Northeast South Africa Research Articles

Collective efficacy, alcohol outlet density, and young men’s alcohol use in rural South Africa

Alcohol use contributes to morbidity and mortality in developing countries by increasing the risk of trauma and disease, including alcohol dependence. Limited research addresses determinants of alcohol use beyond the individual level in sub-Saharan Africa. We test the association of community collective efficacy and alcohol outlet density with young men's drinking in a cross-sectional, locally representative survey conducted in rural northeast South Africa. Informal social control and cohesion show protective associations with men's heavy drinking, while alcohol outlet density is associated with more potential problem drinking. These findings provide initial support for intervening at the community level to promote alcohol reduction.

Incidence, Remission and Mortality of Convulsive Epilepsy in Rural Northeast South Africa.

BackgroundEpilepsy is one of the most common neurological conditions globally, estimated to constitute 0.75% of the global burden of disease, with the majority of this burden found in low- and middle- income countries (LMICs). Few studies from LMICs, including much of sub-Saharan Africa, have described the incidence, remission or mortality rates due to epilepsy, which are needed to quantify the burden and inform policy. This study investigates the epidemiological parameters of convulsive epilepsy within a context of high HIV prevalence and an emerging burden of cardiovascular disease.MethodsA cross-sectional population survey of 82,818 individuals, in the Agincourt Health and Socio-demographic Surveillance Site (HDSS) in rural northeast South Africa was conducted in 2008, from which 296 people were identified with active convulsive epilepsy. A follow-up survey was conducted in 2012. Incidence and mortality rates were estimated, with duration and remission rates calculated using the DISMOD II software package.ResultsThe crude incidence for convulsive epilepsy was 17.4/100,000 per year (95%CI: 13.1-23.0). Remission was 4.6% and 3.9% per year for males and females, respectively. The standardized mortality ratio was 2.6 (95%CI: 1.7-3.5), with 33.3% of deaths directly related to epilepsy. Mortality was higher in men than women (adjusted rate ratio (aRR) 2.6 (95%CI: 1.2-5.4)), and was significantly associated with older ages (50+ years versus those 0-5 years old (RR 4.8 (95%CI: 0.6-36.4)).ConclusionsThe crude incidence was lower whilst mortality rates were similar to other African studies; however, this study found higher mortality amongst older males. Efforts aimed at further understanding what causes epilepsy in older people and developing interventions to reduce prolonged seizures are likely to reduce the overall burden of ACE in rural South Africa.

Impacts of climate variation on the length of the rainfall season: an analysis of spatial patterns in North-East South Africa

This study examines the impacts of climate variation on the length of the rainfall season in the north-east South Africa (Vhembe District). We first demarcated the area into two major homogeneous rainfall zones namely humid and semi-arid using Principal Component Analysis (PCA). Then we determined the rainfall climatology of each zone in terms of rainfall onset and cessation in view of the emerging climate variation. Sixty years of rainfall data were examined, and a significant decreasing trend in rainfall was observed starting in the 1990s. Generally, the seasonal rainfall onset and cessation are changing, making the rainfall season length shorter. The rainfall characteristics are changing gradually in the humid zone, where it was found that there is a marked change in the onset dates between what it used to be before the 1990s and how it has been since. The rainfall season length has decreased by 50 days. Rainfall characteristics in the semi-arid zone are highly variable with a coefficient of variation (CV) of up to 39 %. Continuous significant decline (at the ≥95 % level) since the mid-1990 suggests that the humid areas will continue to dry while the semi-arid might develop into arid zone. Significant changes were also detected in the cessation of rainfall. In general, the uncertainties and changes in rainfall characteristics add strain on farmers who are faced with the season of inconsistent rain and uncertainties in when to plant their crops. Under these circumstances, it is easy to see how rainfall variation can lead to crop failure and cause food insecurity in the district.

