[Show abstract][Hide abstract] ABSTRACT: Background: Understanding how lay people perceive the causes of mortality and their associated risk factors is important for public health. In resource-limited settings, where verbal autopsy (VA) is used as the most expedient method of determining cause of death, it is important to understand how pre-existing concepts of cause of death among VA-informants may influence their VA-responses and the consequential impact on cause of death assessment. This study describes the agreement between VA-derived causes of death and informant-perceived causes and associated influential factors, which also reflects lay health literacy in this setting.
Method: Using 20 years of VA data (n=11,228) from the Agincourt Health and Demographic Surveillance System (HDSS) site in rural South Africa, we explored the agreement between the causes of death perceived by the VA-informants and those assigned by the automated Inter-VA tool. Kappa statistics and concordance correlation coefficients were applied to measure agreement at individual and population levels, respectively. Multivariable regression models were used to explore factors associated with recognised lay perceptions of causes of mortality.
Results: Agreement between informant-perceived and VA-derived causes of death at the individual level was limited, but varied substantially by cause of death. However, agreement at the population level, comparing cause-specific mortality fractions was higher, with the notable exception of bewitchment as a cause. More recent deaths, those in adults aged 15–49 years, deaths outside the home, and those associated with external causes showed higher concordance with InterVA.
Conclusion: Overall, informant perception of causes of death was limited, but depended on informant characteristics and causes of death, and to some extent involved non-biomedical constructs. Understanding discordance between perceived and recognised causes of death is important for public health planning; low community understanding of causes of death may be detrimental to public health. These findings also illustrate the importance of using rigorous and standardised VA methods rather than relying on informants’ reported causes of death.
Global Health Action 07/2015; 8(1654-9880). DOI:10.3402/gha.v8.28302 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Coverage of civil registration and vital statistics varies globally, with most deaths in Africa and Asia remaining either unregistered or registered without cause of death. One important constraint has been a lack of fit-for-purpose tools for registering deaths and assigning causes in situations where no doctor is involved. Verbal autopsy (interviewing care-givers and witnesses to deaths and interpreting their information into causes of death) is the only available solution. Automated interpretation of verbal autopsy data into cause of death information is essential for rapid, consistent and affordable processing.
Verbal autopsy archives covering 54 182 deaths from five African and Asian countries were sourced on the basis of their geographical, epidemiological and methodological diversity, with existing physician-coded causes of death attributed. These data were unified into the WHO 2012 verbal autopsy standard format, and processed using the InterVA-4 model. Cause-specific mortality fractions from InterVA-4 and physician codes were calculated for each of 60 WHO 2012 cause categories, by age group, sex and source. Results from the two approaches were assessed for concordance and ratios of fractions by cause category. As an alternative metric, the Wilcoxon matched-pairs signed ranks test with two one-sided tests for stochastic equivalence was used.
The overall concordance correlation coefficient between InterVA-4 and physician codes was 0.83 (95% CI 0.75 to 0.91) and this increased to 0.97 (95% CI 0.96 to 0.99) when HIV/AIDS and pulmonary TB deaths were combined into a single category. Over half (53%) of the cause category ratios between InterVA-4 and physician codes by source were not significantly different from unity at the 99% level, increasing to 62% by age group. Wilcoxon tests for stochastic equivalence also demonstrated equivalence.
These findings show strong concordance between InterVA-4 and physician-coded findings over this large and diverse data set. Although these analyses cannot prove that either approach constitutes absolute truth, there was high public health equivalence between the findings. Given the urgent need for adequate cause of death data from settings where deaths currently pass unregistered, and since the WHO 2012 verbal autopsy standard and InterVA-4 tools represent relatively simple, cheap and available methods for determining cause of death on a large scale, they should be used as current tools of choice to fill gaps in cause of death data.
Global journal of health science 06/2015; 5(1):010402. DOI:10.7189/jogh.05.010402
[Show abstract][Hide abstract] ABSTRACT: Unacceptably high levels of preventable maternal mortality persist as a problem across sub-Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.
A community-based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15-49 years retrospectively over a one-year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15-49 years. All pregnancy-related deaths were identified after processing the VA material using the InterVA-4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).
The MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy-related deaths. Haemorrhage was the major cause of pregnancy-related death (34%). District-level MMRs were strongly inversely correlated with population density (r(2) = 0.86).
This simple but well-designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub-Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions.
