Estimating injury mortality in South Africa and identifying urban-rural differences

The overarching aim of this thesis is to utilise national data on injury mortality in South Africa, to conduct advanced statistical analyses to identify urban-rural differences for injury deaths, and to gain insight into the explanatory variables for homicide in metropolitan- and non-metropolitan (metro- and non-metro) areas. The literature review describes the global and national estimates of injury mortality and reports higher rural than urban injury mortality rates for high-income countries. It further discusses a framework for assessing data quality and reviews South Africa’s fatal and non-fatal injury data sources, issues of under-reporting and misclassification of deaths. The risk factors for violence are reviewed, which inform particular hypotheses on the role of age, sex, race, day of week and firearms with regard to homicide. The Injury Mortality Survey (IMS) data, which estimated 52 493 injury deaths nationally in 2009, is utilised for this PhD study. Data quality is assessed using an internationally developed conceptual framework for mortality data. Exploratory and multiple correspondence analysis identified possible associations between metro/nonmetro and other explanatory variables, prior to more sophisticated multinomial logistic regression analysis, which adjusted for age, sex, race and metro/non-metro for each manner of death (homicide, suicide, transport-related and other unintentional injury deaths) to explore particular hypotheses for the differences in the metro/non-metro injury mortality profile. Age-standardised injury mortality rates were calculated to take into account the effects of different age structures for metro- and non-metro populations. Generalized linear models were fitted in relation to particular hypotheses to determine the explanatory variables for homicide deaths in both metro and nonmetro areas. Main findings include a significantly higher likelihood for homicide in metro areas compared to non-metro areas, while transport-related deaths were significantly lower in metro areas. The risk of homicide for Coloureds was higher than Blacks in metro areas, while Blacks, Coloureds and Asians had similar risks of homicide in non- metro areas. Whites had a similar risk and Asians a higher risk of homicide in nonmetro areas compared with metro areas. Firearm use was shown to significantly explain metro/non-metro differences in homicide risks. This study’s most significant knowledge contribution includes the identification of metro/non-metro as a significant predictor of the injury mortality profile in South Africa. The association of metro/non-metro differences in the pattern of homicide for Blacks and Coloureds, also resolved conflicting statements found in the literature regarding race and homicide in South Africa. The results are of considerable significance to national and provincial policy makers. Recommendations are made in relation to the main findings of this study

Factors impacting on the criminal investigation process in Cape Town, South Africa

Masters of Public Health - see Magister Public HealthThe World Health Organization (WHO) considers violence to be a global public health problem. It is estimated that 1.6 million people worldwide lost their lives to violence in 2000. This translates to a global rate of 28.8 deaths per 100 000 population. The end of Apartheid in South Africa in 1994 brought about various economic, social and political transitions within the country, resulting in rapid urbanization, increasing unemployment and deepening inequalities. Consequently, these conditions also brought about increased incidences of crime and violence. The South African Police Service (SAPS) recorded approximately 2.58 million crimes in 2000. The SAPS faced many challenges in transforming the eleven South African Police Forces to a combined South African Police Service in 1994. Literature has indicated that while serious crimes increased, the chances of an offender being caught and punished declined between 1994 and 2000. During the 2002-2003 financial year the SAPS recorded a national homicide rate of 47.4 per 100 000 population. The Western Cape and Limpopo province had the highest and lowest provincial homicide rate of 84.8 and 12.1 per 100 000 population respectively. Other studies indicated that city-specific homicide rates for Cape Town increased from 84 to 88 per 100 000 population between 1999 and 2001. A pilot study conducted in Cape Town during 2003 to determine victim-perpetrator relationships and motives for homicide that occurred in 1999 was hampered by difficulties in tracing police dockets, inconsistencies in data capturing, and the absence of perpetrator information due to some court cases not being finalized. It was therefore decided to conduct a qualitative, descriptive, comparative study between two police stations in Cape Town. Semi-structured interviews were conducted with police officers at different ranks to document the procedures and route of reported crimes and to explore the factors impacting on the criminal investigation process. The interviews were audio-recorded, transcribed and analysed using thematic content analysis. The interviews provided an insight to the contextual environment and the attitudes of police officers regarding the transformation of the SAPS, and identified the factors impacting on the criminal investigation process at the two selected police stations. Issues discussed are discipline, restructuring and motivational factors regarding the transformation process, as well as training courses, the court impact and the relationship between the detectives and prosecutors. The main constraints identified at both police stations were human resources, training courses and vehicles. Social support and community factors are also discussed. The interviews with police officers revealed that there are various issues of management at national and provincial level that need to be addressed, such as detective recruitment standards, training courses and the management of different crime types to reduce the workload of detectives. The need for closer collaboration with the courts to avoid the misplacement of dockets and to minimise delays in the finalisation of court cases was also identified. Previous studies have also identified blockages within the South African criminal justice system and it is hoped that this study could highlight those issues that still need to be addressed

The firearm pandemic: time to act and flatten the curve

N/

Mortality trends and diff erentials in South Africa from 1997 to 2012: second National Burden of Disease Study

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 notifi cations 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 misclassifi ed 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 diff erences 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 diff erentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Diff erences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data

Structural and functional characterization of peptides derived from the carboxy-terminal region of a defensin from the tick Ornithodoros savignyi

Tick defensins may serve as templates for the development of multifunctional peptides. The purpose of this study was to evaluate shorter peptides derived from tick defensin isoform 2 (OsDef2) in terms of their antibacterial, antioxidant, and cytotoxic activities. We compared the structural and functional properties of a synthetic peptide derived from the carboxy-terminal of the parent peptide (Os) to that of an analogue in which the three cysteine residues were omitted (Os–C). Here, we report that both peptides were bactericidal (MBC values ranging from 0.94–15mg/ml) to both Gram-positive and Gram-negative bacteria, whereas the parent peptide only exhibited Gram-positive antibacterial activity. The Os peptide was found to be two-fold more active than Os–C against three of the four tested bacteria but equally active against Staphylococcus aureus. Os showed rapid killing kinetics against both Escherichia coli and Bacillus subtilis, whereas Os–C took longer, suggesting different modes of action. Scanning electron microscopy showed that in contrast to melittin for which blebbing of bacterial surfaces was observed, cells exposed to either peptide appeared flattened and empty. Circular dichroism data indicated that in a membrane-mimicking environment, the cysteine-containing peptide has a higher a-helical content. Both peptides were found to be non-toxic to mammalian cells. Moreover, the peptides displayed potent antioxidant activity and were 12 times more active than melittin. Multifunctional peptides hold potential for a wide range of clinical applications and further investigation into their mode of antibacterial and antioxidant properties is therefore warranted.Medical Research Council of South Africa,the National Research Foundation of South Africa, and the University of Pretoriahttp://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1099-1387hb201

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Alcohol diagnostic validation for injury-related trauma : Findings from a pilot study

Introduction: Alcohol consumption is a key driver of the burden of violence and injury in South Africa (SA). Hence, we aim to validate various alcohol assessment tools against a blood test to assess their utility for improving national health practice and policy. Methods: We conducted a cross-sectional pilot study from 3 to 19 August 2022 at Groote Schuur Hospital in Cape Town, SA. This was to test logistics for the time of venous blood centrifugation and validation of alcohol assessment tools used in injured patients ahead of the main validation study. Adults aged 18 years and older, who were injure

Femicide, intimate partner femicide, and non-intimate partner femicide in South Africa: An analysis of 3 national surveys, 1999-2017.

BackgroundIn most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs).Methods and findingsWe conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data.ConclusionsIn this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems