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Background: Personal health behaviours and lifestyle habits of health professionals influence their counselling practices related to non-communicable diseases (NCDs). There are limited data on the prevalence of unhealthy lifestyle habits among medical students and the impact of acquired health knowledge throughout the curriculum. The aim of this study was to determine and compare the prevalence of modifiable behavioural NCD risk factors of medical students in different academic years at a South African tertiary institution., Methods: A cross-sectional observational study of 532 consenting medical students was conducted. Participants completed five online questionnaires regarding lifestyle behaviours (physical activity, dietary habits, smoking, alcohol consumption and sleep)., Results: Lifestyle-related risk factors with the highest prevalence were poor sleep quality (66.0%), low levels of habitual physical activity (55.8%) and low-to-moderate diet quality (54.5%). There were no differences between academic years for all risk factors measured. Over 60% of the cohort had two or more NCD risk factors and this prevalence did not differ across the degree program with the acquisition of more health knowledge., Conclusion: Medical students have a high prevalence of poor sleep quality, low levels of physical activity and low-to-moderate diet quality, which does not appear to change over the course of their academic career. Sleep hygiene, regular physical activity and healthy nutrition should be targeted in intervention programmes and be more prevalent in the medical curriculum.

Purpose: Hypertension is a leading cause of cardiovascular-related morbidity and mortality worldwide, with a prevalence increasing at an alarming rate in both middle- and low-income countries. Various environmental and genetic factors have been attributed to play a significant role in the increasing prevalence of hypertension. Single nucleotide polymorphisms (SNPs) in the angiotensinogen ( AGT ) gene are reported to have a significant association with hypertension; however, there are limited studies done on South African populations. Therefore, this case-control study aimed to investigate the association between AGT SNPs (rs2004776, rs3789678, rs5051 and rs7079) with hypertension in a study population of isiXhosa-speaking participants from the Eastern Cape Province in South Africa., Materials and Methods: The SNPs were genotyped in 250 hypertensive cases and 237 normotensive controls, using TaqMan genotyping assays., Results: For the SNP rs2004776, the frequency of CC genotype (18.4%) and C allele (44%) in hypertensive cases showed no significant differences (p = 0.52, χ2 = 1.32), when compared to the normotensive control group (CC: 19.8% and C allele: 43%). Similar results were obtained for the genotypic and allelic frequencies between hypertensive cases and normotensive controls for rs3789678 (p = 0.88, χ2=0.26) and rs5051 (p = 0.57, χ2=1.12), and rs7079 (p = 0.33, χ2=2.23). These findings demonstrate that there were no significant associations between the SNPs rs2004776, rs3789678, rs7079, rs5051 with hypertension in our study population., Conclusion: These findings suggest that AGT gene polymorphisms are not associated with the development of hypertension in the studied population. The present study represents the first genetic report to investigate the AGT gene polymorphisms with hypertension in an isiXhosa-speaking South African population., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Sharma et al.)

Introduction: Despite the numerous efforts and initiatives, males with HIV are still less likely than women to receive HIV treatment. Across Sub-Saharan Africa, men are tested, linked, and retained in HIV care at lower rates than women, and South Africa is no exception. This is despite the introduction of the universal test-and-treat (UTT) prevention strategy anticipated to improve the uptake of HIV services. The aim of this study was to investigate linkage to and retention in care rates of an HIV-positive cohort of men in a high HIV prevalence rural district in KwaZulu-Natal province, South Africa., Methods: From January 2018 to July 2019, we conducted an observational cohort study in 18 primary health care institutions in the uThukela district. Patient-level survey and clinical data were collected at baseline, 4-months and 12-months, using isiZulu and English REDCap-based questionnaires. We verified data through TIER.Net, Rapid mortality survey (RMS), and the National Health Laboratory Service (NHLS) databases. Data were analyzed using STATA version 15.1, with confidence intervals and p-value of ≤0.05 considered statistically significant., Results: The study sample consisted of 343 male participants diagnosed with HIV and who reside in uThukela District. The median age was 33 years (interquartile range (IQR): 29-40), and more than half (56%; n = 193) were aged 18-34 years. Almost all participants (99.7%; n = 342) were Black African, with 84.5% (n = 290) being in a romantic relationship. The majority of participants (85%; n = 292) were linked to care within three months of follow-up. Short-term retention in care (≤ 12 months) was 46% (n = 132) among men who were linked to care within three months., Conclusion: While the implementation of the UTT strategy has had positive influence on improving linkage to care, men's access of HIV treatment remains inconsistent and may require additional innovative strategies., (© 2024. The Author(s).)

HIV linkage, and retention are key weaknesses in South Africa's national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. We conducted an observational prospective cohort study to investigate LTRIC rates for adults with a new HIV diagnosis in South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status, sex, and age. Of the 5,637 participants recruited, 21.2% had confirmed HIV, of which 70.9% were women, and 46.5% were aged 25-34 years. Although 82.7% of participants were linked-to-care within 3 months, only 46.1% remained-in-care 12 months after initiating ART and 5.2% were deceased. While a significantly higher proportion of men were linked-to-care at 3 months compared to women, a significant proportion of women (49.5%) remained-in-care at 12 months than men (38.0%). Post-secondary education and child support grants were significantly associated with retention. We found high linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required to retain people living with HIV in care, especially during the first year after ART initiation. Our findings suggest that interventions could target men to encourage HIV testing., (© 2022. The Author(s).)

Homelessness is a global issue that is often associated with substance use. Research on this relationship in low- to middle-income countries (LMIC) is limited. We aimed to explore which factors are associated with substance use through secondary data analysis of a sample of 472 adults who attended services for homeless individuals in Cape Town, South Africa. Logistic regression was utilized to investigate if length of homelessness was associated with current alcohol and drug use respectively, after accounting for other factors. Current drug use (44.9%) was higher than current alcohol use (22.7%) and the most prevalent lifetime drug was methamphetamine (32.6%). After adjusting for lifetime substance use, and source of income, length of homelessness was not significantly associated with current alcohol use (less than on year: OR = 2.60; 95% CI: 0.78-8.66; one or more years: OR = 0.90; 95% CI: 0.32-2.57) or current drug use (less than one year: OR = 0.78; 95% CI: 0.41-1.47; one year or more: OR = 1.04; 95% CI: 0.56-1.93). These results highlight the need to further investigate other factors that may influence current alcohol or drug use among populations at risk of being homeless, and to utilize validated measures of substance and other mental health conditions.

This study aimed to investigate the association between consumption of ultra-processed foods, whole foods and breast cancer risk in black women from Soweto, South Africa. A population-based case ( n 396)-control ( n 396) study matched on age and residence, using data from the South African Breast Cancer study. Dietary intake was assessed using a validated quantified FFQ. Food items were categorised using the NOVA system ((1) unprocessed/minimally processed foods, (2) culinary ingredients, (3) processed foods and (4) ultra-processed foods). Conditional logistic regression models were used to estimate OR and 95 % CI of dietary contributions from each NOVA food group (as a percentage of total energy intake (EI)) and adjusting for potential confounders. Considering contributions to total EI per day, ultra-processed food consumption contributed to 44·8 % in cases and 47·9 % in controls, while unprocessed/minimally processed foods contributed to 38·8 % in cases and 35·2 % in controls. Unprocessed/minimally processed food consumption showed an inverse association with breast cancer risk overall (OR = 0·52, 95 % CI 0·35, 0·78), as well as in pre- and postmenopausal women separately (OR = 0·52, 95 % CI 0·27, 0·95 and OR = 0·55, 95 % CI 0·35, 0·89, respectively) and in women with progesterone positive breast cancer (OR = 0·23, 95 % CI 0·06, 0·86). There was no heterogeneity in association with breast cancer when analyses were stratified according to BMI. No significant associations were observed for the consumption of other NOVA food groups. Intake of unprocessed/minimally processed foods may reduce the risk of developing breast cancer in black women from Soweto, South Africa.

