CHANGING LIVES IN RURAL SOUTH AFRICA
ANNUAL RESEARCH BRIEF - MRC/WITS RURAL PUBLIC HEALTH
AND HEALTH TRANSITIONS RESEARCH UNIT (AGINCOURT),
Nov 2011
“It is not because countries are poor that
they cannot afford good health information:
it is because they are poor that they cannot
afford to be without it”
Health Metrics Network, World Health Organization, 2005
This briefing note is based on work prepared by Dr Jane Doherty and Staff of the MRC/Wits Agincourt
Unit, and is primarily based on the results of the annual census results from 1994 to 2010 and the
collection of articles that appear in a special supplement (no. 69 of 2007) of the Scandinavian Journal
of Public Health entitled Health, population and social transitions in rural South Africa. The
supplement showcases research conducted by a Health and Socio-Demographic Surveillance System in
rural South Africa. The supplement was edited by Stephen Tollman and Kathleen Kahn of the School of
Public Health (University of the Witwatersrand) and the MRC/Wits Rural Public Health and Health
Transitions Research Unit (Agincourt), South Africa. All photos were taken by Paul Weinburg.
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Contents
INTRODUCTION ...................................................................................................................................... 4
Purpose of the annual report ................................................................................................................... 4
WHERE AND WHAT IS THE AGINCOURT HDSS? ............................................................................. 4
WHAT IS A HEALTH AND SOCIO-DEMOGRAPHIC SURVEILLANCE SYSTEM? ........................ 4
THE AGINCOURT HEALTH AND SOCIO DEMOGRAPHIC SURVEILLANCE SYSTEM .............. 7
Annual Census ........................................................................................................................................ 7
Additional modules ................................................................................................................................. 7
Specialized nested studies ....................................................................................................................... 9
The RENEWAL Study ....................................................................................................................... 9
HEALTH, DEMOGRAPHIC AND SOCIAL TRANSITIONS IN THE AGINCOURT HDSS: THE
EVIDENCE............................................................................................................................................... 11
Mortality ............................................................................................................................................... 11
Emerging and persistent health problems ............................................................................................. 11
Rapidly changing households ............................................................................................................... 13
Fertility.............................................................................................................................................. 13
Household composition .................................................................................................................... 14
Migration............................................................................................................................................... 14
Migration and households ................................................................................................................. 15
Trends in migration patterns in the Agincourt HDSS Site. .............................................................. 16
Where do temporary migrants go? .................................................................................................... 17
Where do permanent migrants go to and come from? ...................................................................... 18
COPING WITH CHANGE: THE AGINCOURT EXPERIENCE .......................................................... 18
IMPLICATIONS FOR POLICY AND PRACTICE ................................................................................ 19
Respond to the health transition............................................................................................................ 19
Allocate resources locally for migrants ................................................................................................ 20
Design health promotion strategies that respond to people’s underlying beliefs and norms................ 20
Exploit natural resources for household survival.................................................................................. 20
Recognize the role of older women ...................................................................................................... 20
RESEARCH CURRENTLY IN THE FIELD IN THE AGINCOURT HDSS......................................... 21
THEME 1: Levels, trends and transitions ............................................................................................. 21
Mortality ........................................................................................................................................... 21
Fertility and reproductive health ....................................................................................................... 22
Migration........................................................................................................................................... 22
Socio-economic status ...................................................................................................................... 22
THEME 2: Child health and development............................................................................................ 22
Project Ntshembo: Improving the health and nutrition of adolescents and their infants to reduce the
intergenerational risk of metabolic disease ....................................................................................... 22
Child and adolescent growth studies................................................................................................. 22
Kulani Child Health and Resilience Project – evaluation of Soul Buddyz/SNOC ........................... 23
SARI/ROTA - Severe Acute Respiratory Infection (SARI) and Rotavirus diarrhoea surveillance . 23
PCV - Pneumococcal Conjugate Vaccine Introduction .................................................................... 23
Conditional Cash Transfer Study and Community Mobilisation (Swa Koteka) .............................. 23
THEME 3: Adult health and wellbeing ................................................................................................ 23
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Epidemiology and treatment of epilepsy in sub-Saharan Africa (SEEDS) ...................................... 23
Health and wellbeing of ageing populations in Africa and Asia ...................................................... 24
THEME 4: HIV/AIDS and Chronic care .............................................................................................. 24
HIV/NCD prevalence study .............................................................................................................. 24
Chronic care ...................................................................................................................................... 25
THEME 5: Household response to shocks and stresses ....................................................................... 25
The Natural Environment, Vulnerability and Resilience .................................................................. 25
Social Connection, Vulnerability and Resilience ............................................................................. 25
Migration, Livelihoods and Health ................................................................................................... 25
Socio-economic dynamics ................................................................................................................ 26
CONCLUSION ......................................................................................................................................... 26
FUNDERS ................................................................................................................................................ 26
COLLABORATORS ................................................................................................................................ 26
PUBLICATIONS: 2008- AUGUST 2011 ................................................................................................ 27
Peer-review journal articles .................................................................................................................. 27
Book chapters........................................................................................................................................ 30
Editorships : books................................................................................................................................ 31
Editorships: journals ............................................................................................................................. 31
Dissertations and theses ........................................................................................................................ 31
Web-based data publishing ................................................................................................................... 31
Letter ..................................................................................................................................................... 31
ACKNOWLEDGEMENTS ...................................................................................................................... 32
REFERENCES ......................................................................................................................................... 33
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Table of figures
Figure 1: Maps of position of Agincourt HDSS in South Africa and in Bushbuckridge Municipality,
Mpumalanga Province ................................................................................................................................ 5
Figure 2: Population Pyramids Agincourt HDSS 1994 and 2010 .............................................................. 6
Figure 3: Cycle of Additional Modules ...................................................................................................... 8
Figure 4: Change in use of power to cook, Agincourt HDSS 2001-2009 .................................................. 8
Figure 5: Percentage of children enrolled in schools, Agincourt HDSS 2009 ........................................... 9
Figure 6: Percentage of households experiencing food shortages in the last thirty days, 2006 ............... 10
Figure 7: Percent of households who used resources specifically to save money, 2006 .......................... 10
Figure 8: Trends in life expectancy Agincourt HDSS 1992-2010 ............................................................ 11
Figure 9: Trends in cause specific mortality Agincourt, selected non-communicable diseases ............... 13
Figure 10: Trends in proportion of temporary migrants Agincourt HDSS site 1992 -2008 ..................... 16
Figure 11: Framework for research programme with major research themes and their links .................. 21
List of boxes
Box 1: Benefits of a Health and Socio-Demographic Surveillance System ............................................... 6
Box 2: Mortality in Agincourt .................................................................................................................. 12
Box 3: Working with the community, service providers and local government to increase access to child
support grants ............................................................................................................................................ 20
List of tables
Table 1: Agincourt HDSS site Demographic Characteristics, 2010 .......................................................... 7
Table 2: Adolescent pregnancy rates Agincourt HDSS site 1996, 2001 and 2007 .................................. 14
Table 3: Destinations of temporary migrants, by gender, Agincourt HDSS Site, 2007 ........................... 17
Table 4: Origins and destinations of permanent migrants to and from the Agincourt HDSS Site, 2007 . 17
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INTRODUCTION
This annual research brief presents health and demographic indicators and scientific results from nested
projects derived from the Agincourt Health and Demographic Surveillance System site (Agincourt HDSS), located
in the Agincourt area of the Bushbuckridge Local Municipality, Ehlanzeni District, Mpumalanga Province of South
Africa.
Purpose of the annual report
This brief aims to provide information useful to various government and non-governmental service providers
who may use the data to plan their services. In addition, it will be useful to all researchers and students
collaborating with the MRC/Wits Agincourt unit. The information may be used in any way – although it is
requested the work is acknowledged as follows: “Annual Research Brief - MRC/Wits Rural Public Health And
Health Transitions Research Unit (Agincourt), Vol 1:Nov 2011”. Contact detials are on the back of the document
should you want to make further requests for information.
WHERE AND WHAT IS THE AGINCOURT HDSS?
The Agincourt health and socio-demographic surveillance system is the research foundation of the MRC/Wits
Rural Public Health and Health Transitions Research Unit (Agincourt). The Agincourt HDSS site, measuring some
420 sq km, extended in 2007, and currently covering 87,040 people living in 14,382 households and 24 villages,
lies in South Africa’s semi-arid rural north-east. Part of the Bushbuckridge ‘poverty node’ it has long been a
labour sending area with limited employment opportunities despite a population density above 200 persons per
sq km. Located only 40km west of the Mozambican border, the area can be regarded as a cross-border region of
rural southern Africa – indeed former Mozambicans make up about a third of the Agincourt population.
In the apartheid era, the Agincourt area formed part of the black ‘homeland’, Gazankulu. This legacy shapes the
lives of its inhabitants today: farms are too small to support subsistence, land tenure is still under traditional
authority, the local economy is not well-developed and many families are dependent on labour migrancy and
government social security grants for their livelihoods. Poverty is widespread and the HIV/AIDS epidemic casts
its shadow over many of the changes experienced by the community since the first democratic elections in 1994.
WHAT IS A HEALTH AND SOCIO-DEMOGRAPHIC SURVEILLANCE SYSTEM?
Information on health indicators is usually very weak in communities with poor infrastructure and health
systems. It is precisely in these communities, however, that good information is required in order to improve
health and health equity.
Health and socio-demographic surveillance is a response to this problem. It generates accurate information in
communities about which little is usually known. Over a period of time, data are collected through regular visits
to households and interviews with household members.
