MSc (Med), Population-Based Epidemiology, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Introduction: Although socioeconomic inequality in health and mortality is currently on the top of the epidemiologic debate, studies however on the subject among adult population in Africa has been hampered due to the long absence of data in many countries. With the present reliable records of deaths from emerged demographic surveillance systems on the continent, adult mortality can now be accurately estimated. Objectives: The study‟s main objectives were 1. To calculate and show trend in adult mortality rate in ACDIS between 2001 and 2007. 2. To measure the association between mortality and individual‟s socio-economic status in the ACDIS. Methods: Individuals were selected based on age (15-64 yrs) and residency (Resident in the DSA on 1st January 2001). The total number of adults who met the criteria was 33,677; out of whom 4,058 died during the seven years follow up period. Mortality rates were computed using Kaplan-Meier survival estimates expressed per 1000 PYO. Household wealth index was constructed by use of PCA. The association between SES and adult mortality was assessed using Cox proportional Hazard model controlling for potential confounders such as age, sex and marital status. Results: The High group of the socioeconomic quintile had the highest mortality rate of 22.2 per 1000 PYO, 95% CI (20.7 - 23.7). There was no significant trend in the rates among the SES groups. After adjusting for the potential confounders; the effect of socioeconomic status in the highest SES category was 0.10 times less likelihood for death compared to the lowest SES group [HR=0.90, p=0.042, 95% CI (0.81 - 0.99)]. Conclusion: This study revealed that adult socioeconomic status is not significantly associated with adult mortality. Reducing the gap between the rich and the poor might not be the effective way in reducing adult mortality.

MSc(Med)Population Based Field Epidemiology, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Introduction: In Africa, elderly adult mortality, just like many issues affecting the old has not been adequately addressed by research. This study explored the relationship between socioeconomic status (SES) and elderly adult mortality in an economically deprived region of rural Ghana. Methods: Data from the Navrongo DSS was used for the analysis. SES was determined from the asset data using principal component analysis. A total of 15030 adults aged over 60 years were included in the study, out of which 1315 died. We investigated the above relationship using Cox proportional hazards regression methods while controlling for other variables. Results: Socioeconomic status (SES) was found not to be a determinant of elderly mortality. Compared to the lowest SES quintile, the adjusted hazards ratios were, 0.94 (95%CI: 0.79–1.12) for second quintile, 0.91 (95%CI: 0.76–1.08) for third quintile, 0.89 (95%CI: 0.75–1.07) for fourth quintile and 1.02 (95%CI: 0.86–1.21) for the highest income quintile. However, living without a spouse [HR=1.98, 95%CI: 1.74–2.25], being male [HR=1.80, 95%CI: 1.59–2.04] and age [HR=1.05, 95%CI: 1.04– 1.05] were significant factors for elderly adult mortality. Conclusion: These results indicate that companionship, social and family ties in the health of the elderly adults are of more importance than the socioeconomic status of the household. Efforts should therefore be made to support the elderly, such as stipend for the elderly adults, especially those living alone; lowering the provision of free medical care in public hospitals to cover people over the age of 60 and not just 70 year olds and above as is currently done; encourage family care for the elderly relatives through provision of an elderly caretaker allowance among others.