Poor nutrition during the first two years of life has long term consequences, but resource-poor households often do not have the means to access nutrient-dense and diverse diets. Pooled data of 24-h dietary recalls ( n = 3336) and 2019 retail food prices were analyzed to determine associations of retail cost and energy cost (per 100 kcal) with diet quality indicators for diets of 6-24-month-old South African children who were breastfed (BF-diet) and not breastfed (NBF-diet) during the 24-h recall period. Compared to the BF-diet, retail cost for the NBF-diet was three times higher for age 6-11 months, and double for age 12-17 months. Higher retail cost and energy cost were both associated with higher mean adequacy ratios and dietary diversity scores for BF and NBF diets, except energy cost for the NBF-diet for age 6-11 months. Overall, inclusion of flesh foods, vitamin A-rich fruits and vegetables, and other fruit and vegetables increased from the lowest to the highest retail cost tertile. The higher cost of more nutritious diets highlights the importance of the affordability of diets in interventions aimed at improving diet quality. Possible strategies include: identifying the most-affordable foods within each food group, focusing on foods that provide multiple key micronutrients, and the inclusion of locally available indigenous foods.

Background: Real-world evaluation of the safety profile of vaccines after licensure is crucial to accurately characterise safety beyond clinical trials, support continued use, and thereby improve public confidence. The Sisonke study aimed to assess the safety and effectiveness of the Janssen Ad26.COV2.S vaccine among healthcare workers (HCWs) in South Africa. Here, we present the safety data., Methods and Findings: In this open-label phase 3b implementation study among all eligible HCWs in South Africa registered in the national Electronic Vaccination Data System (EVDS), we monitored adverse events (AEs) at vaccination sites through self-reporting triggered by text messages after vaccination, healthcare provider reports, and active case finding. The frequency and incidence rate of non-serious and serious AEs were evaluated from the day of first vaccination (17 February 2021) until 28 days after the final vaccination in the study (15 June 2021). COVID-19 breakthrough infections, hospitalisations, and deaths were ascertained via linkage of the electronic vaccination register with existing national databases. Among 477,234 participants, 10,279 AEs were reported, of which 138 (1.3%) were serious AEs (SAEs) or AEs of special interest. Women reported more AEs than men (2.3% versus 1.6%). AE reports decreased with increasing age (3.2% for age 18-30 years, 2.1% for age 31-45 years, 1.8% for age 46-55 years, and 1.5% for age > 55 years). Participants with previous COVID-19 infection reported slightly more AEs (2.6% versus 2.1%). The most common reactogenicity events were headache (n = 4,923) and body aches (n = 4,483), followed by injection site pain (n = 2,767) and fever (n = 2,731), and most occurred within 48 hours of vaccination. Two cases of thrombosis with thrombocytopenia syndrome and 4 cases of Guillain-Barré Syndrome were reported post-vaccination. Most SAEs and AEs of special interest (n = 138) occurred at lower than the expected population rates. Vascular (n = 37; 39.1/100,000 person-years) and nervous system disorders (n = 31; 31.7/100,000 person-years), immune system disorders (n = 24; 24.3/100,000 person-years), and infections and infestations (n = 19; 20.1/100,000 person-years) were the most common reported SAE categories. A limitation of the study was the single-arm design, with limited routinely collected morbidity comparator data in the study setting., Conclusions: We observed similar patterns of AEs as in phase 3 trials. AEs were mostly expected reactogenicity signs and symptoms. Furthermore, most SAEs occurred below expected rates. The single-dose Ad26.COV2.S vaccine demonstrated an acceptable safety profile, supporting the continued use of this vaccine in this setting., Trial Registration: ClinicalTrials.gov NCT04838795; Pan African Clinical Trials Registry PACTR202102855526180., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: JP received speakers fees from Johnson and Johnson, and spouse is employed by Johnson and Johnson. The other authors have declared that no competing interests exist.

Objective: To determine if scientifically based social network (Facebook) lifestyle interventions reduce 10-year cardiovascular disease (CVD) risk., Methods: Financial sector employees (n = 300) were equally randomly assigned: Facebook plus Health Professionals (FB+HP), Facebook (FB), or control (C). We report changes in 10-year Framingham risk score (FRS) for CVD (%) and risk factors over 12 months., Results: FRS did not change within and between groups. Overweight (-7.4% vs -5.6%, P  = 0.005) and diabetes risk (-10.7% vs 0.2%, P  = 0.011) reduced significantly in FB+HP versus FB and C, respectively. Inadequate fruit/vegetable intake (-9.4% vs 3.6%, P  = 0.011) and smoking (-0.7% vs 14.9%) reduced significantly in FB versus C. No significant changes in physical activity, central obesity, hypertension, and hypercholesterolemia between groups., Conclusions: Scientifically based social network lifestyle intervention programs could be included in workplace health promotional programmes to improve certain non-communicable disease risk factors., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 American College of Occupational and Environmental Medicine.)

Breast cancer prevention is of great importance to reduce high incidence in South Africa. This study aimed to investigate adherence to the 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Cancer Prevention Recommendations and the association with breast cancer risk in black urban women from Soweto, South Africa. A total of 396 breast cancer cases and 396 population-based controls from the South African Breast Cancer study (SABC) matched on age and demographic settings were included. Validated questionnaires were used to collect dietary and epidemiological data. To assess adherence to these recommendations, an eight-point adherence score was developed, using tertiles among controls for scoring each recommendation (0, 0·5 and 1) with zero indicating the lowest adherence to the recommendations. OR and 95 % CI were estimated using multivariate logistic regression models to analyse associations between the WCRF/AICR score and breast cancer risk. Greater adherence (>4·5 v. <3·25) to the 2018 WCRF/AICR Cancer Prevention Recommendations was associated with a significant inverse association with breast cancer risk overall (OR = 0·54, 95 % CI 0·35, 0·91) and specifically in postmenopausal women (OR = 0·55, 95 % CI 0·34, 0·95), in cases with oestrogen positive and progesterone positive breast cancer subtypes (OR = 0·54, 95 % CI 0·39, 0·89 and OR = 0·68, 95 % CI 0·43, 0·89, respectively) and in obese women (OR = 0·52, 95 % CI 0·35, 0·81). No significant association with breast cancer risk was observed in premenopausal women. Greater adherence to the 2018 WCRF/AICR Cancer Prevention Recommendations may reduce breast cancer risk in this black urban population of Soweto. Adherence thereof should be encouraged and form a part of cost-effective breast cancer prevention guidelines.

Background: The majority children living with HIV infection now survive into adulthood because of effective antiretroviral therapy (ART), but few data exist on their growth during adolescent years. This study investigated growth patterns and evaluated factors associated with suboptimal growth in adolescents with perinatally-acquired HIV infection., Methods: This retrospective cohort study included HIV-infected adolescents, aged 13 to 18 years, with at least 5 years of ART follow-up at a large HIV clinic in the Gauteng Province, South Africa. Weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores were calculated using World Health Organization (WHO) growth standards. Growth velocity graphs were generated utilising the mean height change calculated at 6-monthly intervals, using all available data after ART initiation, to calculate the annual change. Other collected data included WHO HIV disease staging, CD4%, HIV viral loads (VLs), ART regimens and tuberculosis co-infection., Results: Included were 288 children with a median age of 6.5 years (IQR 4.2;8.6 years) at ART initiation, and 51.7% were male. At baseline the majority of children had severe disease (92% WHO stages 3&4) and were started on non-nucleoside reverse transcriptase inhibitor-based regimens (79.2%). The median CD4% was 13.5% (IQR 7.9;18.9) and median HIV viral load log 5.0 (IQR 4.4;5.5). Baseline stunting (HAZ <-2) was prevalent (55.9%), with a median HAZ of -2.2 (IQR -3.1;-1.3). The median WAZ was -1.5 (IQR -2.5;-0.8), with 29.2% being underweight-for-age (WAZ <-2). The peak height velocity (PHV) in adolescents with baseline stage 3 disease was higher than for those with stage 4 disease. Being older at ART start (p<0.001) and baseline stunting (p<0.001) were associated with poorer growth, resulting in a lower HAZ at study exit, with boys more significantly affected than girls (p<0.001)., Conclusions: Suboptimal growth in adolescents with perinatally-acquired HIV infection is a significant health concern, especially in children who started ART later in terms of age and who had baseline stunting and is more pronounced in boys than in girls., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine the level of adherence and to assess the association between higher adherence to the South African food based dietary guidelines (SAFBDG) and breast cancer risk., Design: Population-based, case-control study (the South African Breast Cancer study) matched on age and demographic settings. Validated questionnaires were used to collect dietary and epidemiological data. To assess adherence to the SAFBDG, a nine-point adherence score (out of eleven guidelines) was developed, using suggested adherence cut-points for scoring each recommendation (0 and 1). When the association between higher adherence to the SAFBDG and breast cancer risk was assessed, data-driven tertiles among controls were used as cut-points for scoring each recommendation (0, 0·5 and 1). OR and 95 % CI were estimated using multivariate logistic regression models., Setting: Soweto, South Africa., Participants: Black urban women, 396 breast cancer cases and 396 controls., Results: After adjusting for potential confounders, higher adherence (>5·0) to the SAFBDG v. lower adherence (<3·5) was statistically significantly inversely associated with breast cancer risk overall (OR = 0·56, 95 % CI 0·38, 0·85), among postmenopausal women (OR = 0·64, 95 % CI 0·40, 0·97) as well as for oestrogen-positive breast cancers (OR = 0·51, 95 % CI 0·32, 0·89). Only 32·3 % of cases and 39·1 % of controls adhered to at least half (a score >4·5) of the SAFBDG., Conclusions: Higher adherence to the SAFBDG may reduce breast cancer risk in this population. The concerning low levels of adherence to the SAFBDG emphasise the need for education campaigns and to create healthy food environments in South Africa to increase adherence to the SAFBDG.

