https://orcid.org/0000-0001-6834-1838
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ABSTRACT
Background
Community knowledge is a critical input for relevant health programmes and strategies. How community perceptions of risk reflect the burden of mortality is poorly understood.
Objective
To determine the burden of mortality reflecting community-nominated health risk factors in rural South Africa, where a complex health transition is underway.
Methods
Three discussion groups (total 48 participants) representing a cross-section of the community nominated health priorities through a Participatory Action Research process. A secondary analysis of Verbal Autopsy (VA) data was performed for deaths in the same community from 1993 to 2015 (n = 14,430). Using population attributable fractions (PAFs) extracted from Global Burden of Disease data for South Africa, deaths were categorised as ‘attributable at least in part’ to community-nominated risk factors if the PAF of the risk factor to the cause of death was >0. We also calculated ‘reducible mortality fractions’ (RMFs), defined as the proportions of each and all community-nominated risk factor(s) relative to all possible risk factors for deaths in the population .
Results
Three risk factors were nominated as the most important health concerns locally: alcohol abuse, drug abuse, and lack of safe water. Of all causes of deaths 1993–2015, over 77% (n = 11,143) were attributable at least in part to at least one community-nominated risk factor. Causes of attributable deaths, at least in part, to alcohol abuse were most common (52.6%, n = 7,591), followed by drug abuse (29.3%, n = 4,223), and lack of safe water (11.4%, n = 1,652). In terms of the RMF, alcohol use contributed the largest percentage of all possible risk factors leading to death (13.6%), then lack of safe water (7.0%), and drug abuse (1.3%) .
Conclusion
A substantial proportion of deaths are linked to community-nominated risk factors. Community knowledge is a critical input to understand local health risks.
Responsible Editor
Stig Wall
Responsible Editor
Stig Wall
Acknowledgments
The authors would like to thank the community stakeholder study participants for agreeing to be part of the process, and for sharing their time, knowledge, and perspectives. Thanks also to the Verbal Autopsy with Participatory Action Research (VAPAR) team and staff of the Medical Research Council (MRC)/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), especially Simon Khoza, Sizzy Ngobeni and Ella Sihlangu.
Author contributions
PM: Performed the analysis and drafted the manuscript.
JD: Designed and supervised the analysis, co-drafted the manuscript
DM: Led the PAR data collection with supervision from LD and ST (TBC)
ST: Conceived of the study, reviewed, and commented on the manuscript (TBC)
LD: Conceived of the study, supervised the analysis, co-drafted the manuscript
Ethics and consent
The participatory research protocols were reviewed and approved by Institutional boards at the University of the Witwatersrand Human Research Ethics Committee (HREC) (M121039, M1704115, M171050) and the University of Aberdeen College Ethics Review Board (CERB) (CERB/2017/4/1457, CERB/2017/9/1518). Permission for the research was secured from Mpumalanga provincial health authority (MP_201712_003). VA data were obtained from the Agincourt HDSS where on-going ethical clearance has been granted by the University of Witwatersrand’s Committee for Research on Human Subjects (Nos. M960720 & M110138). The principle of informed consent was fully respected with the right to refusal or withdrawal from interviews at both individual and household levels. Informed consent is obtained at individual and household levels, and community consent from traditional leaders, secured at the start of surveillance in 1992, is reaffirmed regularly.
Paper context
Data on mortality provide valuable information for priority setting but it is sometimes incomplete and underused in local decision-making. Community view seems to reflect the direct mortality burden along with the indirect health effects. When used in collaboration with routine data of mortality, it offers a more holistic approach in setting public health priorities.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed here