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

Research output: Contribution to journalArticlepeer-review


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

Colleges, School and Institutes


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 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 1993-2015 were extracted from Verbal Autopsy data.
Results: Between 1993-2015, 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 1993-2015. 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 women. Strategies to improve seeking and receiving care during the final illness are needed.

Strengths and limitations of this study
• This is the first known investigation combining both mortality trends and barriers to access to care for people who have died of cardiovascular diseases.
• In combining quantitative and qualitative analysis to develop a three delays model specific to cardiovascular disease in the Agincourt population, this study provides a basis for development and application to other settings to deal with care access and quality issues in the final stages of chronic illness.
• Utilising two components of Verbal Autopsy data provides complimentary information and a basis for refining Circumstances of Mortality indicators, but direct comparison is limited by methodological differences in data collection.
• The non-specificity of Verbal Autopsy cause of death categories, particularly ‘other and unspecified cardiac diseases,’ reduces the ability of this study to analyse trends in specific CVD conditions.
• Other factors influencing equity in access to care, such as migratory status and socioeconomic status, cannot be included due to lack of available data within Verbal Autopsies.


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