Seasonal changes in movement and habitat use by Southern Ground-Hornbills in the South African lowveld

Southern Ground-Hornbills Bucorvus leadbeateri are Endangered in South Africa and there is a concerted effort to reverse their population decline. They live in groups year round, with only the alpha pair breeding, raising at most one chick per year. Each group has a home range of 50–100 km2, but there are few data for their spatial habitat use within this range. Understanding the factors affecting Southern Ground-Hornbill movement patterns is useful to assess habitat management options for the species, to select sites for artificial nests and to identify suitable areas for reintroduction initiatives. We report daily and seasonal patterns of habitat use by four groups in the Associated Private Nature Reserves, north-east South Africa, based on data from GPS-satellite tags. Daily travel distances averaged 7.4 ± 2.2 km d−1 but were greater during the breeding season, although birds were constrained to forage close to their nest, and were lower in winter, when birds ranged more widely. Hourly travel distances were affected by time of day, season, temperature and group. Birds travelled farthest per hour in the morning, decreasing in the afternoon in winter. However, in summer hourly travel distances were bimodally distributed, with a minimum during the middle of the day when ambient temperatures exceed 25 °C. Acacia-dominated vegetation and riparian habitats were favoured disproportionately during the heat of the day in summer, presumably because they offer more shade than other habitats. Optimal habitat configurations for ground-hornbills include a mosaic of habitat types, including open areas for foraging and dense trees for shade.

The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial.

BackgroundSouth Africa has a high and rising prevalence of hypertension. Many affected individuals are not using medication, and few have controlled blood pressure. Until recently, primary care clinics focused on maternal and child health and management of acute conditions, but new government initiatives have shifted the focus to chronic diseases, including HIV/AIDS and hypertension.Methods/DesignThe Nkateko trial will test the effectiveness of clinic-based lay health workers (LHWs) in supporting hypertension management. It is a pragmatic, cluster randomised controlled trial based in the Agincourt subdistrict of northeast South Africa, and it is underpinned by long-term health and demographic surveillance. Eight primary care facilities, with their catchment communities, are randomised to usual care or the addition of LHWs focused on chronic care. All clinics (intervention and control) will be provided with a clerk to collect information on clinic attendees and will match them to preexisting surveillance records. Intervention clinics will have LHWs working alongside nursing staff and focusing on health care for people with chronic conditions, particularly hypertension. The LHWs will be supported by an implementation manager, who will work with clinic staff to develop the most effective role for the LHWs. Control clinics will continue to provide usual care. The primary outcome will be the change between two population surveys conducted before and after the intervention in the proportion of the population with uncontrolled hypertension and a risk profile indicating at least moderate risk of cardiovascular disease. A process evaluation will be based on a realist approach using patient exit interviews, clinic observations and interviews with health professionals, LHWs and patients to document the intervention and its implementation.DiscussionThere are challenges in the design of this trial. Assessing change through population surveys may reduce measurable effects; however, we feel this is appropriate because we aim to attract those who currently do not use clinics, and we hope to improve care for clinic users. Clinics were randomised at an open meeting because we were concerned that a remote process of randomisation would not be trusted by the community. We are constantly working to achieve an effective balance between the intervention and process evaluations.Trial registrationISRCTN12128227 (registered 5 March 2014)Electronic supplementary materialThe online version of this article (doi:10.1186/1745-6215-15-435) contains supplementary material, which is available to authorized users.

Two decades of mortality change in rural northeast South Africa

Background The MRC/Wits University Agincourt research centre, part of the INDEPTH Network, has documented mortality in a defined population in the rural northeast of South Africa for 20 years (1992–2011) using long-term health and socio-demographic surveillance. Detail on the unfolding, at times unpredicted, mortality pattern has been published. This experience is reviewed here and updated using more recent data. Objective To present a review and summary of mortality patterns across all age-sex groups in the Agincourt sub-district population for the period 1992–2011 as a comprehensive basis for public health action. Design Vital events in the Agincourt population have been updated in annual surveys undertaken since 1992. All deaths have been rigorously recorded and followed by verbal autopsy interviews. Responses to questions from these interviews have been processed retrospectively using the WHO 2012 verbal autopsy standard and the InterVA-4 model for assigning causes of death in a standardised manner. Results Between 1992 and 2011, a total of 12,209 deaths were registered over 1,436,195 person-years of follow-up, giving a crude mortality rate of 8.5 per 1,000 person-years. During the 20-year period, the population experienced a major HIV epidemic, which resulted in more than doubling of overall mortality for an extended period. Recent years show signs of declining mortality, but levels remain above the 1992 baseline recorded using the surveillance system. Conclusions The Agincourt population has experienced a major mortality shock over the past two decades from which it will take time to recover. The basic epidemic patterns are consistent with generalised mortality patterns observed in South Africa as a whole, but the detailed individual surveillance behind these analyses allows finer-grained analyses of specific causes, age-related risks, and trends over time. These demonstrate the complex, somewhat unpredicted course of mortality transition over the years since the dawn of South Africa's democratic era in 1994.