A total of 396 breast cancer cases and 396 population-based controls from the South African Breast Cancer study (SABC) matched on age and demographic settings was included. Validated questionnaires were used to collect dietary and epidemiological data. Dietary patterns were derived using principal component analysis with a covariance matrix from 33 food groups. Odds ratios and 95% confidence intervals were estimated using conditional logistic regression. A traditional, a cereal-dairy breakfast and a processed food dietary pattern were identified, which together explained 40.3% of the total variance in the diet. After adjusting for potential confounders, the traditional dietary pattern and cereal-dairy breakfast dietary pattern were inversely associated with breast cancer risk (highest tertile versus lowest tertile) (OR = 0.72, 95%CI: 0.57-0.89, p -trend = 0.004 and OR = 0.73, 95%CI: 0.59-0.90, p -trend = 0.004, respectively). The processed food dietary pattern was not significantly associated with breast cancer risk. The results of this study show that a traditional dietary pattern and a cereal-dairy breakfast dietary pattern may reduce the risk of developing breast cancer in this population.

Objective: To determine if repeat annual health risk assessments (RAHRAs) with intervention reduce 10-year cardiovascular disease (CVD) risk in financial sector employees., Methods: Retrospective analysis from RAHRAs in 13,737 employees over 4 years. We report changes in 10-year FRS for CVD (%) and risk factors after 1 (GR1), 2 (GR2), and 3 (GR 3) RAHRAs., Results: Mean FRS increased with RAHRAs (GR1: +0.4%; GR2: +0.7%; GR3: +0.8%) (P < 0.001) and was higher for GR3 versus GR1 (P < 0.001) and GR2 (pairwise: P < 0.0355). RAHRAs were associated with increased inadequate fruit/vegetable intake (GR1: +5.4%; GR2: +9.8%; GR3: +15.8%) (all pairwise: P < 0.001) and overweight (GR1: +5.4% vs GR2: +9.8%) (P < 0.001) and only hypercholesterolemia decreased (GR1: -4.4% vs GR3: -9.6%) (P < 0.001)., Conclusion: RAHRAs did not reduce 10-year CVD risk in financial sector employees. Role of RAHRAs in chronic disease management requires further study., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American College of Occupational and Environmental Medicine.)

Objective: To determine the prevalence of non-communicable disease (NCD) risk factors, total NCD risk category and 10-year risk for cardiovascular diseases (CVD) in financial sector employees., Methods: This descriptive observational cross-sectional analysis, data from 36,074 employees was analysed. NCD risk factor data was obtained from health risk assessments that included a questionnaire and clinical measures. The 10-year risk for CVD was calculated using the Framingham non-laboratory based equation., Results: Inadequate fruit and vegetable intake (89.3%), insufficient physical activity (77.4%), and being overweight (66.8%) were the most prevalent risk factors. Women had significantly higher prevalence ratios for central obesity (2.28; P < 0.001), insufficient physical activity (1.21; P < 0.001), hypercholesterolaemia (1.15; P < 0.001), and overweight (1.08; P < 0.001) compared with men., Conclusion: A more concerted effort is required to provide employees with appropriate tools and education at the workplace to decrease and manage NCDs., Competing Interests: Conflicts of interests: None declared., (Copyright © 2020 American College of Occupational and Environmental Medicine.)

This paper describes how an up-to-date national population register recording deaths by age and sex, whether deaths were due to natural or unnatural causes, and the offices at which the deaths were recorded can be used to monitor excess death during the SARS-CoV-2 pandemic, both nationally, and sub-nationally, in a country with a vital registration system that is neither up to date nor complete. Apart from suggesting an approach for estimating completeness of reporting at a sub-national level, the application produces estimates of the number of deaths in excess of those expected in the absence of the SARS-CoV-2 epidemic that are highly correlated with the confirmed number of COVID-19 deaths over time, but at a level 2.5 to 3 times higher than the official numbers of COVID-19 deaths. Apportioning the observed excess deaths more precisely to COVID, COVID-related and collateral deaths, and non-COVID deaths averted by interventions with reduced mobility and gatherings, etc., requires access to real-time cause-of-death information. It is suggested that the transition from ICD-10 to ICD-11 should be used as an opportunity to change from a paper-based system to electronic capture of the medical cause-of-death information., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2021.)

Introduction: South Africa has seen a sharp increase in treatment admission trends for opioids despite beliefs that rates of opioid use remain low and do not represent a major problem. To advocate for the extension of Opioid Use Disorder (OUD) treatment and harm minimisation services in South Africa, better estimates of the extent of opioid use is needed. This paper responds to this need by describing (i) trends in treatment utilization for opioid-related problems in South Africa and (ii) differences in the profile of patients accessing treatment for different classes of opioids - heroin, 'nyaope' and codeine use., Methods: Data were collected from 83 specialist treatment centres participating in the South African Community Epidemiology Network on Drug Use between 2012 and 2017. Descriptive analyses were conducted to describe the sociodemographic profile of patients and multiple logistic regression was used to explore socio-demographic and clinical factors associated with admission to treatment for opioid use disorders (OUD) ., Results: From January 2012 to December 2017, data from 11 2032 treatment episodes were collated. Of these, 20 319 (18.1%) were from patients admitted for an OUD. Over time, the proportion of overall opioid-related admissions increased significantly from 16.1% of all admissions in 2012 to 20.0% in 2017 (p <0.001). Data also suggests a significant increase in the overall proportion of patients reporting injection drug use, from 1.6% in 2013 to 3.5% in 2017 (p <0.001). Clear differences in employment status, referral sources between classes of opioids were also noted., Conclusion: Over the last 5 years, South Africa has seen an increase in the proportion of opioid related disorders (OUD) treatment admissions. Public health interventions, evidence-based harm reduction approaches and improving access to treatment are among the interventions urgently needed to reduce the harms associated with the increased use of opioids in South Africa., Competing Interests: Declaration of Competing Interests The authors declare no conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

Limited information on the prevalence and risk factors for chronic pain is available for developing countries. Therefore, we investigated the prevalence of chronic pain and the association between this pain and various personal and sociodemographic factors by including questions in the South Africa Demographic and Household Survey 2016. The survey was conducted by face-to-face interviews with a nationally representative sample of the adult population (ages 15 and older, n = 10,336). Chronic pain was defined as pain or discomfort that had been experienced all the time or on and off for 3 months or more. The prevalence of chronic pain was 18.3% (95% confidence interval [CI]: 17.0-19.7). Women were more likely than were men to have chronic pain (men = 15.8% [95% CI: 13.9-17.8]; woman = 20.1% [95% CI: 18.4-21.8]), and the prevalence of chronic pain increased from 11.3% (95% CI: 9.6-13.3) for the age range 15 to 24 years to 34.4% (95% CI: 30.6-38.4) for the age range over 65 years. The body sites affected most frequently were the limbs (43.6% [95% CI: 40.4-46.9]), followed by the back (30.5% [95% CI: 27.7-33.6]). This article presents the prevalence of chronic pain in the general population of a middle-income African country. These data give much needed insights into the burden of, and risk factors for, chronic pain in low-resource settings, and identify priority groups for intervention.

