Levels, Trends and Transitions

Theme leaders: Mark A. Collinson and Samuel J. Clark, with Kathleen Kahn, F. Xavier Gómez-Olivé and Stephen M. Tollman

Life expectancy

Understanding population dynamics is critical for planning service delivery and anticipating emerging health and social problems. Rural southern African populations are undergoing rapid and complex transitions.  This HDSS provides an unparalleled opportunity to examine interconnected trends in mortality, fertility, migration, household structure and socio-economic status. Covariates and longitudinal statistical methods can be used to establish which factors are driving these changes.  The HDSS also provides a high functioning platform for research and intervention.

Triangulation of the HDSS with the national census can improve confidence and understanding about the representativeness of the trends found in the HDSS. The national census also benefits from calibration with the HDSS in the sub-district. Using the longitudinal data can help to help to re-interpret the national trends for rural households. Thus, a combination of HDSS and national census can inform planning and a scientific understanding of population transition in rural South Africa.

The effects of enumeration on a population: a study of communities participating in the Agincourt Health and Demographic Surveillance System
Rhian Twine, John Kinsman, Kathleen Kahn, Gillian Lewando-Hundt Funded by an NRF Public Engagement Grant and the EU (Marie Curie Fund)
This exploratory study will take an anthropological approach to assessing the impact of more than 20 years’ surveillance within the Agincourt population, to elicit possible detriments and benefits.  The study will involve in-depth interviews and focus group discussions with  ordinary people systematically sampled from the population residing within villages in the HDSS, traditional and civil leadership and service providers working in the site.  Fieldwork started in September 2015.  The interviews will investigate people’s individual experiences of living in the Agincourt study area, including questions about their overall views, the visits they receive from the Agincourt field workers, community feedback of studies conducted by the Agincourt HDSS, any problems they have encountered, as well as positive impressions. The focus groups will explore similar issues but at a broader, community level.

The Agincourt Health and Socio-Demographic Surveillance System (HDSS) is the foundation of the the MRC/Wits-Agincourt Unit’s research mandate. With the baseline conducted in 1992, the Agincourt HDSS is a longitudinal population registration system that monitors demographic dynamics in a geographically defined population.The longitudinal nature of its existence allows for the  documentation of complex and changing levels, trends and transitions within the rural South and southern African context.  At baseline, some 57,600 people were recorded in 8,900 households in 20 villages; by 2006 the population had increased to about 70,000 people in 11,700 households. In 2007 the study area was extended to include the catchment area of a new privately supported community health centre established to provide HIV treatment prior to public sector roll-out of HAART. By mid 2011, the population under surveillance comprised some 90,000 people residing in 16,000 households in 27 villages. In the first quarter of 2013, another 4 villages were added making the number of research villages under surveillance 31, the population some 110 000 in 21 000 households.  Households are self-defined as “people who eat from the same pot of food”. There have been 20 census and vital event update rounds, conducted strictly annually since 2000. Participation is virtually complete with historically less than 10 households refusing per round.

Collaborators: University of Washington, USA; Pasteur Institute, France; Umeå University, Sweden

a.  Mortality patterns are examined, including cause of death, by age and sex, and spatio-temporal clustering of mortality, by cause, using the geographic information system.

b.  Strengthening verbal autopsy assessments (VA): validation of InterVA, a deterministic model to assess probable cause of death using VA. The model produces standardised assessments compared to physician diagnoses, costs less and produces more timely outputs. This work has contributed to WHO efforts to improve community-based cause-of-death ascertainment and make these tools widely available for policy and planning.

c. Trends in maternal mortality have been examined, determining how all-cause mortality compares with cause-specific estimates and how to estimate maternal mortality more accurately.

VAPAR – Verbal Autopsy with Participatory Action Research (VA-PAR): Developing a people-centred health systems research methodology (Phase 2)Oct 2016
Lucia D’Ambruoso, Ryan Wagner, Kerstin Edin funded by MRC, ESRC, Wellcome Trust, DFID

Sizzy Ngobeni facilitating discussion about a photovoice picture

Sizzy Ngobeni facilitating discussion about a photovoice picture

BACKGROUND: The overall purpose of the proposed research was to develop methods to improve the stock of knowledge on health for marginalized population groups. The work brought together researchers, local service providers and planners to develop methods to combine the insights from Verbal Autopsy (VA) with Participatory Action Research (PAR) in an action-oriented process. AIM AND OBJECTIVES: The research aimed to elicit the perspectives of three village-based groups in the Agincourt Health and Demographic Surveillance Site (HDSS) on two leading causes of death. Community views on the methods by which health information was generated in the locality, via routine health surveillance, were also sought. The objectives were to engage with local service users and providers in a participatory process to review mortality data and extended COD classifications from Agincourt HDSS, to further amplify these data with local knowledge, to set priorities for local services, and explore the potential for benefits related to empowerment and social inclusion. METHODS: The three village-based groups operated independently in a series of meetings to verify and amplify extended COD classifications developed from VA data gained in three rounds of Agincourt surveillance (2012-14) and with new indicators on social and health systems circumstances at the time of death. Two conditions were selected on the basis of (1) high incidence and prevalence identified via the census data and (2) local relevance and community preferences. In the meetings, PAR methods were used to systematize local knowledge and life histories through collective analysis to generate valid forms of evidence on the relationships between problems and their causes, and to articulate action agendas for changes to local services that respond to the issue identified. The discussions also considered how communities view health surveillance and participation in health issues. OUTPUTS:  The outputs are a set of locally relevant health priorities, a series of recommendations for the method, and an account of the community’s views on knowledge production and participation in health issues in this setting. Policy-report/s and peer-reviewed articles that focus on the organisation and delivery of community health services in Agincourt have also been produced and disseminated (see below).




  • ‘Ambruoso, L., Kahn, K., Wagner, R., Twine, R., Spies, B., Van Der Merwe, M., Gomez-Olive, X., Tollman, S. & Byass, P. (2016). ‘Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality’. Global Health Research and Policy, vol 1, 2. http://ghrp.biomedcentral.com/articles/10.1186/s41256-016-0002-y
  • Hullur, N., D’Ambruoso, L., Edin, K., Wagner, R., Ngobeni, S., Kahn, K., Tollman, S. & Byass, P. (2016). ‘Community perspectives on HIV, violence and health surveillance in rural South Africa: a participatory pilot study’. Journal of Global Health, vol 6, no. 1, 010406. HTTP://JOGH.ORG/PDFVIEWER.ASPX?PDF=DOCUMENTS%2FISSUE201601%2FJOGH-06-010406.PDF


Collaborators: Pasteur Institute, France; University of Colorado at Boulder, USA; Wits University, Demography and Population Studies

Determinants of fertility trends and the dynamics of fertility stall are examined, including the comparison of former refugees with local South African fertility rates. The findings suggest that the fertility levels of self-settled, Mozambican refugees residing in the Agincourt population are converging to the levels of their host community.

Collaborators: Brown University and University of Colorado at Boulder, USA; Université Catholique de Louvain, Belgium

Migration trends are examined, by age, sex and type of migration, including determinants and consequences for the migrants and their households remaining in the rural sub-district. The work has highlighted high levels of temporary, circular migration, mostly for reasons of education, employment and seeking employment. Migration levels have increasing for young adult men and women in the 2000 to 2011 period. Rural households remain heavily dependent of labour migration for socio-economic well-being, especially female migration from poorer households and male migration from better-off households.

Fact sheet on Migration and Settlement Change – whats happening in Agincourt

Household change
Collaborators: University of Cape Town, SA; Universities of Missouri and Maryland, USA

Patterns of household change are examined. The HDSS captures co-resident household memberships, keeping track of the start-dates and end-dates and periods of absence in-between. Existing work shows that the average household size is declining. There is considerable short-term flux into and out of households. Overall patterns show a reduction in nuclear family formation and increase in complex multi-generational households.

Socio-economic status
Collaborators: University of Washington: University of Colorado at Boulder

Coke ad and market

Ownership of assets (fridge or stove; building materials; access to electricity, communication and transport) can be assessed quite accurately in surveys and used as a measure of household socioeconomic status. Asset ownership has increased for typical, rural households in the last decade (2000-2011) reflecting improvements in housing, electricity access, and ownership of modern goods.

Triangulation with the National census
Collaborator: Statistics South Africa

The Unit has two projects underway with Statistics South Africa. The first is a collaboration with MRC Burden of Disease Research Unit and national Vital Registration office with the aims of deriving indicators of the completeness of death reporting in the Vital Registration system and thereby improving national cause-specific mortality estimates.  The second is a triangulation of the HDSS migration findings with the 2011 national census. This will repeat the project on migration and urbanisation conducted in 2006, which triangulated the 2001 national census and the Agincourt HDSS. This highlighted the extent of temporary migration and concomitant rural-urban exchange of people, money and goods.

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