Estimating the changing burden of disease attributable to interpersonal violence in South Africa for 2000, 2006 and 2012.

BACKGROUND: South Africa (SA)'s high rate of interpersonal violence persists as a leading public health problem for the country. The first South African Comparative Risk Assessment Study (SACRA1) in 2000 quantified the long-term mental and physical health burden attributable to interpersonal violence by supplementing the direct injury burden of disease attributable to interpersonal violence injuries with the substantial contribution of mental health, behavioural and reproductive health consequences accruing from exposure to intimate partner violence (IPV) and child sexual abuse. OBJECTIVES: To revise and improve these estimates by including the additional burden from other forms of child maltreatment, community violence, sexual violence by non-partners, and bullying victimisation in SA for 2000, 2006 and 2012, and trends over time. METHODS: We used comparative risk assessment methods to calculate population attributable fractions (PAFs) for interpersonal violence. This method requires inputs on the prevalence of exposure to the interpersonal violence risk factor subtypes, namely child maltreatment, bullying, IPV, sexual violence by non-partners and other community violence; the burden of related health outcomes (mortality and morbidity); and relative risks of health outcomes in individuals exposed to the risk factor v. those unexposed. We estimated the PAF for the combinations of all interpersonal violence subtypes together to estimate the burden attributable to interpersonal violence overall for 2000, 2006 and 2012. RESULTS: Between 2000 and 2012, there was a decrease in interpersonal violence age-standardised attributable death rates from 100 to 71 per 100 000. In the second South African Comparative Risk Assessment Study (SACRA2), estimates of the attributable disability-adjusted life years (DALYs) for interpersonal violence for the year 2000 were revised, from 1.7 million to 2 million DALYs, taking into account attributable mortality and disability from additional forms of violence. There was a decrease in DALYs attributable to interpersonal violence from 2 million in 2000 to 1.75 million in 2012, accounting for 8.5% of the total burden for SA, ranking second highest, after unsafe sex, among 18 risk factors evaluated in 2012. CONCLUSION: Overall, interpersonal violence-attributable DALYs decreased substantially but remain high. The reduction in age-standardised attributable death rates indicates that some policy and social intervention aspects are effective. Further strengthening of existing laws pertaining to interpersonal violence, and other prevention measures, are needed to intensify the prevention of violence, particularly gender-based violence. Additional forms of violence included in this analysis have improved our understanding of the interpersonal violence burden, but the attributable burden in males, although exceedingly high, remains an underestimate. There is a need to improve the epidemiological data on prevalence and risks for the different types of interpersonal violence, particularly for males.

Utility of crime surveys for Sustainable Development Goals monitoring and violence prevention using a public health approach.

The Sustainable Development Goals (SDGs) have highlighted interpersonal violence and violence against women and girls as impediments to development globally. South Africa is adversely affected by violence and injury. The annual Victims of Crime Survey (VoCS) provides a potentially useful source of complementary data to bolster vital registration and police crime statistics, but it may not provide data that are sufficiently accurate and reliable to inform prevention efforts. We conducted a critical assessment of the VoCS's methodological robustness and strength as a data source for high-level analyses, adopting a public health and SDGs monitoring perspective that was based on expert opinion and comparison with other data sources. We concluded that either the survey methods should be improved to provide findings that are better aligned with the SDGs agenda and are robust enough to inform high-quality research and prevention, or the funds used to conduct the VoCS should be redirected to other more suitable instruments.

Psychological distress among women suffering from couple infertility in South Africa: a quantitative assessment.

BACKGROUND: Infertility in Africa is commonly associated with negative psycho-social consequences. To date, most studies from African countries addressing these consequences have been qualitative in nature. The aim of this study was to assess psychological distress quantitatively among women suffering from couple infertility in an urban community in South Africa. METHODS: The Symptom Checklist-90-R (SCL-90-R), a standardized instrument for the measurement of current psychological symptom status, was administered to 120 women at the time of their first presentation to an infertility clinic in a tertiary referral centre. The control group comprised 120 women presenting to local family planning clinics. In addition, socio-demographic information and data pertaining to the prevalence of abuse was captured through a structured questionnaire designed for the purpose of this study. RESULTS: Women suffering from involuntary childlessness scored significantly higher on all sub-scales and the global indices of distress of the SCL-90-R when compared to controls. In addition, women who reported abuse from their male partners had significantly higher scores on six of the 12 test scales when compared to infertile women in non-abusive relationships. CONCLUSIONS: Involuntary childlessness is associated with high levels of psychological distress. Women in abusive relationships are particularly at risk. This result is in keeping with several qualitative studies from African countries which describe infertility as an overwhelmingly negative and distressing experience. Cognizance needs to be taken of these experiences and effective interventions require medical, psychological and socio-cultural strategies.

'You are a man because you have children': experiences, reproductive health knowledge and treatment-seeking behaviour among men suffering from couple infertility in South Africa.

BACKGROUND: In Africa, infertility traditionally has been viewed as a female problem. This study explores reproductive health knowledge, health-seeking behaviour and experiences related to involuntary childlessness in men suffering from couple infertility. METHODS: Twenty-seven men from a diverse cultural urban community in South Africa participated in in-depth interviews at the time of their first visit to an infertility clinic in a tertiary referral centre. RESULTS: Men had little knowledge about the physiology of human fertility, causes of infertility and modern treatment options. Awareness of male factor infertility was, however, high. Most men appeared involved in the health-seeking process. Men described their emotional reactions to childlessness and the impact of infertility on marital stability, and many reported that infertile men suffered from stigmatization, verbal abuse and loss of social status. CONCLUSIONS: These findings improve our understanding of the reproductive health needs of men suffering from couple infertility in Africa. This understanding is essential for the effective integration of male partners into modern infertility management. The need for appropriate counselling of men and, most particularly, for education of the community is recognized.