We determined the associations of dietary patterns with energy/nutrient intakes and diet quality. Previously collected single 24-hr dietary recalls for children aged 6-11 months (n = 1,585), 12-17 months (n = 1,131), and 18-24 months (n = 620) from four independent studies in low socio-economic populations in South Africa were pooled. A maximum-likelihood factor model, with the principal-factor method, was used to derive dietary (food) patterns. Associations between dietary pattern scores and nutrient intakes were determined using Kendall's Rank Correlations, with Bonferroni-adjusted significance levels. For both 6-11 months and 12-17 months, the formula milk/reverse breast milk pattern was positively associated with energy and protein intake and mean adequacy ratio (MAR). The family foods pattern (6-11 months) and rice and legume pattern (12-17 months) were positively associated with plant protein, fibre, and PU fat; both for total intake and nutrient density of the complementary diet. These two patterns were also associated with the dietary diversity score (DDS; r = 0.2636 and r = 0.2024, respectively). The rice pattern (18-24 months) showed inverse associations for nutrient intakes and nutrient densities, probably because of its inverse association with fortified maize meal. The more westernized pattern (18-24 months) was positively associated with unfavourable nutrients, for example, saturated fat and cholesterol. These results highlight that underlying dietary patterns varied in terms of energy/nutrient composition, nutrient adequacy, nutrient densities of the complementary diet, and dietary diversity., (© 2019 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.)

In Botswana, traditional diets are gradually being replaced by westernized diets high in energy-dense and nutrient- poor, while micro nutrient deficiencies among the population remain. We determined the consumption of traditional and indigenous foods (TIF) and their contribution to nutrient intake among children and women in Botswana. TIF accounted for relatively high percentages of energy intake in children (41%) and women (36%) respectively. The mean intake of vitamin A in children and vitamin A and zinc in women was high from TIF compared to non-TIF. Research attention to determining the full potential of TIF in contributing to nutrition and health is warranted.

Fortification of two staple foods, maize meal and wheat flour (bread), is mandatory, and commercial infant products are widely available in South Africa. Using a 24-hr recall, we determined the contribution of these foods towards nutrient intakes at ages 6 (n = 715), 12 (n = 446), and 18 (n = 213) months in a cohort of children in a peri-urban community, North West province. On the day of recall, commercial infant products were consumed by 83% of children at 6 months, 46% at 12 months, and 15% at 18 months; fortified staples were consumed by 23%, 81%, and 96%, respectively. For consumers thereof, commercial infant products contributed 33% energy and 94% iron intakes at 6 months and 27% energy and 56% iron intakes at 12 months; nutrient densities of the complementary diet was higher than for nonconsumers for most micronutrients. For consumers of fortified staples, energy contribution thereof was 11% at 6 months versus 29% at 18 months; at 18 months, fortified staples contributed >30% of iron, zinc, vitamin A, thiamine, niacin, vitamin B6, and folate; at 12 months, nutrient densities of the complementary diet were higher for zinc, folate, and vitamin B6 but lower for calcium, iron, vitamin A, niacin, and vitamin C than nonconsumers. At ages 12 and 18 months, ~75% of children had low calcium intakes. At 12 months, 51.4% of consumers versus 25.0% (P = 0.005) of nonconsumers of fortified staples had adequate intakes (>EAR) for all eight fortificant nutrients. However, despite fortification, nutrient gaps remain., (© 2018 John Wiley & Sons Ltd.)

Incidence rates of breast cancer (BC) are increasing in South Africa. The aim of this study was to investigate the association between dietary intake and BC risk in black South African women. The study population included 396 BC cases and 396 population-based controls matched on age and residence, participating in the South African Breast Cancer study. Diet was assessed using a validated quantified FFQ from which twelve energy-adjusted food groups were formed and analysed. OR were estimated using conditional logistic regressions, adjusted for confounding factors, comparing highest v. lowest median intake. Fresh fruit consumption showed an inverse association with BC risk (OR=0·3, 95 % CI 0·12, 0·80) in premenopausal women, whilst red and organ meat consumption showed an overall inverse association with BC risk (OR=0·6, 95 % CI 0·49, 0·94 and OR=0·6, 95 % CI 0·47, 0·91). Savoury food consumption (sauces, soups and snacks) were positively associated with BC risk in postmenopausal women (OR=2·1, 95 % CI 1·15, 4·07). Oestrogen receptor-positive stratification showed an inverse association with BC risk and consumption of nuts and seeds (OR=0·2, 95 % CI 0·58, 0·86). Based on these results, it is recommended that black South African women follow a diet with more fruit and vegetables together with a decreased consumption of less energy-dense, micronutrient-poor foods such as savoury foods. More research is necessary to investigate the association between BC risk and red and organ meat consumption. Affordable and practical methods regarding these recommendations should be implemented within health intervention strategies.

Background: The rising incidence of colorectal cancer in sub-Saharan Africa may be partly caused by changing dietary patterns. We sought to establish the association between dietary patterns and colorectal cancer in Zimbabwe., Methods: One hundred colorectal cancer cases and 200 community-based controls were recruited. Data were collected using a food frequency questionnaire, and dietary patterns derived by principal component analysis. Generalised linear and logistic regression models were used to assess the associations between dietary patterns, participant characteristics and colorectal cancer., Results: Three main dietary patterns were identified: traditional African, urbanised and processed food. The traditional African diet appeared protective against colorectal cancer (Odds Ratio (OR) 0.35; 95% Confidence Interval (CI), 0.21 - 0.58), which had no association with the urban (OR 0.68; 95% CI, 0.43-1.08), or processed food (OR 0.91; 0.58-1.41) patterns. The traditional African diet was associated with rural domicile, (OR 1.26; 95% CI, 1.00-1.59), and a low income (OR1.48; 95% CI, 1.06-2.08). The urbanised diet was associated with urban domicile (OR 1.70; 95% CI, 1.38-2.10), secondary (OR 1.30; 95% CI, 1.07-1.59) or tertiary education (OR 1.48; 95% CI, 1.11-1.97), and monthly incomes of $201-500 (OR 1.30; 95% CI, 1.05-1.62), and the processed food pattern with tertiary education (OR 1.42; 95% CI, 1.05-1.92), and income >$1000/month (OR 1.48; 95% CI, 1.02-2.15)., Conclusion: A shift away from protective, traditional African dietary patterns may partly explain the rising incidence of colorectal cancer in sub-Saharan Africa., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: We have shown that nutrient intakes of rural and urban black Africans in the North West Province (NWP) of South Africa (SA) followed the typical nutrition transition pattern upon urbanization and modernization. The current study aimed to examine and report on the changes in food intakes from 2005 to 2010 in rural and urban black South Africans participating in the PURE-NWP-SA study.Design/Setting/SubjectsThe PURE-NWP-SA study recruited 2010 volunteers aged 35-70 years in 2005, from which detailed food intakes, measured with a validated quantified FFQ, for 1858 participants were available. In 2010, food intakes of a cohort of 1154 of these participants were measured., Results: Median energy intake increased in men and women in both rural and urban areas from 2005 to 2010. Changes in food intake were interpreted keeping these changes in energy intake and the contribution of foods and food groups to total energy intake in mind. No 'new' foods were eaten in 2010, but more participants consumed certain foods and products in 2010 than in 2005. Beneficial changes were increased intakes of vegetables, fruit and milk in most groups. The contribution of cooked staple porridges and bread made from fortified maize and bread flour decreased and therefore also did their contribution to micronutrient intakes., Conclusions: By promoting and supporting observed beneficial changes such as increased intakes of milk, vegetables and fruit by appropriate policies and educational interventions, it should be possible to steer the nutrition transition in this population into a positive direction.

