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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. 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.

  • 5. 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)
  • 6. Bertram, Melanie Y.
    et al.
    Steyn, Krisela
    Wentzel-Viljoen, Edelweiss
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hofman, Karen J.
    Reducing the sodium content of high-salt foods: Effect on cardiovascular disease in South Africa2012In: SAMJ South African Medical Journal, ISSN 0256-9574, E-ISSN 2078-5135, Vol. 102, no 9, p. 743-745Article in journal (Refereed)
    Abstract [en]

    Background. Average salt intake in South African (SA) adults, 8.1 g/day, is higher than the 4 - 6 g/day recommended by the World Health Organization. Much salt consumption arises from non-discretionary intake (the highest proportion from bread, with contributions from margarine, soup mixes and gravies). This contributes to an increasing burden of hypertension and cardiovascular disease (CVD). Objectives. To provide SA-specific information on the number of fatal CVD events (stroke, ischaemic heart disease and hypertensive heart disease) and non-fatal strokes that would be prevented each year following a reduction in the sodium content of bread, soup mix, seasoning and margarine. Methods. Based on the potential sodium reduction in selected products, we calculated the expected change in population-level systolic blood pressure (SBP) and mortality due to CVD and stroke. Results. Proposed reductions would decrease the average salt intake by 0.85 g/person/day. This would result in 7 400 fewer CVD deaths and 4 300 less non-fatal strokes per year compared with 2008. Cost savings of up to R300 million would also occur. Conclusion. Population-wide strategies have great potential to achieve public health gains as they do not rely on individual behaviour or a well-functioning health system. This is the first study to show the potential effect of a salt reduction policy on health in SA.

  • 7. 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.

  • 8.
    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.

  • 9.
    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.

  • 10.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    de Courten, Maximilian
    Graham, Wendy J
    Laflamme, Lucie
    McCaw-Binns, Affette
    Sankoh, Osman A
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Zaba, Basia
    Reflections on the global burden of disease 2010 estimates2013In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 10, no 7, p. e1001477-Article in journal (Refereed)
  • 11.
    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.

  • 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.
    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)
  • 13.
    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.

  • 14.
    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.

  • 15.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sankoh, Osman
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lessons from history for designing and validating epidemiological surveillance in uncounted populations2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 8, p. e22897-Article in journal (Refereed)
    Abstract [en]

    Background

    Due to scanty individual health data in low- and middle-income countries (LMICs), health planners often use imperfect data sources. Frequent national-level data are considered essential, even if their depth and quality are questionable. However, quality in-depth data from local sentinel populations may be better than scanty national data, if such local data can be considered as nationally representative. The difficulty is the lack of any theoretical or empirical basis for demonstrating that local data are representative where data on the wider population are unavailable. Thus these issues can only be explored empirically in a complete individual dataset at national and local levels, relating to a LMIC population profile.

    Methods and Findings

    Swedish national data for 1925 were used, characterised by relatively high mortality, a low proportion of older people and substantial mortality due to infectious causes. Demographic and socioeconomic characteristics of Sweden then and LMICs now are very similar. Rates of livebirths, stillbirths, infant and cause-specific mortality were calculated at national and county levels. Results for six million people in 24 counties showed that most counties had overall mortality rates within 10% of the national level. Other rates by county were mostly within 20% of national levels. Maternal mortality represented too rare an event to give stable results at the county level.

    Conclusions

    After excluding obviously outlying counties (capital city, island, remote areas), any one of the remaining 80% closely reflected the national situation in terms of key demographic and mortality parameters, each county representing approximately 5% of the national population. We conclude that this scenario would probably translate directly to about 40 LMICs with populations under 10 million, and to individual states or provinces within about 40 larger LMICs. Unsubstantiated claims that local sub-national population data are “unrepresentative” or “only local” should not therefore predominate over likely representativity.

  • 16.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Twine, Wayne
    Collinson, Mark
    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.
    Kjellström, Tord
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing a population's exposure to heat and humidity: an empirical approach2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5421-Article in journal (Refereed)
    Abstract [en]

    Background: It is widely accepted that assessing the impact of heat on populations is an important aspect of climate change research. However, this raises questions about how best to measure people’s exposure to heat under everyday living conditions in more detail than is possible by relying on nearby sources of meteorological data. Objective: This study aimed to investigate practical and viable approaches to measuring air temperature and humidity within a population, making comparisons with contemporaneous external data sources. This was done in a rural South African population during the subtropical summer season. Results: Air temperature and humidity were measured indoors and outdoors at three locations over 10 days and the datalogger technology proved reliable and easy to use. There was little variation in measurements over distances of 10 km. Conclusions: Small battery-powered automatic dataloggers proved to be a feasible option for collecting weather data among a rural South African population. These data were consistent with external sources but offered more local detail. Detailed local contemporary data may also allow post hoc modelling of previously unmeasured local weather data in conjunction with global gridded climate models.

  • 17.
    Clark, Samuel J
    et al.
    Univ of Washington, USA; MRC /Wits, University of Witwatersrand, South Africa.
    Collinson, Mark A
    Witwatersrand University, Johannesburg, South Africa.
    Kahn, Kathleen
    Witwatersrand University, Johannesburg, South Africa.
    Drullinger, Kyle
    University of Colorado at Boulder, USA.
    Tollman, Stephen M
    University of Witwatersrand, South Africa.
    Returning home to die: circular labour migration and mortality in South Africa2007In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 35, no Suppl. 69, p. 35-44Article in journal (Refereed)
    Abstract [en]

    AIM: To examine the hypothesis that circular labour migrants who become seriously ill while living away from home return to their rural homes to convalesce and possibly to die. METHODS: Drawing on longitudinal data collected by the Agincourt health and demographic surveillance system in rural northeastern South Africa between 1995 and 2004, discrete time event history analysis is used to estimate the likelihood of dying for residents, short-term returning migrants, and long-term returning migrants controlling for sex, age, and historical period. RESULTS: The annual odds of dying for short-term returning migrants are generally 1.1 to 1.9 times (depending on period, sex, and age) higher than those of residents and long-term returning migrants, and these differences are generally highly statistically significant. Further supporting the hypothesis is the fact that the proportion of HIV/TB deaths among short-term returning migrants increases dramatically as time progresses, and short-term returning migrants account for an increasing proportion of all HIV/TB deaths. CONCLUSIONS: This evidence strongly suggests that increasing numbers of circular labour migrants of prime working age are becoming ill in the urban areas where they work and coming home to be cared for and eventually to die in the rural areas where their families live. This shifts the burden of caring for them in their terminal illness to their families and the rural healthcare system with significant consequences for the distribution and allocation of health care resources.

  • 18. Clark, Samuel J
    et al.
    Gómez-Olivé, F. Xavier
    Houle, Brian
    Thorogood, Margaret
    Klipstein-Grobusch, Kerstin
    Angotti, Nicole
    Kabudula, Chodziwadziwa
    Williams, Jill
    Menken, Jane
    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.
    Cardiometabolic disease risk and HIV status in rural South Africa: establishing a baseline2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 135Article in journal (Refereed)
    Abstract [en]

    Background: To inform health care and training, resource and research priorities, it is essential to establish how non-communicable disease risk factors vary by HIV-status in high HIV burden areas; and whether long-term anti-retroviral therapy (ART) plays a modifying role. Methods: As part of a cohort initiation, we conducted a baseline HIV/cardiometabolic risk factor survey in 2010-2011 using an age-sex stratified random sample of ages 15+ in rural South Africa. We modelled cardiometabolic risk factors and their associations by HIV-status and self-reported ART status for ages 18+ using sex-stratified logistic regression models. Results: Age-standardised HIV prevalence in women was 26% (95% CI 24-28%) and 19% (95% CI 17-21) in men. People with untreated HIV were less likely to have a high waist circumference in both women (OR 0.67; 95% CI 0.52-0.86) and men (OR 0.42; 95% CI 0.22-0.82). Untreated women were more likely to have low HDL and LDL, and treated women high triglycerides. Cardiometabolic risk factors increased with age except low HDL. The prevalence of hypertension was high (40% in women; 30% in men). Conclusions: Sub-Saharan Africa is facing intersecting epidemics of HIV and hypertension. In this setting, around half the adult population require long-term care for at least one of HIV, hypertension or diabetes. Together with the adverse effects that HIV and its treatment have on lipids, this may have serious implications for the South African health care system. Monitoring of the interaction of HIV, ART use, and cardiometabolic disease is needed at both individual and population levels.

  • 19. 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.

  • 20.
    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)
  • 21.
    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.

  • 22.
    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.