These ‘longitudinal’ data allow the analysis of population
‘[W]e submit that South Africa today faces a real
“crisis of evidence.” This is reflected in the
dynamics as well as health and social change, in order to
limited availability of empirically-derived
inform ongoing policy and practice.
population-based data, weak investments to
support their production, and limited public
sector capacity to absorb, sift, interpret and
respond to findings.’ [1]
Because of the long-term presence of researchers in a
community, surveillance systems have to pay special attention
to relationships with the community. To this end, the LINC
(Learning, Information Dissemination and Networking with
the Community) office was established, charged with ensuring partnerships between the unit, the study
communities and the local service provider.This and other features make surveillance systems expensive to set
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up and complex to run. However, once established, they are powerful mechanisms for generating accurate and
relevant information (see Box 1). As a result, the number of surveillance sites around the world has proliferated
over the past two decades. These sites are linked through an active global network called INDEPTH.1
Participation in the network strengthens the ability of sites to articulate and address the essential questions
confronting poor communities, especially in rural areas.
Figure 1: Maps of position of Agincourt HDSS in South Africa and in Bushbuckridge Municipality,
Mpumalanga Province
1
The International Network for the Demographic Evaluation of Populations and Their Health
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•
•
•
•
•
•
•
Box 1: Benefits of a Health and Socio-Demographic Surveillance System
The denominator population of a geographically defined area is reliably known: this
makes it possible to calculate reliable rates.
It is possible to track conditions over time and understand complex, dynamic processes
that affect households: this is not possible with cross-sectional studies.
The site’s research infrastructure can be used as a platform in which to ‘nest’
additional, specialized studies, and established relationships with the community make
it easier to engage with the community during future work: this makes the overall
research exercise cost-effective.
As all households and household members are registered, it becomes easier to select
relevant participants for research studies (e.g. households which have experienced a
recent death).
It becomes possible to consider the findings generated by different studies together,
providing richer insight into the community.
It is possible to evaluate the impact of interventions.
Preserving the relationship with the community helps to ensure that research is
relevant [1].
An example of population trends that are possible to quantify in demographic surveillance is shown in the two
population pyramids in Figure 2. These population pyramids show a rapid transition in the villages in the
Agincourt HDSS between 1994 and 2010 from a pyramid typical of a developing nation with a wide base showing
a high fertility rate, to a pyramid with a narrower base in 2010 (excluding new villages added in 2007) showing a
lower fertility rate, and the 0-4 year olds from 1994 moving up to form the wide mid section of 15-19 and 20-24
year olds in 2010. The result of the large numbers of 0-4 year old females in 1994 reaching child bearing age in
2010 means that there is a concurrent increase in the numbers of 0-4 year olds in 2010. Note also the slight
increase in the number of older people in 2010, possibly owing to better access to health care and reduction in
poverty probably due to increases in social security. These pyramids serve to show just one trend illustrated by
the data emanating from the annual census run by the Agincourt HDSS.
Figure 2: Population Pyramids Agincourt HDSS 1994 and 2010
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THE AGINCOURT HEALTH AND SOCIO DEMOGRAPHIC SURVEILLANCE SYSTEM
Annual Census
The Agincourt HDSS was initiated in 1992 and is a founding member of INDEPTH, the global network of similar
sites. Once a year, the Agincourt HDSS carries out a census of all 14 500 households, identifying births, deaths
and instances of in- and out-migration. Subsequently, a verbal ‘autopsy’ is conducted by speaking to members of
households where a death has occurred: this is
National datasets estimated TB incidence in Agincourt to
done to improve the accuracy of information on
be 106/100,000 but a study conducted at through the
the cause of death, as official death certificates are
Agincourt surveillance site found that it is actually closer
often missing or incomplete. The verbal autopsy is
to 212/1000,000. In other words, TB incidence is double
a feature that has enhanced the analytic power of
what was previously thought. This study was also the first
the site immensely. The compilation of an asset
in South Africa to use multiple methods to arrive at a
register for each house is a further regular
composite estimate [2].
research exercise that provides information on the
socioeconomic circumstances of households.
Table 1 shows demographic data derived from the 2010 annual census.
Table 1: Agincourt HDSS site Demographic Characteristics, 2010
Indicator
Male Population PY
Female Population Py
Total Population PY
Crude Birth Rate
Crude Death Rate
Crude Rate of Natural Increase
In-Migration Rate
Out-Migration Rate
Total Fertility Rate
Infant Mortality Rate 1q0
Child Mortality Rate 4q1
Under Five Mortality Rate 5q0
Life Expectancy at Birth years
2010
2009/08/01
to
2010/08/02
41641
45399
87040
22.02
9.69
12.34
17.52
16.79
2.36
35.019
15.332
49.81
60.17
Additional modules
Additional modules are also added periodically to the census, in the form of one or two page questionnaires.
This allows for cost effective data collection of information other than the purely demographic data (births,
deaths, in and out migrations) collected annually. Figure 3 shows the additional modules collected so far by the
Agincourt HDSS and the years in which they were collected.
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MODULES
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Education (1992, 1997)
Labour
Assets
Temporary migrations
Child Care Grants
Health Care Utilisation
All
<5
Food security
Adult Health
Father support
Vital documents
National ID
Cell phones
Additional names
Figure 3: Cycle of Additional Modules
Two examples of simple data that can be extracted from the module data are included in Figures 4 and 5 below.
Figure 4 shows data from the Socio Economic Status (SES) module and shows how households use of power to
cook has changed between 2001 and 2009. The percentage of households using electricity to cook is steadily
rising, and the percentage of households using wood to cook is steadily decreasing.
Figure 4: Change in use of power to cook, Agincourt HDSS 2001-2009
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Figure 5 shows data from the education module conducted in 2009. Almost 90% of children from ages 8 to 13
were attending school in 2009. However, from age 13 to 18 there is a steep drop out until there were only 70%
of 18 years attending school in the same year.
Figure 5: Percentage of children enrolled in schools, Agincourt HDSS 2009
Figures 4 and 5 show very simple data from the additional modules, but researchers also use the module data
for more complex analysis, such as showing how socio economic status and education status of mothers could
affect the health of children in the study site.
Specialized nested studies
Additional specialized nested studies are conducted periodically, and increasingly regularly. Thus, a special set
of questions may be added to the survey questionnaires administered during the census (for example, on child
health - the Growth studies, epilepsy - the SEEDS study, or stroke - the SASPI study). Alternatively, a new study
which a completely different might be conducted on a sample of households (for example, evaluating the impact
of conditional cash transfers on adolescent girls’ school attendance and incidence of HIV - the current Swa
Koteka HPTN 068 study, or in the past, the RENEWAL study). Additional information on all current nested
studies is included later in this report, and a few key results from a previous nested study are included below.
The RENEWAL Study
The RENEWAL study investigated the relationship between household experience of the death of a prime-age
adult member, household food security, and the use of natural resources in a sample of 290 households. The
Agincourt HDSS was used to select a random sample of roughly equal numbers of households that had
experienced either 1) an adult death due to HIV/AIDS, 2) a sudden adult death due to some other cause (e.g.
heart attack), 3) or no adult death in the last two years. A detailed questionnaire was used to collect data on
household use of natural resources and food security among these households.
Households that had experienced the death of a prime-age adult, regardless of the cause, were less food secure
than households that had not experienced an adult death over the same period. For most measures of food
security, it was the households impacted by a sudden non-HIV/AIDS death that were most severely impacted
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(e.g. Figure 6). This was probably because such a death was totally unexpected, casting the household into crisis
without much time to adapt in the short term. Such people were also more likely to have been a bread-winner
before they died, compared to those who died from HIV/AIDS. However, regardless of experience of an adult
death, the poorest households were the least food secure.
There was not much difference in the use of natural resources between the three categories of households.
However, households that had lost an adult member in the last two years were much more likely than unimpacted households to state that they used a range of natural resources specifically to save money (Figure 7).
The use of natural resources thus potentially buffers households from some of the economic impacts of losing a
prime-age adult.
70
HIV Death
Non-HIV Death
No Death
Percent of housholds (%)
60
50
40
30
20
10
0
Worried about food
Ran out of food
Went hungry
Experienced all three
Figure 6: Percentage of households experiencing food shortages in the last thirty days, 2006
35
HIV Death
Non-HIV Death
No Death
Percent of households (%)
30
25
20
15
10
5
ms
ro
o
oo
elw
sb
as
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ge
ve
ild
W
d
le s
ta b
ma
ed
Re
Fu
ts
s
o le
ts
ca
lp
ec
Lo
ar
de
oo
W
Ins
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gs
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it
ild
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lm
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ic i
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ed
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ss
0
Figure 7: Percent of households who used resources specifically to save money, 2006
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HEALTH, DEMOGRAPHIC AND SOCIAL TRANSITIONS IN THE AGINCOURT HDSS: THE
EVIDENCE
Over time, the research focus of the site has expanded from basic demographic and health status analysis to
comprehensive exploration of the complex health, population and social changes affecting the Agincourt people.
A distinctive feature of the Agincourt research is that it is truly multi-disciplinary, drawing on the strengths of
different theoretical frameworks and implementing a host of quantitative and qualitative methods.
Now, after 19 years in the field, the Agincourt HDSS is a mature research site with sophisticated data
management capacity [3]. It has generated a substantive body of work and achieved international recognition.
Some details from the Agincourt work are summarized below.
The Agincourt surveillance site has shown that, since its inception, the community has undergone rapid health,
demographic and social change: the supposed transition from diseases of poverty to diseases of affluence has
become protracted and, in some cases, inverted; health and health inequity worsened but mortality seems to be
decreasing; household composition is fluid and the roles and relationships of household members are changing.
Mortality
‘[T]hese discussions of life in the post-apartheid milieu
When the Agincourt surveillance site was initiated evoked an environment within which illness and
in the early 1990s, death rates were relatively low subsequent death proliferates … [A] heightened sense of
for a rural area in Africa. Since then, rapidly fragility of life infuses the experience of everyday life in
worsening death rates among young adults and Agincourt.’ [4:141]
young children saw a reversal of long-term mortality trends in these age groups [4] (See Box 2). However, more
recent evidence from the DSS suggests that there might be a reversal in death rates – possibly due to increased
access to anti retrovirals (see Figure 8).
Figure 8: Trends in life expectancy Agincourt HDSS 1992-2010
Emerging and persistent health problems
HIV/AIDS has become the leading cause of death among young adults and young children and has had a
profound effect on fertility, migration and familial arrangements. Research at Agincourt is seeking to
understand how the community makes sense of this phenomenon. One study found that community members
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provide cultural explanations for ‘bad death’ (AIDS death): these centre on the erosion of cultural norms and
traditions and the consequences for physical health of ‘cultural lapses’ [5]. In this context, scientific
explanations and therapies have limited appeal. This is confirmed by another study which found that folk beliefs
about illness and its causes deter people from seeking life-saving treatment – such as antiretrovirals – from
Western health services [6]. When this is the case, disease transmission remains unchecked.
The HIV/AIDS epidemic has been accompanied by the resurgence of tuberculosis which has also reversed
favourable trends since the 1950s. It is a cause for concern that only 70% of prevalent pulmonary TB cases that
were identified by an Agincourt study in the permanent population were detected by the health service: 15%
were undiagnosed in the community and a further 15% died of the disease prior to diagnosis [2]. Most of these
cases had presented repeatedly to the health service.
Box 2: Mortality in Agincourt
•
•
•
•
•
•
Death rates increased since the mid-1990s to the mid 2000s.
Increases were most marked for:
o young adults between 20 and 49;
o children under 5; and
o females.
There is an increase in mortality amongst older women between the
ages of 50 and 64.
There was been a rapid decline in life expectancy:
o a 12-year decline in females; and
o a 14-year decline in males. [4].
Unpublished results from more recent surveys indicate that there
might be a reversal of the increase in mortality
Non-communicable disease has placed an additional burden on a community that already suffers from the
traditional diseases of poverty. Lifestyle, dietary and occupational changes have made obesity, hypertension
and diabetes major public health issues: an unexpected finding is that these problems are most severe in older
women [7]. A startling 43% of people 35 and over have hypertension but few are receiving treatment: it is likely
that untreated hypertension is a causal factor in the high death rate from strokes. In the absence of health
system intervention, Agincourt is likely to be at risk of increasing cardiovascular disease [8].
Indeed, recent data (Figure 9) suggests that the most problematic non communicable disease is in fact
cardiovascular disease, and this has persisted over the years of surveillance. The unit and collaborating
researchers are currently working with the National Department of Health in order to develop and evaluate an
intervention study aimed at reducing the effects of hypertension. It is hoped that this study will go into the field
in September 2011.
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Figure 9: Trends in cause specific mortality Agincourt, selected non-communicable diseases
Malnutrition amongst children is persistent with many children not attaining their potential weight and height.
Mortality rates from malnutrition are high at 25%. HIV/AIDS contributes to this problem but one of the
Agincourt studies found that many of the traditional risk factors remain important – food insecurity, unhealthy
feeding practices, poor access to a quality health system, disruptions to family structure and poor access to child
support grants [9]. A striking finding of this research is that the number of women practicing exclusive
breastfeeding is low; supplementary foods are introduced early with possibly negative implications for child
health.
A separate study explored the social context of childrens’ nutritional status, identifying parental and residential
factors that are important: nutrition is compromised in the absence of a mother within the house and the lack
of financial support from a father [10]. Both studies confirmed, for the first time, that children born after other
siblings – that is, lower in the birth order - tend to be worse off.
Rapidly changing households
Fertility
In the Agincourt area there has been a consistent decline in fertility over the past 25 years, including amongst
adolescents [11]. The net reproduction rate has declined much faster than expected for a rural, African area:
Agincourt is one of the first sites in which this phenomenon has been recorded. The reasons for declining
fertility are complex, including increased use of contraception. Migration has certainly played a role and
HIV/AIDS has probably been responsible for about 20% of the fall.
Adolescent pregnancy is a ‘hot topic’ in South Africa presently. Table 2 tells a very interesting story from the
Agincourt HDSS data. Although adolescent pregnancies as a percentage of total pregnancies has indeed risen
between 1996 and 2007, the actual rate of teenage pregnancy has decreased rate. Total fertility rate across all
women of child bearing age has decreased [11], but it has just not decreased as fast in adolescents. We await
data from 2010 to learn more about this apparent trend.
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Table 2: Adolescent pregnancy rates Agincourt HDSS site 1996, 2001 and 2007
Year
1996
2001
2007
Adolescent
Pregnancies
(Aged12-19)
Pregnancies
(Total)
497
422
401
2924
1946
1851
Female
Adolescent
Adolescent
Adolescent
Pregnancies as
Pregnancies as
Population ( Aged Percentage of total Percentage of female
12-19)
pregnancies
adolescent Population
6280
17.0%
7.9%
7106
21.7%
5.9%
7298
21.7%
5.5%
Household composition
Over recent years, average household size has decreased, the proportion of female-headed households has
increased and the proportion of households with at least one maternal orphan has doubled [12]. Again,
migration and HIV/AIDS have probably played an important role in these changes. Contrary to expectations,
Agincourt has not yet seen an increase in ‘fragile families’ such as child-headed households or skippedgeneration families (where grandparents and children live together in the absence of working-age adults [12]. In
fact, national datasets that suggest there is an increase in single person households are not supported by
research in Agincourt where there is no evidence of individuals becoming more isolated residentially. On the
contrary, it seems more likely that the future, in this region at least, will see an increase in the proportion of
three-generation households [13]. Given the importance of the extended family, especially in protecting child
health, this is a positive factor.
Migration
As intimated already, migration dynamics have important implications for the Agincourt population: ironically,
although migration supports livelihoods it can also jeopardize health. Increasing numbers of people are seeking
employment outside of Agincourt and increasing numbers of women are included in this migration, changing
family arrangements. At the same time, adults who have migrated return to their village when they are seriously
ill and eventually die there, mainly from HIV/AIDS and TB. This research challenges notions of the permanency of
migration and provides strong evidence of the close ties between rural and urban areas in the form of ‘circular’
migration [14].
‘Returning home to die’ seems to have increased in recent years, imposing a new burden on families and local
health services [15]. Apart from the human suffering involved, there are costs to the household in the form of
the cessation of remittances, increased household health expenditure for health care and funerals and the
opportunity cost of caring for a severely ill person. Migration patterns like these also foster disease transmission
and pose a challenge to health information systems that attempt to track the occurrence of ill-health and
utilization of health services.
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Throughout the developing world rural households that are unable to sustain themselves with local resources
use migration to access opportunities and employment elsewhere [16]. Often people with special skills or
higher education use migration to participate in the urban economy and get higher returns for their skills.
Poverty is a key feature in South Africa’s rural areas due to half a century of socially repressive laws with
geographical policies locating poor families in rural areas [17]. Labour migration was a cornerstone of apartheid,
but, nowadays, it is one of the prime strategies used by rural households to kick back against poverty. Despite
the removal of apartheid restrictions the level of temporary migration is increasing as described below [14].
Although this means that many people leave rural areas to work in urban settings it does not mean that they
become permanently embedded in the city. For many rural residents the trip may be short or long in duration
but often involves eventual return to the rural household. Sometimes migrants visit for family events like births,
marriages and funerals. Often over Christmas and Easter holidays the rural villages swell with returning migrants
coming back to be with family and friends. Sometimes when migrants get sick they return to be cared for by
their families [15]. Also, when migrants retire they often return to rural households. Therefore, there are twoway flows between South Africa’s cities and rural areas, which are represented in the data below [18:19]. The
dynamic nature of migration in South Africa is often misunderstood and conceived of as a one-way trip to an
urban area, so this chapter helps to rebalance some of that misunderstanding.
Migration and households
Migration is generally good for the socio-economic status of the household left behind. Although not all
migrants are able to find employment, those that do usually send money back to rural households. This can
relieve pressure on household budgets and even translate into more assets. Both male and female labour
migration is helpful for the economy of rural households. There is a basic relationship between migration and
households, such that it is better-off households that can afford to send a migrant and they usually benefit from
the migrant’s remittances, which helps them to remain better-off. However, even poorer households that are
able to send a migrant often obtain economic benefit in return [20].
Regarding the health of household members, better income can translate into better health, but there are also
health risks and challenges that arise from migration itself. In many parts of southern Africa there has been an
important link made between certain forms of migration and HIV transmission. The first issue is the exposure to
outside partners due to the break in regular sexual relations which expose the migrant and their home spouse to
sexually transmitted illness. In addition, some employments are associated with chronic infectious diseases like
tuberculosis in certain mining sectors. HIV and TB are inter-connected chronic infectious diseases that have
emerged and spread through migration.
On a more subtle level migration can involve social change and moving from a traditional to a more modern
setting can change people’s outlooks, diets and life-styles. This can include increased risks of smoking, alcohol
use, and in-take of salt, sugar and consuming unhealthy oils. For many migrants there is a background of stress
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associated with disruption from home brought about by migration. If the migration is successful there may be
an associated risk of cardiovascular and other life-style related chronic illnesses.
The kinds of interventions that can lessen the health costs of migration include cheaper and safer transport
between home and work-place, accessible and affordable services and food availability in poor urban settings,
and using patient retained medical records, so that chronic medication can be started in an urban clinic or
hospital and continued by the health system in the rural setting if a migrant returns home.
Trends in migration patterns in the Agincourt HDSS Site.
Temporary migration occurs when a person migrates from a rural household without the intention of
permanently leaving, but remains part of the rural household. Usually, if the migration is successful, some
money flows back to the household in the form of remittances. It is not always money that is remitted and
migrants are often an important source of food, clothing or other investments in the rural household, like
building materials or appliances [21].
Some age-groups in the population are more likely to be temporary migrants. Figure 10 shows the trends in
temporary migration for men and women of different age-groups over a sixteen year period. Men aged 30-44
years are the most likely to migrate. Sixty-five percent of men in this age-group migrate. Older adult men also
migrate intensively with an average of 55% to 60% of the age-group 45-59 years migrating.
