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Proximity to healthcare clinic and depression risk in South Africa: geospatial evidence from a nationally representative longitudinal study


Proximity to primary healthcare facilities may be a serious barrier to accessing mental health services in resource-limited settings. In this study, we examined whether the distance to the primary healthcare clinic (PHCC) was associated with risk of depression in KwaZulu-Natal Province, South Africa. Depressive symptoms and household coordinates data were accessed from the nationally representative South African National Income Dynamics Study. Distances between households and their nearest PHCCs were calculated and mixed-effects logistic regression models fitted to the data. Participants residing <6 km from a PHCC (aOR = 0.608, 95% CI 0.42–0.87) or 6–14.9 km (aOR = 0. 612, 95% CI 0.44–0.86) had a lower depression risk compared to those residing ≥15 km from the nearest PHCC. Distance to the PHCC was independently associated with increased depression risk, even after controlling for key socioeconomic determinants. Minimizing the distance to PHCC through mobile health clinics and technology could improve mental health.

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Fig. 1


  1. 1.

    Cooke GS, Tanser FC, Bärnighausen TW, Newell ML (2010) Population uptake of antiretroviral treatment through primary care in rural South Africa. BMC Public Health 10:1

  2. 2.

    Govindasamy D, Ford N, Kranzer K (2012) Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS 26:2059–2067

  3. 3.

    Siedner MJ, Lankowski A, Tsai AC, Muzoora C, Martin JN, Hunt PW, Haberer JE, Bangsberg DR (2013) GPS-measured distance to clinic, but not self-reported transportation factors, are associated with missed HIV clinic visits in rural Uganda. AIDS 27:1503

  4. 4.

    Weiser S, Wolfe W, Bangsberg D, Thior I, Gilbert P, Makhema J, Kebaabetswe P, Dickenson D, Mompati K, Essex M, Marlink R (1999) Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. J Acquir Immune Defic Syndr 34:281

  5. 5.

    Geng EH, Nash D, Kambugu A, Zhang Y, Braitstein P, Christopoulos KA, Muyindike W, Bwana MB, Yiannoutsos CT, Petersen ML, Martin JN (2010) Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions. Curr HIV/AIDS Rep 7:234–244

  6. 6.

    Coetzee B, Kagee A, Vermeulen N (2011) Structural barriers to adherence to antiretroviral therapy in a resource-constrained setting: the perspectives of health care providers. AIDS Care 23:146–151

  7. 7.

    Lancet Global Mental Health Group (2007) Scale up services for mental disorders: a call for action. Lancet 370:1241–1252

  8. 8.

    Saxena S, Thornicroft G, Knapp M, Whiteford H (2007) Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370:878–889

  9. 9.

    Murray CJ et al (2010) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2197–2223

  10. 10.

    Lund C, Kleintjes S, Kakuma R, Flisher AJ, MHaPP Research Programme Consortium (2010) Public sector mental health systems in South Africa: inter-provincial comparisons and policy implications. Soc Psychiatry Psychiatr Epidemiol 45:393–404

  11. 11.

    Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, Williams DR (2009) The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. S Afr Med J 99:339–344

  12. 12.

    Seedat S, Williams DR, Herman AA, Moomal H, Williams SL, Jackson PB, Myer L, Stein DJ (2009) Mental health service use among South Africans for mood, anxiety and substance use disorders. S Afr Med J 99:346–345

  13. 13.

    Hassim A, Heywood M, Berger J (2007) Health and democracy: A guide to human rights, health law and policy in postapartheid South Africa. SiberInk, Cape Town

  14. 14.

    Goudge J, Gilson L, Russell S, Gumede T, Mills A (2009) Affordability, availability and acceptability barriers to health care for the chronically ill: longitudinal case studies from South Africa. BMC Health Serv Res 9:1

  15. 15.

    Maillacheruvu P, McDuff E (2014) South Africa’s return to primary care: the struggles and strides of the primary health care system. J Global Health.

  16. 16.

    Burns JK (2010) Mental health services funding and development in KwaZulu-Natal: a tale of inequity and neglect. S Afr Med J 100:662–666

  17. 17.

    Iacoviello BM, Alloy LB, Abramson LY, Choi JY (2010) The early course of depression: a longitudinal investigation of prodromal symptoms and their relation to the symptomatic course of depressive episodes. J Abnorm Psychol 119:459

  18. 18.

    KwaZulu-Natal Department of Health (2012) New mobile clinics to enhance the School Health Programme and access for people in informal settlements and rural communities.

  19. 19.

    Andersen RM (1995) Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 36:1–10

  20. 20.

    Andersen R (1968) A behavioral model of families’ use of health services. University of Chicago, Chicago

  21. 21.

    Andersen R, Newman JF (1973) Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q 51:95–124

  22. 22.

    Arcury TA, Gesler WM, Preisser JS, Sherman J, Spencer J, Perin J (2005) The effects of geography and spatial behavior on health care utilization among the residents of a rural region. Health Serv Res 40:135–156

  23. 23.

    Cornwell EY, Waite LJ (2009) Social disconnectedness, perceived isolation, and health among older adults. J Health Soc Behav 50:31–48

  24. 24.

