Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

Abstract

ObjectivesCardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.DesignA mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.SettingThis study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.ParticipantsDeaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.ResultsBetween 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).ConclusionsThe temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Cardiovascular disease mortality based on verbal autopsy in low- and middle-income countries: a systematic review

“… 60 More than three quarters of the studies (32/42) were surveillance studies. 19 , 21 – 24 , 26 , 28 – 44 , 48 – 52 , 54 , 55 , 57 , 58 Of 39 studies that recorded the study setting, 19 – 39 , 41 – 55 , 57 , 59 , 60 18 covered rural populations, 26 , 28 , 30 , 32 , 34 , 35 , 37 , 39 , 41 – 44 , 48 – 50 , 52 , 53 , 55 six covered urban populations, 21 , 25 , 46 , 47 , 51 , 59 and 15 covered both rural and urban populations at the country level. 19 , 20 , 22 – 24 , 27 , 29 , 31 , 33 , 36 , 38 , 45 , 54 , 57 , 60 The number of verbal autopsy deaths reported across all ages ranged between studies from 515 to 22 535, 47 , 53 and 20 studies reported deaths by sex.…”

“… 20 , 36 , 59 In just over half the studies (22/42), the cause of death was ascertained by physicians; 22 , 24 , 27 – 31 , 33 , 36 – 38 , 40 , 41 , 43 , 45 , 49 – 52 , 54 – 56 , 60 in 15 studies, cardiovascular disease deaths were ascertained using InterVA (Umeå Centre for Global Health Research, Umeå, Sweden) or SmartVA (Institute for Health Metrics and Evaluation, Seattle, USA) software. 19 , 21 , 23 , 25 , 26 , 32 , 34 , 35 , 39 , 42 , 44 , 48 , 53 , 57 , 58 …”