Figure 10: Trends in proportion of temporary migrants Agincourt HDSS site 1992 -2008
It can be seen that there has been an increase in the number of young male migrants aged 15-29 years. From
the early 1990s to the late 2000s the proportion of young men migrating each year has doubled from about 20%
(one in five young men) to 40% (two in five young men). Young men are increasingly mobile and move between
rural and urban areas.
It can also be seen that women of all adult age groups are increasingly becoming temporary migrants. Women
are now much more likely to migrate than in the past, especially young women aged 15-29 years. The reason for
women migrating varies. Mostly it is for work on game farms or commercial farms, or to a town or city for
domestic work or other jobs. Also, women migrate to sell rural produce in urban areas. For very poor
households in the population the income from female temporary migrants is a critical source of income. Young
women (and men) also migrate for better education, especially from better off households.
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Where do temporary migrants go?
Table 3 shows the types of destinations that men and women are temporarily migrating to. Temporary
migration occurs most frequently to destinations in large cities and towns and much less to nearby villages.
Shorter distance migration tends to be permanent migration, mainly due to marriage, which is described below
in Table 4. Both men and women temporarily migrate to nearby farms, but it is much more likely to be a
destination for women. Both men and women temporarily migrate to towns and secondary urban centres, like
Nelspruit, Giyani, Witbank and Middleburg, but mostly these are destinations for men. The primary metropolis
of Johannesburg/Pretoria/Mid-rand (Gauteng) is the most important destination for temporary migrants, both
male and female.
Table 3: Destinations of temporary migrants, by gender, Agincourt HDSS Site, 2007
male
migrants in
2007
Nearby village or town
Agriculture/game farm
Secondary urban centre (Nelspruit, Giyani,
Witbank and Middleburg)
Other province
Primary metropolis (Gauteng)
Destination category
Other/ unknown
Total
percent
female
migrants in
2007
percent
302
3%
302
7%
1063
12%
726
17%
2667
30%
1190
27%
549
6%
145
3%
4208
47%
1999
46%
92
1.1%
29
0.7%
8881
100%
4391
100%
Table 4: Origins and destinations of permanent migrants to and from the Agincourt HDSS Site, 2007
in-migration
Origin and Destination categories
out-migration
number
percent
number
Village to village moves
3792
79.0%
3695
Bushbuckridge town
315
6.6%
Limpopo Province urban
79
Limpopo Province non-urban
number
Percent
75.8%
97
3.2%
481
9.9%
-166
-3.3%
1.6%
86
1.8%
-7
-0.1%
12
0.3%
20
0.4%
-8
-0.2%
Mpumalanga Province urban
107
2.2%
142
2.9%
-35
-0.7%
Mpumalanga Province non-urban
87
1.8%
98
2.0%
-11
-0.2%
Gauteng Province
228
4.8%
261
5.4%
-33
-0.6%
Mozambique
118
2.5%
43
0.9%
75
1.6%
Other provinces
54
1.1%
18
0.4%
36
0.8%
Other neighbouring countries
5
0.1%
6
0.1%
-1
0.0%
Unknown
1
0.0%
23
0.5%
-22
-0.5%
4798
100.0%
4873
100.0%
-75
0.0%
Total
percent
net-migration
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Where do permanent migrants go to and come from?
It is clear in Table 4 that the largest proportion of permanent migrants move within the sub-district, so-called
village to village moves. Seventy-nine percent of permanent in-migrations are from other villages and 75% of
out-migrations are to other villages. These proportions differ because there is more movement into the subdistrict villages than out of sub-district villages. There is a net in- migration of 3%, so in terms of village-to-village
moves, also known as local mobility, the sub-district is gaining people from other villages.
It is noteworthy that nearby towns are attracting people from rural villages. The highest proportion of moves of
this kind were to Mkhuhlu, a town that developed in the late 1980’s, on the main road leading to Hazyview. The
mechanism involved in this migration has important socio-political implications. Prior to 1986, when the Influx
Control laws were abolished, movement between homeland areas was impossible, movement to and from
urban areas strictly controlled, and, although less documented, movement within the ‘homeland’ areas was also
extremely difficult. Traditional authorities usually aligned with the state in Pretoria, strongly encouraged people
to stay within small, well-defined chieftaincies. With the coming to power of the African National Congress in
1994 the Reconstruction and Development Programme was launched and a democratically elected committee
placed in charge of community affairs at a village level. In the late 1980’s Mkhuhlu was somewhat larger than a
village, with an established hospital, private health facilities, schools and public services. When people arrived to
settle in 1994 the elected civic leadership allowed settlement on land that had been previously been held as
common grazing land by the traditional authority. Once settlement started the word got around, and the chief
could not prevent a flood of families from villages to the newly budding town. The attraction of towns like these
remains important and is due to the availability of services, like health and education, and basic comforts like
tap-water and electricity. These are sufficient attractions, since employment opportunities in the town remained
low [22].
Bi-directional permanent migration to and from Gauteng Province is more balanced than migration to and from
nearby towns. There are modest flows from the field-site population to Gauteng (4.8% of moves) and returning
from Gauteng to the field-site population (5.4 % of moves).
The rural sub-district of the Agincourt field site is close to the border with Mozambique. The civil war in
Mozambique in the 1980’s resulted in the settlements of former refugees in north eastern South Africa. As a
consequence of their history they are less able to acquire property, engage in the labour market or access
government services, resulting in higher levels of poverty compared to South African households. There are still
population flows between the sub-district and Mozambique. In 2007 there was a modest net in-flow of people,
with 118 people entering from Mozambique and 43 moving back to Mozambique.
COPING WITH CHANGE: THE AGINCOURT EXPERIENCE
Increasing migration and the re-shaping of households
are both strategies adopted by the Agincourt ‘[Zodwa’s] husband had held a good job at a local game
community to sustain livelihoods and preserve the reserve, but once he became ill, he no longer worked.
integrity of the (extended) family. Detailed research is She explained that her household had experienced
underway to explore in more detail how households substantial changes in diet: “there is a big change now
cope with the cost burden of illness [23]. Another study because we no longer have food, we just get assisted by
the relatives … and we depend more now on the field”.’
has already been completed on the use of natural [23:171]
resources as a coping strategy following the death of an
adult household member. The study found that food security is certainly affected by the death of a wageearner [24]. The responsibility for collecting natural resources is thereafter shifted among remaining household
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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members and wild foods tend to substitute for previously purchased goods. This is probably a long-term change
in the habits of households and emphasizes the
‘Now their mother is dead. No one was going to look
importance of the environment to sustaining livelihoods after them; that is the reason they came and stayed
in rural South Africa.
with me … I am [also] taking care of my grandchildren …
Now my son and his wife both died … If they have
Research at Agincourt has shown how important social problems, they come to me [and] I help them. I am also
She has three
grants are for protecting household health against the staying with my sister-in-law.
grandchildren.
Their
father
died,
no
one
is taking care
socioeconomic impacts of change. Pensions received by
of
them.
I
use
my
pension
money
to
help them.’
the elderly benefit two vulnerable groups, the
(Mumsy,
an
older
woman
who
takes
care
of orphans
pensioners themselves and their grand-children [25]. It
who live in her household as well as orphans who live
seems that grandparents – especially grandmothers –
elsewhere.) [abbreviated from 26:152]
achieve higher status within the family once they bring in
abbreviated from Schatz 2007: 152
an income through their pensions. They are able to influence household decisions about the allocation of
resources and ensure better food security and increased access to schooling, especially for girls. In fact, older
women generally provide crucial support – financial, physical and emotional - to adult children who have
become ill and to fostered and orphaned grandchildren [26]. These obligations are
likely to increase as a result of migration and the impact of HIV/AIDS.
As mentioned earlier, child support grants – for children up to the age of 14 years –
have resulted in improved child nutritional status [9]. However, there are many
barriers that prevent access to these grants: only a third of South African families
living in Agincourt in the lowest socioeconomic stratum had applied at the time of
the research [27]. It is the less-impoverished families that make better use of
these grants. Barriers to access include lack of the necessary documentation,
unmanageable distance to offices and a low educational level of the household
head.
IMPLICATIONS FOR POLICY AND PRACTICE
The findings of the Agincourt research site throw light on the experience of a poor, rural population. This sort of
community is seldom well-researched. The findings are invaluable for understanding priorities for policy and
practice locally, as well as in the region.
Respond to the health transition
The health system needs to improve its ability to respond not only to the usual conditions of poverty, such as
malnutrition and tuberculosis, but also the HIV/AIDS epidemic and increasing hypertension, obesity and
diabetes. Removing barriers to access is essential but
so, too, is improving the quality of care. Specific ‘A return to favourable mortality trends will require not
only control of HIV/AIDS and pulmonary TB, but also
actions identified by research at Agincourt include:
meeting the challenges of rapid modernization in
comprehensive
strategies
against
childhood traditional societies with its numerous health and social
malnutrition (including better monitoring of children); consequences, in particular changing diet, changing
improved access to antiretrovirals (including for the lifestyle, changing marriage and sexual behaviour, and a
prevention
of
mother-to-child
transmission); variety of new stresses and hazards associated with daily
improved case detection of TB; and secondary personal and working life.’ [11:67]
prevention of hypertension.
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Allocate resources locally for migrants
Because of economic patterns established under apartheid, former homelands are bearing a heavy burden of
sickness and death. In these communities, there is a need to respond more effectively to the special needs of
highly mobile populations and their home communities.
Design health promotion strategies that respond to people’s underlying beliefs and norms
People are being deterred from accessing life-saving treatment – such as antiretrovirals and hypertensive drugs because they have beliefs that contradict scientific explanations. Health promotion strategies need to take this
into account and find ways of accommodating these beliefs to enhance access. This is critical for dealing with the
HIV/AIDS epidemic.