Student Number : 0516841M - MSc research report - School of Public Health - Faculty of Health Sciences / Objective This work investigates the hypothesis that individuals recently migrating into rural areas have a higher mortality than those always resident and that migrant deaths are more likely to be HIV/AIDS related than non migrant deaths. Methods Data from the Africa Centre Demographic Surveillance System (ACDIS), South Africa, was used for the analysis. A total of 41519 adults aged 18 to 60 years since their last visit dates were categorized into three groups; internal migrants, external in migrants and always resident individuals since 2001. Follow up period was from 1st January 2001 to 31st December 2005. Cox proportional hazard regression method was used to quantify the additional risk of dying for migrants who have recently migrated into the DSS area. Logistic regression was used to examine the relationship between migration status and dying from AIDS related complications for the members in the sample whose cause of death have been identified using verbal autopsy procedures. Results External in migrants into the DSS area were 1.52 times more likely to die than those always resident. After adjusting for the effects of sex, age group, socio-economic status and educational level an external in migrant has a relative risk of 1.19, [adjusted HR=1.19, P=0.001, 95% CI (1.08,1.32)] of dying compared to those always resident. Internal migrants were 18% less likely to die compared to always resident individuals, [adjusted HR=0.82, P=0.008, 95% CI (0.71, 0.95)] and males were 1.38 times more likely to die within the follow up period compared to females, [HR=1.38, P<0.001, 95% CI (1.28, 1.49)]. These results were statistically significant at 95% confidence level. Out of a total of 1119 deaths that occurred in 2001 and 2002 whose cause of death have been identified through verbal autopsy procedures, 763 (66%) died of AIDS. The odds of dying from AIDS are 2.09 if you are an external in migrant compared to an always resident member, [unadjusted OR = 2.09, P = 0.009 95% CI (1.38, 3.16)]. After controlling for other factors in the model, the odds of dying from AIDS as an external immigrant was 1.79 times, [adjusted OR = 1.79, P = 0.009, 95% CI (1.15, 2.77)] compared to those always resident. There was no significant difference in AIDS mortality between always resident individuals and internal migrants. The odds of a female dying of AIDS was 2.33 times, [OR = 2.33, P<0.001, 95% CI (1.78, 3.06)] compared to males after controlling for migration status, age, socioeconomic status and educational level. Conclusion External in migrants have an increased risk of death among adults aged 18 to 60 years compared to those always resident. External in migrants are also more at risk of dying from AIDS related illnesses than those always resident. Internal migrants are less likely to die than those always resident. Females are more at risk of dying from AIDS than males. In resource-poor settings, especially in many parts of Africa and other developing countries with very high prevalence of HIV/AIDS and over burdened health services in rural areas, it is important to identify and quantify some of these trends contributing to high disease burdens and mortality in rural areas in order to put in place effective interventions to better the health conditions of the people in these areas.

The study of the relationship between socioeconomic characteristics and mortality patterns has been a traditional research focus in demography, representing one of the core areas of the discipline. In Latin America, there is an important set of studies that show a significant inverse relationship between socioeconomic status and mortality rates. However, mainly due to limitations in the available data, we know very little about the specific relation between educational attainment and adult mortality. This inverse relationship between educational attainment and mortality rates provides just the tip of the iceberg for a large set of questions: How wide are educational differences in overall adult mortality in Argentina? Does the association between educational attainment and adult mortality vary by age group, gender and region? Are there unique adult mortality patterns by education among specific causes of death? Has the adult mortality differential by education attainment widened or narrowed as education attainment increased between 1991 and 2010? The main objective of this research was to describe and analyze the relationship between educational attainment and adult mortality patterns during the 1991-2010 period in Argentina. The data used in this study come from the Argentinian Mortality Files for the period 1991-2010 and from the 1991, 2001 and 2010 Argentinian Censuses. Results show a clear gradient in the specific mortality rates according to educational groups, for both sexes and for all age groups. The existence and direction of this relationship was as expected; however, the magnitude of educational differences was much higher than what has been found in other countries. The data also exhibited a clear declining trend in mortality inequalities by education as age increased. Educational differences in overall adult mortality did not display an increasing pattern over time. The year 2001, which was characterized by serious economic and social crisis in the country, displayed the highest educational inequalities in mortality in comparison to either 1991 or 2010. The findings of this dissertation are relevant to policy questions about health care and social inequalities in death. / text

