Thesis. / Bibliography: 2d prelim. ℓ.

Thesis--Universität München. / No more published? Vita. Bibliographical footnotes.

Immunisations are one of the most important interventions to decrease mortality and provide a foundation for a successful health system. Eliminating disparities in immunisation access is needed to meet immunisation coverage goals. Although migrants have been identified as influencing recent measles outbreaks in South Africa, research on access to immunisations is lacking for migrants in the country. Numerous barriers to accessing health care have been reported for international migrants in South Africa despite official policies of equal access. Children of Mozambican refugees may be a vulnerable group and not being immunised because of their migration status or other socio-economic and demographic factors. This study aims to determine immunisation rates in rural South Africa and identify socioeconomic and demographic factors influencing immunisation access including being a child of a refugee. All children under 5 years during 2003 and 2006 censuses in the Agincourt subdistrict, Mpumalanga, South Africa (N=17,532) are included in this retrospective, nested cross-sectional multivariate analysis of immunisation access community level data. Immunisation rates are approximately 85% for the first immunisation but rates for subsequent dosing decreased and only 5% of children of appropriate age obtained all immunisations on the South African immunisation schedule. Children of former Mozambican refugees were significantly more likely to be immunised than South African children (OR=1.59, p=0.018) controlling for other socio-economic and demographic characteristics. Children who lived in a village with a clinic (OR=1.43, p=0.015), children with older mothers (OR=1.02, p=0.028), and children in households with higher wealth (OR=1.13, p=0.033) were also more likely to be immunised. Strategies for increasing immunisation access should focus on delivery of services to villages without health care facilities, providing support and outreach to poorer and younger mothers, and ensuring continuing engagement with the immunisation programme. This study adds to the sparse existing research on predictors of immunisation access in South Africa as well as health care access for refugees in South Africa. This research shows that health care access can be higher for international migrants than the host population. Policymakers can use this research to target vulnerable groups to decrease disparities. / Thesis (M.Dev.Studies)-University of KwaZulu-Natal, Durban, 2011.

MSc (Med) , Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2009

M.Sc. (Med.), Faculty of Health Sciences, University of the Witwatersrand, 2011 / Epilepsy, a chronic, often treatable condition, is one of the most common neurological conditions globally, with the prevalence of epilepsy significantly higher in developing regions of the world. In 2008, a household survey was undertaken within the Agincourt Health and Demographic Surveillance System (AHDSS) in rural, northeastern South Africa to identify the prevalence of and risk factors for active convulsive epilepsy. A single question was administered as part of the annual census to each household head. This single question sought to identify people with convulsions, while a random sample of 4,500 individuals was drawn from the Agincourt HDSS population as a way to validate the Stage One screening tool. During initial piloting of the Stage One screening question, the question was found to be adequately sensitive and significant (98.3% and 93.1%, respectively). A more specific questionnaire was administered in Stage Two, while a clinical exam and history was performed in Stage Three to conclusively diagnose epilepsy. The adjusted prevalence of active convulsive epilepsy in the three-stage study was 3.26 per 1,000, while the adjusted prevalence in the population sample was 7.72 per 1,000 individuals highlighting a significant difference due to possible methodological or cultural issues. Furthermore, a heterogeneous, random distribution of active convulsive epilepsy was found across the site, with the identification of possible familial clustering in a number of households. By utilizing univariate and multivariate analysis, this study found sex and a family history of seizures to be significant risk factors for developing epilepsy in rural South Africa. Abnormal deliveries and problems after delivery were found to be significant in the bivariate analysis, but not the multivariate analysis. These findings highlight the need for additional research exploring epilepsy in rural South Africa.