Box 3: Working with the community, service providers and local government to increase access
to child support grants
A special module of the 2002 Agincourt census update assessed household access to the
government child support grants which had been introduced in 1998. The research found high
levels of non-access, especially amongst the poorest households. In 2004, these findings, and an
analysis of the main barriers to access, were presented to the provincial and local Departments of
Home Affairs, Education and Social Security. This resulted in:
2-day mobile Home Affairs and Social Security campaigns in 20 villages, during which 8,000 people
applied for identity documents and birth certificates; 2 community workshops providing
information on services for orphans and vulnerable children; the special deployment of 6 child
support grant extension officers employed by Social Security; a partnership between the research
site, another Wits research unit, Home Affairs and the Mozambique Consulate in ongoing planning
to assist former Mozambican refugees who are stateless; and a partnership between the research
site, the local municipality and NGOs to form a multi-departmental district task team on orphans
and vulnerable children.
[adapted 4:14]
Exploit natural resources for household survival
Agincourt research has shown that natural food sources help to buffer impoverished households against shocks,
both through contributing to diets and providing an opportunity for generating income. Indeed, local vegetation
forms an important part of the diet of all households. It is important to improve the productivity of homestead
gardens and encourage the cultivation of wild herbs and traditional crops.
Recognize the role of older women
Research at Agincourt has shown that older women play an
important role in sustaining the family and improving both health
and gender equity. Intervention strategies need to build on this
role but also find ways to support the efforts of this sector of the
community.
‘Girls are significantly more likely to be
enrolled in school if they are living with a
pensioner, an effect that is driven entirely by
living with a female pensioner.’ [25:157]
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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RESEARCH CURRENTLY IN THE FIELD IN THE AGINCOURT HDSS
Unit research is organised into five thematic areas:
Theme 1:
Theme 2:
Theme 3:
Theme 4:
Theme 5:
Levels, trends and transitions
Child health and development
Adult health and wellbeing
HIV/AIDS and Chronic care
Household response to shocks and stresses
The Agincourt health and socio-demographic surveillance system, part of Theme 1 (see Figure 11), serves as the
essential scientific foundation for a programme of advanced research and intervention studies.
Figure 11: Framework for research programme with major research themes and their links
THEME 1: Levels, trends and transitions
(Theme leader: Clark with Collinson)
Demographic and epidemiological changes taking place in rural populations need to be understood for health
and development planning at district, provincial and national levels. We need to identify the forces driving
population change in mortality, morbidity, fertility, migration and socio-economics. The HDSS updates annually
individual’s residence dynamics including dates of entering or leaving the population (births, deaths, in and outmigrations), pregnancy outcomes, maternity history, relationship to household head, links to parents, marital
status, identity document status and national identity number. Research clusters represent collaborations of
scientists who use the HDSS to compute and publish trends in mortality, fertility, migration, and socio-economic
status.
Mortality
Collaborators: Univ Washington, USA; Wits Population Studies; Pasteur Institute, France; Umeå Univ, Sweden
a. Trends in age, sex and cause-specific mortality, including spatio-temporal analyses using GIS data
b. Strengthening verbal autopsy assessment (VA): validation of InterVA, a probabilistic model to assess
probable cause of death using VA. Model produces standardised assessments compared to physician
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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diagnoses, costs less and produces more timely outputs. Work will contribute to WHO efforts to
improve cause-of-death ascertainment and make tools available
c. Estimating and assessing levels and trends in maternal mortality.
Fertility and reproductive health
Collaborators: Wits Population Studies, Pasteur Institute, France, Univ Colorado Boulder, USA; London School of Hygiene
and Tropical Medicine, UK
a. INDEPTH - multi-site fertility monograph (Agincourt chapter is authored by Mildred Shabangu,
Chodziwadziwa Kabudula , Jill Williams and Michel Garenne)
b. Unit is a member of the Alpha Network, an international scientific network studying HIV in remote
populations using HDSS and embedded HIV surveillance data. Emphasis is on adolescent fertility, sexual
networks and reproductive health with an aim of strengthening policy in these areas.
Migration
Collaborators: Wits Public Health and Population Studies; Brown, Washington & Colorado Universities, USA
Examines impacts of migration trends on livelihoods and health; includes INDEPTH multi-country study.
Socio-economic status
Collaborators: Univ Cape Town; Wits Population Studies, School of Accountancy; Univ Missouri and Maryland, USA
Socioeconomic status indicators are collected during census update rounds. Repeat cross-sectional modules are
done and used for longitudinal analyses of livelihood strategies, their outcomes, and how these change in time.
In 2009, modules included: asset status, food security, education and labour status.
THEME 2: Child health and development
(Theme leader: Kahn with Pettifor; Theme officer: R Twine)
In rural South Africa, morbidity, mortality and growth failure associated with undernutrition exist alongside
female obesity and emerging cardiovascular disease. By tackling proximal issues of infant growth and nutrition,
and social/emotional development, we aim to impact more distal outcomes including cognitive development,
educational attainment, HIV infection, adult vascular risk and economic productivity.
Project Ntshembo: Improving the health and nutrition of adolescents and their infants to reduce the
intergenerational risk of metabolic disease
Collaboration with Birth-to-Twenty, Oxford and Cambridge Univs, UK; Umeå Univ, Sweden, Univ of North Carolina,
Chapel Hill, USA
Project aims to promote adolescent health as a critical pathway to improve intrauterine and infant growth and
thereby interrupt the intergenerational transfer of metabolic disease and HIV/AIDS. This will be achieved by
innovative community-based interventions targeting female adolescents prior to and during pregnancy, and in
the postnatal period. In 2010, funds were obtained from the British MRC to conduct the baseline survey from
July to December 2011 and follow up assessments over 5 years. Pilot work in May/June 2011 focused on
physical activity, beliefs and practices regarding childbirth and the postpartum period, and the availability and
distribution of food vendors.
Child and adolescent growth studies
Collaboration with Birth-to-Twenty
Studies seek to document and understand the double burden of undernutrition in children (particularly stunting)
and overweight/obesity in adolescents, particularly girls. One PhD was completed in 2010; another, on the
association of nutrition on body composition and metabolic disease risk, is ongoing.
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Kulani Child Health and Resilience Project – evaluation of Soul Buddyz/SNOC
Collaboration with Soul City and Oxford Univ, UK
School-based, cluster-randomised trial to evaluate an established school-based intervention by an NGO, Soul
City, to provide emotional/social support to pupils 10-12 years and enhance their ability to cope and learn in an
environment of chronic adversity. Baseline study in 2009 examined rates of anxiety, depression and posttraumatic stress disorder, and environmental factors (parental death or migration, poverty) associated with
these symptoms. During 2010 there was ongoing monitoring of NGO intervention and the end-of-intervention
survey took place in October 2010. Data entry is almost complete. Analysis of baseline data has commenced,
and analysis of qualitative data on school management systems is complete.
SARI/ROTA - Severe Acute Respiratory Infection (SARI) and Rotavirus diarrhoea surveillance
Collaboration with NICD and the Respiratory and Meningeal Pathogens Research Unit, Wits
Aims to describe trends in numbers of SARI and diarrhoeal cases at 4 sentinel surveillance sites. Data will inform
health policy on SARI and diarrhoeal disease management, prevention and control, and assist in planning for
future influenza pandemics. Project will contribute to assessment of influenza, pneumococcal conjugate and
rotavirus vaccine strategies, reflecting on recent introduction of rotavirus & pneumococcal vaccines into the
national Expanded Programme on Immunisation. Surveillance system in two district hospitals in Bushbuckridge
(and other sites in South Africa) was set up in 2009 and data collection continues.
PCV - Pneumococcal Conjugate Vaccine Introduction
Collaboration with Respiratory and Meningeal Pathogens Research Unit, Wits
Study to examine the effect of pneumococcal conjugate vaccine immunization upon nasopharyngeal ecology of
Streptococcus pneumonia in vaccinated and non-vaccinated individuals at household level. In 2009,
nasopharyngeal swabs were taken, and questionnaires completed, in 600 households. There was no fieldwork in
2010, but there is a further survey currently underway.
Conditional Cash Transfer Study and Community Mobilisation (Swa Koteka)
Collaboration with University of North Carolina, USA, University of San Francisco, USA and Wits Reproductive Health and
HIV Institute
Study to determine effects of a multi-level HIV prevention intervention to jointly address structural and social
factors contributing to young women’s increased vulnerability to HIV, through providing cash transfers to
families of young women conditional on her attending school. Goal is to reduce young women’s HIV risk by
keeping her in school through improving her family’s economic resources. This intervention will be
complemented by a community-level mobilization intervention, One Man Can run by Sonke Gender Justice
focused on young men. Currently 1932 of the required population sample of 2660 HIV –ve young woman has
been recruited.
THEME 3: Adult health and wellbeing
(Theme leader: Tollman; Theme officer: Gómez-Olivé)
Dynamics of a protracted health transition are reflected in the disease burdens affecting rural adults.
Epidemiology and treatment of epilepsy in sub-Saharan Africa (SEEDS)
Collaboration with KEMRI/Wellcome Trust, Kilifi and University College, London
Study will establish burden, risk factors and outcome for active convulsive epilepsy (ACE) in Agincourt and four
other African INDEPTH sites. Aims to develop interventions to reduce incidence and mortality from epilepsy, and
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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to provide insight into management of a non-infectious chronic illness that spans all age groups. In 2010, three
data collection rounds were completed to identify new cases. There is close interaction with health services in
the study area with nurses providing information on patients’ clinic attendance. Study participants/patient
satisfaction is high since they are receiving improved health care including surgery for a brain tumour with
consequent health and social improvements. One MSc dissertation will be submitted in Feb 2011.
Cost evaluation of epilepsy treatment is part of PRICELESS study. In 2010, data entry was completed and data
cleaning commenced, 5 potential publications were identified and 1 PhD is to be nested in the work.
