Research Findings and Research Translation

Insight into health, population and social transitions in rural Southern Africa

For the latest demographic data you can access this excel spreadsheet “Core Agincourt demographic data 2015

Rural South Africa is in the midst of multiple interrelated transitions that have led to marked changes in population structure over two decades (add in population pyramids). Fuelled by fast-declining fertility and by the HIV/AIDS epidemic causing an increase in child mortality, the mid-1990s to mid-2000s saw rapid narrowing of  the pyramid base. By 2011, this pattern was reversing, partly reflecting the population effects of prevention-of-mother-to-child transmission programmes and stabilizing of fertility trends. Spatial patterns of mortality reflect inequalities between former Mozambican refugees and South African host communities. Despite a recent slight upswing, fertility remains at near replacement level.

  • Kahn K, Tollman SM, Collinson MA et al. Research into health, population and social transitions in rural South Africa: data and methods of the Agincourt Health and Demographic Surveillance System. Scand J Public Health 2007;35(Suppl 69):8–20.
  • Garenne M, Tollman SM, Collinson MA, Kahn K. Fertility trends and net reproduction in Agincourt, rural South Africa, 1992-2004. Scand J Public Health 2007;35(Suppl 69):68–76.
  • Sartorius B, Kahn K, Vounatsou P, Collinson MA, Tollman SM. Space and time clustering of mortality in rural South Africa (Agincourt HDSS) 1992-2007. Glob Health Action 2010 (Suppl 1):50–58;
  • Sartorius B, Kahn K, Vounatsou P, Collinson MA, Tollman SM. Survived infancy but still vulnerable: spatial-temporal trends and risk factors for child mortality in rural South Africa. Geospat Health 2011;5: 285–95

There is evidence of increased cardiometabolic disease risk across the life course (Table 5). In children, we find early stunting (one-third of 1–year-olds) and adolescent overweight and obesity (20–25% in older girls) in the   same socio-geographic population. Central obesity increased from 15% of girls during puberty to 35% at the end of puberty, indicating elevated risk for metabolic disease that is associated with higher socio-economic   status. In adults, evidence for a cardiovascular disease transition is clear despite the massive increase in deaths from AIDS and tuberculosis.  High blood pressure and obesity in middleaged women are at nprecedented levels, fostered by changes in lifestyle, diet and occupation.

  • Kimani-Murage EW, Kahn K, Pettifor JM et al. The prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children. BMC Public Health 2010;10:158.
  • Kimani-Murage EW, Kahn K, Pettifor JM et al. The prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children. BMC Public Health 2010;10:158
  • Kimani-Murage EW, Kahn K, Pettifor JM, Tollman SM, Klipstein-Grobusch K, Norris SA. Predictors of adolescent weight status and central obesity in rural South Africa. Public Health Nutr 2011;14:1114–22. Tollman SM, Kahn K, Sartorius B, Collinson MA,
  • Clark SJ, Garenne ML. Implications of mortality transition for primary health care in rural South Africa: a population-based surveillance study. Lancet 2008;372: 893–901.
  • Thorogood M, Connor MD, Tollman SM, Lewando-Hundt G, Fowkes G, Marsh J. A cross-sectional study of vascular risk factors in a rural South African population: data from the Southern African Stroke PreventionInitiative (SASPI). BMC Public Health 2007;7:326.

In rural settings, primary care management of non-communicable disease and associated risk factors is limited,. and chronic infectious disease is dominating service development. The rising mortality and risk for non-communicable diseases, notably among older women, alongside pervasive HIV/AIDS mitigated by expanding HAART availability, argue for integrated approaches to community-oriented provision of long-term care. Although women experience greater longevity, they consistently report a poorer quality of life.

Mortality, mainly from AIDS and tuberculosis, is highest among recently returned migrants of both sexes, imposing high demands on local health services and  communities. Older women play key roles supporting child care and schooling while having to meet health care and funeral costs.

Pressure on the ‘near-old’—women aged <60 years and not yet eligible for a pension—can be considerable, Whereas self-reported health and quality of life in pension-eligible older women are markedly improved. Clark SJ,

More rural women are migrating for work than ever before.

  • Kowal P, Kahn K, Ng N et al. Ageing and adult health status in eight lower-income countries: the INDEPTH WHO-SAGE collaboration. Glob Health Action 2010 Suppl 2):11–22
  • Collinson MA, Tollman SM, Kahn K. Migration, settlement change and health in post-Apartheid South Africa: triangulating health and demographic surveillance with national census data. Scand J Public Health 2007; 35(Suppl 69):77–84.
  • Tollman SM, Kahn K, Sartorius B, Collinson MA, Clark SJ, Garenne ML. Implications of mortality transition for primary health care in rural South Africa: a population-based surveillance study. Lancet 2008;372: 893–901.
  • Schatz EJ. ‘‘Taking care of my own blood’’: older women’s relationships to their households in rural South Africa. Scand J Public Health 2007;35(Suppl 69)
  • Schatz EJ, Ogunmefun C. Caring and contributing: the role of older women in multi-generational households in the HIV/AIDS era. World Dev 2007;35:1390–403.
  • Schatz E, Madhavan S, Williams J. Female-headed households contending with AIDS-related hardship in rural South Africa. Health Place 2011;17:598–605
  • Gomez-Olive FX, Thorogood M, Clark BD, Kahn K, Tollman SM. Assessing health and well-being among older people in rural South Africa. Glob Health Action 2010 (Suppl 2):23–35.
  • Schatz E, Madhavan S, Williams J. Female-headed households contending with AIDS-related hardship in rural South Africa. Health Place 2011;17:598–605;
  • Sartorius B, Kahn K, Vounatsou P, Collinson M, Tollman S. Young and vulnerable: spatial-temporal trends and risk factors for infant mortality in rural South Africa (Agincourt) 1992-2007. BMC Public Health 2010;10:645.
  • Collinson MA, Kahn K, Drullinger K, Tollman SM. Returning home to die: circular labour migration and mortality in South Africa. Scand J Public Health 2007;35(Suppl 69):35–44.Madhavan S, Schatz E, Clark S, Collinson M. Child mobility, maternal status, and household composition in rural South Africa. Demography 2012;49:699–718.

