Stephen M Tollman

Umeå University, Umeå, Västerbotten, Sweden

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Publications (142)567.61 Total impact

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    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. · 1.88 Impact Factor
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    ABSTRACT: Given the importance of Africa to studies of human origins and disease susceptibility, detailed characterization of African genetic diversity is needed. The African Genome Variation Project provides a resource with which to design, implement and interpret genomic studies in sub-Saharan Africa and worldwide. The African Genome Variation Project represents dense genotypes from 1,481 individuals and whole-genome sequences from 320 individuals across sub-Saharan Africa. Using this resource, we find novel evidence of complex, regionally distinct hunter-gatherer and Eurasian admixture across sub-Saharan Africa. We identify new loci under selection, including loci related to malaria susceptibility and hypertension. We show that modern imputation panels (sets of reference genotypes from which unobserved or missing genotypes in study sets can be inferred) can identify association signals at highly differentiated loci across populations in sub-Saharan Africa. Using whole-genome sequencing, we demonstrate further improvements in imputation accuracy, strengthening the case for large-scale sequencing efforts of diverse African haplotypes. Finally, we present an efficient genotype array design capturing common genetic variation in Africa.
    Nature 12/2014; · 42.35 Impact Factor
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    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.
    Global Health Action. 11/2014; 7.
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    ABSTRACT: South Africa has a high and rising prevalence of hypertension. Many affected individuals are not using medication, and few have controlled blood pressure. Until recently, primary care clinics focused on maternal and child health and management of acute conditions, but new government initiatives have shifted the focus to chronic diseases, including HIV/AIDS and hypertension.
    Trials 11/2014; 15(1):435. · 2.12 Impact Factor
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    ABSTRACT: This paper investigates household dissolution and changes in asset wealth (socio-economic position) in a rural South African community containing settled refugees. Survival analysis applied to a longitudinal dataset indicated that the covariates increasing the risk of forced household dissolution were a reduction in socio-economic position (asset wealth), adult deaths and the permanent outmigration of more than 40% of the household. Conversely, the risk of dissolution was reduced by bigger households, state grants and older household heads. Significant spatial clusters of former refugee villages also showed a higher risk of dissolution after 20 years of permanent residence. A discussion of the dynamics of dissolution showed how an outflow/inflow of household assets (socio-economic position) was precipitated by each of the selected covariates. The paper shows how an understanding of the dynamics of forced household dissolution, combined with the use of geo-spatial mapping, can inform inter-disciplinary policy in a rural community.
    Development Southern Africa 11/2014; 31(6). · 0.43 Impact Factor
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    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. · 1.65 Impact Factor
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    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. · 1.65 Impact Factor
  • Development Southern Africa 09/2014; · 0.43 Impact Factor
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    ABSTRACT: South African civil registration (CR) provides a key data source for local health decision making, and informs the levels and causes of mortality in data-lacking sub-Saharan African countries. We linked mortality data from CR and the Agincourt Health and Socio-demographic Surveillance System (Agincourt HDSS) to examine the quality of rural CR data.
    International Journal of Epidemiology 08/2014; · 9.20 Impact Factor
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    ABSTRACT: 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.
    Global Health Action 08/2014; 7:24771. · 1.65 Impact Factor
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    ABSTRACT: Purpose: Epilepsy, one of the most common neurological disorders globally, affects roughly 70 million individuals. There are few studies that estimate the burden of epilepsy in low income countries, in terms of Disability Adjusted Life Years (DALYs), a summary measure of both morbidity and mortality, used most recently in the 2010 global burden of disease study. Method: Using prevalence, incidence and mortality data on convulsive epilepsy collected within the Agincourt Health and Socio-demographic surveillance site in rural northeastern South Africa between 2008 and 2012, we estimated the DALYs due to convulsive epilepsy, using both prevalence and incidence-based methods for calculating years of life lived with disability (YLD). Results: Using the prevalence-based method, we found that convulsive epilepsy was responsible for 332.1 (95% CI: 215.9–454.8) DALYs in the Agincourt HDSS. This equated to 4.1 DALYs per 1,000 individuals (95% CI: 2.7–5.7). Seventy-four percent of this was due to morbidity while 26% was due to excess mortality. The overall number of DALYs increased by 10% when using the incidence-based method to calculate YLDs. Sensitivity analysis concluded that using Agincourt life expec- tancy values resulted in a 24% reduction in DALYs. Conclusion: This is the first study to report the DALY burden of convul- sive epilepsy in South Africa and the findings are similar to figures reported from rural Kenya and those from the 2010 global burden of dis- ease study. Excess mortality is associated with a significant portion of the burden. Using context-specific life expectancy values (rather than those used in the 2010 global burden of disease study) reduced the burden of epilepsy suggesting that a substantial portion of the burden may be due to context rather than epilepsy. Interventions aimed at increasing treatment coverage and improving the quality of life in people with epilepsy would likely lower the burden of convulsive epilepsy in rural South Africa.
