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

Jessica Newberry Le Vay, Andrew Fraser, Peter Byass, Stephen M Tollman, Kathleen Kahn, Lucia D’Ambruoso , Justine Davies

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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.

Original languageEnglish
Article numbere048592
Number of pages11
JournalBMJ open
Issue number6
Publication statusPublished - 25 Jun 2021

Bibliographical note

Funding Information:
Twitter Jessica Newberry Le Vay @Jess_NLV, Lucia D’Ambruoso @luciadambruoso and Justine I Davies @drjackoids Acknowledgements Thank you to the team at the Medical Research Council/ Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), particularly Chodziwadziwa Kabudula for his assistance with assembling the Agincourt HDSS data set for our use. The MRC/Wits Rural Public Health and Health Transitions Research Unit and Agincourt Health and Socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN), is supported by the Department of Science and Innovation, the University of the Witwatersrand, and the Medical Research Council, South Africa, and previously the Wellcome Trust, UK (grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z).

Funding Information:
Funding A travel scholarship to enable this project was provided by King’s College London. Article processing fees will be covered by University of Birmingham.

Publisher Copyright:
© 2021 Authors.


  • cardiology
  • epidemiology
  • health policy
  • qualitative research
  • quality in health care

ASJC Scopus subject areas

  • Medicine(all)


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