Suchergebnisse

Background: The challenge of research in resource-poor settings remains a profound concern and is closely linked to African social development. Work of this thesis spans the end of apartheid and first decade of the democratic era in South Africa, along with emergence of the HIV/AIDS pandemic. It also covers the founding decade of the INDEPTH Network. Aims: Through appraising health and population research in a rural southern African sub-district over the past decade, to evaluate the utility of health and socio-demographic surveillance in rural African settings for: • capturing the dynamics of health, population and social transitions • supporting a mix of research designs, and • contributing to policy and programme development and evaluation. To extend this appraisal by examining the multi-site opportunities offered by the INDEPTH Network. Methods: Work was sited in the Agincourt sub-district, a heavily populated border area of rural north-eastern South Africa. Health and socio-demographic surveillance, introduced in 1992, involved prospective follow-up of the entire sub-district population of 70,000 people (including some 30% Mozambican immigrants) who lived in 11,700 households and 21 villages. Annual census rounds systematically updated household membership and recorded all vital events (births, deaths and migrations) since the previous census. A maternity history was asked of women of reproductive age and a verbal autopsy carried out on all deaths registered. The resulting 'data and research platform' – a core feature of all INDEPTH field sites – provided data for computation of trends in vital events and supported an extensive interdisciplinary project portfolio. The population under surveillance can be disaggregated into cohorts selected by age, sex or other criteria. Analyses are possible at multiple levels (individual, family/household or neighborhood) and can include socioeconomic factors. Findings: The Agincourt community experienced a serious worsening of mortality among most age-sex groups, rapidly declining fertility to near replacement level, and changing patterns of labour migration. This resulted in major changes in population structure and household composition. The rising burden of chronic disease involved both chronic infectious illness (HIV/AIDS and tuberculosis) and non-communicable disorders (such as stroke and related vascular disease). The burden of illness requiring chronic care increased disproportionately to that needing acute care. Potential contributions of field sites based on health and socio-demographic surveillance to local and national health policy are considerable yet remain underexploited. Interpretation: Rural South and southern Africa is in the midst of multiple, interrelated transitions with implications for health, social and development sectors. Health and socio-demographic surveillance systems are effective research instruments that can capture the rapidly-changing dynamics of health and social transitions in developing settings. Similarly, they can support a range of observational and intervention study designs including policy evaluations. The INDEPTH Network should boost much-needed comparative research; yet singly, and as a group, many of these sites have yet to fulfil their undoubted potential.

Many Mozambican refugees in South Africa have managed to move on from initial short-term survival strategies to achieve long-term livelihoods. Adapted from the source document.

The age pattern of fertility in a rural area of South Africa under demographic surveillance (Agincourt subdistrict) was investigated over the 1992–97 period. The total fertility rate (TFR) averaged 3.3 births per woman of reproductive age over the period, a major drop from earlier estimates in the same area (6.0 births in 1970–74). Age‐specific fertility rates showed an atypical bimodal pattern. They were decomposed into two components of similar magnitude: premarital fertility (among women aged 12–26) and marital fertility (among women aged 15–49). The decomposition revealed the two underlying modes: a mode of premarital fertility (among women aged 18–20) and a mode of marital fertility (among women aged 28–30). Premarital fertility accounted for 21 percent of all births and for 47 percent of births among women aged 12–26. This pattern of high premarital fertility appears to reflect a low incidence of contraceptive use before the first birth, especially among adolescents, a low prevalence of abortion, and a high contraceptive prevalence thereafter. This finding calls for a reorientation of the family planning policy, which until now has targeted married women and women who have been pregnant once, but has failed to address the contraceptive needs of young women before their first pregnancy, especially adolescents.

The cardiovascular disease (CVD) burden in South Africa (SA) is increasing amongst all age groups and is predicted to become the prime contributor to overall morbidity and mortality in the over 50-year age group. Several factors contribute to this – an epidemiological transition, which has seen a rise in chronic non-communicable disease, and a demographic transition with much reduced fertility and a growing proportion of the population above 60 years. In parallel with unfolding urbanisation, the population burden of vascular risk factors namely hypertension, hypercholesterolemia, diabetes and obesity has increased. The scale of CVD burden poses a threat to the health system and calls for timely intervention. This paper discusses the burden of CVD in SA and current initiatives to address it. Evidence is presented from studies that focus on prevention including salt reduction and trans-fatty acids legislation. The economic and clinical impact of an inadequate private and public sector response is summarised. The paper documents lessons from other countries and proposes health systems strengthening measures that could improve care of patients with CVD.

Abstract 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.

ABSTRACT
ObjectivesTo assess the impact of late presentation (CD4 cell count <200 cells/μl at presentation) for care and treatment on short-term mortality (death within a year of presentation) among HIV-infected adults in rural South Africa.
ApproachWe applied deterministic and probabilistic record linkage approaches to link adult patients seeking care and treatment for HIV from a health facility between 2007 and 2013 to population under continuous surveillance by the Agincourt Health and Demographic Surveillance System (HDSS) in rural northeast South Africa. The resulting record-linked dataset was thereafter analysed to estimate short-term mortality (death within a year of presentation) differences in late presenters (initial presentation at health facility with CD4 cell count less than 200 cells/μl) and early presenters (presentation with CD4 cell count of 200 or more cells/μl). In the linked dataset, CD4 cell count was extracted from the health facility database where as date of death came from the HDSS database.
ResultsA total of 3,553 patients who sought care and treatment for HIV at Bhubhezi clinic between 2007 and 2013 were linked to the Agincourt HDSS surveillance population. Proportion of patients classified as late presenters was 60.9%. Short-term mortality was 8.9% (317/3,553): 11.1% among those who presented late and 5.5 % among those who presented early (P<0.001).
ConclusionRecord linkage facilitated the assessment of the impact of late presentation for care and treatment on short-term mortality among HIV-infected adults in rural South Africa. In the population studied, late presentation is high and is contributing to high mortality among people living with HIV. Strategies that would facilitate early presentation are needed in order to reduce mortality among people living with HIV.

This article reports on a pilot study of the use of applied theatre in the dissemination of health research findings and validation of data. The study took place in South Africa, as part of the Southern Africa Stroke Prevention Initiative (SASPI) and was based at the University/Medical Research Council Rural Public Health and Health Transitions Research Unit (also known as the Agincourt Unit). The aim of SASPI was to investigate the prevalence of stroke and understand the social context of stroke. It was decided to use an applied theatre approach for validating the data and disseminating findings from the anthropological component of the study. The pilot study found that applied theatre worked better in smaller community groups. It allowed data validation and it elicited ideas for future interventions resulting from the health research findings. Evaluation methods of the impact of applied theatre as a vehicle for the dissemination and communication of research findings require further development.

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.