2nd South African Risk Assessment Study (SACRA2)

This flagship project (MRC-RFA-IFSP-01-2013) aims to quantify the contribution of selected modifiable risk factors to the burden of disease experienced in South Africa and inform the prevention strategies.  Making use of estimates of the disease burden in terms of deaths, years of life lost (YLLs), years lived with disability (YLDs) and disability adjusted life years (DALYs) from the 2nd National Burden of Disease Study , the SACRA 2 study aims to assess the changing burden attributable to 18 risk factors.

Selected modifiable risk factors in SACRA2 study
Selected modifiable risk factors in SACRA2 study
Non-communicable disease cluster
1. High systolic blood pressure
2. High body mass index
3. High fasting plasma glucose
4. Low density lipoprotein cholesterol
5. Low fruit intake
6. Low vegetable intake
7. High sodium intake
8. Low physical activity
Addictive substances
9. Tobacco smoking
10. Alcohol
Undernutrition cluster
11. Childhood undernutrition
12. Iron deficiency
Sexual and reproductive health cluster
13. Unsafe sex
Interpersonal violence cluster
14. Interpersonal violence
Environmental cluster
15. Ambient air pollution - PM2.5
16. Ambient air pollution - ozone
17. Household air pollution
18. Unsafe water, sanitation and hygiene
2nd South African Comparative Risk Assessment Collaborating Group

Nada Abdelatif

Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa.

Naeemah Abrahams

Gender Research Unit, South African Medical Research Council, Cape Town, South Africa and School of Public Health and Family Medicine, University of Cape Town, South Africa.

Lillian Artz

Gender, Health and Justice Research Unit, University of Cape Town, Cape Town, South Africa and Department of Pathology, Division of Forensic Medicine, University of Cape Town, South Africa.

Oluwatoyin F. Awotiwon

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.
Olalekan Ayo-Yusuf

Research and Graduate Studies, Sefako Makgatho Health Sciences University, Pretoria, South Africa

Joel Botai

Department of Research and Innovation, South African Weather Service, Pretoria, South Africa.

Debbie Bradshaw

Burden of Disease Research Unit, South African Medical Research Council and Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa.

Eugene Cairncross

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Kamaseelan Chetty

Department of SAAQIS, South African Weather Service, Centurion, South Africa.

Annibale Cois

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa and Division of Health Systems and Public Health, Department of Global Health, University of Stellenbosch, South Africa.

Muhammad A. Dhansay

Burden of Disease Research Unit, South African Medical Research Council and Division of Human Nutrition, Department of Global Health and Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa.

Pam Groenewald

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Charl Janse van Rensburg

Biostatistics Research Unit, South African Medical Research Council, Pretoria, South Africa.

Rachel Jewkes

Gender and Health Research Unit and Office of the Executive Scientist, South African Medical Research Council, Pretoria, South Africa and School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.

Jané D. Joubert

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Thandi Kapwata

Environment and Health Research Unit, South African Medical Research Council, Pretoria, South Africa.

Reshma Kassanjee

Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa.

Andre P. Kenge

Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa and Department of Medicine, University of Cape Town, Cape Town, South Africa.

Demetre Labadarios

Professor Emeritus: Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch and Professor Extraordinaire: University of Limpopo.

Estelle V. Lambert

Research Centre for Health through Physical Activity, Lifestyle and Sport, Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa.

Ria Laubscher

Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa.

Naomi Levitt

Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa.

Mercilene Machisa

Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa and School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.

Samuel Manda

Biostatistics Research Unit, South African Medical Research Council, Pretoria, South Africa and Statistics Department, University of Pretoria, Pretoria, South Africa.

Richard Matzopoulos

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa and School of Public Health and Family Medicine, University of Cape Town, South Africa.

Nadine Nannan

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Ian Neethling

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa and Institute for Lifecourse Development, University of Greenwich, Greenwich, London, United Kingdom.

Johanna H. Nel

Department of Logistics, Stellenbosch University, Stellenbosch, South Africa.

Beatrice Nojilana

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Rosana Pacella

Institute for Lifecourse Development, University of Greenwich, Greenwich, London, United Kingdom.

Charles D.H. Parry

Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa and Department of Psychiatry, Stellenbosch University, Cape Town, South Africa.

Nasheeta Peer

Non-communicable Diseases Research Unit, South African Medical Research Council, Durban, South Africa and Department of Medicine, University of Cape Town, Cape Town, South Africa.

Victoria Pillay-van Wyk

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Megan Prinsloo

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa and Institute for Lifecourse Development, University of Greenwich, London, United Kingdom.

Charlotte Probst

Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada and Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany.

Rifqah A. Roomaney

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Aletta E. Schutte

School of Population Health, University of New South Wales, Australia, The George Institute for Global Health, Sydney, Australia Hypertension in Africa Research Team and South African Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa.

Freddy Sitas

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa; Centre for Primary Health Care and Equity, School of Population Health, University of NSW-Sydney and Menzies Centre for Health Policy, School of Public Health, University of Sydney.

Katherine Sorsdahl

Alan J Flisher Centre for Public Mental Health, Department of Psychiatry, University of Cape Town, Cape Town, South Africa. 

Nelia P. Steyn

Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa.

Melaku Tesfaye

Department of Research and Innovation, South African Weather Service, Centurion, South Africa.

Eunice B. Turawa

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Lize van Stuijvenberg

Non-communicable Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.