Record-linkage comparison of verbal autopsy and routine civil registration death certification in rural north-east South Africa: 2006-09.

Background: South African civil registration (CR) provides a key data source for local health decision making, and informs the levels and causes of mortality in data-lacking sub-Saharan African countries. We linked mortality data from CR and the Agincourt Health and Socio-demographic Surveillance System (Agincourt HDSS) to examine the quality of rural CR data.Methods: Deterministic and probabilistic techniques were used to link death data from 2006 to 2009. Causes of death were aggregated into the WHO Mortality Tabulation List 1 and a locally relevant short list of 15 causes. The matching rate was compared with informant-reported death registration. Using the VA diagnoses as reference, misclassification patterns, sensitivity, positive predictive values and cause-specific mortality fractions (CSMFs) were calculated for the short list.Results: A matching rate of 61% [95% confidence interval (CI): 59.2 to 62.3] was attained, lower than the informant-reported registration rate of 85% (CI: 83.4 to 85.8). For the 2264 matched cases, cause agreement was 15% (kappa 0.1083, CI: 0.0995 to 0.1171) for the WHO list, and 23% (kappa 0.1631, CI: 0.1511 to 0.1751) for the short list. CSMFs were significantly different for all but four (tuberculosis, cerebrovascular disease, other heart disease, and ill-defined natural) of the 15 causes evaluated.Conclusion: Despite data limitations, it is feasible to link official CR and HDSS verbal autopsy data. Data linkage proved a promising method to provide empirical evidence about the quality and utility of rural CR mortality data. Agreement of individual causes of death was low but, at the population level, careful interpretation of the CR data can assist health prioritization and planning.

Use of the Stinkbug, Encosternum delegorguei (Hemiptera, Tessaratomidae), for Food and Income in South Africa

The use of Encosternum delegorguei, an edible stinkbug with high nutritional value, is restricted to three distinct groups of people in the northeast of South Africa, the Bolobedu, the Mapulana, and the Vhavenda. The two latter groups consider stinkbugs a seasonal delicacy, whereas the Bolobedu do not enjoy eating stinkbugs but sell them in Thohoyandou and surrounding villages to the Vhavenda. Structured interview schedules with 106 harvesters indicated that an estimated total of 3803 ± 43.4 kg (mean ±SE) dry stinkbugs was harvested ( = 122.4 kg harvester−1 annum−1). Difficulties cited by harvesters include distances between harvesting areas or markets and the stinkbug's defense chemical. An annual gross income of = US$345, which can be procured from stinkbugs, contributes to improving rural livelihoods. Bolobedu women were the most successful sellers, with a mean annual income of US$746. Opportunities to reduce impediments to harvesting and selling in a sustainable framework are discussed.

CLUSTERING SOUTH AFRICAN HOUSEHOLDS BASED ON THEIR ASSET STATUS USING LATENT VARIABLE MODELS.

The Agincourt Health and Demographic Surveillance System has since 2001 conducted a biannual household asset survey in order to quantify household socio-economic status (SES) in a rural population living in northeast South Africa. The survey contains binary, ordinal and nominal items. In the absence of income or expenditure data, the SES landscape in the study population is explored and described by clustering the households into homogeneous groups based on their asset status. A model-based approach to clustering the Agincourt households, based on latent variable models, is proposed. In the case of modeling binary or ordinal items, item response theory models are employed. For nominal survey items, a factor analysis model, similar in nature to a multinomial probit model, is used. Both model types have an underlying latent variable structure-this similarity is exploited and the models are combined to produce a hybrid model capable of handling mixed data types. Further, a mixture of the hybrid models is considered to provide clustering capabilities within the context of mixed binary, ordinal and nominal response data. The proposed model is termed a mixture of factor analyzers for mixed data (MFA-MD). The MFA-MD model is applied to the survey data to cluster the Agincourt households into homogeneous groups. The model is estimated within the Bayesian paradigm, using a Markov chain Monte Carlo algorithm. Intuitive groupings result, providing insight to the different socio-economic strata within the Agincourt region.