Infant and child survival are profoundly affected by a mother’s death, as is child mobility, and fostering by women pensioners is clearly advantageous.

  • Sartorius B, Kahn K, Vounatsou P, Collinson MA, Tollman SM. Survived infancy but still vulnerable: spatial-temporal trends and risk factors for child mortality in rural South Africa. Geospat Health 2011;5: 285–95
  • Hunter LM, Twine W, Johnson A. Adult mortality and natural resource use in rural South Africa: evidence from the Agincourt Health and Demographic Surveillance site. Soc Nat Resour 2011;24:256–75.
  • Twine W, Hunter L. Adult mortality household food security in rural South Africa; does AIDS represent a unique mortality shock? Dev South Afr 2011;28:431–44.
  • Case A, Menendez A. Does money empower the elderly? Evidence from the Agincourt demographic surveillance site, South Africa. Scand J Public Health 2007;35(Suppl 69):157–64
  • Schatz E, Madhavan S, Williams J. Female-headed households contending with AIDS-related hardship in rural South Africa. Health Place 2011;17:598–605.

Food security among poorer households remains precarious, with harvesting of natural resources acting as an important buffer against ‘shocks’ such as death of a breadwinner.

Among the poorest households, reliance on natural resources is high, no matter what the specific cause of adult death.

  • Williams JR, Schatz EJ, Clark BD et al. Linking research and training through research data and transnational collaborations. Glob Health Action 2010;3:5287.
  • Thorogood M, Connor MD, Lewando-Hundt G, Tollman SM. Understanding and managing hypertension in an African sub-district: a multidisciplinary approach.  Scand J Public Health 2007;35(Suppl 69):52–59.  8. back to top

Research translation

Local, district and provincial efforts, including local government and NGOs, are anchored by the Unit’s 3-person LINC office (Learning, Information dissemination and Networking with Community); while the PRICELESS initiative is particularly active with the National Dept of Health and other national institutions such as the Treasury, MRC and NGOs e.g. Health Systems Trust.  

  • Strong engagement with study communities and leadership, building ‘research-savvy’ communities
  • Strong partnership with Statistics South Africa / MRC Burden of Disease Unit to validate vital registration and cause-of-death mortality data
  • Strong and growing partnership with national government on dietary salt restriction; integrated chronic care; child and adolescent interventions
  • New methods of verbal autopsy assessment tested and introduced as WHO standard      (2012)

A detailed listing of research translation activities includes:

Community level                 

  • Village-level project entry and feedback: LINC office discusses aims of every study as well as key findings, highlighting those most useful in village fact sheets
  • Community Advisory Group (CAG) well-established and involved in various training opportunities
  • ‘Point of care’ results provided, where appropriate, to study participants (eg blood pressure, glucose) with referral to sub-district clinics

Local government              

  • Multiple engagements and briefings; LINC chairs Orphans and Vulnerable Children task force
  • Annual report – “Changing Lives in Rural South Africa” – the Annual Research Brief of the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Nov 2011. For government and NGO service providers who use the information to plan services

Provincial      

  • Report on VCT to district health authorities; ongoing VCT monitoring to increase access
  • Monitoring and evaluation of public and private-public rollout of ARVs (Bhubezi Health Centre); includes linking health facility records with HDSS database
  • Prevalence of HIV and non-communicable disease risk factors: to benefit local, district and provincial health planning for integrated chronic care – results in 2012
  • Severe acute respiratory infection (SARI) and rotavirus surveillance reports disseminated by National Institute for Communicable Diseases to participating hospitals, Mpumalanga Communicable Diseases Unit and Research Office. To monitor flu epidemic, develop annual flu vaccine, evaluate new vaccines
  • Evaluation of NGO/Government partnership to address social, emotional wellbeing of primary school children (Kulani project). Intervention involved regular meetings with District Dept of Education

National         

  • Ministerial Committee, DOH – the Health Data Advisory Coordinating Committee (HDACC) which includes Kahn and Tollman (2010-2014)
  • Partnerships
    • PRICELESS-SA (Priority cost effective lessons for systems strengthening) Steering Committee includes DOH, Treasury, Dept of Science and Technology, MRC, and Health Systems Trust. PRICELESS engaging with DOH on economic evaluation and service costing, sodium content of food and appropriate legislation, supplementary immunization activities, chronic care including diabetes, and breastfeeding practice
    • Chief Directorate, Non-communicable Disease to evaluate models of integrated care
    • Stats SA to improve vital registration, recording of mobility, and analysis of Census 2011
  • Swa Koteka (conditional cash transfers to school-going young women and their families) – engaged with National Dept of Education (DOE) during protocol development followed by DOE field visits; Dept of Social Development showing keen interest re conditionalities for child support grant
  • Household Vulnerability & Coping – presentations to DST, Office of Presidency, Dept of Agriculture.

International

  • WHO Verbal autopsy instrument 2012, developed for use in routine national or sub-national civil or health information systems. Cause of death list, questionnaires and InterVA-4 software for assessment are all aligned; electronic data collection tools recently piloted in Agincourt.

 

Annual Research Brief
The LINC office produces an annual research brief.  The 2011 Agincourt Research Briefing was titled “Changing Lives in Rural South Africa – Annual research Brief of the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) Nov 2011”.back to top