Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

Abstract

Objectives: Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.

Design: A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.

Setting: This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.

Participants: Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.

Results: Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).

Conclusions: The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Keywords: cardiology; epidemiology; health policy; qualitative research; quality in health care.

Figure 1

Trends in CVD mortality 1993–2015. (A) CVD mortality rates for each 5-year time period disaggregated by condition. (B) Male and female CVD mortality rates over time. (C) Mortality rates due to cardiovascular disease for each 10-year age group. (D) CVD mortality rates for each 20-year age group over time. CVD, Cardiovascular disease.

Figure 2

Flow diagram showing access to care of all people who had CVD deaths between 2012 and 2015, analysed using the free text. Notes: number of cases at each stage of the care pathway are shown as a proportion of total cases which reached the previous step (shown in bold). CoM, circumstances of mortality; CVD, cardiovascular disease.