Nicole Vellios

Research Unit on the Economics of Excisable Products, University of Cape Town, Cape Town, South Africa.

Catherine L. Ward

Department of Psychology, University of Cape Town, South Africa and Safety and Violence Initiative, University of Cape Town, South Africa.

Edelweiss Wentzel-Viljoen

Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.

Caradee Y. Wright

Environment and Health Research Unit, South African Medical Research Council, Pretoria, South Africa and Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa.

Key Findings

Trend in attributable burden of each risk factor

What does it mean?

  • The year 2006 represented the peak of the HIV epidemic and there has been a significant decline in the DALYs attributable to HIV by 2012
  • This is still the leading cause of DALY so intensive programming is still required for South Africa to meet international goals in HIV reduction and management e.g., medical male circumcision campaigns, and risk awareness campaigns.
  • HPV vaccination coverage for young girls must be extended to maximise the potential for preventing cervical cancer.

  • Rates of interpersonal violence have decreased for men but remain unchanged for women in the period 2000 to 2012.
  • Despite a decline in interpersonal violence, the exceedingly high burden indicates that South Africa requires further reinforcement and strengthening of the implementation of existing laws on and responses to gender-based violence, child protection and firearm use, and other prevention programmes to address the burden of violence.

  • The average BMI increased between 2000 and 2012, with DALY rates also increasing.
  • Although obesity prevention strategies have been initiated by the Department of Health, a comprehensive framework is needed to target underlying determinants such as food systems, urban systems, and economic systems to stem the increasing prevalence of obesity.

  • DALYs related to systolic blood pressure have decreased since 2006, however, this could be related to an increase in treatment for hypertension.
  • More preventative strategies are needed, accompanied by improved diagnosis and care of hypertension.

  • DALYs due to alcohol consumption have decreased in men but increased in women.
  • Despite previous recommendations for interventions, the burden due to alcohol remains large and much more vigorous implementation of existing measures is required to address the harm due to alcohol.

  • There has been a concerning increase in the DALY rate attributable to fasting plasma glucose.
  • A multi-pronged approach is required to reduce the burden, including, mass screening and promotion of the uptake of healthy activities. Diagnosis, treatment and control also need to be promoted.

  • Rates of decline in smoking prevalence have plateaued between 2010 and 2012, suggesting that tobacco control measures need review and strengthening
  • Increasing excise taxes is the most effective measure to reduce smoking prevalence and should be implemented along with a track and trace system to improve tax compliance and reduce illicit trade. In-clinic interventions for high-risk patients are also required for intensive cessation support.

  • Despite a reduction since 2006, an estimated 33% of child deaths in South Africa were attributable to undernutrition.
  • Addressing undernutrition must include measures that address household poverty and food security, and ensuring nutrition as a basic human right. The health system response also needs to be strengthened. Also, regarding, routine child nutrition surveillance, current programs need to be evaluated.

  • There has been a slight reduction in DALYs due to water, sanitation, and hygiene since 2006. However, there are stark provincial inequalities in attributable burden, mediated through good versus poor water and sanitation supply and unequal improvement in water and sanitation supply across provinces.
  • High priority needs to be given to improving access to safe and sustainable sanitation and water supply, particularly in underserved urban and rural communities in South Africa.

  • The vast majority of South Africans were exposed to harmful levels of ambient air pollution in the period.
  • Efforts are needed to reduce ambient air pollution in the country by enforcing national air quality standards and lowering the reliance on fossil fuels.

  • The average intake of fruit decreased between 2000 and 2012, and the DALY burden decreased.
  • The burden of disease attributable to a diet low in fruits remains high and effective interventions supported by legislation and policy are needed to reverse the declining trends in fruit consumption observed across most age groups.

  • The burden due to LDL cholesterol decreased between 2000 and 2012.
  • Mean population LDL cholesterol values remain high and can be lowered further through nationwide nutrition education programmes, collaboration with the food industry to improve labelling and cheaper pricing of healthy foods.

  • There has been a decrease in the DALY rate attributable to iron deficiency.
  • However, iron-deficiency anaemia prevalence can be markedly reduced if iron deficiency is eliminated. Hence, it is essential to encourage, measures that have been implemented to address iron deficiency, including food fortification and the iron supplementation programme for infants over 6 months of age and women of reproductive age.
  • The intersection of anaemia and HIV especially amongst pregnant women, requires that the dietary requirement of these individuals be evaluated.

  • DALY rates due to low physical activity decreased between 2000 and 2006.
  • The burden still remains high, indicating that existing policies need to be implemented so that there is universal access to sports and recreational facilities, as well as walkable communities.

  • The DALY rate attributable to household air pollution due to cooking with solid fuels has reduced between 2000 and 2012.
  • Legislation and interventions are needed to eradicate the use of solid fuels, especially in the light of worsened loadshedding in the country.

  • The average intake of vegetables decreased between 2000 and 2012.
  • The burden of disease attributable to a diet low in vegetables remain high and effective interventions are needed to increase vegetable consumption.

  • There has been a decrease in the DALY rate due to high sodium between 2000 and 2012.
  • The regulation of salt content is a step in the right direction, but sustained effort is needed to also monitor sodium consumption to reduce the risk of cardiovascular disease.

  • There has been a drop in age-standardised DALYs between 2000 and 2006.
  • National air quality standards for ozone need to be enforced.
 

SACRA2: Publications  

SACRA2: Technical Reports

SACRA2: Data Visualisation Tools

 

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