MSc (Med), Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2008

ABSTRACT: Temporary migration, especially men moving to their place of work, was an intrinsic feature of the former Apartheid system in South Africa. Since the demise of Apartheid an increasing proportion of women have also been migrating to their place of work, and oscillating between work place and home. Temporary migration can be defined as oscillating migration between a home base and at least one other place, usually for work, but also for other reasons like education. This study demonstrates that in the Agincourt study population, in the rural northeast of South Africa, adult female temporary migration is an increasing trend. By conducting a survival analysis, the study evaluates the mortality outcomes, specifically infant and child mortality rates, of children born to female temporary migrants compared with children of non-migrant women. Based on the findings presented we accept the null hypothesis that there is presently no discernable impact (positive or negative) of maternal temporary migration on infant and child mortality. There seems to be a slight protective factor associated with mother’s migration when tested at a univariate level. However, through multivariate analysis, it is shown that this advantage relates to the higher education status of migrating mothers. When women become tertiary educated there is a survival advantage to their children and these women are also more likely to migrate. The study highlights greater child mortality risks associated with settled Mozambicans (former refugees) and unmarried mothers. Both of these risk factors reflect the impact of high levels of social deprivation.

This report examines the influence of parent’s migration status on childhood mortality in sending households in the South African rural sub-district of Agincourt. A survival analysis of a cohort of children born in Agincourt between 1 January 1997 and 31 December 2003 was conducted using the Cox proportional hazards model to estimate the influence of parent’s migration status on under-5 year mortality. Starting with a baseline census in 1992, the Agincourt Health and Demographic Surveillance System (AHDSS) data are collected and updated every 12 months wherein fieldworkers visit each household at the site to record the vital events, including births, deaths, and migrations that occurred since the previous census. Results of the survival analysis show that children born in households where the father was a temporary migrant while the mother remained at the rural household had a 35% lower risk of death compared to children in households where both parents were non-migrant (RR=0.647, 95% CI 0.439-0.954). The results also reveal that, controlling for parent migration status, children in single-parent (mother only) households had about 28% higher death hazard than children in two-parent households (RR=1.284, 95% CI 0.936-1.673). The findings suggest that temporary labour migration could be a means to improving household incomes and quality of life for children, particularly where the father is a temporary migrant while the mother remains behind taking care of the children. At the same time, children whose fathers are not indicated appear to be worse off whether their parents are temporary migrants or not.

Rationale: Vital registration is lacking in developing settings where health and development problems are most pressing. Policy-makers confront an “information paradox”: the critical need for information on which to base priorities and monitor progress, and the profound shortage of such information. Aims: To better understand the dynamics of mortality transition in rural South Africa over a decade of profound socio-political change coupled with emerging HIV/AIDS. Thereby to inform health and development programming, policy formulation, and the research agenda; and contribute to debate on the nature of the ‘health transition’. Methods: The Agincourt health and demographic surveillance system is based on continuous monitoring of the Agincourt sub-district population in rural north-east South Africa. This involves annual recording of all vital events, specifically deaths, births and migrations in 11,700 households comprising some 70,000 persons. A “verbal autopsy” is conducted on every death, and special modules provide additional data. Key findings: A major health transition has occurred over the past decade, with marked changes in population structure and rapidly escalating mortality particularly among children and younger adults. A quadruple burden of disease is evident with persisting infectious disease and malnutrition in children, emerging non-communicable disease in the middle-aged and older, high levels of violence in an apparently peaceful community, and rapidly escalating HIV/AIDS and tuberculosis. There is evidence of sex differences and socio-economic differentials in mortality; vulnerable sub-groups include the children of Mozambican immigrants and recently returned labour migrants. Implications: With respect to health transition, empirical data demonstrate a marked “counter transition” with mortality increasing in children and young adults; “epidemiologic polarization” is evident with the most vulnerable experiencing a higher mortality burden; and a “protracted transition” is reflected in the co-existence of persisting infectious disease and malnutrition, emerging HIV/AIDS, and increasing chronic non-communicable disease. With respect to health policy and practice there is urgent need to: strengthen HIV/AIDS prevention, treatment and care; offer effective long-term care to control the rising burden of chronic illness and related risk; maintain and improve maternal and child health services; and address differential access to care. This poses a substantial challenge to a severely stretched health system.