Health and wellbeing of ageing populations in Africa and Asia
Collaboration with INDEPTH sites, WHO, Umeå Univ, Sweden, Harvard and Colorado Univs, USA
Under Agincourt leadership, eight INDEPTH sites2 applied a short version of the WHO-SAGE3 instrument,
adapted to routine surveillance, to adults 50+ to assess baseline measures of physical and cognitive function and
establish cohorts of older adults in African and Asian settings. Comparative work sets out to test hypotheses
including: Poor self-rated general health (SRGH) is associated with premature mortality, and Individual SRGH
correlates with household characteristics such as wealth, presence of labour migrants, and loss of a prime-age
adult. In 2010 analyses examining mortality outcomes were undertaken on the longitudinal dataset. During the
2010 census update a 2nd round of data collection on adult health and aging was undertaken.
Health Care Utilisation: A module on health care utilization of people 50 years and older was conducted during
the 2010 census update round. Data entry was completed; analysis will be undertaken in 2011 and data will be
compared with data from the SAGE Long survey in 2006.
THEME 4: HIV/AIDS and Chronic care
(Theme leader: Tollman with Gómez-Olivé)
Immediate and longer-run community impacts of HIV/AIDS cannot be overstated. Evaluation of HAART delivery
will support provincial and national efforts and provide evidence on delivery models, coverage and
individual/population impacts.
HIV/NCD prevalence study
Collaboration with Wits Public Health, Colorado and Washington Universities, USA
Study to measure HIV prevalence, biomarkers for non-communicable chronic diseases (mainly cardiovascular
and diabetes) using dried blood spots, physical measurements including blood pressure and anthropometry, and
lifestyle and sexual risk behaviours. Fieldwork commenced in Aug 2010 after community entry and training. An
on-site post-doctoral fellow is responsible for managing day-to-day fieldwork. The sample consists of 7,428
people aged 15 years and older from all villages in the study site. Data collection finished end-Junel. Laboratory
results were returned on a weekly basis and those who wanted their HIV result went to the health centre. Blood
pressure, cholesterol and glucose results were given at the household with referral to nearest health facility for
all abnormal results. Funds will be sought for a further round of HIV and NCD testing and for conducting the
cBED assay. Results of this study will be available at the end of 2011.
2
Ifakara (Tanzania), Nairobi (Kenya), Navrongo (Ghana), Matlab (Bangladesh), Purworejo (Indonesia), Filabavi (Vietnam), Vadu (India) and
Agincourt
3
SAGE: Survey on Adult Health and Global Aging
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Chronic care
A major effort addressing weaknesses in chronic care systems – and emphasizing commonalities in management
of both chronic infectious and non-communicable diseases – is planned. Research will be facilitated by the clinicHDSS link.
1. A partnership with the National Department of Health Chronic Disease Directorate has been established to
develop, implement and test an integrated chronic disease package at primary care level. In 2010 meetings
were held in the Mpumalanga Dept of Health and the Agincourt Health Centre, with follow-up discussions in
Johannesburg in January 2011.
2. Cost evaluation of epilepsy treatment will be conducted under the PRICELESS initiative.
THEME 5: Household response to shocks and stresses
(Theme leader: Collinson with W Twine)
Rural households remain under pressure. Sudden shocks, whether job loss or death of a breadwinner, can
destabilise households; similarly, protracted stresses such as drought or chronic illness can undermine coping
capacity and livelihoods. Key to understanding how to improve health and social development is to examine
the strategies employed by households to gain livelihoods and cope with shocks and stresses. The sustainable
livelihoods framework has been used in this theme with four productive research clusters:
The Natural Environment, Vulnerability and Resilience
Collaboration with APES, Wits and Colorado University, USA
Previous work showed that food security is threatened by adult mortality. We examine (i) how natural resources
are used to offset adversity, (ii) influence of climate change on environment (temperature, humidity, rainfall
monitoring introduced). In 2010 an NRF-funded project undertook the baseline of a cohort study of 600
households within the HDSS to examine household livelihood strategies and outcomes.
Social Connection, Vulnerability and Resilience
Collaboration with Maryland, Missouri, Colorado and Brown University, USA
The life-cycle of households are changing due to changing migration patterns and increasing mortality of prime
age adults. Qualitative studies are triangulated with surveillance-based analyses to investigate changing
household structure and composition. Changing social roles of fathers, mothers and older adults are examined
as well as the importance of links to social networks beyond the household. With NIH funds, we examine the
measurement of social connections (type, number and qualities of people’s relationships) through analyses of
ethnographic and HDSS data.
Migration, Livelihoods and Health
Collaboration with Brown University, Wits Demography and Population studies and INDEPTH
Migration brings risks and gains to health and wellbeing, affecting both the migrant and those who remain. The
HDSS has highlighted high levels of temporary migration which are increasing for younger women. Outcomes for
children’s health and household poverty are key research areas. Collinson was lead editor of a 2009 peerreviewed volume involving INDEPTH multi-country work; a second phase is underway. Grants awarded in 2010:
(i) Center for AIDS Research (CFAR), USA, for work on migration, HIV and socioeconomic change in South Africa;
(ii) Economic & Social Research Council (ESRC), UK, to assess impact of internal labour migration on patterns of
intergenerational support and the health and well-being of children and older people in China and South Africa.
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Socio-economic dynamics
Collaboration with Washington University, USA; School of Accountancy, Wits
The HDSS meticulously tracks socio-economic status of households and uses this data to examine the dynamics
of household poverty and its relations to migration and other household livelihood strategies.
CONCLUSION
In the words of Professor Fred Binka, Executive Director of INDEPTH Network in Accra,
“Never before has the need for demographic and health data been so urgent in Africa. The emergence and reemergence of infectious diseases such as HIV/AIDS, malaria and tuberculosis, coupled with the rapid transition to
non-communicable diseases, is transforming African population and household structures in unprecedented
ways. Unfortunately, for millions of people living in the world’s most impoverished settings, there is little or no
information on their lives. Demographic surveillance brings welcome relief to this data void.” [21:3]
FUNDERS
International: The Wellcome Trust, UK; National Institute on Aging, USA; National Institute of Child Health and
Human Development, USA; National Institutes of Health, USA; National Institute of Mental Health, USA; William
and Flora Hewlett Foundation, USA; Bill and Melinda Gates Foundation, USA; INDEPTH Network, Ghana. Local:
Anglo American Chairman’s Fund; Soul City Institute for Health and Development Communication; South African
Medical Research Council; South African National Research Foundation; Swiss/SA Joint Research Programme
administered by the Council for Scientific and Industrial Research; University of the Witwatersrand.
COLLABORATORS
At Wits University: School of Public Health, Centre for Health Policy; Departments of Child Health, Demography
and Population studies, Sociology, Computer and Applied Mathematics; Birth to Twenty, African Centre for
Migration and Society, Centre for African Ecology, Reproductive Health Research Unit. In South Africa: Africa
Centre Demographic Information System , University of KwaZulu-Natal; Dikgale HDSS, University of Limpopo;
Medical Research Council; Statistics South Africa; Centre for AIDS Research; University of Cape Town.
International: Africa: INDEPTH Network, Ghana. UK: London School of Hygiene and Tropical Medicine, Warwick,
Oxford, Cambridge and Edinburgh Universities. Europe: Pasteur Institut, France; Umeå University, Sweden;
World Health Organization, Geneva; Université Catholique de Louvain, Louvain-la-Neuve, Belgium. USA:
Colorado, Brown, Princeton and Harvard Universities; Disease Control Priorities Network, IHME; USA; University
of North Carolina; University of San Francisco; HIV Prevention Trials Network
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PUBLICATIONS: 2008- AUGUST 2011
Peer-review journal articles
1. Schatz E, Gilbert L. “My heart is very painful”: Physical, mental and social wellbeing of older women at the
times of HIV/AIDS in rural South Africa. Journal of Aging Studies. In press.
2. Byass P, Kahn K, Fottrell E, Mee P, Collinson MA, Tollman SM. Using verbal autopsy to track epidemic
dynamics: the case of HIV-related mortality in South Africa. Population Health Metrics. In press.
3. Twine W, Hunter LM. Adult mortality and household food security in rural South Africa: Does AIDS represent
a unique mortality shock? Development South Africa. In press
4. Fottrell E, Tollman S, Byass P, Gooloba-Mutebi F, Kahn K. The epidemiology of ‘bewitchment’ as a lay
reported cause of death in rural South Africa. Journal of Epidemiology and Community Health 2011; DOI:
10.1136/JECH.2010.124305
5. Kimani-Murage EW, Holding PA, Fotso JC, Ezeh AC, Madise NJ, Kahurani EN, Zulu ZM. Food security and
nutritional outcomes among urban poor orphans in Nairobi, Kenya. Journal of Urban Health 2011, 88(suppl
2):282-297
6. Schatz E, Madhavan S, Williams J. Female-headed households contending with AIDS-related hardship in rural
South Africa. Health and Place 2011,DOI:10.1016/jhealthplace.2010.12.017
7. Kimani-Murage EW, Kahn K, Pettifor JM, Tollman SM, Klipstein-Grobusch K, Norris SA. Predictors of
adolescent weight status and central obesity in rural South Africa. Public Health Nutrition 2011, DOI:
10.1017/S1368980011000139
8. Sartorius B, Kahn K, Vounatsou P, Collinson MA, Tollman SM. Survived infancy but still vulnerable: spatialtemporal trends and risk factors for child mortality in rural South Africa (Agincourt) 1992-2007. Geospatial
Health 2011, 5(2):285-295
9. Kimani-Murage EW, Norris SA, Pettifor JM, Tollman SM, Klipstein-Grobusch K, Gómez-Olivé FX, Dunger DB,
Kahn K. Nutritional ststus and HIV in rural South African children. BMC Paediatrics 2011, 11:23
10. Ogunmefun C, Gilbert L, Schatz E. Older female caregivers and HIV/AIDS-related secondary stigma in rural
South Africa. Journal of Cross Cultural Gerontology 2010, 26:85-102
11. Maredza M, Hofman K, Tollman SM. A hidden menace: cardiovascular disease in South Africa and the costs
of an inadequate policy response. SA Heart 2100, 8(1):48-55
12. Byass P, Kahn K, Ivarsson A. The global burden of childhood celiac disease: a neglected component of
diarrhoeal mortality. PLoS ONE 2011, 6(7): e22774
13. Byass P, Sankoh O, Tollman SM, Högberg, Wall S. Lessons from history for designing and validating
epidemiological surveillance in uncounted populations. PLoS ONE 2011,6(8): e22897
14. Byass P, Kahn K, Fottrell E, Mee P, Collinson MA, Tollman SM. Using verbal autopsy to track epidemic
dynamics: the case of HIV-related mortality in South Africa. Population Health Metrics 2011, 9:46
15. Kimani-Murage EW, Kahn K, Pettifor JM, Tollman SM, Dunger DBN, Gómez-Olivé XF, Norris SA. The
prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children.
BMC Public Health 2010, 10:158
16. Byass P, Twine W, Collinson M, Tollman S, Kjellstrom T. Assessing a population’s exposure to heat and
humidity: an empirical approach. Global Health Action 2010, 3:5421
17. Sartorius B, Kahn K, Vounatsou P, Collinson MA, Tollman SM. Space and time clustering of mortality in rural
South Africa (Agincourt HDSS), 1992-2007. Global Health Action 2010, supplement 1:50-58
18. Garenne M. Urbanisation and child health in resource poor settings with special reference to under 5
mortality in Africa. Archives of Disease in Childhood 2010,95:464-468
19. Serwaa-Bonsu A, Herbst K, Reniers G, Ijaa W, Clark B, Kabudula C, Sankoh O. First experiences in the
implementation of biometric technology to link data from health and demographic surveillance systems
with health facility data. Global Health Action 2010, 3:2120
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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20. Collinson MA. Striving against adversity: the dynamics of migration, health and poverty in rural South Africa.
Global Health Action 2010, 3:5080
21. Hunter L, Strife S, Twine W. Environmental perceptions of rural South African residents: the complex nature
of environmental concern. Society and Natural Resources 2010, 23;525-541
22. Williams JR. Doing feminist-demography. International Journal of Social Research Methodology 2010,
13;3:197-210
23. Bangdiwala SI, Fonn S, Okoye O, Tollman S. Workforce resources for health in developing countries. Public
Health Reviews 2010, 32;1:296-318
24. Hosegood V, Madhavan S. Data availability on men’s involvement in families in sub-Saharan Africa to inform
family-centred programmes for children affected by HIV and AIDS. Journal of the International AIDS Society
2010, 13 (supplement 2): S5
25. Byass P, Kahn K, Fottrell E, Collinson MA, Tollman S. Moving from data on deaths to public health policy in
Agincourt, South Africa: approaches to analyzing and understanding verbal autopsy findings. PloS Medicine
2010, 7(8): e1000325
26. Hofman KJ, Tollman SM. Setting priorities for health in 21st-century South Africa. South African Medical
Journal 2010, 100(12): 798-800
27. Fottrell E, Kahn K, Ng N, Sartorius B, Huong DL, Minh HV, Fantahun M, Byass P. Mortality measurement in
transition: proof of principle for standardised multi-country comparisons. Tropical Medicine and
International Health 2010, 15(10):1256-1265
28. Williams JR, Schatz E, Clark BD, Collinson MA, Clark SJ, Menken J, Kahn K, Tollman SM. Improving public
health training and research capacity in Africa: a replicable model for linking training to health and sociodemographic surveillance data. Global Health Action 2010, 3:5287
29. Kowal P, Kahn K, Ng N, Naidoo N, Abdullah S, Bawah A, Binka F, Chuc NTK, Debpuur C, Ezeh A, Gómez-Olivé
FX, Hakimi M, Hirve S, Hodgson A, Juvekar S, Kyobutungi C, Menken J, Minh HV, Mwanyangala A, Razzaque
A, Sankoh O, Streatfield PK, Wall S, Wilopo S, Byass P,Chatterji S, Tollman SM. Ageing and adult health status
in eight lower-income countries: the INDEPTH WHO-SAGE collaboration. Global Health Action 2010,
Supplement 2:11-22
30. Gómez-Olivé FX, Thorogood M, Clark BD, Kahn K, Tollman SM. Assessing health and well-being among older
people in rural South Africa. Global Health Action 2010, Supplement 2:23-35
31. Ng N, Kowal P, Kahn K, Naidoo N, Abdullah S, Bawah A, Binka B, Chuc NTK, Debpuur C, Egondi T, GómezOlivé FX, Hakimi M, Hirve S, Hodgson A, Juvekar S, Kyobutungi C, Minh HV, Mwanyangala MA, Nathan R,
Razzaque A, Sankoh O, Streatfield PK, Thorogood M, Wall S, Wilopo S, Byass P, Tollman SM, Chatterji S.
Health inequalities among older men and women in Africa and Asia: evidence from eight Health and
Demographic Surveillance Systems sites in the INDEPTH WHO-SAGE study. Global Health Action 2010,
Supplement 2:96-107
32. Sartorius BKD, Kahn K, Vounatsou P, Collinson M, Tollman S. Young and vulnerable: spatial-temporal trends
and risk factors for infant mortality in rural South Africa (Agincourt) 1992-2007. BMC Public Health
2010,10:645
33. Ezeh AC, Izugbara CO, Kabiru CW, Fonn S, Kahn K, Manderson L, Undieh AS, Omigbodun A, Thorogood M.
Building capacity for public health research in Africa: the Consortium for Advanced Research Training in
Africa(CARTA ) model. Global Health Action 2010, 3:5693
34. Hofman K, Tollman S. Strengthening capacity for local decision making. BMJ 2010; August 5.
35. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable
diseases in South Africa. The Lancet 2009, 12;374(9694):1023-31
36. Goudge J, Russell S, Gilson L, Gumede T, Tollman S, Mills A. Illness related impoverishment in rural South
Africa: why does social protection work for some households but not others? Journal for International
Development. 2009, 21(2): 231-251
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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37. Madhavan S, Schatz E, Clark, B. Effect of HIV/AIDS mortality and household dependency ratios in rural South
Africa 2000-2005. Population Studies 2009; 63(1): 37-51
38. Ogunmefun C, Schatz E. Caregivers' sacrifices: the opportunity costs of adult morbidity and mortality for
female pensioners in rural South Africa. Development Southern Africa 2009; 26(1): 95-109
39. Reniers G, Tesfai R. Health services utilization during terminal illness in Addis Ababa, Ethiopia. Health Policy
and Planning 2009, 24(4):312-319
40. Kimani-Murage E, Manderson L, Norris SA, Kahn K. ‘You opened our eyes’: care-giving after learning a child’s
positive HIV status in rural South Africa. Health and Social Care in the Community 2009, 1-8. DOI
10.1111/j.1365-2524.2009.00891.x
41. Undie C, Ziraba AK, Madise N, Kebaso J, Kimani-Murage EW. ‘If you start thinking positively, you won’t miss
sex’: narratives of sexual (in)activity among people living with HIV in Nairobi’s informal settlements. Culture,
Health and Sexuality 2009, 11(8):767-782
42. Reniers G, Eaton J. Refusal bias in HIV prevalence estimates from nationally representative seroprevalence
surveys. AIDS 2009, 23(5):621-629
43. Reniers G, Araya T, Davey G, Nagelkerkee N, Berhane Y, Coutinho T, Sandersi EJ. Steep declines in
population-level AIDS mortality following the introduction of antiretroviral therapy in Addis Ababa, Ethiopia.
AIDS 2009, 23(4):511-518
44. Reniers G, Araya T, Berhane Y, Davey G, Sanders EJ. Implications of the HIV testing protocol for refusal bias
in seroprevalence surveys. BMC Public Health 2009, 9:163-1 – 163-6. DOI:10.1186/1471-2458-9-163
45. Schatz, E. Reframing vulnerability: Mozambican refugees access to state-funded pensions in rural South
Africa. Journal of Cross Cultural Gerontology 2009, 24(3):241-58
46. Chopra M, Lawn JE, Sanders D, Barron P, Abdool Karim SS, Bradshaw D, Jewkes R, Abdool Karim Q, Flisher
AJ, Mayosi BM, Tollman SM, Churchyard GJ, Coovadia H, Lancet South Africa Team. Achieving the health
Millenium Goals for South Africa: challenges and priorities. Lancet 2009, 374(9694):1023-31
47. White MJ, Hunter LM. Public perception of environmental issues in a developing setting: environmental
concern in coastal Ghana. Social Science Quarterly 2009,90(4):960-982
48. Wagner R, Newton CR. Do helminths cause epilepsy? Parasite Immunology 2009,31:697-705
49. Connor MD, Modi G, Warlow CP. Differences in the nature of stroke in a multiethnic urban South African
population: the Johannesburg Hospital stroke register. Stroke 2009, 40(2):355-62
50. Boileau C, Clark S, Poulin M, Reniers G, Watkins S, Heyman J. Sexual and marital trajectories and HIV
infection among ever-married women in rural Malawi. Sexually Transmitted Infections 2009, 85(suppl 1):i27i33
51. de Sherbinin A, Vanwey LK, McSweeney K, Aggarwal R, Barbieri A, Henry S, Hunter LM, Twine W. Rural
household demographics, livelihoods and the environment. Global Environmental Change 2008;18(1):38-53.
52. Madhavan S, Towensend N, Garey AI. Absent Breadwinners: Father-child connections and paternal support
in rural South Africa. Journal of Southern African Studies 2008, 34(3):647-663.
53. Tollman SM, Kahn K, Sartorius B, Collinson MA, Clark SJ, Garenne ML. Implications of mortality transition for
primary health care in rural South Africa: a population-based surveillance study. Lancet 2008; 372: 893-901.
54. Garenne M, Zwang J. Premarital fertility and HIV/AIDS in sub-Saharan Africa. African Journal of Reproductive
Health 2008, 12(2):64-74
55. Zwang J, Garenne M. Social context of premarital fertility in rural South Africa. African Journal of
Reproductive Health 2008, 12(2);98-110
56. Cortina MA, Kahn K, Fazel M, Hlungwani T, Tollman S, Bhana A, Prothrow-Smith D, Stein A. School-based
interventions can play a critical role in enhancing children’s development and health in the developing
world. Child: Care, Health and Development 2008,34(1):1-3
57. Cappucio FP, Kerry SM, Adeyemo A, Luke A, Amoah AGB, Bovet P, Connor MD, Forester T, Gervasoni JP, Kaki
GK, Plange-Rhule J, Thorogood M, Cooper RS. Body size and blood pressure: an analysis of Africans and the
African diaspora. Epidemiology 2008, 19(1):38-46
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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58. Cassels S, Clark SJ, Morris M. Mathematical models for HIV transmission dynamics: Tools for social and
behavioural science research. Journal of Acquired Immunodeficiency Syndrome 2008,47 (suppl 1): S34-39
59. Hargreaves J, Morison I, Kim J, Bonnell C, Porter J, Watts C, Busza J, Phetla G, Pronyk P. The association
between school attendance, HIV infection and the sexual behaviour among young people in rural South
Africa. Journal of Epidemiology and Community Health 2008, 62:113-119
60. Garenne M, McCaa R, Nacro K. Maternal mortality in South Africa in 2001: from demographic census to
epidemiological investigation. Population Health Metrics 2008, 6:4
61. Havenaar M, Geerlings MI, Vivian I, Collinson MA, Robertson B. Common mental health problems in
historically disadvantaged urban and rural communities in South Africa: prevalence and risk factors. Social
Psychiatry and Psychiatric Epidemiology 2008,43(3):209-215
62. Reniers G. Marital strategies for regulating exposure to HIV. Demography 2008, 45(2):417-438
63. Reniers G, Tfaily R. Polygyny and HIV in Malawi. Demographic Research 2008, 19(53):1811-1830
64. Hunter LM, De Souza R-M, Twine W. The environmental dimensions of the HIV/AIDS pandemic: a call for
scholarship and evidence-based intervention. Population & Environment 2008;29:103–107.
65. MacPherson P, Martinson N, Moshabela M, Pronyk P. Mortality and loss to follow –up among HAART
initiators in rural South Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene 2008,
103:588-593
66. Tekola F, Reniers G, Araya T, Damen HM, Davey G. The economic impact of AIDS morbidity and mortality on
households in Addis Ababa, Ethiopia. AIDS Care 2008,20(8):995-1001
67. Polzer T. Invisible integration: how bureaucratic academic and social categories obscure integrated refugees.
Journal of Refugee Studies 2008, 21(4):476-497
Book chapters
1. Salojee H, Kahn K, Clark S, Khosa P, Tollman S. Cause of death patterns in the Agincourt DSS South Africa. In
Binka F et al (eds). Population and Health in Developing Countries, Volume 2.Cause of death patterns at
INDEPTH sites.Ashgate Publishing Limited, England. In press.
2. Reniers G, Masquelier B, Gerland P. 2011. Adult mortality trends in Africa. In Rogers R, Crimmins E,(eds).
International Handbook of Adult Mortality Springer, Dordrecht, Germany. ISBN 978-90-481-9995-2
3. Heuveline P, Clark S. 2011. Model schedules of mortality. In: Rogers RG, Crimmins EM (eds). International
Handbook of Adult Mortality. Springer, Dordrecht, Germany. ISBN 978-90-481-9995-2
4. Pfaff C, Tollman SM, Kahn K. 2010. Developing Community-Oriented Primary Care in contemporary rural
South Africa: the case of stroke. In Gofin J, Gofin R (eds). Essentials of Global Community Health. Jones &
Bartlett Publishers ISBN 13:978-0-7637-7329-8
5. Twine W, Hunter LM. 2010. Adult mortality, food security and the use of wild natural resources in a rural
district of South Africa: exploring the environmental dimensions of AIDS. In Niehof A, Rugalema G, Gillespie S
(eds). AIDS and Rural Livelihoods. Earthscan, London. ISBN: 978-1-84971-126-5
6. Case A, Deaton A. 2009.Health and wellbeing in Udaipur and South Africa. In Wise D (ed). Developments in
the Economics of Aging. University of Chicago Press, Chicago. ISBN 978-0-2269-0335-4
7. Collinson MA.2009. Age sex profiles of migration: who is a migrant? In: Collinson MA, et al (eds) The
dynamics of migration, health and livelihoods: INDEPTH Network perspectives. Ashgate Publishing Ltd,
Farnham, England. ISBN 978-0-7546-7875-5
8. Collinson MA, Gerritsen AM, Clark SJ, Kahn K, Tollman SM. 2009. Migration and socio-economic change in
rural South Africa, 2000-2007. In: Collinson MA, et al (eds). The dynamics of migration, health and
livelihoods: INDEPTH network perspectives . Ashgate Publishing Ltd, Farnham, England. ISBN 978-0-75467875-5
9. Konsiega A, Zulu EM, Bocquier P, Muindi K, Beguy D, Yazoume Y. 2009.Assessing the effect of mother’s
migration on childhood mortality in the informal settlements of Nairobi. In Collinson MA, et al (eds). The
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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dynamics of migration, health and livelihoods: INDEPTH Network perspectives. Ashgate Publishing Ltd,
Farnham, England. ISBN 978-0-7546-7875-5
10. White MJ, Mberu, BU, Collinson MA.2008. African Urbanisation: Recent Trends and Implications. In: Martine
G, McGranahan G, Montgomery M, Fernandez-Castilla R (eds). ‘The New Global Frontier: Urbanisation,
Poverty and Environment in the 21st Century’. Earthscan, London. ISBN 978-1-84407-559-1
11. Kautzky K, Tollman SM.2008. A perspective on primary health care in South Africa. In: Barron P, RomaReardon J (eds). South African Health Review. Health Systems Trust, Durban.
Editorships : books
1. Collinson MA, Adazu K, White MJ, Findley SE.2009. The dynamics of migration, health and livelihoods:
INDEPTH Network perspectives. Ashgate Publishing Ltd, Farnham, England. ISBN 978-0-7546-7875-5
Editorships: journals
1. Suzman R, Tollman SM, Kahn K, Ng N. Growing older in Africa and Asia: Multicentre study on aging, health
and well-being. Global Health Action (supplement 2) 2010, ISSN 1654-9716
2. Tollman SM. Associate editor: Epidemiology and Community Medicine.
3. Tollman SM. Editor: Population Health Metrics.
Dissertations and theses
1. Collinson MA. Striving against adversity: the dynamics of migration, health and poverty in rural South Africa.
Umeå University Medical Dissertations, 2009. ISBN 978-91-7264-746-6
2. Tollman SM. Closing the gap: applying health and socio-demographic surveillance to complex health
transitions in South and sub-Saharan Africa. Umeå University Medical Dissertations, 2008. ISBN: 978-917264-681-0
Web-based data publishing
1. Collinson MA, Tollman SM, Kahn K. ‘The Agincourt Health and Demographic Surveillance System: A unique
platform for research, training and development’. An introductory presentation about the Agincourt Health
and Demographic Surveillance System published on the Global Health Action website URL:
http://www.globalhealthaction.net/index.php/gha/article/downloadSuppFile/5080/802
Letter
1. Mayosi BM, Flisher AJ, Laloo VG, Sitas F, Tollman SM, Bradshaw D. Transmissable cancer in Africa- authors
reply. Lancet 2009;374(9707)2052-2053
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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ACKNOWLEDGEMENTS
The MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) wishes to acknowledge
•
•
•
•
•
•
•
•
•
•
•
•
the people who live in the 24 villages that form the Agincourt health and socio-demographic surveillance
system field site
The University of the Witwatersrand
The Mpumalanga Department of Health and Social Development
The Mpumalanga Department of Education
Bushbuckridge Municipality for their support of the geographic information system
The clinics serving the population in the Agincourt HDSS site – Lillydale, Belfast, Xanthia, Bhubezi,
Cunningmore, Kildare, Oakley and the Agincourt and Thulamahashe Health Centres
All staff in the PHC directorate in the Bushbuckridge Local Municipal area
Tintswalo hospital and Agincourt village for accommodating our offices
StatsSA
Paul Weinburg for all the photos in this document
Funders - International: The Wellcome Trust, UK; National Institute on Aging, USA; National Institute of
Child Health and Human Development, USA; National Institutes of Health, USA; National Institute of
Mental Health, USA; William and Flora Hewlett Foundation, USA; Bill and Melinda Gates Foundation,
USA; INDEPTH Network, Ghana. Local: Anglo American Chairman’s Fund; Soul City Institute for Health
and Development Communication; South African Medical Research Council; South African National
Research Foundation; Swiss/SA Joint Research Programme administered by the Council for Scientific and
Industrial Research; University of the Witwatersrand.
Collaborators - At Wits University: School of Public Health, Centre for Health
Policyhttp://wits.ac.za/radar; Departments of Child Health, Demography and Population studies,
Sociology, Computer and Applied Mathematics; Birth to Twenty, African Centre for Migration and
Society, Centre for African Ecology, Reproductive Health Research Unit. In South Africa: Africa Centre
Demographic Information System , University of KwaZulu-Natal; Dikgale HDSS, University of Limpopo;
Medical Research Council; Statistics South Africa; Centre for AIDS Research; University of Cape Town.
International: Africa: INDEPTH Network, Ghana. UK: http://www.brown.edu/London School of Hygiene
and Tropical Medicine, Warwick, Oxford, Cambridge and Edinburgh Universities. Europe: Pasteur
Institut, France; Umeå University, Sweden; World Health Organization, Geneva; Université Catholique de
Louvain, Louvain-la-Neuve, Belgium. USA: Colorado, Brown, Princeton and Harvard Universities; Disease
Control Priorities Network, IHME; USA; University of North Carolina; University of San Francisco; HIV
Prevention Trials Network
Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
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Annual Research Brief - MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt). Vol 1, Nov 2011
MRC/WITS RURAL PUBLIC HEALTH AND
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