Migration and the epidemiological transition: insights from the Agincourt sub-district of northeast South Africa

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.

Breeding biology of the White-headed Vulture Trigonoceps occipitalis in Kruger National Park, South Africa

Information on the breeding biology of the White-headed Vulture Trigonoceps occipitalis is limited and published data are few. Within the Kruger National Park in north-east South Africa there is a regionally important population of about 60 White-headed Vulture pairs, of which 22 pairs were monitored for five years between 2008 and 2012 to determine key aspects of their breeding biology. Across 73 pair/years the mean productivity of 55 breeding attempts was 0.69 chicks per pair. Median egg-laying date across all of the Kruger National Park was 27 June, but northern nests were approximately 30 d later than southern nests. Mean (±SD) nearest-neighbour distance was 9 976 ± 7 965 m and inter-nest distances ranged from 1 400 m to more than 20 km, but this did not differ significantly between habitat types. Breeding productivity did not differ significantly between habitat types. The results presented here are the first for this species in Kruger National Park and provide details against which future comparisons can be made.

Prevalence and risk factors for active convulsive epilepsy in rural northeast South Africa

Epilepsy is among the most common neurological disorders worldwide. However, there are few large, population-based studies of the prevalence and risk factors for epilepsy in southern Africa. From August 2008 to February 2009, as part of a multi-site study, we undertook a three-stage, population-based study, embedded within the Agincourt health and socio-demographic surveillance system, to estimate the prevalence and identify risk factors of active convulsive epilepsy (ACE) in a rural South African population. The crude prevalence of ACE, after adjusting for non-response and the sensitivity of the screening method, was 7.0/1,000 individuals (95% CI 6.4-7.6) with significant geographic heterogeneity across the study area. Being male (OR=2.3; 95% CI 1.6-3.2), family history of seizures (OR=4.0; 95% CI 2.0-8.1), a sibling with seizures (OR=7.0; 95% CI 1.6-31.7), problems after delivery (OR=5.9; 95% CI 1.2-24.6), and history of snoring (OR=6.5; 95% CI 4.5-9.5) were significantly associated with ACE. For children, their mother's exposure to some formal schooling was protective (OR=0.30; 95% CI 0.11-0.84) after controlling for age and sex. Human immunodeficiency virus was not found to be associated with ACE. ACE is less frequent in this part of rural South Africa than other parts of sub-Saharan Africa. Improving obstetric services could prevent epilepsy. The relationship between snoring and ACE requires further investigation, as does the relative contribution of genetic and environmental factors to examine the increased risk in those with a family history of epilepsy.

Recent global dust trend and connections to climate forcing

AbstractDust is an important indicator of climate change. In paleoclimate research, sediments bearing signals of dust deposition offer a rich archive for climate change history. However, the dust‐climate link is very complex due to the various direct and indirect feedbacks in the Earth system. In this study, we examine two issues: (1) given the recent global warming, what are the dust variations, both globally and in key dust regions, and (2) what are the climate drivers behind the variations? Using synoptic data for the period 1974–2012, we analyzed the global trend of dust frequency and visibility‐derived dust concentrations and their characteristics in key dust regions, including North Africa, the Middle East, Southwest Asia, Northeast Asia, South America, and Australia. We also examined the likely climate drivers for dust variations in the different regions by computing the correlations between the time series of dust and of major climate indices—the Multivariate El Niño/Southern Oscillation Index, North Atlantic Oscillation, and Atlantic Multidecadal Oscillation (AMO). It was found that over the period 1984–2012, the global mean (excluding North America and Europe) near‐surface dust concentration decreased at 1.2% yr−1. This decrease is mainly due to reduced dust activities in North Africa, accompanied by reduced activities in Northeast Asia, South America, and South Africa. A significant negative correlation between Saharan dust and AMO was detected, and it seems reasonable to suggest that under present climate, the global dust trend is determined by the climate systems governing the Atlantic and North African regimes.

Household context and child mortality in rural South Africa: the effects of birth spacing, shared mortality, household composition and socio-economic status.

Background Household characteristics are important influences on the risk of child death. However, little is known about this influence in HIV-endemic areas. We describe the effects of household characteristics on children’s risk of dying in rural South Africa.Methods We use data describing the mortality of children younger than 5 years living in the Agincourt health and socio-demographic surveillance system study population in rural northeast South Africa during the period 1994–2008. Using discrete time event history analysis we estimate children’s probability of dying by child characteristics and household composition (other children and adults other than parents) (N = 924 818 child-months), and household socio-economic status (N = 501 732 child-months).Results Children under 24 months of age whose subsequent sibling was born within 11 months experience increased odds of dying (OR 2.5; 95% CI 1.1–5.7). Children also experience increased odds of dying in the period 6 months (OR 2.1; 95% CI 1.2–3.6), 3–5 months (OR 3.0; 95% CI 1.5–5.9), and 2 months (OR 11.8; 95% CI 7.6–18.3) before another household child dies. The odds of dying remain high at the time of another child’s death (OR 11.7; 95% CI 6.3–21.7) and for the 2 months following (OR 4.0; 95% CI 1.9–8.6). Having a related but non-parent adult aged 20–59 years in the household reduces the odds (OR 0.6; 95% CI 0.5–0.8). There is an inverse relationship between a child’s odds of dying and household socio-economic status.Conclusions This detailed household profile from a poor rural setting where HIV infection is endemic indicates that children are at high risk of dying when another child is very ill or has recently died. Short birth intervals and additional children in the household are further risk factors. Presence of a related adult is protective, as is higher socio-economic status. Such evidence can inform primary health care practice and facilitate targeting of community health worker efforts, especially when covering defined catchment areas.

Rainfall-derived growing season characteristics for agricultural impact assessments in South Africa

Precipitation variability imposes significant pressure in areas where agricultural practice is dominated by smallholder farmers who are dependent on subsistence farming. Advances in the understanding of this variability, in both time and space, have an important role to play in increasing the resilience of agricultural systems. The need is particularly pressing in regions of the world such as the African continent, which is already affected by multiple stresses including poverty and economic and political instability. In this paper, we explore the use of generalised linear models (GLMs) for this purpose, via a case study from north-east South Africa. A GLM is used to link the local rainfall variability to large-scale climate drivers identified from previous subcontinental-scale analyses, and the ability of the resulting model to simulate precipitation features that are relevant in agricultural applications is evaluated. We focus in particular on a set of growing season indices, proposed for the investigation of intraseasonal characteristics relevant for maize production in the region. Seven indices were computed from spatially averaged daily rainfall series from nine stations in the study area. As a first attempt to use GLMs for this type of application, the results are encouraging and suggest that the models are able to reproduce a range of agriculture-relevant indices. However, further research into spatial correlation structure is recommended to improve the multisite generation of the rainfall-derived characteristics.

IS6110 Restriction Fragment Length Polymorphism Typing of Drug-resistant Mycobacterium tuberculosis Strains from Northeast South Africa

Tuberculosis (TB) remains a deadly infectious disease affecting millions of people worldwide; 95% of TB cases, with 98% of death occur in developing countries. The situation in South Africa merits special attention. A total of 21,913 sputum specimens of suspected TB patients from three provinces of South Africa routinely submitted to the TB laboratory of Dr. George Mukhari (DGM) Hospital were assayed for Mycobacterium tuberculosis (MTB) growth and antibiotic susceptibility. The genetic diversity of 338 resistant strains were also studied. DNA isolated from the strains were restricted with Pvu II, transferred on to a nylon membrane and hybridized with a PCR-amplified horseradish peroxidase 245 bp IS6110 probe. Of the 338 resistant strains, 2.09% had less than 5 bands of IS6110, and 98% had 5 or more bands. Unique restriction fragment length polymorphism (RFLP) patterns were observed in 84.3% of the strains, showing their epidemiological independence, and 15.7% were grouped into 22 clusters. Thirty-two strains (61.5%) from the 52 that clustered were from Mpumalanga, 16/52 (30.8%) from Gauteng, and 4/52 (9.6%) from Limpopo province. Clustering was not associated with age. However, strains from male patients in Mpumalanga were more likely to be clustered than strains from male patients in Limpopo and/or Gauteng province. The minimum estimate for the proportion of resistant TB that was due to transmission is 9.06% (52-22 = 30/331). Our results indicate that transmission of drug-resistant strains may contribute substantially to the emergence of drug-resistant tuberculosis in South Africa.