  • 23.
    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)
  • 24.
    Collinson, Mark A
    et al.
    University of Witwatersrand, South Africa.
    Wolff, Brent
    Medical Research Council Programme on AIDS, Uganda.
    Tollman, Stephen M
    University of Witwatersrand, South Africa.
    Kahn, Kathleen
    Brown University, SUA.
    Trends in internal labour migration from rural Limpopo Province, male risk behaviour and implications for the spread of HIV/AIDS in rural South Africa2006In: Journal of ethnic and migration studies, ISSN 1369-183X, E-ISSN 1469-9451, Vol. 32, no 4, p. 633-648Article in journal (Refereed)
    Abstract [en]

    Given improvements in the transport infrastructure and the end of travel restrictions characteristic of the apartheid period, there could be a reasonable expectation that male risk behaviour in sexual relations would be reduced as rural-/urban connections were enhanced. Using the example of Limpopo Province, South Africa, this research draws on an existing demographic surveillance system and a specialised survey to test the hypothesis. We find that male risk behaviour and lack of awareness of risks have not altered significantly and that there are potentially explosive possibilities for the spread of HIV/AIDS to and from Limpopo Province. There have to be enhanced measures to bring the labour market closer to rural settings to arrest this phenomenon.

  • 25.
    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.

  • 26. Desai, Nikita
    et al.
    Aleksandrowicz, Lukasz
    Miasnikof, Pierre
    Lu, Ying
    Leitao, Jordana
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå.
    Tollman, Stephen
    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 and International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Mee, Paul
    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.
    Alam, Dewan
    Rathi, Suresh Kumar
    Singh, Abhishek
    Kumar, Rajesh
    Ram, Faujdar
    Jha, Prabhat
    Performance of four computer-coded verbal autopsy methods for cause of death assignment compared with physician coding on 24,000 deaths in low- and middle-income countries2014In: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 12, no 1, p. 20-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Physician-coded verbal autopsy (PCVA) is the most widely used method to determine causes of death (CODs) in countries where medical certification of death is uncommon. Computer-coded verbal autopsy (CCVA) methods have been proposed as a faster and cheaper alternative to PCVA, though they have not been widely compared to PCVA or to each other.

    METHODS: We compared the performance of open-source random forest, open-source tariff method, InterVA-4, and the King-Lu method to PCVA on five datasets comprising over 24,000 verbal autopsies from low- and middle-income countries. Metrics to assess performance were positive predictive value and partial chance-corrected concordance at the individual level, and cause-specific mortality fraction accuracy and cause-specific mortality fraction error at the population level.

    RESULTS: The positive predictive value for the most probable COD predicted by the four CCVA methods averaged about 43% to 44% across the datasets. The average positive predictive value improved for the top three most probable CODs, with greater improvements for open-source random forest (69%) and open-source tariff method (68%) than for InterVA-4 (62%). The average partial chance-corrected concordance for the most probable COD predicted by the open-source random forest, open-source tariff method and InterVA-4 were 41%, 40% and 41%, respectively, with better results for the top three most probable CODs. Performance generally improved with larger datasets. At the population level, the King-Lu method had the highest average cause-specific mortality fraction accuracy across all five datasets (91%), followed by InterVA-4 (72% across three datasets), open-source random forest (71%) and open-source tariff method (54%).

    CONCLUSIONS: On an individual level, no single method was able to replicate the physician assignment of COD more than about half the time. At the population level, the King-Lu method was the best method to estimate cause-specific mortality fractions, though it does not assign individual CODs. Future testing should focus on combining different computer-coded verbal autopsy tools, paired with PCVA strengths. This includes using open-source tools applied to larger and varied datasets (especially those including a random sample of deaths drawn from the population), so as to establish the performance for age- and sex-specific CODs.

  • 27.
    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.

  • 28.
    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.

  • 29. 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.

  • 30. 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)
  • 31. 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.

  • 32. 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.

  • 33. 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)
  • 34. Gaziano, Thomas A.
    et al.
    Bertram, Melanie
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hofman, Karen J.
    Hypertension education and adherence in South Africa: a cost-effectiveness analysis of community health workers2014In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, p. 240-Article in journal (Refereed)
    Abstract [en]