    11th European Congress on Epileptology, Stockholm, Sweden; 06/2014
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    ABSTRACT: The HIV pandemic has led to dramatic increases and inequalities in adult mortality, and the diffusion of antiretroviral treatment, together with demographic and socioeconomic shifts in sub-Saharan Africa, has further changed mortality patterns. We describe all-cause and cause-specific mortality patterns in rural South Africa, analyzing data from the Agincourt health and socio-demographic surveillance system from 1994 to 2009 for those aged 5 years and older. Mortality increased during that period, particularly after 2002 for ages 30-69. HIV/AIDS and TB deaths increased and recently plateaued at high levels in people under age 60. Noncommunicable disease deaths increased among those under 60, and recently also increased among those over 60. There was an inverse gradient between mortality and household SES, particularly for deaths due to HIV/AIDS and TB and noncommunicable diseases. A smaller and less consistent gradient emerged for deaths due to other communicable diseases. Deaths due to injuries remained an important mortality risk for males but did not vary by SES. Rural South Africa continues to have a high burden of HIV/AIDS and TB mortality while deaths from noncommunicable diseases have increased, and both of these cause-categories show social inequalities in mortality.
    PLoS ONE 06/2014; 9(6):e100420. · 3.53 Impact Factor
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    ABSTRACT: Youth-friendly health services are a key strategy for improving young people's health. This is the first study investigating provision of the Youth Friendly Services programme in South Africa since the national Department of Health took over its management in 2006. In a rural area of South Africa, we aimed to describe the characteristics of the publicly-funded primary healthcare facilities, investigate the proportion of facilities that provided the Youth Friendly Services programme and examine healthcare workers' perceived barriers to and facilitators of the provision of youth-friendly health services.
    BMC Health Services Research 06/2014; 14(1):259. · 1.66 Impact Factor
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    ABSTRACT: 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.
    Global journal of health science 06/2014; 4(1):010403.
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    ABSTRACT: Health 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.
    BMC Medical Research Methodology 05/2014; 14(1):71. · 2.17 Impact Factor
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    ABSTRACT: Background: Nearly one in three South Africans will suffer from a mental disorder in his or her lifetime, a higher prevalence than many low- and middle-income countries. Understanding the economic costs and consequences of prevention and packages of care is essential, particularly as South Africa considers scaling-up mental health services and works towards universal health coverage. Economic evaluations can inform how priorities are set in system or spending changes. Objective: To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use (MNS) disorders and the cost-effectiveness of treatment interventions. Design: Narrative overview methodology. Results and conclusions: Reviewed studies indicate that integrating mental health care into existing health systems may be the most effective and cost-efficient approach to increase access to mental health services in South Africa. Integration would also direct treatment, prevention, and screening to people with HIV and other chronic health conditions who are at high risk for mental disorders. We identify four major knowledge gaps: 1) accurate and thorough assessment of the health burdens of MNS disorders, 2) design and assessment of interventions that integrate mental health screening and treatment into existing health systems, 3) information on the use and costs of traditional medicines, and 4) cost-effectiveness evaluation of a range of specific interventions or packages of interventions that are tailored to the national context.
    Global Health Action 05/2014; 7:23431. · 1.65 Impact Factor
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    ABSTRACT: Background: Migration and urbanization are central to sustainable development and health, but data on temporal trends in defined populations are scarce. Healthy men and women migrate because opportunities for employment and betterment are not equally distributed geographically. The disruption can result in unhealthy exposures and environments and income returns for the origin household. Objectives: The objectives of the paper are to describe the patterns, levels, and trends of temporary migration in rural northeast South Africa; the mortality trends by cause category over the period 2000-2011; and the associations between temporary migration and mortality by broad cause of death categories. Method: Longitudinal, Agincourt Health and Demographic Surveillance System data are used in a continuous, survival time, competing-risk model. Findings: In rural, northeast South Africa, temporary migration, which involves migrants relocating mainly for work purposes and remaining linked to the rural household, is more important than age and sex in explaining variations in mortality, whatever the cause. In this setting, the changing relationship between temporary migration and communicable disease mortality is primarily affected by reduced exposure of the migrant to unhealthy conditions. The study suggests that the changing relationship between temporary migration and non-communicable disease mortality is mainly affected by increased livelihood benefits of longer duration migration. Conclusion: Since temporary migration is not associated with communicable diseases only, public health policies should account for population mobility whatever the targeted health risk. There is a need to strengthen the rural health care system, because migrants tend to return to the rural households when they need health care.
    Global Health Action 05/2014; 7:23514. · 1.65 Impact Factor
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    ABSTRACT: South Africa is experiencing a health and social transition including an ageing population and an HIV epidemic. We report mortality experience of an older rural South African population.
    International Journal of Epidemiology 05/2014; · 9.20 Impact Factor
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    ABSTRACT: The Study on global AGEing and adult health (SAGE) aims at improving empirical understanding of the health and well-being of older adults in low- and middle-income countries. A total of 321 adults aged 50 years and older were interviewed in rural Pune district, India, in 2007. We used Structural Equation Modelling (SEM) to examine the pathways through which social factors, functional disability, risk behaviours, and chronic disease experience influence self-rated health (SRH) and quality of life (QOL) amongst older adults in India. Both SRH and QOL worsened with increased age (indirect effect) and limitations in functional ability (direct effect). QOL, socio-economic status (SES), and social networking had no significant effect on SRH. Smoking was associated with the presence of at least one chronic illness, but this did not have a statistically significant effect on SRH. Higher social networking was seen amongst the better educated and those with regular income, which in turn positively affected the QOL rating. QOL had a direct, but statistically not significant, effect on SRH. In conclusion, the indirect effects of age on SRH mediated through functional ability, and the effects of SES on QOL mediated through social networking, provide new understanding of how age and socio-economic status affect SRH and QOL. By allowing for measurement errors, solving for collinearity in predictor variables by integrating them into measurement models, and specifying causal dependencies between the underlying latent constructs, SEM provides a strong link between theory and empirics.
    Social Indicators Research 05/2014; · 1.26 Impact Factor
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    ABSTRACT: Rationale Epilepsy is among the most common neurological disorders worldwide. However, there are no large, population-based studies of the prevalence and risk factors for epilepsy in southern Africa. Methods From August 2008 to February 2009, as part of a multi-site study, we undertook a three-stage, population-based study, embedded within the Agincourt health and socio-demographic surveillance system, to estimate the prevalence and identify risk factors of active convulsive epilepsy (ACE) in a rural South African population. Results The crude prevalence of ACE, after adjusting for non-response and the sensitivity of the screening method, was 7.0/1,000 individuals (95%CI 6.4-7.6) with significant geographic heterogeneity across the study area. Being male (OR = 2.3; 95%CI 1.6- 3.2), family history of seizures (OR= 4.0; 95%CI 2.0-8.1), a sibling with seizures (OR = 7.0; 95%CI 1.6-31.7), problems after delivery (OR= 5.9; 95%CI 1.2-24.6), and history of snoring (OR = 6.5; 95%CI 4.5-9.5) were significantly associated with ACE. For children, their mother's exposure to some formal schooling was protective (OR = 0.30; 95%CI 0.11-0.84) after controlling for age and sex. Human immunodeficiency virus was not found to be associated with ACE. Conclusions ACE is less frequent in this part of rural South Africa than other parts of sub-Saharan Africa. Improving obstetric services could prevent epilepsy. The relationship between snoring and ACE requires further investigation, as does the relative contribution of genetic and environmental factors to examine the increased risk in those with a family history of epilepsy.
    Epilepsy research 05/2014; · 2.48 Impact Factor

Publication Stats

2k Citations
567.61 Total Impact Points

Institutions

  • 2010–2014
    • Umeå University
      • Department of Public Health and Clinical Medicine
      Umeå, Västerbotten, Sweden
    • University of Colorado at Boulder
      • Institute of Behavioral Science (IBS)
      Boulder, CO, United States
  • 1999–2014
    • University of the Witwatersrand
      • School of Public Health
      Johannesburg, Gauteng, South Africa
  • 2007–2013
    • University of Washington Seattle
      • • Department of Global Health
      • • Department of Sociology
      Seattle, WA, United States
    • Makerere University
      Kampala, Central Region, Uganda
    • Max Planck Institute for Demographic Research
      Rostock, Mecklenburg-Vorpommern, Germany
    • Institut Pasteur
      Lutetia Parisorum, Île-de-France, France
    • The University of Edinburgh
      Edinburgh, Scotland, United Kingdom
  • 2006
    • American University Washington D.C.
      Washington, Washington, D.C., United States
    • University of St Andrews
      • School of Geography and Geosciences
      Saint Andrews, SCT, United Kingdom
  • 1995
    • Johannesburg Hospital
      Johannesburg, Gauteng, South Africa