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Poverty and Chronic Diseases in South Africa

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Poverty and Chronic Diseases in South Africa Poverty and Chronic Diseases in South Africa Technical Report 2001 Editors: Debbie Bradshaw Burden of Disease Research Unit Krisela Steyn Chronic Diseases of Lifestyle Unit WHO Collaborating Centre ISBN: 1-919809-17-1 Acknowledgements This report was commissioned by Dr Ruth Bonita, Director of Surveillance in the Non- communicable Disease and Mental Health Cluster at the World Health Organisation. Financial support was provided by the Swedish Government (SIDA/SAREC) and the Government of the United Kingdom (DIFD), for which we are duly grateful. A large part of the report is based on secondary analysis of the South African Demographic and Health Survey. The authors wish to acknowledge the South African National Department of Health as the initiator and main funder, the Medical Research Council as coordinator, the Centre for Health Systems Research and Development and their teams for the fieldwork, Macro International for technical assistance and USAID for additional funding for SADHS. The valuable contributions of Ms Desireé Pieterse for her assistance with the graphs and Ms Karin Barnard for her assistance with tables, Ms Inbirani Moodley for her assistance with the map, Ms Elize de Kock for typing and layout of the document and Ms Jean Fourie and Ms Michelle Galloway for editorial advice are greatly appreciated. The Department of Health is acknowledged for granting access to the data from the 1998 Demographic and Health Survey. The MRC’s GIS unit is gratefully acknowledged for their assistance with the analysis of the 1996 census data. The advice provided by Dr Ian Timæus and Dr Brent Wolf on the modelling of the DHS data was invaluable. i Executive Summary South Africa, a middle income country, has amongst the most extreme disparities in wealth in the world. Although the extent of poverty depends on the poverty line and methodology employed, analyses by the national statistical office suggests that 52% of households were living in poverty in 1996. While poor maternal and child health, infectious diseases and malnutrition are known to be associated with poverty, there remains a need to investigate the relationship between poverty and chronic diseases and their determinants. This report presents a detailed analysis of mortality data from vital registration in 1996 and chronic disease and risk factor data from the South African Demographic and Health Survey (SADHS) conducted in 1998. A factor analysis of socio-economic variables in the SADHS data yielded an asset index based on 14 household items and is shown to provide a robust indicator of poverty that correlates well at provincial level with indicators based on other income and expenditure data. Multivariate analyses of the SADHS data were conducted to investigate the association of a range of related chronic conditions, risk factors, lifestyle and health care indicators with this asset index, while assessing the independent effects of education, urban/rural setting and population group while adjusting for age. Due to the lack of alternatives, the mortality data have been analysed by contrasting the premature mortality experienced in the poorest quintile of the population with that in the richest quintile. The quintiles were identified on the basis of the proportions of households living in poverty in each magisterial district. The findings of the study reveal complex patterns of mortality, morbidity, risk factors and unhealthy lifestyles – an amalgam of a stratified society undergoing a health transition at a rapid pace. This study demonstrates the value of detailed analysis of large national data sets such as mortality statistics and SADHS for surveillance and research in order to address the complex interactions of lifestyle, risk factors and related chronic diseases in a country with multiple burdens of disease. The key findings, their policy implications and future research needs based on these findings are presented. Key findings: • Although the rich areas are further ahead in the epidemiological transition, the poor areas are also in the process of transition and suffer a substantial burden of premature mortality due to chronic disease including stroke, COPD, asthma, epilepsy, oesophageal cancer and cervical cancer. Heart disease also plays a large role but details of the actual cause were missing as the majority were ill-defined cardiovascular disease. Ischaemic heart disease, lung cancer and breast cancer were common in the rich areas. • Asthma has a relatively high mortality burden among the poor, particularly women. This could be related to the finding that the poor were using appropriate asthma medication less frequently than the wealthier South Africans. • The prevalence of abnormal peak expiratory flow rate and airway limitation (“asthma”) was similar for all levels of wealth. This suggests that being richer does not mean that the required healthy lifestyle that will protect against lung disease is followed. A high level of education appears to be an additional prerequisite to adopt a healthier lifestyle. ii • The poor are at greater risk of being exposed to cigarette smoking (albeit light) and are at greater risk of being exposed to smoky fuels predominantly in rural areas. • Wealthier and more educated non-smoking men are less exposed to environmental tobacco smoke (ETS) than their poor counterparts. For women no such differences were observed. Non-smokers were more frequently exposed to ETS in urban settings than in rural settings. • Obesity and hypertension emerge as risk factors with increasing wealth and poor people will need to be protected from developing these risk factors as they undergo development and upward social mobility. • The poorest and the richest prefer less salty food, than those of average wealth. However salty food is preferred by the youngest group and is associated with being African and for men, living in urban areas. This may have consequences for the future development of hypertension in these groups. • Excessive alcohol use was associated with poverty, which is a concern not only due to its association with hypertension but also for the many physical and psycho-social pathologies associates with excessive alcohol use. • Access to and quality of health care, measured by the treatment status of hypertension and medication use of patients with airflow limitation (“asthma”), was worse for the poor. This is also reflected in the higher relative mortality burden of asthma and stroke in the poor. Policy implications: • The need to improve health care for people with chronic conditions has been identified for all sectors of South African society. However, the poor and the previously disadvantaged have the largest need for these improvements. • There is an urgent need to ensure that women in poor areas are screened for cervical cancer so that this mortality can be reduced. The need for screening for oesaphageal cancer in poor areas which are at high risk should also be investigated. • Strategies to prevent future development of chronic diseases are needed as the country undergoes further development. These strategies must include a total population approach to prevent or reduce the burden of unhealthy lifestyles and the emergence of risk factors as well as a high risk approach to diagnose those with risk factors and chronic conditions early and provide cost-effective management. • This report highlights the need for an integrated nutrition policy that focuses on all forms of malnutrition (over and under-nutrition). It must include policy on the use of salt in the formal and informal food industry. • The need to develop a comprehensive set of chronic disease health care indicators, based on data that can realistically be collected in South Africa, has been highlighted in this technical report. iii Research needs: • There is a need to improve the burden of disease data-base for the country, particularly for the poor areas. These data should also be used to monitor the impact of interventions already in place, such as the Tobacco Control legislation, and those interventions that still need to be developed and implemented. • The development and evaluation of a wide range of interventions for many aspects of chronic conditions and their risk factors and the lifestyle modifications are needed, particularly focusing on the needs of the poor. These interventions must be culturally sensitive to the diversity in South Africa. • The next SADHS needs to address the inadequacies found in the survey tool. For example, the smoking questionnaire previously suggested by WHO did not work well in South African populations. Additions need to be made to the questionnaire, such as questions on physical exercise, to make the survey more comprehensive. • Epidemiological research to further investigate the determinance of oesophageal cancer is needed as a first step towards reducing this burden. iv TABLE OF CONTENTS CHAPTER 1 Overview on Poverty in South Africa (Krisela Steyn & Michelle Schneider) 1 DEVELOPMENT AND HEALTH .............................................................................................................. 1 2 CHANGING VIEWS ON POVERTY, DEVELOPMENT AND HEALTH ............................................... 1 3 EQUITY........................................................................................................................................................ 2 4 THE WORLD HEALTH ORGANISATIONS’S APPROACH TO POVERTY ......................................... 3 5 DEMOGRAPHIC, EPIDEMIOLOGICAL AND HEALTH TRANSITION ..............................................
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