    Background: To determine whether training community health workers (CHWs) about hypertension in order to improve adherence to medications is a cost-effective intervention among community members in South Africa. Methods: We used an established Markov model with age-varying probabilities of cardiovascular disease (CVD) events to assess the benefits and costs of using CHW home visits to increase hypertension adherence for individuals with hypertension and aged 25-74 in South Africa. Subjects considered for CHW intervention were those with a previous diagnosis of hypertension and on medications but who had not achieved control of their blood pressure. We report our results in incremental cost-effectiveness ratios (ICERs) in US dollars per disability-adjusted life-year (DALY) averted. Results: The annual cost of the CHW intervention is about $8 per patient. This would lead to over a 2% reduction in CVD events over a life-time and decrease DALY burden. Due to reductions in non-fatal CVD events, lifetime costs are only $6.56 per patient. The CHW intervention leads to an incremental cost-effectiveness ratio of $320/DALY averted. At an annual cost of $6.50 or if the blood pressure reduction is 5 mmHg or greater per patient the intervention is cost-saving. Conclusions: Additional training for CHWs on hypertension management could be a cost-effective strategy for CVD in South Africa and a very good purchase according to World Health Organization (WHO) standards. The intervention could also lead to reduced visits at the health centres freeing up more time for new patients or reducing the burden of an overworked staff at many facilities.

  • 35. 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.

  • 36.
    Gomez-Olive, F. Xavier
    et al.
    School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Thorogood, Margaret
    School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Bocquier, Philippe
    School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Mee, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, and INDEPTH Network .
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, and INDEPTH Network .
    Berkman, Lisa
    Harvard Centre for Population and Development Studies.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, and INDEPTH Network.
    Social conditions and disability related to the mortality of older people in rural South Africa2014In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 43, no 5, p. 1531-1541Article in journal (Refereed)
    Abstract [en]

    Background: South Africa is experiencing a health and social transition including an ageing population and an HIV epidemic. We report mortality experience of an older rural South African population.

    Methods: Individual survey data and longer-term demographic data were used to describe factors associated with mortality. Individuals aged 50 years and over (n = 4085) answered a health and quality of life questionnaire in 2006 and were followed for 3 years thereafter. Additional vital events and socio-demographic data were extracted from the Agincourt Health and Demographic Surveillance System from 1993 to 2010, to provide longer-term trends in mortality. Cox regression analysis was used to determine factors related to survival.

    Results: In 10 967 person-years of follow-up between August 2006 and August 2009, 377 deaths occurred. Women had lower mortality {hazard ratio [HR] 0.35 [95% confidence interval (CI) 0.28-0.45]}. Higher mortality was associated with being single [HR 1.48 (95% CI 1.16-1.88)], having lower household assets score [HR 1.79 (95% CI 1.28-2.51)], reporting greater disability [HR 2.40 (95% CI 1.68-3.42)] and poorer quality of life [HR 1.59 (95% CI 1.09-2.31)]. There was higher mortality in those aged under 69 as compared with those 70 to 79 years old. Census data and cause specific regression models confirmed that this was due to deaths from HIV/TB in the younger age group.

    Conclusions: Mortality due to HIV/TB is increasing in men, and to some extent women, aged over 50. Policy makers and practitioners should consider the needs of this growing and often overlooked group.

  • 37. Gomez-Olive, Francesc Xavier
    et al.
    Angotti, Nicole
    Houle, Brian
    Klipstein-Grobusch, Kerstin
    Kabudula, Chodziwadziwa
    Menken, Jane
    Williams, Jill
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    Clark, Samuel J.
    Prevalence of HIV among those 15 and older in rural South Africa2013In: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 25, no 9, p. 1122-1128Article in journal (Refereed)
    Abstract [en]

    A greater knowledge of the burden of HIV in rural areas of Southern Africa is needed, especially among older adults. We conducted a cross-sectional biomarker survey in the rural South African Agincourt Health and Socio-demographic Surveillance site in 2010-2011 and estimated HIV prevalence and risk factors. Using an age-sex stratified random sample of ages 15+, a total of 5037 (65.7%) of a possible 7662 individuals were located and 4362 (86.6%) consented to HIV testing. HIV prevalence was high (19.4%) and characterized by a large gender gap (10.6% for men and 23.9% for women). Rates peaked at 45.3% among men and 46.1% among women - both at ages 35-39. Compared with a similar study in the rural KwaZulu-Natal Province, South Africa, peak prevalence occurred at later ages, and HIV prevalence was higher among older adults - with rates above 15% for men and 10% for women through to age 70. High prevalence continues to characterize Southern Africa, and recent evidence confirms that older adults cannot be excluded from policy considerations. The high prevalence among older adults suggests likely HIV infection at older ages. Prevention activities need to expand to older adults to reduce new infections. Treatment will be complicated by increased risk of noncommunicable diseases and by increasing numbers of older people living with HIV.