Global journal of health science 06/2015; 5(1):010404. DOI:10.7189/jogh.05.010404
[Show abstract][Hide abstract] ABSTRACT: Background
The 2012 World Health Assembly set a target for Member States to reduce premature non-communicable disease (NCD) mortality by 25% over the period 2010 to 2025. This reflected concerns about increasing NCD mortality burdens among productive adults globally. This article first considers whether the WHO target of a 25% reduction in the unconditional probability of dying between ages of 30 and 70 from NCDs (cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases) has already taken place in Sweden during an equivalent 15-year period. Secondly, it assesses which population sub-groups have been more or less successful in contributing to overall changes in premature NCD mortality in Sweden.
A retrospective dynamic cohort database was constructed from Swedish population registers in the Linnaeus database, covering the entire population in the age range 30 to 69 years for the period 1991 to 2006, which was used directly to measure reductions in premature NCD mortality using a life table method as specified by the WHO. Multivariate Poisson regression models were used to assess the contributions of individual background factors to decreases in premature NCD mortality.
A total of 292,320 deaths occurred in the 30 to 69 year age group during the period 1991 to 2006, against 70,768,848 person-years registered. The crude all-cause mortality rate declined from 5.03 to 3.72 per 1,000 person-years, a 26% reduction. Within this, the unconditional probability of dying between the ages of 30 and 70 from NCD causes as defined by the WHO fell by 30.0%. Age was consistently the strongest determinant of NCD mortality. Background determinants of NCD mortality changed significantly over the four time periods 1991–1994, 1995–1998, 1999–2002, and 2003–2006.
Sweden, now at a late stage of epidemiological transition, has already exceeded the 25% premature NCD mortality reduction target during an earlier 15-year period. This should be encouraging news for countries currently implementing premature NCD mortality reduction programmes. Our findings suggest, however, that it may be difficult for Sweden and other late-transition countries to reach the current 25 × 25 target, particularly where substantial premature mortality reductions have already been achieved.
BMC Medicine 03/2015; 13(1). DOI:10.1186/s12916-015-0313-8 · 7.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period.
Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use.
There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008-2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003-2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated.
There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.
BMC Complementary and Alternative Medicine 12/2014; 14(1):504. DOI:10.1186/1472-6882-14-504 · 1.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-communicable diseases (NCDs) result in more deaths globally than other causes. Monitoring systems require strengthening to attribute the NCD burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal.
Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya, attributed into broad categories using InterVA-4 computer algorithms; 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% (39% male, 48% female) of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010 (χ2 linear trend 93.4; p<0.001). While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. The substantial fall in CD MRs resulted in similar MRs for CDs and NCDs among all adult females by 2010. NCD MRs for adults aged 15y to <65y fell from 409 to 183 per 100,000 among females and from 517 to 283 per 100,000 population among males. NCD MRs were higher among males than females aged both below, and at or above, 65y.
NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.
PLoS ONE 11/2014; 9(11):e114010. DOI:10.1371/journal.pone.0114010 · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.
This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.
Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.
In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.
[Show abstract][Hide abstract] ABSTRACT: The MRC/Wits University Agincourt research centre, part of the INDEPTH Network, has documented mortality in a defined population in the rural northeast of South Africa for 20 years (1992-2011) using long-term health and socio-demographic surveillance. Detail on the unfolding, at times unpredicted, mortality pattern has been published. This experience is reviewed here and updated using more recent data.
Global Health Action 10/2014; 7:25596. DOI:10.3402/gha.v7.25596 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The vast majority of deaths in the Kilifi study area are not recorded through official systems of vital registration. As a result, few data are available regarding causes of death in this population.
To describe the causes of death (CODs) among residents of all ages within the Kilifi Health and Demographic Surveillance System (KHDSS) on the coast of Kenya.
Verbal autopsies (VAs) were conducted using the 2007 World Health Organization (WHO) standard VA questionnaires, and VA data further transformed to align with the 2012 WHO VA instrument. CODs were then determined using the InterVA-4 computer-based probabilistic model.
Five thousand one hundred and eighty seven deaths were recorded between January 2008 and December 2011. VA interviews were completed for 4,460 (86%) deaths. Neonatal pneumonia and birth asphyxia were the main CODs in neonates; pneumonia and malaria were the main CODs among infants and children aged 1–4, respectively, while HIV/AIDS was the main COD for adult women of reproductive age. Road traffic accidents were more commonly observed among men than women. Stroke and neoplasms were common CODs among the elderly over the age of 65.
We have established the main CODs among people of all ages within the area served by the KHDSS on the coast of Kenya using the 2007 WHO VA questionnaire coded using InterVA-4. We hope that our data will allow local health planners to estimate the burden of various diseases and to allocate their limited resources more appropriately.
Global Health Action 10/2014; 7:25593. DOI:10.3402/gha.v7.25593 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
For public health purposes, it is important to see whether men and women in different age groups die of the same causes in South Africa.
