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Overall and cause-specific mortality and associated risk factors among middle-aged and older South Africans: findings from the health and ageing in Africa: a longitudinal study of an INDEPTH community in rural South Africa (HAALSI)
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Age and Ageing, 01 July 2026
Most participants were aged 50-59 years [n = 1389 (27.5%)] or 60-69 years [n = 1310 (25.9%)] and slightly more than half [n = 2712 (53.6%)] were women. This study investigates the salience of demographic, socioeconomic, self-reported and objectively measured health-related factors on overall and cause-specific mortality in a rural South African setting.
CVDs were the leading cause of death for both men (25.9%, n = 162) and women (35.8%, n = 176), accounting for 30.3% of all deaths (n = 338; MR: 11.7), followed by other infectious diseases [n = 265 (23.8%); MR: 9.2], neoplasms [n = 161 (14.4%); MR: 5.6] and HIV/AIDS/TB [n = 113 (10.1%); MR: 3.90] (Table 2). For both sexes, CVD and metabolic mortality increased with age, while HIV/AIDS/TB mortality declined with age, as shown in Appendix 6. Women had higher HIV/TB cause-specific mortality fraction (CSMF) at ages 40-59 years, slightly higher CVD CSMF across all ages and higher early-age NCD CSMF likely due to obstetric causes (Appendix 7).
Key points
There is persistent dual mortality burden from non-communicable and infectious diseases.
Existing need for interventions targeting non-communicable disease prevention, physical function and infectious disease control.
Cardiovascular diseases were the leading causes of death in both men and women.
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Abstract
Background
Assessing mortality levels, causes of death and associated risk factors is critical for strengthening health systems and guiding targeted health interventions. We examined overall and cause-specific mortality and their associated risk factors among middle-aged and older adults in a rural, rapidly transitioning South African setting.
Methods
Data were drawn from the Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community (HAALSI) cohort. Risk factors for mortality from 2014/2015 to 2021 were analysed using Cox-Proportional Hazards and Fine and Gray competing-risk models.
Results
The 5059 adults aged 40 years and older at enrolment in the HAALSI cohort in 2014/2015 experienced 1116 (22.1%) deaths over 28 955 person-years of follow-up by 2021. Overall, mortality was higher in men (48.3 deaths per 1000 person-years) than women (30.7 deaths per 1000 person-years). Risk of death increased with age and was significantly associated with male sex, lower education, history of smoking or alcohol use, poor self-rated health, underweight, limitations in activities of daily living, slower walk speed, lower grip strength and histories of hypertension, diabetes, stroke, tuberculosis and unsuppressed Human Immunodeficiency Virus (HIV) infection. Cardiovascular diseases were the leading causes of death (30.3%) in both men (25.9%) and women (35.8%), followed by other infectious diseases (23.8%), neoplasms (14.4%), HIV/AIDS and tuberculosis (10.1%).
Conclusion
These findings highlight the dual mortality burden from non-communicable and infectious diseases among older adults in rural South Africa. Integrated interventions targeting non-communicable diseases, infectious diseases and physical function are urgently needed to reduce premature mortality and improve health outcomes.
Mortality rates were higher for participants who self-reported any of the chronic conditions. Mortality rate was the highest among participants with hypotension (SBP <90/DBP <60 mmHg) (MR: 138.7; 95% CI: 108.2-177.9) and increased with increasing blood pressure levels reaching a peak among those with DBP >110 mmHg or SBP >180 mmHg (MR: 57.6; 95% CI: 47.7-69.6). Further results on mortality by hypertension and treatment status are reported in Appendix 4. Mortality rate was highest among participants with weakest grip strength (MR: 50.9; 95% CI: 46.3-56.1) and slowest pace (MR: 51.6; 95% CI: 46.9-56.7), and increased with worsening levels of self-reported health (MR = 129.9 for very bad self-rated health) and with increasing number of ADL limitations (MR = 171.62 for 4+ ADL limitations) (Table 1). Annual mortality rates (Figure 1) show an overall decrease in age-standardised mortality from 2015 to 2019 and a substantial increase in 2020 and 2021, likely due to the added mortality burden associated with the COVID-19 pandemic.
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