  • 38. Gomez-Olive, Francesc Xavier
    et al.
    Schröders, Julia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Aboderin, Isabella
    Byass, Peter
    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.
    Chatterji, Somnath
    Davies, Justine I.
    Debpuur, Cornelius
    Hirve, Siddhivinayak
    Hodgson, Abraham
    Juvekar, Sanjay
    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.
    Kowal, Paul
    Nathan, Rose
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Razzaque, Abdur
    Sankoh, Osman
    Streatfield, Peter K.
    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, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Wilopo, Siswanto A.
    Witham, Miles D.
    Variations in disability and quality of life with age and sex between eight lower income and middle-income countries: data from the INDEPTH WHO-SAGE collaboration2017In: BMJ Global Health, E-ISSN 2059-7908, Vol. 2, no 4, article id e000508Article in journal (Refereed)
    Abstract [en]

    Background: Disability and quality of life are key outcomes for older people. Little is known about how these measures vary with age and gender across lower income and middle-income countries; such information is necessary to tailor health and social care policy to promote healthy ageing and minimise disability.

    Methods: We analysed data from participants aged 50 years and over from health and demographic surveillance system sites of the International Network for the Demographic Evaluation of Populations and their Health Network in Ghana, Kenya, Tanzania, South Africa, Vietnam, India, Indonesia and Bangladesh, using an abbreviated version of the WHO Study on global AGEing survey instrument. We used the eight-item WHO Quality of Life (WHOQoL) tool to measure quality of life and theWHO Disability Assessment Schedule, version 2 (WHODAS-II) tool to measure disability. We collected selected health status measures via the survey instrument and collected demographic and socioeconomic data from linked surveillance site information. We performed regression analyses to quantify differences between countries in the relationship between age, gender and both quality of life and disability, and we used anchoring vignettes to account for differences in interpretation of disability severity.

    Results: We included 43 935 individuals in the analysis. Mean age was 63.7 years (SD 9.7) and 24 434 (55.6%) were women. In unadjusted analyses across all countries, WHOQoL scores worsened by 0.13 points (95% CI 0.12 to 0.14) per year increase in age and WHODAS scores worsened by 0.60 points (95% CI 0.57 to 0.64). WHODAS-II and WHOQoL scores varied markedly between countries, as did the gradient of scores with increasing age. In regression analyses, differences were not fully explained by age, socioeconomic status, marital status, education or health factors. Differences in disability scores between countries were not explained by differences in anchoring vignette responses.

    Conclusions: The relationship between age, sex and both disability and quality of life varies between countries. The findings may guide tailoring of interventions to individual country needs, although these associations require further study.

  • 39. Gomez-Olive, Francesc Xavier
    et al.
    Thorogood, Margaret
    Kandala, Ngianga-Bakwin
    Tigbe, William
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Stranges, Saverio
    Sleep problems and mortality in rural South Africa: novel evidence from a low-resource setting2014In: Sleep Medicine, ISSN 1389-9457, E-ISSN 1878-5506, Vol. 15, no 1, p. 56-63Article in journal (Refereed)
    Abstract [en]

    Objective: Sleep problems are associated with mortality in Western populations. In low-resource settings, evidence of sleep problems and their potential association with mortality is lacking. Our study aimed to fill this gap by examining the prospective association of sleep problems with mortality among older adults in rural South Africa, as well as potential sex differences in this association.

    Methods: The study was conducted in 2006 in Agincourt (South Africa), as part of the Health and Demographic Surveillance System. A community-wide sample of 4044 men and women aged 50 years or older participated in the survey. Two measures of sleep quality over the last 30 days were assessed alongside sociodemographic variables, measures of quality of life (QoL), and functional ability. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality risk over time associated with the two sleep measures at baseline, while allowing adjustment for other covariates.

    Results: Overall, 394 deaths occurred during 3 years of follow-up. Both men and women reporting severe/extreme nocturnal sleep problems (vs none/mild/moderate) experienced a significantly greater mortality risk in models adjusted for sociodemographic variables only (HR, 1.65 [95% CI, 1.18-2.31] and HR, 1.42 [95% CI, 1.07-1.88], respectively). However, these associations were nonsignificant in fully adjusted models (HR, 1.23 [95% CI, 0.85-1.79] and HR, 1.07 [95% CI, 0.78-1.47], respectively). Men who reported severe/extreme difficulty related to daytime function (vs none/mild/moderate) experienced a 2-fold increased mortality risk (HR, 2.01 [95% CI, 1.32-3.07]) in fully adjusted models, whereas no significant association was observed for women (1.16 [95% CI, 0.80-1.67]).

    Conclusions: In this population, nocturnal sleep problems were not associated with mortality once analyses were adjusted for QoL, functional ability, and psychologic comorbidities. By contrast, severe or extreme problems with feeling unrested or unrefreshed during the day were associated with a 2-fold increased mortality risk, but this association was only significant in men.

    (C) 2013 Elsevier B. V. All rights reserved.

  • 40. Gómez-Olivé, F. Xavier
    et al.
    Montana, Livia
    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 (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa; INDEPTH Network, East Legon, Accra, Ghana.
    Kabudula, Chodziwadziwa W.
    Rohr, Julia K.
    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), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa; INDEPTH Network, East Legon, Accra, Ghana.
    Bärnighausen, Till
    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), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa; INDEPTH Network, East Legon, Accra, Ghana.
    Canning, David
    Gaziano, Thomas
    Salomon, Joshua A.
    Payne, Collin F.
    Wade, Alisha
    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), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa; INDEPTH Network, East Legon, Accra, Ghana.
    Berkman, Lisa
    Cohort Profile: Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI)2018In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 47, no 3, p. 689-690jArticle in journal (Refereed)
  • 41. Gómez-Olivé, F Xavier
    et al.
    Thorogood, Margaret
    Clark, Benjamin D
    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.
    Assessing health and well-being among older people in rural South Africa2010In: Global health action, ISSN 1654-9880, Vol. 3Article in journal (Refereed)
    Abstract [en]

    This study presents the first population-based data from South Africa on health status, functional ability and quality of life among older people. Health and social services will need to be restructured to provide effective care for older people living in rural South Africa with impaired functionality and other health problems.

  • 42. Gómez-Olivé, Francesc Xavier
    et al.
    Thorogood, Margaret
    Clark, Benjamin
    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.
    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 Network, Accra, Ghana.
    Self-reported health and health care use in an ageing population in the Agincourt sub-district of rural South Africa2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, p. 181-192, article id 19305Article in journal (Refereed)
    Abstract [en]

    Background: South Africa is experiencing a demographic and epidemiological transition with an increase in population aged 50 years and older and rising prevalence of non-communicable diseases. This, coupled with high HIV and tuberculosis prevalence, puts an already weak health service under greater strain.

    Objective: To measure self-reported chronic health conditions and chronic disease risk factors, including smoking and alcohol use, and to establish their association with health care use in a rural South African population aged 50 years or older.

    Methods: The Study on Global Ageing and Adult Health (SAGE), in collaboration with the INDEPTH Network and the World Health Organization, was implemented in the Agincourt sub-district in rural northeast South Africa where there is a long-standing health and socio-demographic surveillance system. Household-based interviews were conducted in a random sample of people aged 50 years and older. The interview included questions on self-reported health and health care use, and some physical measurements, including blood pressure and anthropometry.

    Results: Four hundred and twenty-five individuals aged 50 years or older participated in the study. Musculoskeletal pain was the most prevalent self-reported condition (41.7%; 95% Confidence Interval [CI] 37.0-46.6) followed by hypertension (31.2%; 95% CI 26.8-35.9) and diabetes (6.1%; 95% CI 4.1-8.9). All self-reported conditions were significantly associated with low self-reported functionality and quality of life, 57% of participants had hypertension, including 44% of those who reported normal blood pressure. A large waist circumference and current alcohol consumption were associated with high risk of hypertension in men, whereas in women, old age, high waist-hip ratio, and less than 6 years of formal education were associated with high risk of hypertension. Only 45% of all participants reported accessing health care in the last 12 months. Those who reported higher use of the health facilities also reported lower levels of functioning and quality of life.

    Conclusions: Self-reported chronic health conditions, especially hypertension, had a high prevalence in this population and were strongly associated with higher levels of health care use. The primary health care system in South Africa will need to provide care for people with non-communicable diseases.

  • 43.
    Hirve, Siddhivinayak
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gomez-Olive, Xavier
    Oti, Samuel
    Debpuur, Cornelius
    Juvekar, Sanjay
    Tollman, Stephen
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    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.
    Use of anchoring vignettes to evaluate health reporting behavior amongst adults aged 50 years and above in Africa and Asia: testing assumptions2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-15Article in journal (Refereed)
    Abstract [en]

    Background: Comparing self-rating health responses across individuals and cultures is misleading due to different reporting behaviors. Anchoring vignettes is a technique that allows identifying and adjusting self-rating responses for reporting heterogeneity (RH). Objective: This article aims to test two crucial assumptions of vignette equivalence (VE) and response consistency (RC) that are required to be met before vignettes can be used to adjust self-rating responses for RH. Design: We used self-ratings, vignettes, and objective measures covering domains of mobility and cognition from the WHO study on global AGEing and adult health, administered to older adults aged 50 years and above from eight low-and middle-income countries in Africa and Asia. For VE, we specified a hierarchical ordered probit (HOPIT) model to test for equality of perceived vignette locations. For RC, we tested for equality of thresholds that are used to rate vignettes with thresholds derived from objective measures and used to rate their own health function. Results: There was evidence of RH in self-rating responses for difficulty in mobility and cognition. Assumptions of VE and RC between countries were violated driven by age, sex, and education. However, within a country context, assumption of VE was met in some countries (mainly in Africa, except Tanzania) and violated in others (mainly in Asia, except India). Conclusion: We conclude that violation of assumptions of RC and VE precluded the use of anchoring vignettes to adjust self-rated responses for RH across countries in Asia and Africa.

  • 44.
    Hirve, Siddhivinayak
    et al.
    Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India.
    Juvekar, Sanjay
    Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India.
    Sambhudas, Somnath
    Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India.
    Lele, Pallavi
    Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India.
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Berkman, Lisa
    3 Harvard Center for Population and Development Studies, Harvard University, Boston, MA, USA.
    Tollman, Steve
    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.
    Does self-rated health predict death in adults aged 50 years and above in India? Evidence from a rural population under health and demographic surveillance.2012In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 41, no 6, p. 1719-1727Article in journal (Refereed)
    Abstract [en]

    Background The Study on Global Ageing and Adult Health (SAGE) aims to improve empirical understanding of health and well-being of adults in developing countries. We examine the role of self-rated health (SRH) in predicting mortality and assess how socio-demographic and other disability measures influence this association.

    Methods In 2007, a shortened SAGE questionnaire was administered to 5087 adults aged >= 50 years under the Health Demographic Surveillance System in rural Pune district, India. Respondents rated their own health with a single global question on SRH. Disability and well-being were assessed using the WHO Disability Assessment Schedule Index, Health State Score and quality-of-life score. Respondents were followed up every 6 months till June 2011. Any change in spousal support, migration or death during follow-up was updated in the SAGE dataset.

    Results In all, 410 respondents (8%) died in the 3-year follow-up period. Mortality risk was higher with bad/very bad SRH [hazard ratio (HR) in men: 3.06, 95% confidence interval (CI): 1.93-4.87; HR in women: 1.64, 95% CI: 0.94-2.86], independent of age, disability and other covariates. Disability measure (WHO Disability Assessment Schedule Index) and absence of spousal support were also associated with increased mortality risk.

    Conclusion Our findings confirm an association between bad/very bad SRH and mortality for men, independent of age, socio-demographic factors and other disability measures, in a rural Indian population. This association loses significance in women when adjusted for disability. Our study highlights the strength of nesting cross-sectional surveys within the context of the Health Demographic Surveillance System in studying the role of SRH and mortality.

  • 45.
    Hirve, Siddhivinayak
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Vadu Rural Health Program, KEM Hospital Research Center, Pune, India .
    Oud, JH
    Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sambhudas, Somnath
    Vadu Rural Health Program, KEM Hospital Research Center, Pune, India .
    Juvekar, Sanjay
    Vadu Rural Health Program, KEM Hospital Research Center, Pune, India.
    Blomstedt, Yulia
    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. Health and Population Division, School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Unpacking self-rated health and quality of life in older adults and elderly in India: a structural equation modelling approach2014In: Social Indicators Research, ISSN 0303-8300, E-ISSN 1573-0921, Vol. 117, no 1, p. 105-119Article in journal (Refereed)
    Abstract [en]

    The Study on global AGEing and adult health (SAGE) aims at improving empirical understanding of the health and well-being of older adults in low- and middle-income countries. A total of 321 adults aged 50 years and older were interviewed in rural Pune district, India, in 2007. We used Structural Equation Modelling (SEM) to examine the pathways through which social factors, functional disability, risk behaviours, and chronic disease experience influence self-rated health (SRH) and quality of life (QOL) amongst older adults in India. Both SRH and QOL worsened with increased age (indirect effect) and limitations in functional ability (direct effect). QOL, socio-economic status (SES), and social networking had no significant effect on SRH. Smoking was associated with the presence of at least one chronic illness, but this did not have a statistically significant effect on SRH. Higher social networking was seen amongst the better educated and those with regular income, which in turn positively affected the QOL rating. QOL had a direct, but statistically not significant, effect on SRH. In conclusion, the indirect effects of age on SRH mediated through functional ability, and the effects of SES on QOL mediated through social networking, provide new understanding of how age and socio-economic status affect SRH and QOL. By allowing for measurement errors, solving for collinearity in predictor variables by integrating them into measurement models, and specifying causal dependencies between the underlying latent constructs, SEM provides a strong link between theory and empirics.

  • 46.
    Hirve, Siddhivinayak
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Verdes, E
    Lele, P
    Juvekar, S
    Blomstedt, Yulia
    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.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chatterjee, S
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Evaluating reporting heterogeneity in self-rating health responses amongst adults aged 50 years and above in India: an anchoring vignettes analytic approachIn: Article in journal (Refereed)
  • 47.
    Hirve, Siddhivinayak
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. KEM Hosp Res Ctr, Pune 411011, Maharashtra, India.
    Verdes, Emese
    WHO, CH-1211 Geneva, Switzerland.
    Lele, Pallavi
    KEM Hosp Res Ctr, Pune 411011, Maharashtra, India.
    Juvekar, Sanjay
    KEM Hosp Res Ctr, Pune 411011, Maharashtra, India.
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Steve
    University of the Witwatersrand, Johannesburg, South Africa.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chatterji, Somnath
    WHO, CH-1211 Geneva, Switzerland.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Evaluating Reporting Heterogeneity in Self-Rated Health Among Adults Aged 50 Years and Above in India: An Anchoring Vignettes Analytic Approach2014In: Journal of Aging and Health, ISSN 0898-2643, E-ISSN 1552-6887, Vol. 26, no 6, p. 1015-1031Article in journal (Refereed)
    Abstract [en]

    Objective: To use anchoring vignettes to evaluate reporting heterogeneity (RH) in self-rated mobility and cognition in older adults. Method: We analyzed vignettes and self-rated mobility and cognition in 2,558 individuals aged 50 years and above. We tested for assumptions of vignette equivalence (VE) and response consistency (RC). We used a joint hierarchical ordered probit (HOPIT) model to evaluate self-rating responses for RH. Results: The assumption of VE was met except for "learning" vignettes. Higher socioeconomic status (SES) and education significantly lowered thresholds for cognition ratings. After correction for RH, women, lower SES, and older respondents were significantly more likely to report greater difficulty in mobility. The influence of age, SES, and education on thresholds was less apparent for cognition. Discussion: Our study provides strong evidence of RH in self-rated mobility and cognition. We highlight the need to formally test basic assumptions before using vignettes to adjust self-rating responses for RH.

  • 48. Hofman, Karen J.
    et al.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Population health in South Africa: a view from the salt mines2013In: lancet Global Health, ISSN 2214-109X, Vol. 1, no 2, p. E66-E67Article in journal (Other academic)
  • 49. Hofman, Karen J
    et al.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Setting priorities for health in 21st century South Africa2010In: SAMJ South African Medical Journal, ISSN 0256-9574, E-ISSN 2078-5135, Vol. 100, no 12, p. 798-800Article in journal (Refereed)
    Abstract [en]

    The Priority Cost Effective Lessons for Systems Strengthening - South Africa (PRICELESS SA) intends to be catalytic, to show where gains in efficiency can be gained at reasonable cost, and to stimulate further work along these lines. Ultimately, it is hoped that policy makers and health care providers will value and incorporate this approach into future planning for health services at both the national and at the district level.

  • 50. Houle, Brian
    et al.
    Angotti, Nicole
    Clark, Samuel J.
    Williams, Jill
    Gomez-Olive, F. Xavier
    Menken, Jane
    Kabudula, Chodziwadziwa
    Klipstein-Grobusch, Kerstin
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Let's Talk about Sex, Maybe: Interviewers, Respondents, and Sexual Behavior Reporting in Rural South Africa2016In: Field Methods, ISSN 1525-822X, E-ISSN 1552-3969, Vol. 28, no 2, p. 112-132Article in journal (Refereed)
    Abstract [en]

    Researchers are often skeptical of sexual behavior surveys: Respondents may lie or forget details of their intimate lives, and interviewers may exercise authority in how they capture responses. We use data from a 2010-2011 cross-sectional sexual behavior survey in rural South Africa to explore who says what to whom about their sexual lives. Results show an effect of fieldworker age across outcomes: Respondents report safer, more responsible sexual behavior to older fieldworkers, and an effect of fieldworker sex; men report more sexual partners to female fieldworkers. Understanding fieldworker effects on the production of sexual behavior survey data serves methodological and analytical goals.

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