Biogeographic patterns on shallow subtidal reefs in the western Indian Ocean

To resolve biogeographic limits and patterns on the east coast of Africa, the presence/absence and quantitative biomass data were collected from 55 shallow subtidal reefs along 4,800 km of coastline (5.2°–31.1°S). Multivariate analysis of distributions, trophic structure and biomass revealed two distinct marine provinces, the Tropical Indo-West Pacific and Subtropical Natal, with a transitional overlap (of ca. 120 km) located between Leven Point and Kosi Mouth on north-east South Africa. This region of overlap was one of three bioregions revealed by post hoc analyses. Biomass was unexpectedly highest in the tropics. ‘Auto-heterotrophs’ (species with autotrophic symbionts such as corals and clams), deposit feeders and grazers contributed significantly more biomass to the Tropical Indo-West Pacific Bioregion, whereas filter feeders dominated the Subtropical Natal Bioregion. ‘Auto-heterotrophs’ declined with latitude while filter feeders increased; soft corals made a defining contribution in the overlap bioregion. Possible underlying causes of these patterns include productivity, nutrient levels, riverine input, light penetration and temperature.

The contribution of spatial analysis to understanding HIV/TB mortality in children: a structural equation modelling approach

Background: South Africa accounts for more than a sixth of the global population of people infected with HIV and TB, ranking her highest in HIV/TB co-infection worldwide. Remote areas often bear the greatest burden of morbidity and mortality, yet there are spatial differences within rural settings.Objectives: The primary aim was to investigate HIV/TB mortality determinants and their spatial distribution in the rural Agincourt sub-district for children aged 1–5 years in 2004. Our secondary aim was to model how the associated factors were interrelated as either underlying or proximate factors of child mortality using pathway analysis based on a Mosley-Chen conceptual framework.Methods: We conducted a secondary data analysis based on cross-sectional data collected in 2004 from the Agincourt sub-district in rural northeast South Africa. Child HIV/TB death was the outcome measure derived from physician assessed verbal autopsy. Modelling used multiple logit regression models with and without spatial household random effects. Structural equation models were used in modelling the complex relationships between multiple exposures and the outcome (child HIV/TB mortality) as relayed on a conceptual framework.Results: Fifty-four of 6,692 children aged 1–5 years died of HIV/TB, from a total of 5,084 households. Maternal death had the greatest effect on child HIV/TB mortality (adjusted odds ratio=4.00; 95% confidence interval=1.01–15.80). A protective effect was found in households with better socio-economic status and when the child was older. Spatial models disclosed that the areas which experienced the greatest child HIV/TB mortality were those without any health facility.Conclusion: Low socio-economic status and maternal deaths impacted indirectly and directly on child mortality, respectively. These factors are major concerns locally and should be used in formulating interventions to reduce child mortality. Spatial prediction maps can guide policy makers to target interventions where they are most needed.Appendices available online under Reading Tools.

Self-reported health and health care use in an ageing population in the Agincourt sub-district of rural South Africa

BackgroundSouth 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.ObjectiveTo 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.MethodsThe 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.ResultsFour 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.ConclusionSelf-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.

“It's my secret”: Barriers to paediatric HIV treatment in a poor rural South African setting

In South Africa, a third of children born are exposed to HIV, while fewer undergo an HIV confirmatory test. Anti-retroviral therapy (ART) coverage among children remains low-despite roll-out of the national ART programme in South Africa in 2004. This study sought to understand critical barriers to seeking HIV-related care for children in rural South Africa. Data presented in this article derive from community-based qualitative research in poor rural villages in north-east South Africa; this includes 21 in-depth interviews in 2008 among caregivers of children identified as HIV-positive in 2007 from a randomly selected community-based sample. Using NVIVO 8, data were coded and analysed, using a constant comparative method to identify themes and their repetitions and variations. Structural barriers leading to poor access to health care, and social and systems barriers, all influenced paediatric HIV treatment seeking. Of concern was the expressed need to maintain secrecy regarding a child's HIV status to avoid stigma and discrimination, and misconceptions regarding the course of HIV disease in children; this led to a delay in seeking appropriate care. These barriers need to be addressed, including through focused awareness campaigns, improved access to health care and interventions to address rural poverty and development at both household and community levels. In addition, training of health care professionals to improve their attitudes and practice may be necessary. However, this study only provides the perspective of the caregivers; further studies with health care providers are needed to gain a fuller picture for appropriate policy and practice guidance.