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Time-critical conditions: assessment of burden and access to care using verbal autopsy in Agincourt, South Africa
  1. Andrew Fraser1,
  2. Jessica Newberry Le Vay2,
  3. Peter Byass3,4,5,
  4. Stephen Tollman4,
  5. Kathleen Kahn4,
  6. Lucia D'Ambruoso4,5,
  7. Justine I Davies4,6
  1. 1Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
  2. 2Cancer Policy Research Centre, Cancer Research UK, London, UK
  3. 3Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
  4. 4Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  5. 5Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Dentistry, University of Aberdeen, Aberdeen, UK
  6. 6Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  1. Correspondence to Dr Andrew Fraser; andy.fraser{at}


Background Time-critical conditions (TCC) are estimated to cause substantial mortality in low and middle-income countries. However, quantification of deaths and identification of contributing factors to those deaths are challenging in settings with poor health records.

Aim To use verbal autopsy (VA) data from the Agincourt health and sociodemographic surveillance system in rural South Africa to quantify the burden of deaths from TCC and to evaluate the barriers in seeking, reaching and receiving quality care for TCC leading to death.

Methodology Deaths from 1993 to 2015 were analysed to identify causality from TCC. Deaths due to TCC were categorised as communicable, non-communicable, maternal, neonatal or injury-related. Proportion of deaths from TCC by age, sex, condition type and temporal trends was described. Deaths due to TCC from 2012 to 2015 were further examined by circumstances of mortality (CoM) indicators embedded in VA. Healthcare access, at illness onset and during the final day of life, as well as place of death, was extracted from free text summaries. Summaries were also analysed qualitatively using a Three Delays framework to identify barriers to healthcare.

Results Of 15 305 deaths, 5885 (38.45%) were due to TCC. Non-communicable diseases were the most prevalent cause of death from TCC (2961/5885 cases, 50.31%). CoM indicators highlighted delays in a quarter of deaths due to TCC, most frequently in seeking care. The most common pattern of healthcare access was to die outwith a facility, having sought no healthcare (409/1324 cases, 30.89%). Issues in receipt of quality care were identified by qualitative analysis.

Conclusion TCCs are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than those in reaching care, and thus further research and solution development should focus on healthcare-seeking behaviour and quality care provision.

  • health services research
  • health systems
  • infections, diseases, disorders, injuries

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  • LD and JID are co-senior authors

  • Handling editor Sanni Yaya

  • Contributors AF helped develop the idea, performed the analyses, drafted and revised the paper. JNLV helped develop the idea and inputted into the paper drafts. PB refined the data set, inputted into the paper drafts and is responsible for InterVA-5. ST inputted into the paper drafts and is responsible for the Agincourt HDSS. KK inputted into the paper drafts and is responsible for the system of verbal autopsies at Agincourt. LD inputted into the idea, supported the analyses and inputted into the paper drafts. JID led the project, developed the idea, supported the analyses and inputted into the paper drafts and revisions. All authors approved the final paper for submission.

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

  • Disclaimer These funding sources were not involved in this study design, in the collection, analysis and interpretation of the data, in the writing of the manuscript, nor in the decision to submit the paper for publication.

  • Competing interests None declared.

  • Patient and public involvement We did not directly include public involvement in this study. The database, from which this study derives data, is used to inform a public engagement programme at the Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt).

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for secondary use of the VA data set from MRC/Wits Agincourt Unit had been granted by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (M960720 and M110138). Ethical approval was also granted by the Biomedical and Health Sciences, Dentistry, Medicine and Natural and Mathematical Sciences Research Ethics Subcommittees of King’s College London (RESCM-17/18-5635).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data is not publicly available. Deidentified verbal autopsy data from Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt) (