Objective: South Africa (SA) is in the midst of a health transition characterized by a quadruple burden of diseases and a nutrition transition. The existing nutrition transition in SA, accompanied by the coexistence of under- and overnutrition in the population, motivated the present study. Its objectives were to measure and report the changes in nutrient intakes of rural and urban black Africans over time to assess the impact of urbanization and modernization of lifestyles on dietary intakes and non-communicable disease (NCD) risk., Design: The PURE-NWP-SA study recruited 2000 black South African volunteers aged 35-70 years in 2005, of which detailed nutrient intakes from 1858 participants were available. In 2010 nutrient intakes of a cohort of 1154 participants were measured., Results: Median energy intake increased over time. In 2010, rural participants consumed the amount of energy (men 9·7 MJ/d; women 9·1 MJ/d) that urban participants consumed in 2005 (men 9·9 MJ/d; women 9·0 MJ/d). The nutrition transition was characterized by increases in the percentage of energy from animal protein, total fat (rural men and women), saturated (not urban women) and monounsaturated fat, as well as added sugar. Despite the higher energy intake, not all the participants met total micronutrient needs in 2010., Conclusions: The PURE nutrient intake data confirmed that the nutrition transition in the North West Province of SA is extremely rapid in rural areas. The shift towards higher energy intakes, an animal food-based diet, higher intakes of fat and lower intake of fibre, at the cost of lower plant protein and starchy food intakes, could increase the risk of NCD.

Objectives: We aimed to identify individual and sexual partnership characteristics associated with partner notification (PN) among people with STI. We hypothesised that PN would be less likely in more casual sexual partnerships and in partnerships with intimate partner violence (IPV)., Methods: We conducted an observational study among the first 330 patients with STI enrolled in a trial of a behavioural intervention to reduce STI incidence, at a clinic in a poor, Cape Town community. We included 195 index patients (those reporting STI symptoms), and conducted longitudinal analyses using participant-completed questionnaires on the day of diagnosis and 2 weeks later. Using partnership data for five recent sexual partners, we assessed factors associated with reported PN with logistic regressions, adjusting for repeated measurements on the same participant for each partner., Results: The sample included 99 males with 303 partners and 96 females with 158 partners. Males reported perpetrating IPV in 46.2% of partnerships. Females reported being IPV victims in 53.2% of partnerships. Males notified 58.1%, females 75.4% of partners during the 2 weeks following diagnosis. Type of partner was an independent correlate of PN for males and females, with the odds of PN lower in more casual partnerships. For males, reporting physical IPV perpetration in the partnership was an independent correlate of PN. For females, there was no association between IPV victimisation in a partnership and PN., Conclusions: Efforts to decrease the pool of infectious partners need to have a strong focus on the promotion of PN in casual relationships and one-night stands. IPV was not identified as a barrier to PN. In future, we need to investigate the association between IPV with an objective measure of PN success such as partner testing or treatment, or index patient reinfection., Clinical Trial Registration: PACTR201606001682364; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Female university students are at risk for weight gain and use of inappropriate weight-loss strategies. By gaining a greater understanding of the weight-loss strategies used by and weight management related characteristics of these students, effective weight management interventions for this vulnerable group can be developed., Methods: Two hundred and fifty female students from South Africa universities, aged 18-25 years, participated in this cross-sectional study; 162 attempted weight loss during the year preceding the study (dieters) and 88 were non-dieters. Weight and height were measured and BMI (kg/m(2)) computed. A self-administered questionnaire was used to record all other variables. Weight loss strategies were described for dieters and compared between BMI groups within the dieters group. Weight management related characteristics were compared between dieters and non-dieters. Statistical tests included Pearson Chi-square test, independent samples t-test or Mann-Whitney U test (depending on distribution of the data). Predictors for a higher BMI and being overweight/obese (BMI ≥25 kg/m(2)) were identified using regression models., Results: Healthy weight-loss strategies included increased exercise and fruit/vegetable intake and decreased intake of sugar and fat containing items; unhealthy methods included eating little food and skipping meals; and extreme weight loss strategies included laxatives and vomiting. The most commonly used weight-loss product was Herbex. Dieters were characterized by a higher BMI, overestimation of their weight (especially normal weight students), dissatisfaction with weight and select body parts, higher intake of breakfast and healthy foods, lower intake of unhealthy foods, higher levels of vigorous physical activity, higher use of select informal weight-loss information sources and experiencing more pressure to lose weight from mothers, siblings and friends. Predictors of higher BMI and/or increased risk for BMI ≥25 included weight-loss attempt during the past year, race, dissatisfaction with waist, perception of currently being "chubby," and higher frequencies of intake of a snack and fatty foods., Conclusion: Attempting weight-loss is common among female students and predicts BMI. Healthy (mainly), unhealthy and extreme weight loss methods are used. Dieters are characterized by a less realistic body image, lower body satisfaction, higher pressure to lose weight, use of informal weight-management information and a healthier life-style.

Background: South Africa continues to witness an increase in illicit poly-substance use, although a precise measurement continues to be compounded by difficulties in accessing users. In a pilot attempt to use respondent-driven sampling (RDS)-a chain referral sampling method used to access populations of individuals who are 'hard-to-reach'-this article documents the feasibility of the method as recorded in a simultaneously run, multisite, poly-substance study in Cape Town. Here we aim to a) document the piloting of RDS among poly-substance users in the three socio-economic disparate communities targeted; b) briefly document the results; and c) review the utility of RDS as a research tool., Methods: Three cross-sectional surveys using standard RDS procedures were used to recruit active poly-substance users and were concurrently deployed in three sites. Formative research was initially conducted to assess the feasibility of the survey. To determine whether RDS could be used to successfully recruit poly-substance users, social network characteristics, such as network size was determined., Results: A 42.5 % coupon return rate was recorded in total from 12 initial seeds. There were vast differences in the recruitment chains of individual seeds-two generated more than 90 recruits, and 2 of the 10 recruitment chains showing a length of more than 10 waves. Findings include evidence of the use of 3 or more substances in all three sites, high levels of unemployment among users, with more than a third of participants in two sites reporting arrest for drug use in the past 12 months., Conclusions: Our results indicate that RDS was a feasible and acceptable sampling method for recruiting participants who may not otherwise be accessible. Future studies can use RDS to recruit such cohorts, and the method could form part of broader efforts to document vulnerable populations.

Background: The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997-2012 and develop national, population group, and provincial estimates of the levels and causes of mortality., Method: We used underlying cause of death data from death notifications for 1997-2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison., Findings: All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29·1%) followed by cerebrovascular disease (7·5%) and lower respiratory infections (4·9%). All-cause age-standardised death rates were 1·7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2·2 times higher in black Africans compared to whites, and 1·4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence., Interpretation: This study shows the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data., Funding: South African Medical Research Council's Flagships Awards Project., (Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)

Infants and toddlers have high nutritional requirements relative to body size but consume small amounts of food and therefore need nutrient-dense complementary foods. A cross-sectional study included children aged 6-24 months, stratified in three age categories (6-11 months, 12-17 months and 18-24 months) and randomly selected from an urban (n = 158) and a rural (n = 158) area, both of low socio-economic status, in the KwaZulu-Natal Province of South Africa. Dietary diversity and nutrient density of the complementary diet (excluding breast milk and formula milk) based on a repeated 24-h dietary recall was assessed. For breastfeeding children, nutrient density of the complementary diet was adequate for protein, vitamin A and vitamin C; and inadequate for 100% of children for zinc, for >80% of children for calcium, iron and niacin; and between 60% and 80% of children for vitamin B6 and riboflavin. Urban/rural differences in density for animal and plant protein, cholesterol and fibre occurred in 18-24-month-old children. Fewer than 25% of children consumed ≥4 food groups, with no urban/rural differences. Higher dietary diversity was associated with higher nutrient density for protein and several of the micronutrients including calcium, iron and zinc. The poor nutrient density for key micronutrients can probably be ascribed to lack of dietary variety, and little impact of mandatory fortification of maize meal/wheat flour on infants/toddlers' diet. Targeted strategies are needed to enable mothers to feed their children a more varied diet., (© 2014 John Wiley & Sons Ltd.)

