Francesc Xavier Gómez-Olivé

Profile: Agincourt Health and Socio-demographic Surveillance System

The Agincourt health and socio-demographic surveillance system (HDSS), located in rural northeast South Africa close to the Mozambique border, was established in 1992 to support district health systems development led by the post-apartheid ministry of health. The HDSS (90 000 people), based on an annual update of resident status and vital events, now supports multiple investigations into the causes and consequences of complex health, population and social transitions. Observational work includes cohorts focusing on different stages along the life course, evaluation of national policy at population, household and individual levels and examination of household responses to shocks and stresses and the resulting pathways influencing health and well-being. Trials target children and adolescents, including promoting psycho-social well-being, preventing HIV transmission and reducing metabolic disease risk. Efforts to enhance the research platform include using automated measurement techniques to estimate cause of death by verbal autopsy, full ‘reconciliation’ of in- and out-migrations, follow-up of migrants departing the study area, recording of extra-household social connections and linkage of individual HDSS records with those from sub-district clinics. Fostering effective collaborations (including INDEPTH multi-centre work in adult health and ageing and migration and urbanization), ensuring cross-site compatibility of common variables and optimizing public access to HDSS data are priorities.

Research into health, population and social transitions in rural South Africa: Data and methods of the Agincourt Health and Demographic Surveillance System

Rationale for study: Vital registration is generally lacking in infrastructurally weak areas where health and development problems are most pressing. Health and demographic surveillance is a response to the lack of a valid information base that can provide high-quality longitudinal data on population dynamics, health, and social change to inform policy and practice. Design and measurement procedures: Continuous demographic monitoring of an entire geographically defined population involves a multi-round, prospective community study, with annual recording of all vital events (births, deaths, migrations). Status observations and special modules add value to particular research areas. A verbal autopsy is conducted on every death to determine its probable cause. A geographic surveillance system supports spatial analyses, and strengthens field management. Population and sample size considerations: Health and demographic surveillance covers the Agincourt sub-district population, sited in rural north-eastern South Africa, of some 70,000 people (nearly a third are Mozambican immigrants) in 21 villages and 11,700 households. Data enumerated are consistent or more detailed when compared with national sources; strategies to improve incomplete data, such as counts of perinatal deaths, have been introduced with positive effect. Basic characteristics: A major health and demographic transition was documented over a 12-year period with marked changes in population structure, escalating mortality, declining fertility, and high levels of temporary migration increasing particularly amongst women. A dual burden of infectious and non-communicable disease exists against a background of dramatically progressing HIV/AIDS. Potential and research questions: Health and demographic surveillance sites — fundamental to the INDEPTH Network — generate research questions and hypotheses from empirical data, highlight health, social and population priorities, provide cost-effective support for diverse study designs, and track population change and the impact of interventions over time.

Sleep Problems: An Emerging Global Epidemic? Findings From the INDEPTH WHO-SAGE Study Among More Than 40,000 Older Adults From 8 Countries Across Africa and Asia

OBJECTIVE To estimate the prevalence of sleep problems and the effect of potential correlates in low-income settings from Africa and Asia, where the evidence is lacking. DESIGN Cross-sectional. SETTING Community-wide samples from 8 countries across Africa and Asia participating in the INDEPTH WHO-SAGE multicenter collaboration during 2006-2007. The participating sites included rural populations in Ghana, Tanzania, South Africa, India, Bangladesh, Vietnam, and Indonesia, and an urban area in Kenya. PARTICIPANTS There were 24,434 women and 19,501 men age 50 yr and older. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Two measures of sleep quality, over the past 30 days, were assessed alongside a number of sociodemographic variables, measures of quality of life, and comorbidities. Overall, 16.6% of participants reported severe/extreme nocturnal sleep problems, with a striking variation across the 8 populations, ranging from 3.9% (Purworejo, Indonesia and Nairobi, Kenya) to more than 40.0% (Matlab, Bangladesh). There was a consistent pattern of higher prevalence of sleep problems in women and older age groups. In bivariate analyses, lower education, not living in partnership, and poorer self-rated quality of life were consistently associated with higher prevalence of sleep problems (P < 0.001). In multivariate logistic regression analyses, limited physical functionality or greater disability and feelings of depression and anxiety were consistently strong, independent correlates of sleep problems, in both women and men, across the 8 sites (P < 0.001). CONCLUSIONS A large number of older adults in low-income settings are currently experiencing sleep problems, which emphasizes the global dimension of this emerging public health issue. This study corroborates the multifaceted nature of sleep problems, which are strongly linked to poorer general well-being and quality of life, and psychiatric comorbidities.

Prevalence of HIV among those 15 and older in rural South Africa

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.

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

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. Conclusion 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.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. Conclusion 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.

A comparative analysis of national HIV policies in six African countries with generalized epidemics

Abstract Objective To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries. Methods We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance. Findings There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy. Conclusion Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Sexual Behaviors and HIV Status: A Population-Based Study Among Older Adults in Rural South Africa

Objective: To identify the unmet needs for HIV prevention among older adults in rural South Africa. Methods: We analyzed data from a population-based sample of 5059 men and women aged 40 years and older from the study Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI), which was carried out in the Agincourt health and sociodemographic surveillance system in the Mpumalanga province of South Africa. We estimated the prevalence of HIV (laboratory-confirmed and self-reported) and key sexual behaviors by age and sex. We compared sexual behavior profiles across HIV status categories with and without age–sex standardization. Results: HIV prevalence was very high among HAALSI participants (23%, 95% confidence interval [CI]: 21 to 24), with no sex differences. Recent sexual activity was common (56%, 95% CI: 55 to 58) across all HIV status categories. Condom use was low among HIV-negative adults (15%, 95% CI: 14 to 17), higher among HIV-positive adults who were unaware of their HIV status (27%, 95% CI: 22 to 33), and dramatically higher among HIV-positive adults who were aware of their status (75%, 95% CI: 70 to 80). Casual sex and multiple partnerships were reported at moderate levels, with slightly higher estimates among HIV-positive compared to HIV-negative adults. Differences by HIV status remained after age–sex standardization. Conclusions: Older HIV-positive adults in an HIV hyperendemic community of rural South Africa report sexual behaviors consistent with high HIV transmission risk. Older HIV-negative adults report sexual behaviors consistent with high HIV acquisition risk. Prevention initiatives tailored to the particular prevention needs of older adults are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.

Predictors of health care use by adults 50 years and over in a rural South African setting

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.Background South Africas 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.

The promise of record linkage for assessing the uptake of health services in resource constrained settings: a pilot study from South Africa

BackgroundHealth and Demographic Surveillance Systems (HDSS) have been instrumental in advancing population and health research in low- and middle- income countries where vital registration systems are often weak. However, the utility of HDSS would be enhanced if their databases could be linked with those of local health facilities. We assess the feasibility of record linkage in rural South Africa using data from the Agincourt HDSS and a local health facility.MethodsUsing a gold standard dataset of 623 record pairs matched by means of fingerprints, we evaluate twenty record linkage scenarios (involving different identifiers, string comparison techniques and with and without clerical review) based on the Fellegi-Sunter probabilistic record linkage model. Matching rates and quality are measured by their sensitivity and positive predictive value (PPV). Background characteristics of matched and unmatched cases are compared to assess systematic bias in the resulting record-linked dataset.ResultsA hybrid approach of deterministic followed by probabilistic record linkage, and scenarios that use an extended set of identifiers including another household member’s first name yield the best results. The best fully automated record linkage scenario has a sensitivity of 83.6% and PPV of 95.1%. The sensitivity and PPV increase to 84.3% and 96.9%, respectively, when clerical review is undertaken on 10% of the record pairs. The likelihood of being linked is significantly lower for females, non-South Africans and the elderly.ConclusionUsing records matched by means of fingerprints as the gold standard, we have demonstrated the feasibility of fully automated probabilistic record linkage using identifiers that are routinely collected in health facilities in South Africa. Our study also shows that matching statistics can be improved if other identifiers (e.g., another household member’s first name) are added to the set of matching variables, and, to a lesser extent, with clerical review. Matching success is, however, correlated with background characteristics that are indicative of the instability of personal attributes over time (e.g., surname in the case of women) or with misreporting (e.g., age).

Characteristics of Age-discordant Partnerships Associated with HIV Risk Among Young South African Women (HPTN 068)

Objective:Sexual liaisons between older men and younger women have been linked to greater risk of HIV acquisition. This study aims to (1) identify psychosocial and behavioral factors associated with age-discordant (partner ≥5 years) versus age-concordant partnerships (−1< partner <5) and (2) examine the association between partner age discordance and young South African womens sexual behavior. Methods:We used generalized estimating equations to analyze responses from 656 sexually experienced women (aged 13–20 years) from rural Mpumalanga province. Results:Partner age discordance was associated with greater odds of reporting both more frequent sex [adjusted odd ratio (aOR) = 1.77; 95% confidence interval (CI): 1.20 to 2.60] and having a partner with concurrent partnerships (aOR = 1.77; 95% CI: 1.22 to 2.57). Age-discordant partnerships were associated with greater odds of casual partnerships (aOR = 1.50; 95% CI: 1.06 to 2.13), having a partner with concurrent partnerships (aOR = 1.71; 95% CI: 1.19 to 2.46), and more frequent intercourse (ie, having sex at least 2 or 3 times per month) (aOR = 2.04; 95% CI: 1.39 to 3.00). They were associated with lower odds of reporting condom use at last sex (aOR = 0.70; 95% CI: 0.50 to 0.98) and always using condoms (aOR = 0.53; 95% CI: 0.32 to 0.88) in age-discordant partnerships. Conclusions:Our findings suggest that a history of age-discordant partnerships, and to a lesser extent having an age-discordant partner, is linked to HIV risk among young South African women; however, the link between partner age discordance and HIV risk may be more strongly related to the characteristics of age-discordant partnerships than to the characteristics of young women who form such partnerships.