We explored sex- and age-specific patterns of causes of deaths in a rural demographic surveillance site in northern KwaZulu-Natal in South Africa over the period 2000–2011.
Deaths reported through the demographic surveillance were followed up by a verbal autopsy (VA) interview using a standardised questionnaire. Causes of death were assigned likelihoods using the publicly available tool InterVA-4. Cause-specific mortality fractions were determined by age and sex.
Over the study period, a total of 5,416 (47%) and 6,081 (53%) deaths were recorded in men and women, respectively. Major causes of death proportionally affecting more women than men were (all p<0.0001): human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (20.1% vs. 13.6%), other and unspecified cardiac disease (5.9% vs. 3.2%), stroke (4.5% vs. 2.7%), reproductive neoplasms (1.7% vs. 0.4%), diabetes (2.4% vs. 1.2%), and breast neoplasms (0.4% vs. 0%). Major causes of deaths proportionally affecting more men than women were (all p<0.0001) assault (6.1% vs. 1.7%), pulmonary tuberculosis (34.5% vs. 30.2%), road traffic accidents (3.0% vs. 1.0%), intentional self-harm (1.3% vs. 0.3%), and respiratory neoplasms (2.5% vs. 1.5%). Causes of death due to communicable diseases predominated in all age groups except in older persons.
While mortality during the 2000s was dominated by tuberculosis and HIV/AIDS, we found substantial sex-specific differences both for communicable and non-communicable causes of death, some which can be explained by a differing sex-specific age structure. InterVA-4 is likely to be a valuable tool for investigating causes of death patterns in other similar Southern African settings.
Global Health Action 10/2014; 7:25496. DOI:10.3402/gha.v7.25496 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This synthesis brings together findings on cause-specific mortality documented by means of verbal autopsies applied to over 110,000 deaths across Africa and Asia, within INDEPTH Network sites.
Developments in computerised methods to assign causes of death on the basis of data from verbal autopsy (VA) interviews have made possible these standardised analyses of over 110,000 deaths from 22 African and Asian Health and Demographic Surveillance System sites in the INDEPTH Network. In addition to previous validations of the InterVA-4 probabilistic model, these wide-ranging analyses provide further evidence of the applicability of this approach to assigning the cause of death. Plausible comparisons with existing knowledge of disease patterns, as well as substantial correlations with out-of-model parameters such as time period, country, and other independent data sources were observed.
Substantial variations in mortality between sites, and in some cases within countries, were observed. A number of the mortality burdens revealed clearly constitute grounds for public health actions. At an overall level, these included high maternal and neonatal mortality rates. More specific examples were childhood drowning in Bangladesh and homicide among adult males in eastern and southern Africa. Mortality from non-communicable diseases, particularly in younger adulthood, is an emerging cause for concern. INDEPTH’s approach of documenting all deaths in particular populations, and successfully assigning causes to the majority, is important for formulating health policies.
The pooled dataset underlying these analyses is available at the INDEPTH Data Repository for further analysis. INDEPTH will continue to fill cause-specific mortality knowledge gaps across Africa and Asia, which will also serve as a baseline for post-2015 development goals. The more widespread use of similar VA methods within routine civil registration systems is likely to become an important medium-term strategy in many countries.
Global Health Action 10/2014; 7:25590. DOI:10.3402/gha.v7.25590 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.
Global Health Action 10/2014; 7:25362. DOI:10.3402/gha.v7.25362 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders.
Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications.
There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects.
Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.
Global Health Action 10/2014; 7:25606. DOI:10.3402/gha.v7.25606 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: New Global Burden of Disease estimates for liver cirrhosis, published in BMC Medicine, suggest that cirrhosis caused over a million deaths in 2010, with a further million due to liver cancer and acute hepatitis. Cause-specific mortality data were very sparse for some regions, particularly in Africa, with no relevant mortality data for 58/187 countries. Liver disease involves infectious, malignant and chronic aetiologies with overlapping symptoms. Where available mortality data come from verbal autopsies, separating different types of liver disease is challenging.
Cirrhosis is a disease of rich and poor alike; key public health risk factors such as alcohol consumption play an important role. Risk-reduction strategies such as controlling the price of alcohol are being widely discussed. Since these estimates used alcohol consumption as a covariate, they cannot be used to explore relationships between alcohol consumption and cirrhosis mortality.
There is hope: coming generations of adults will have been vaccinated against hepatitis B, and this is envisaged to reduce the burden of fatal liver disease. But more complete civil registration globally is needed to fully understand the burden of liver disease.