Objectives: National trends in age-standardised death rates (ASDRs) for non-communicable diseases (NCDs) in South Africa (SA) were identified between 1997 and 2010., Methods: As part of the second National Burden of Disease Study, vital registration data were used after validity checks, proportional redistribution of missing age, sex and population group, demographic adjustments for registration incompleteness, and identification of misclassified AIDS deaths. Garbage codes were redistributed proportionally to specified codes by age, sex and population group. ASDRs were calculated using mid-year population estimates and the World Health Organization world standard., Results: Of 594 071 deaths in 2010, 38.9% were due to NCDs (42.6% females). ASDRs were 287/100 000 for cardiovascular diseases (CVDs), 114/100 000 for cancers (malignant neoplasms), 58/100 000 for chronic respiratory conditions and 52/100 000 for diabetes mellitus. An overall annual decrease of 0.4% was observed resulting from declines in stroke, ischaemic heart disease, oesophageal and lung cancer, asthma and chronic respiratory disease, while increases were observed for diabetes, renal disease, endocrine and nutritional disorders, and breast and prostate cancers. Stroke was the leading NCD cause of death, accounting for 17.5% of total NCD deaths. Compared with those for whites, NCD mortality rates for other population groups were higher at 1.3 for black Africans, 1.4 for Indians and 1.4 for coloureds, but varied by condition., Conclusions: NCDs contribute to premature mortality in SA, threatening socioeconomic development. While NCD mortality rates have decreased slightly, it is necessary to strengthen prevention and healthcare provision and monitor emerging trends in cause-specific mortality to inform these strategies if the target of 2% annual decline is to be achieved.

Objectives: Empirical estimates of the number of HIV/AIDS deaths are important for planning, budgeting, and calibrating models. However, there is an extensive misattribution of HIV/AIDS as an underlying cause-of-death. This study estimates the true numbers of AIDS deaths from South African vital statistics between 1997 and 2010., Methods: Individual-level cause-of-death data were grouped according to a local burden of disease list and source causes (i.e. causes under which AIDS deaths are misclassified) that recorded a rapid increase. After adjusting for completeness of registration, the mortality rate of the source causes, by age and sex, was regressed on the lagged HIV prevalence to estimate the rate of increase correlated with HIV. Background trends in the source-cause mortality rates were estimated from the trend experienced among 75-84 year olds., Results: Of 214 causes considered, 19 were identified as potential sources for cause misattribution. High proportions of deaths from tuberculosis, lower respiratory infections (mostly pneumonia), diarrhoeal diseases, and ill-defined natural causes were estimated to be HIV-related, with only 7% of the estimated AIDS deaths being recorded as HIV. Estimated HIV/AIDS deaths increased rapidly, then reversed after 2006, totalling 2.8 million deaths over the whole period. The number was lower than model estimates from Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Global Burden of Disease Study., Conclusion: Empirically based estimates confirm the considerable loss of life from HIV/AIDS and should be used for calibrating models of the AIDS epidemic which generally appear too low for infants but too high for other ages. Doctors are urged to specify HIV on death notifications to provide reliable cause-of-death statistics.

Introduction: There is uncertainty regarding the completeness of death recording by civil registration and by health centres in South Africa. This paper aims to compare death recording by the two systems, in cohorts of South African patients receiving antiretroviral treatment (ART)., Methods: Completeness of death recording was estimated using a capture-recapture approach. Six ART programmes linked their patient record systems to the vital registration system using civil identity document (ID) numbers and provided data comparing the outcomes recorded in patient files and in the vital registration. Patients were excluded if they had missing/invalid IDs or had transferred to other ART programmes., Results: After exclusions, 91,548 patient records were included. Of deaths recorded in patients files after 2003, 94.0% (95% CI: 93.3-94.6%) were recorded by civil registration, with completeness being significantly higher in urban areas, older adults and females. Of deaths recorded by civil registration after 2003, only 35.0% (95% CI: 34.2-35.8%) were recorded in patient files, with this proportion dropping from 60% in 2004-2005 to 30% in 2010 and subsequent years. Recording of deaths in patient files was significantly higher in children and in locations within 50 km of the health centre. When the information from the two systems was combined, an estimated 96.2% of all deaths were recorded (93.5% in children and 96.2% in adults)., Conclusions: South Africa's civil registration system has achieved a high level of completeness in the recording of mortality. However, the fraction of deaths recorded by health centres is low and information from patient records is insufficient by itself to evaluate levels and predictors of ART patient mortality. Previously documented improvements in ART mortality over time may be biased if based only on data from patient records.

Objective: To test the effectiveness of a programme aimed at reducing the risky use of alcohol and alcohol-related HIV risk and increase help-seeking behaviour among a sample of municipal employees in the Western Cape Province, South Africa., Methods: A clustered randomised controlled trial was conducted in 2011-2012 among 325 employees. The eight hour intervention, Team Awareness (TA), addressing behavioural risk among employees was administered to 168 employees in the intervention arm and the 157 employees in the control arm who received a one-hour wellness talk., Results: The results show that TA had the greatest impact on risky drinking practices and hangover effects. There was a significant group × time interaction (F (1, 117) = 25.16, p<0.0001) with participants in the intervention condition reducing number of days on which they engaged in binge drinking. There was also a significant time effect with participants in the intervention condition reducing the likelihood of going to work with a hangover (F (1,117) = 4.10, p=0.045). No reduction in HIV-related risk behaviours were found., Conclusions: This intervention study was able to demonstrate a modest but significant reduction in risky drinking practices and hangover effects. This provides encouraging evidence for the effectiveness of interventions that address risky use of alcohol among employed persons, further providing a launch pad for strengthening and replicating future RCT studies on workplace prevention, especially in developing country settings., Clinical Trial Registration Number: Pan-African Control Trial Registry (201301000458308) .

Objective: To investigate injury-related mortality in South Africa using a nationally representative sample and compare the results with previous estimates., Methods: We conducted a retrospective descriptive study of medico-legal postmortem investigation data from mortuaries using a multistage random sample, stratified by urban and non-urban areas and mortuary size. We calculated age-specific and age-standardized mortality rates for external causes of death., Findings: Postmortem reports revealed 52,493 injury-related deaths in 2009 (95% confidence interval, CI: 46,930-58,057). Almost half (25,499) were intentionally inflicted. Age-standardized mortality rates per 100,000 population were as follows: all injuries: 109.0 (95% CI: 97.1-121.0); homicide 38.4 (95% CI: 33.8-43.0; suicide 13.4 (95% CI: 11.6-15.2) and road-traffic injury 36.1 (95% CI: 30.9-41.3). Using postmortem reports, we found more than three times as many deaths from homicide and road-traffic injury than had been recorded by vital registration for this period. The homicide rate was similar to the estimate for South Africa from a global analysis, but road-traffic and suicide rates were almost fourfold higher., Conclusion: This is the first nationally representative sample of injury-related mortality in South Africa. It provides more accurate estimates and cause-specific profiles that are not available from other sources.

Background: Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs., Objective: To review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example., Methods: Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010., Results: The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ≥25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled., Conclusion: Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential.

eHealth has been identified as a useful approach to disseminate HIV/AIDS information. Together with Consumer Health Informatics (CHI), the Web-to-Public Knowledge Transfer Model (WPKTM) has been applied as a theoretical framework to identify consumer needs for AfroAIDSinfo, a South African Web portal. As part of the CHI practice, regular eSurveys are conducted to determine whether these needs are changing and are continually being met. eSurveys show high rates of satisfaction with the content as well as the modes of delivery. The nature of information is thought of as reliable to reuse; both for education and for referencing of information. Using CHI and the WPKTM as a theoretical framework, it ensures that needs of consumers are being met and that they find the tailored methods of presenting the information agreeable. Combining ICTs and theories in eHealth interventions, this approach can be expanded to deliver information in other sectors of public health.

Introduction: Harmful alcohol use can compromise worker health and productivity. Persons employed in safety-sensitive occupations are particularly vulnerable to hazardous alcohol use and its associated risks. This study describes the patterns of harmful alcohol use, related HIV risks and risk factors for the harmful use of alcohol among a sample of employees in South Africa working in the safety and security sector., Methods: A cross-sectional study that formed the baseline for a clustered randomized control trial was undertaken in 2011. A random sample of 325 employees employed within a safety and security sector of a local municipality in the Western Cape Province of South Africa participated in the study. Data were collected by means of an 18-page self-administered structured questionnaire and analyzed using SAS/STAT software version 9.2. For all significance testing, the F-statistic and p-values are reported., Results: Three hundred and twenty-five employees were surveyed. Findings suggest that more than half (76.1%) of the 78.9% of participants who consumed alcohol engaged in binge drinking, with close to a quarter reporting a CAGE score greater than the cut-off of 2, indicating potentially hazardous drinking patterns. The study further found that employees who use alcohol are more likely to engage in risky sexual practices when under the influence. A favorable drinking climate (p < 0.001) and poor levels of group cohesion (p = 0.009) were significantly correlated to binge drinking., Conclusion: This study identifies alcohol-related behaviors and associated risks in the context of safety-sensitive occupations at the workplace. It suggests that persons employed within such positions are at high risk for developing alcohol-related disorders and for contracting HIV. This study highlights the need for testing a comprehensive package of services designed to prevent hazardous alcohol use among safety and security employees.