This dissertation is a historically comparative study of adult mortality between Taiwan and the United States throughout the 20th century. The 20th century was characterized by the largest rise in life expectancy at birth and the most rapid decrease in mortality in recorded human history. This dissertation aims not only to examine and compare the trends and levels of life expectancy in Taiwan and the United States over an extended period of time, but also to evaluate the extent to which smoking behavior and obesity play an important role in the recent levels of adult mortality in the United States. I used logistic models of mortality to examine and compare the trends and levels of life expectancy in Taiwan from 1906 to 2008 and in the United States from 1933 to 2007. Second, I re-estimated life expectancy by introducing smoking-attributable mortality to further compare the levels of life expectancy between the two countries. Third, I estimated event history models to investigate whether and how smoking behavior and obesity are related to mortality in the United States in the 1990 to 2006 and the 2000 to 2006 periods. At the end of the 20th century, the level of life expectancy at birth for females in the U.S. was higher than in Taiwan, but they were close. In this century, however, the level of life expectancy at birth in Taiwan has increased to a higher level than in the U.S. The levels of male life expectancy at birth for the two countries are similar in this century, but there were significant differences in the 20th century. The great improvements in juvenile, background and senescent mortality rates in Taiwan may be used to explain this correspondence of life expectancy between the two countries today. Besides, higher smoking-attributed mortality can also serve as another possible reason for the stagnant levels of life expectancy in the U.S. Finally, smoking-related and obesity-related mortality have become progressively more important as predictors of adult mortality in the U.S. in past decades.

Background: The study is based in post-apartheid South Africa and looks at the health and well being of households in the rural northeast. Temporary migration remains important in South Africa because it functions as a mainstay for income and even survival of rural communities. The economic base of rural South Africans is surprisingly low because there is high inequity at a national level, within and between racial groups. There has now been a democratic system in place for 15 years and there is no longer restriction of mobility, but there remain high levels of poverty in rural areas and rising mortality rates. Migration patterns did not change after apartheid in the manner expected. We need to examine consequences of migration and learn how to offset negative impacts with targeted policies. Aims: To determine a relevant typology of migration in a typical rural sending community, namely the Agincourt sub-district of Mpumalanga, South Africa, and relate it to the urban transition at a national level – Paper (I) . To evaluate the dynamics of socio-economic status in this rural community and examine the relationship with migration – Paper (II). To explore, using longitudinal methods, the impact of migration on key dimensions of health, including adult and child mortality, and sexual partnerships, over a period of an emerging HIV/AIDS epidemic – Papers (III), (IV) and (V). Methods: The health and socio-demographic surveillance system (HDSS) is a large open cohort where the migration dynamics are monitored as they unfold. They are recorded as temporary or permanent migration. Settled refugees are captured using nationality on entry into the HDSS. Longitudinal methods, namely a household panel and two discrete time event history analyses, are used to examine consequences of migration. Results: Migration features prominently and different types have different age and sex profiles. Temporary migration impacts the most on socio-economic status (SES) and health, but permanent migration and the settlement of former refugees are also important. Remittances from migrants make a significant difference to SES. For the poorest households the key factors improving SES are government grants and female temporary migration, while for less poor it is male temporary migration and local employment. Migration has been associated with HIV. Migrants that return more frequently may be less exposed to outside partners and therefore less implicated in the HIV epidemic. There are links between migration and mortality including a higher risk of dying for returnee migrants compared to permanent residents. A mother’s migration can impact on child survival after accounting for other factors. There remains a higher mortality risk for children of Mozambican former refugee parents. Interpretation: Migration changes the risks and resources for health with positive and negative implications. Measures such as improved transportation and roads should be seen as a positive, not a negative intervention, even though it will create more migration. Health services need to adapt to a reality of high levels of circular migration ranging from budget allocation to referral systems. Data should be enhanced at a national level by accounting for temporary migration in national censuses and surveys. At individual level we can offset negative consequences by treating migrants as persons striving against adversity, instead of unwelcome visitors in our better-off communities.

The overall aim of this thesis is to evaluate the risk for increased morbidity and mortality due to long-term arsenic exposure via drinking water by use of epidemiological and spatial approaches in studies performed in Matlab, Bangladesh. A total of 166,934 individuals aged 4 years and above were screened for skin lesions in 2002-2003. Another sample of 115,903 adults aged 15 years or more and a third sample of 26,972 pregnancies in 1991-2000 were considered in a historical cohort and an ecological study, respectively, where risk of adult mortality and spatial clusters of foetal loss and infant death were analysed in relation to arsenic exposure. More than 70% of the tube-wells in the study area exceeded the threshold for arsenic contamination according to the WHO guideline (10 µg/L). The prevalence of arsenic-induced skin lesions was 3/1000 and men had significantly higher prevalence of skin lesions (SMR 158, 95% CI: 133-188) compared to women. There was an increased risk for death in adulthood due to all non-accidental causes (hazards ratio = 1.16, [95% CI 1.06-1.26]) even at a low level of arsenic contamination (10-49 µg/L). Slightly lower risks were observed for death in cancers (1.44 [1.06-1.95]) and infectious diseases (1.30 [1.13-1.49]) at 50-149 µg/L, but for cardiovascular diseases, it was evident (1.23 [1.01-1.51]) from the level 150-299 µg/L. A dose-response relationship was observed for each of these causes. We identified high and low risk clusters of foetal loss and infant death that coincided with identified high and low clusters of arsenic exposure. Water arsenic concentration of the reported main water source was significantly correlated with arsenic concentration in urine, which reflects current arsenic intake from all sources (R2=0.41, ρ&lt; 0.0001), and the influence of neighbouring water sources was minimal. The study findings underlines that the ongoing arsenic exposure has resulted in a series of severe public health consequences in Bangladesh that call for reinforcement in the mitigation efforts. Knowledge about the spatial distribution of exposure and health effects may be of value in that process.

Ce mémoire présente, dans une première partie, une étude détaillée de la mortalité adulte des Canadiens-français nés entre 1620 et 1749. Des résultats inédits sont présentés sous forme de tables de mortalité abrégées avec entrées échelonnées. La comparaison de celles-ci permet de décrire les différences de comportement observées entre les hommes et les femmes, les populations de régions urbaines et rurales ainsi que trois groupes de générations s’étant succédé au cours de la période étudiée. Dans une deuxième partie, une étude de cas visant à confirmer l’influence du caractère familial sur la longévité est présentée. Une famille se distinguant par les durées de vie exceptionnellement longues de plusieurs de ses membres est comparée à une famille fictive de référence, représentative de la population moyenne de l’époque. Les résultats opposant ces deux familles consistent en des âges moyens au décès et des proportions de survivants à différents âges. Cette deuxième étude s’inscrit dans le prolongement des recherches effectuées avec les ascendances de Jeanne Calment et Marie-Louise Meilleur. Les informations tirées des registres paroissiaux du Québec ancien et consolidées informatiquement par le Programme de recherche en démographie historique (PRDH) dans une base de données appelée Registre de la population du Québec ancien (RPQA) constituent la source exploitée pour la réalisation des deux parties du mémoire. / This thesis presents, in the first part, a detailed study of adult mortality of French-Canadians born between 1620 and 1749. New time published results are presented in the form of abridged life tables with staggered entries. The life tables are compared to ascertain behavioural differences between men and women, between residents of urban and rural regions and across three generations during the period studied. In the second part, the thesis presents a case study conducted to test the influence of inheritance on human longevity. A family distinguished by the exceptional longevity of several of its members is compared to a reference fictional family representative of the average population of the time. Evidence provided on these two families consists of mean ages at death and proportions of survivors at different ages. This case study builds on research conducted with the ancestry of Jeanne Calment and Marie Louise Meilleur. Information drawn from the parish registers of old Quebec computerized by the Programme de recherche en démographie historique (PRDH) in a database called Registre de la population du Québec ancien (RPQA) is the primary source used for the life tables and case study.