Please see related article: http://www.biomedcentral.com/1741-7015/12/145/abstract.
BMC Medicine 09/2014; 12(1):159. DOI:10.1186/s12916-014-0159-5 · 7.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The lack of adequate documentation of deaths, and particularly their cause, is often noted in African and Asian settings, but practical solutions for addressing the problem are not always clear. Verbal autopsy methods (interviewing witnesses after a death) have developed rapidly, but there remains a lack of clarity as to how these methods can be effectively applied to large unregistered populations. This paper sets out practical details for undertaking a representative survey of cause-specific mortality in a population of several million, taking Tigray Region in Ethiopia as a prototype.
Sampling was designed around an expected level of maternal mortality ratio of 400 per 100,000 live births, which needed measuring within a 95% confidence interval of approximately ±100. Taking a stratified cluster sample within the region at the district level for logistic reasons, and allowing for a design effect of 2, this required a population of around 900,000 people, equating to six typical districts. Since the region is administered in six geographic zones, one district per zone was randomly selected.
The survey was implemented as a two-stage process: first, to trace deaths that occurred in the sampled districts within the preceding year, and second to follow them up with verbal autopsy interviews. The field work for both stages was undertaken by health extension workers, working in their normally assigned areas. Most of the work was associated with tracing the deaths, rather than undertaking the verbal autopsy interviews.
This approach to measuring cause-specific mortality in an unregistered Ethiopian population proved to be feasible and effective. Although it falls short of the ideal situation of continuous civil registration and vital statistics, a survey-based strategy of this kind may prove to be a useful intermediate step on the road towards full civil registration and vital statistics implementation.
Global Health Action 09/2014; 7:25264. DOI:10.3402/gha.v7.25264 · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent global malaria burden modeling efforts have produced significantly different estimates, particularly in adult malaria mortality. To measure malaria control progress, accurate malaria burden estimates across age groups are necessary. We determined age-specific malaria mortality rates in western Kenya to compare with recent global estimates. We collected data from 148,000 persons in a health and demographic surveillance system from 2003-2010. Standardized verbal autopsies were conducted for all deaths; probable cause of death was assigned using the InterVA-4 model. Annual malaria mortality rates per 1,000 person-years were generated by age group. Trends were analyzed using Poisson regression. From 2003-2010, in children <5 years the malaria mortality rate decreased from 13.2 to 3.7 per 1,000 person-years; the declines were greatest in the first three years of life. In children 5-14 years, the malaria mortality rate remained stable at 0.5 per 1,000 person-years. In persons ≥15 years, the malaria mortality rate decreased from 1.5 to 0.4 per 1,000 person-years. The malaria mortality rates in young children and persons aged ≥15 years decreased dramatically from 2003-2010 in western Kenya, but rates in older children have not declined. Sharp declines in some age groups likely reflect the national scale up of malaria control interventions and rapid expansion of HIV prevention services. These data highlight the importance of age-specific malaria mortality ascertainment and support current strategies to include all age groups in malaria control interventions.
PLoS ONE 09/2014; 9(9):e106197. DOI:10.1371/journal.pone.0106197 · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
In this study we analysed the spatial and temporal changes in patterns of mortality over a period when antiretroviral therapy (ART) was rolled out in a rural region of north–eastern South Africa. Previous studies have identified localised concentrated HIV related sub–epidemics and recommended that micro–level analyses be carried out in order to direct focused interventions.
Data from an ongoing health and socio–demographic surveillance study was used in the analysis. The follow–up was divided into two periods, 2007–2008 and 2009–2010, representing the times immediately before and after the effects on mortality of the decentralised ART provision from a newly established local health centre would be expected to be evident. The study population at the start of the analysis was approximately 73 000 individuals. Data were aggregated by village and also using a 2 × 2 km grid. We identified villages, grid squares and regions in the site where mortality rates within each time period or rate ratios between the periods differed significantly from the overall trends. We used clustering techniques to identify cause–specific mortality hotspots.
Comparing the two periods, there was a 30% decrease in age and gender standardised adult HIV–related and TB (HIV/TB) mortality with no change in mortality due to other causes. There was considerable spatial heterogeneity in the mortality patterns. Areas separated by 2 to 4 km with very different epidemic trajectories were identified. There was evidence that the impact of ART in reducing HIV/TB mortality was greatest in communities with higher mortality rates in the earlier period.
This study shows the value of conducting high resolution spatial analyses in order to understand how local micro–epidemics contribute to changes seen over a wider area. Such analyses can support targeted interventions.
Global journal of health science 06/2014; 4(1):010403. DOI:10.7189/jogh.04.010403