Introduction: Evidence suggests that comorbid psychopathology can negatively affect treatment outcomes in substance users. In South Africa, limited information exists regarding the prevalence, nature and role of psychiatric comorbidity in substance users. This study examined psychiatric comorbidity and its association with specific substance use, and young adult substance users in treatment for substance use., Methods: Male and female inpatient substance users (n=95; ages 17-30 years) were sampled consecutively in order of admission from three clinics in Cape Town. An interview schedule was administered to elicit patients' sociodemographic and substance use history details. The computer-assisted Diagnostic Interview Schedule DSM IV (C-DIS IV) was administered to screen patients for current psychiatric disorders., Results: The sample was largely male, Coloured, Muslim and single. Cannabis (51.6%) and crystal methamphetamine (17.9%) were the most common first substances of use. Heroin (53.7%) and crystal methamphetamine (33.7%) were the most common substances for which treatment was sought (primary substances). The most common comorbid psychopathologies were anti-social personality disorder (ASPD 87.4%) and conduct disorder (CD 67.4%). Regression analyses showed a marginally significant association between specific phobia and first use of cannabis, but indicated no statistically significant associations between psychopathology and substance use., Conclusion: The results demonstrated a high proportion of previously unidentified comorbid psychopathology in inpatient substance users. Further research is needed to investigate psychiatric comorbidity in inpatient substance users.

Background: The full eventual effects of current smoking patterns cannot yet be seen in Africa. In South Africa, however, men and women in the coloured (mixed black and white ancestry) population have smoked for many decades. We assess mortality from smoking in the coloured, white, and black (African) population groups., Methods: In this case-control study, 481,640 South African notifications of death at ages 35-74 years between 1999 and 2007 yielded information about age, sex, population group, education, smoking 5 years ago (yes or no), and underlying disease. Cases were deaths from diseases expected to be affected by smoking; controls were deaths from selected other diseases, excluding only HIV, cirrhosis, unknown causes, external causes, and mental disorders. Disease-specific case-control comparisons yielded smoking-associated relative risks (RRs; diluted by combining some ex-smokers with the never-smokers). These RRs, when combined with national mortality rates, yielded smoking-attributed mortality rates. Summation yielded RRs and smoking-attributed numbers for overall mortality., Findings: In the coloured population, smoking prevalence was high in both sexes and smokers had about 50% higher overall mortality than did otherwise similar non-smokers or ex-smokers (men, RR 1·55, 95% CI 1·43-1·67; women, 1·49, 1·38-1·60). RRs were similar in the white population (men, 1·37, 1·29-1·46; women, 1·51, 1·40-1·62), but lower among Africans (men, 1·17, 1·15-1·19; women, 1·16, 1·13-1·20). If these associations are largely causal, smoking-attributed proportions for overall male deaths at ages 35-74 years were 27% (5608/20,767) in the coloured, 14% (3913/28,951) in the white, and 8% (20,398/264,011) in the African population. For female deaths, these proportions were 17% (2728/15,593) in the coloured, 12% (2084/17,899) in the white, and 2% (4038/205,623) in the African population. Because national mortality rates were also substantially higher in the coloured than in the white population, the hazards from smoking in the coloured population were more than double those in the white population., Interpretation: The highest smoking-attributed mortality rates were in the coloured population and the lowest were in Africans. The substantial hazards already seen among coloured South Africans suggest growing hazards in all populations in Africa where young adults now smoke., Funding: South African Medical Research Council, UK Medical Research Council, Cancer Research UK, British Heart Foundation, New South Wales Cancer Council., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: All rigorous primary cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk scores to identify high- and low-risk patients, but laboratory testing can be impractical in low- and middle-income countries. The purpose of this study was to compare the ranking performance of a simple, non-laboratory-based risk score to laboratory-based scores in various South African populations., Methods: We calculated and compared 10-year CVD (or coronary heart disease (CHD)) risk for 14,772 adults from thirteen cross-sectional South African populations (data collected from 1987 to 2009). Risk characterization performance for the non-laboratory-based score was assessed by comparing rankings of risk with six laboratory-based scores (three versions of Framingham risk, SCORE for high- and low-risk countries, and CUORE) using Spearman rank correlation and percent of population equivalently characterized as 'high' or 'low' risk. Total 10-year non-laboratory-based risk of CVD death was also calculated for a representative cross-section from the 1998 South African Demographic Health Survey (DHS, n = 9,379) to estimate the national burden of CVD mortality risk., Results: Spearman correlation coefficients for the non-laboratory-based score with the laboratory-based scores ranged from 0.88 to 0.986. Using conventional thresholds for CVD risk (10% to 20% 10-year CVD risk), 90% to 92% of men and 94% to 97% of women were equivalently characterized as 'high' or 'low' risk using the non-laboratory-based and Framingham (2008) CVD risk score. These results were robust across the six risk scores evaluated and the thirteen cross-sectional datasets, with few exceptions (lower agreement between the non-laboratory-based and Framingham (1991) CHD risk scores). Approximately 18% of adults in the DHS population were characterized as 'high CVD risk' (10-year CVD death risk >20%) using the non-laboratory-based score., Conclusions: We found a high level of correlation between a simple, non-laboratory-based CVD risk score and commonly-used laboratory-based risk scores. The burden of CVD mortality risk was high for men and women in South Africa. The policy and clinical implications are that fast, low-cost screening tools can lead to similar risk assessment results compared to time- and resource-intensive approaches. Until setting-specific cohort studies can derive and validate country-specific risk scores, non-laboratory-based CVD risk assessment could be an effective and efficient primary CVD screening approach in South Africa.

Availability and consumption of fruits and vegetables were assessed in peri-urban households in KwaZulu-Natal Province, South Africa. Caregivers of 400 randomly selected grade 6 and 7 learners were interviewed using a questionnaire that included unquantified food frequency questions. Using a repeated 24-h dietary recall, dietary intake was quantified for learners, caregivers and 2- to 5-year-old children in the household. Usual household fruit and vegetable consumption was expressed over three Living Standard Measure (LSM) categories. Average per capita intake of fruit and/or vegetables was 99 g for 2- to 5-year-old children and 124 g for caregivers. For consumers, fruits and/or vegetables contributed towards total dietary intake of fibre (16-21%), calcium (13-21%), vitamin A (27-31%) and vitamin C (47-62%). For households not consuming fruits (n = 297) and vegetables (n = 178) daily, cost was the major constraint (≥75%). Of all households, 52% had fruit trees and 25% had a vegetable garden. Animals destroying vegetables was the major constraint to 59% of vegetable growers. Household consumption of fruits and vegetables increased over the LSM categories. Caregivers in the higher LSM group more likely used printed material for information on healthy eating, had fruit trees, were confident about vegetable gardening and sold some of their produce. To enable peri-urban populations of low socio-economic status to consume more frequently a bigger variety of fruits and vegetables, the cost of purchasing these food items needs to be addressed by government and business sector. Households should further receive support to overcome constraints which hamper the success of home gardens., (© 2011 John Wiley & Sons Ltd.)