Ce mémoire présente, dans une première partie, une étude détaillée de la mortalité adulte des Canadiens-français nés entre 1620 et 1749. Des résultats inédits sont présentés sous forme de tables de mortalité abrégées avec entrées échelonnées. La comparaison de celles-ci permet de décrire les différences de comportement observées entre les hommes et les femmes, les populations de régions urbaines et rurales ainsi que trois groupes de générations s’étant succédé au cours de la période étudiée. Dans une deuxième partie, une étude de cas visant à confirmer l’influence du caractère familial sur la longévité est présentée. Une famille se distinguant par les durées de vie exceptionnellement longues de plusieurs de ses membres est comparée à une famille fictive de référence, représentative de la population moyenne de l’époque. Les résultats opposant ces deux familles consistent en des âges moyens au décès et des proportions de survivants à différents âges. Cette deuxième étude s’inscrit dans le prolongement des recherches effectuées avec les ascendances de Jeanne Calment et Marie-Louise Meilleur. Les informations tirées des registres paroissiaux du Québec ancien et consolidées informatiquement par le Programme de recherche en démographie historique (PRDH) dans une base de données appelée Registre de la population du Québec ancien (RPQA) constituent la source exploitée pour la réalisation des deux parties du mémoire. / This thesis presents, in the first part, a detailed study of adult mortality of French-Canadians born between 1620 and 1749. New time published results are presented in the form of abridged life tables with staggered entries. The life tables are compared to ascertain behavioural differences between men and women, between residents of urban and rural regions and across three generations during the period studied. In the second part, the thesis presents a case study conducted to test the influence of inheritance on human longevity. A family distinguished by the exceptional longevity of several of its members is compared to a reference fictional family representative of the average population of the time. Evidence provided on these two families consists of mean ages at death and proportions of survivors at different ages. This case study builds on research conducted with the ancestry of Jeanne Calment and Marie Louise Meilleur. Information drawn from the parish registers of old Quebec computerized by the Programme de recherche en démographie historique (PRDH) in a database called Registre de la population du Québec ancien (RPQA) is the primary source used for the life tables and case study.

La réduction de la mortalité maternelle et infantile est universellement acceptée comme un objectif du millénaire pour le développement. L'aide étrangère est un des moyens utilisés pour l'atteindre. Cependant, malgré les succès, à l'échelle microéconomique, de certains programmes de santé financés par les aides étrangères, l'efficacité globale de ces aides demeure inconnue. Plusieurs travaux ont traité de l'efficacité de l'aides sur la croissance économique, mais peu d'entre eux concernent le secteur de la santé. Le but de cette thèse, est précisément d'évaluer l'efficacité des aides étrangères sur des indicateurs de santé à l'échelle macroéconomique. On va essayer d'explorer l'impact des aides étrangères octroyées par des bailleurs privés et publics sur l'état de santé telle que la mortalité infantile, maternelle et des adultes dans les pays en développement. La thèse examine l'affectation des aides étrangères au secteur de la santé, à travers trois documents de travail à soumettre à publication. / The reduction of child and maternal mortality is universally accepted as a millennium development goal (MDG). Foreign aid for health is one of the means implemented to reach it. However, even if many successes of health aid activities have been underlined at the microeconomic level, the effectiveness of health aid in general remains unknown. In spite of many macroeconomic works on aid effectiveness on economic growth, only little deals with its effectiveness in health. The purpose of this thesis is precisely to assess the effectiveness of foreign aid in improving health measurements, at the macroeconomic level. I tried to explore the impact of health aid disbursed by the donors through the government and private sector on health outcomes like child, maternal and adult mortality rates in developing economies. The thesis examines the issue of foreign aid earmarked for health sector using a three-paper format. The three chapters of this thesis can be read independently.