Methods: Semi-structured interviews were conducted with nurses of all eight publicly-funded primary healthcare facilities in Agincourt sub-district, Mpumalanga Province, South Africa. Thematic analysis of interview transcripts was conducted and data saturation was reached.

    Results: Participants largely felt that the Youth Friendly Services programme was not implemented in their primary healthcare facilities, with the exception of one clinic. Barriers to provision reported by nurses were: lack of youth-friendly training among staff and lack of a dedicated space for young people. Four of the eight facilities did not appear to uphold the right of young people aged 12 years and older to access healthcare independently. Breaches in young people's confidentiality to parents were reported.

    Conclusions: Participants reported that provision of the Youth Friendly Services programme is limited in this sub-district, and below the Department of Health's target that 70% of primary healthcare facilities should provide these services. Whilst a dedicated space for young people is unlikely to be feasible or necessary, all facilities have the potential to be youth-friendly in terms of staff attitudes and actions. Training and on-going support should be provided to facilitate this; the importance of such training is emphasised by staff. More than one member of staff per facility should be trained to allow for staff turnover. As one of a few countrywide, government-run youth-friendly clinic programmes in a low or middle-income country, these results may be of interest to programme managers and policy makers in such settings.

  • 50. Geldsetzer, Pascal
    et al.
    Vaikath, Maria
    Wagner, Ryan
    Rohr, Julia K.
    Montana, Livia
    Gomez-Olive, Francesc X.
    Rosenberg, Molly S.
    Manne-Goehler, Jennifer
    Mateen, Farrah J.
    Payne, Collin F.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Salomon, Joshua A.
    Gaziano, Thomas A.
    Baernighausen, Till
    Berkman, Lisa F.
    Depressive Symptoms and Their Relation to Age and Chronic Diseases Among Middle-Aged and Older Adults in Rural South Africa2019In: The journals of gerontology. Series A, Biological sciences and medical sciences, ISSN 1079-5006, E-ISSN 1758-535X, Vol. 74, no 6, p. 957-963Article in journal (Refereed)
    Abstract [en]

    Background: Understanding how depression is associated with chronic conditions and sociodemographic characteristics can inform the design and effective targeting of depression screening and care interventions. In this study, we present some of the first evidence from sub-Saharan Africa on the association between depressive symptoms and a range of chronic conditions (diabetes, HIV, hypertension, and obesity) as well as sociodemographic characteristics. Methods: A questionnaire was administered to a population-based simple random sample of 5,059 adults aged 40 years and older in Agincourt, South Africa. Depressive symptoms were measured using a modified version of the eight-item Center for Epidemiological Studies-Depression screening tool. Diabetes was assessed using a capillary blood glucose measurement and HIV using a dried blood spot. Results: 17.0% (95% confidence interval: 15.9%-18.1%) of participants had at least three depressive symptoms. None of the chronic conditions were significantly associated with depressive symptoms in multivariable regressions. Older age was the strongest correlate of depressive symptoms with those aged 80 years and older having on average 0.63 (95% confidence interval: 0.40-0.86; p<.001) more depressive symptoms than those aged 40-49 years. Household wealth quintile and education were not significant correlates. Conclusions: This study provides some evidence that the positive associations of depression with diabetes, HIV, hypertension, and obesity that are commonly reported in high-income settings might not exist in rural South Africa. Our finding that increasing age is strongly associated with depressive symptoms suggests that there is a particularly high need for depression screening and treatment among the elderly adults in rural South Africa.

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