Background: Non-communicable chronic diseases (NCDs) have increased in South Africa over the past 15 years. While these usually manifest during mid-to-late adulthood, the development of modifiable risk factors that contribute to NCDs are usually adopted early in life., Objective: To describe the urban-rural and gender patterns of NCD risk factors in black adolescents and young adults (15- to 24-year-olds) from two South African Demographic and Health Surveys conducted 5 years apart., Design: An observational study based on interviews and measurements from two cross-sectional national household surveys. Changes in tobacco and alcohol use, dietary intake, physical inactivity, and overweight/ obesity among 15- to 24-year-olds as well as urban-rural and gender differences were analysed using logistic regression. The 'Surveyset' option in Stata statistical software was used to allow for the sampling weight in the analysis., Results: Data from 3,186 and 2,066 black 15- to 24-year-old participants in 1998 and 2003, respectively, were analysed. In males, the prevalence of smoking (1998: 21.6%, 2003: 19.1%) and problem drinking (1998: 17.2%, 2003: 15.2%) were high and increased with age, but in females were much lower (smoking - 1998: 1.0%, 2003: 2.1%; problem drinking - 1998: 4.2%, 2003: 5.8%). The predominant risk factors in females were overweight/obesity (1998: 29.9%, 2003: 31.1%) and physical inactivity (2003: 46%). Urban youth, compared to their rural counterparts, were more likely to smoke (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.09-1.75), have high salt intake (OR: 1.75, 95% CI: 1.12-2.78), be overweight/obese (OR: 1.39, 95% CI: 1.14-1.69), or be physically inactive (OR: 1.45, 95% CI: 1.12-1.89). However, they had lower odds of inadequate micronutrient intake (OR: 0.46, 95% CI 0.34-0.62), and there was no overall significant urban- rural difference in the odds for problem drinking but among females the odds were higher in urban compared to rural females., Conclusion: Considering that the prevalence of modifiable NCD risk factors was high in this population, and that these may persist into adulthood, innovative measures are required to prevent the uptake of unhealthy behaviours, and regular surveillance is needed.

Adequate vitamin D and calcium are essential for optimal adolescent skeletal development. Adolescent vitamin D insufficiency/deficiency and poor calcium intake have been reported worldwide. Heavy alcohol use impacts negatively on skeletal health, which is concerning since heavy adolescent drinking is a rising public health problem. This study aimed to examine biochemical vitamin D status and dietary intakes of calcium and vitamin D in 12-16 year-old adolescents with alcohol use disorders (AUD), but without co-morbid substance use disorders, compared to adolescents without AUD. Substance use, serum 25-hydroxyvitamin D (s-25(OH)D) concentrations, energy, calcium and vitamin D intakes were assessed in heavy drinkers (meeting DSM-IV criteria for AUD) (n = 81) and in light/non-drinkers without AUD (non-AUD) (n = 81), matched for age, gender, language, socio-economic status and education. Lifetime alcohol dose was orders of magnitude higher in AUD adolescents compared to non-AUD adolescents. AUD adolescents had a binge drinking pattern and "weekends-only" style of alcohol consumption. Significantly lower (p = 0.038) s-25(OH)D (adjusted for gender, smoking, vitamin D intake) were evident in AUD adolescents compared to non-AUD adolescents. High levels of vitamin D insufficiency/deficiency (s-25(OH)D < 29.9 ng/mL) were prevalent in both groups, but was significantly higher (p = 0.013) in the AUD group (90%) compared to the non-AUD group (70%). All participants were at risk of inadequate calcium and vitamin D intakes (Estimated Average Requirement cut-point method). Both groups were at risk of inadequate calcium intake and had poor biochemical vitamin D status, with binge drinking potentially increasing the risk of the latter. This may have negative implications for peak bone mass accrual and future osteoporosis risk, particularly with protracted binge drinking.

Homicide rates for South African children were estimated at double the global average in 2000. This article presents a secondary data analysis of the National Injury Mortality Surveillance System (NIMSS), with full coverage in four major metropolitan cities. Child homicide rates for 2001-2005 were calculated within the 0-4, 5-9 and 10-14 year age groups. The homicide rates were similar to the global pattern, with higher rates for boys, and among children aged 0-4 years than for older children. Poisson regression, accounting for city level clustering, was used to investigate age, sex and period effects in the homicide rate. The model indicated that the gender difference was more marked in the 10-14 year age groups (RR = 2.17; 95% CI 1.97-2.38) than in the 5-9 year (RR = 1.43; 95% CI 1.27-1.62) with the 0-4 year age group in-between (RR = 1.80; 95% CI 1.55-2.10). These data confirm previous observations that fatal violence among children is a public health concern, but, given the high rates of homicide among South African adults and other competing public health problems, it is difficult to motivate for action to address the issue of violence against children. Nonetheless, there are sufficient indications that efforts to reduce childhood violence are urgently needed.

Background: Heavy alcohol consumption during adolescence has many known harmful health and social consequences and is strongly associated with numerous health risk behaviours. The consequences of heavy alcohol use during adolescence on nutritional status, specifically growth and weight status are largely unknown at this time., Methods: Substance use, anthropometric indices of growth and weight, dietary energy intake and physical activity in heavy drinking adolescents (meeting DSM-IV criteria for alcohol use disorders) and matched light/non-drinking control adolescents were assessed., Results: Lifetime alcohol dose, measured in standard drinks of alcohol, was orders of magnitude higher in adolescents with alcohol use disorders (AUDs) compared to controls. The AUDs group was selected to represent relatively 'pure' AUDs, with minimal other drug use and no psychiatric diagnoses. The growth and weight status of adolescents with AUDs were generally comparable to that of controls, and is in line with the growth and weight status of the South African adolescent population. A greater proportion of overweight/obese females was found in both groups, with this percentage tending to be greater, although not significantly so, in the AUDs group. Adolescent females with AUDs had increased odds of being overweight/obese compared to controls, after adjustment for smoking, physical activity and energy intake., Conclusion: Anthropometric indices of growth and weight status of participants in the Control and AUD groups were generally comparable. Female adolescents with AUDs may have an increased risk of being overweight/obese compared to adolescent females without AUDs. The presence of an AUD in our adolescent sample was associated with higher energy intake. Longitudinal studies are needed to elucidate the effects of heavy alcohol use on energy balance, growth and weight status in adolescents as they age. Nonetheless, the current study contributes to our understanding of the impacts of heavy alcohol consumption on important aspects of adolescent development.

Little information is available on the response of vervet monkeys to different housing conditions or on the suitability of enrichment devices or methods for vervet monkeys. In this study, the authors evaluated the occurrence of stereotyped behavior in adult vervet monkeys under various conditions of housing and enrichment. The variables included cage size, cage level (upper or lower), enrichment with a foraging log, enrichment with an exercise cage and presence of a mate. The authors first determined the incidence of stereotyped behavior in captive-bred, singly housed adult female and male vervet monkeys. They then exposed monkeys to different housing and enrichment situations and compared the incidence of stereotyped behavior among the monkeys. The authors found that more females than males engaged in stereotyped behavior and that females, on average, engaged in such behavior for longer periods of time than males. Stereotyped behavior was most often associated with a small, single cage. The average amount of observed stereotyped activity in monkeys housed in a small cage was significantly lower when the monkeys had access to either a foraging log or an exercise cage. Stereotyped behavior was also lower in female monkeys that were housed (either with a male or without a male) in a larger cage. The least amount of abnormal behavior was associated with the largest, most complex and enriched housing situation. Males and females housed in cages on the lower level of two-level housing engaged in more stereotyped behavior than did monkeys housed in the upper level, regardless of the presence or type of enrichment provided.

Introduction: Since peaking in the early 1990s in South Africa, tobacco use has declined significantly. The reduction has been attributed to the government's comprehensive tobacco control policies that were introduced at the time., Objective: To assess the pattern of tobacco use in the South African Demographic and Health Surveys of 1998 and 2003., Methods: Multi-stage sampling was used to select approximately 11 000 households in cross-sectional national surveys. Face-to-face interviews, conducted with 13 826 adults (41% men) aged > or = 15 years in 1998, and 8 115 (42% men) in 2003, included questions on tobacco use according to the WHO STEP-wise surveillance programme. Logistic regression analysis was used to assess the independent effects of selected characteristics on smoking prevalence., Results: Daily or occasional smoking prevalence among women remained unchanged at 10 - 11%; it decreased among men from 42% (1998) to 35% (2003). The decline for men was significant among the poorest and those aged 25 - 44 years. Strong age patterns were observed, peaking at 35 - 44 years, which was reduced among men in 2003. Higher income and education were associated with low prevalence of smoking, while living in urban areas was associated with higher rates. Black men and women smoked significantly less than other population groups., Conclusion: Despite decreased smoking rates in some subgroups, a lapse exists in the efforts to reduce tobacco use, as smoking rates have remained unchanged among women, and also among young adults aged 15 - 24 years.