    Southern Africa Labour and Development Research Unit (2013) NIDS Wave 2: overview 2012. Southern Africa Labour and Development Research Unit, Cape Town

  25. 25.

    Radloff LS (1977) The CES-D Scale. Appl Psychol Meas 1:385–401

  26. 26.

    Andersen EM, Malmgren JA, Carter WB, Patrick DL (1994) Screening for depression in well older adults: evaluation of a short form of the CES-D. Am J Prev Med 10:77–84

  27. 27.

    Björgvinsson T, Kertz SJ, Bigda-Peyton JS, McCoy KL, Aderka IM (2013) Psychometric properties of the CES-D-10 in a psychiatric sample. Assessment 20:429–436

  28. 28.

    Cole JC, Rabin AS, Smith TL, Kaufman AS (2004) Development and validation of a Rasch-derived CES-D short form. Psychol Assess 16:360–372

  29. 29.

    KwaZulu-Natal Department of Health (2013) List of clinics. Accessed Oct 2016

  30. 30.

    QGIS Development Team (2015) QGIS Geographic Information System. Open Source Geospatial foundation

  31. 31.

    Picard R (2012) GEODIST: Stata module to compute geodetic distances. Statistical Software Components

  32. 32.

    Vincenty T (1975) Direct and inverse solutions of geodesics on the ellipsoid with application of nested equations. Survey Rev 22:88–93

  33. 33.

    McLaren ZM, Ardington C, Leibbrandt M (2014) Distance decay and persistent health care disparities in South Africa. BMC Health Serv Res 14:1

  34. 34.

    Wittenberg M (2009) Weights: report on NIDS Wave 1. Southern Africa Labour and Development Research Unit, Cape Town

  35. 35.

    Brown M, Daniels RC, de Villiers L, Leibbrandt M, Woolard I (2013) National Income Dynamics Study Wave 2 user manual. Southern Africa Labour and Development Research Unit, Cape Town

  36. 36.

    Simon GE, Fleck M, Lucas R, Bushnell DM (2004) Prevalence and predictors of depression treatment in an international primary care study. Am J Psychiatry 161:1626–1634

  37. 37.

    Fortney J, Rost K, Zhang M, Warren J (1999) The impact of geographic accessibility on the intensity and quality of depression treatment. Med Care 37:884–893

  38. 38.

    Pfeiffer PN, Glass J, Austin K, Valenstein M, McCarthy JF, Zivin K (2011) Impact of distance and facility of initial diagnosis on depression treatment. Health Serv Res 46:768–786

  39. 39.

    Marcus SC, Fortney JC, Olfson M, Ryan ND (1997) Travel distance to outpatient treatment for depression. Psychiatr Serv 48:1005

  40. 40.

    Schmitt SK, Phibbs CS, Piette JD (2003) The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment. Addict Behav 28:1183–1192

  41. 41.

    Dohrenwend BP, Dohrenwend BS (1974) Psychiatric disorders in urban settings. In: Arieti S, Caplan S (eds) American handbook of psychiatry. Basic Books, New York, pp 424–447

  42. 42.

    Mueller DP (1981) The current status of urban-rural differences in psychiatric disorder. An emerging trend for depression. J Nerv Ment Dis 169:18–27

  43. 43.

    Marsella AJ (1998) Urbanization, mental health, and social deviancy: A review of issues and research. Am Psychol 53:624

  44. 44.

    Neff JA (1983) Urbanicity and depression reconsidered: The evidence regarding depressive symptomatology. J Nerv Ment Dis 171:546–552

  45. 45.

    Verheij RA (1996) Explaining urban-rural variations in health: a review of interactions between individual and environment. Soc Sci Med 42:923–935

  46. 46.

    Webb SD (1984) Rural-urban differences in mental health. In: Freeman H (ed) Mental health and the environment. Churchill Livingston, London, pp 226–249

  47. 47.

    Peen J, Schoevers RA, Beekman AT, Dekker J (2010) The current status of urban-rural differences in psychiatric disorders. Acta Psychiatr Scand 121:84–93

  48. 48.

    Gibbs A, Govender K, Jewkes R (2016) An exploratory analysis of factors associated with depression in a vulnerable group of young people living in informal settlements in South Africa. Global Public Health. doi:10.1080/17441692.2016.1214281

  49. 49.

    Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D (2009) The health and health system of South Africa: historical roots of current public health challenges. Lancet 374:817–834

  50. 50.

    Harington JS, McGlashan ND, Chelkowska EZ (2004) A century of migrant labour in the gold mines of South Africa. J S Afr Inst Min Metall 104:65–72

  51. 51.

    Smit R (2001) The impact of labor migration on African families in South Africa: yesterday and today. J Comp Fam Stud 32:533–548

  52. 52.

    Moeno SN (2006) Family life in Soweto, Gauteng, South Africa. In: Oheneba-Sakyi Y, Takyi BK (eds) African families at the turn of the 21st century. Praeger, Westport, p 249

  53. 53.

    Lurie MN, Williams BG (2014) Migration and health in Southern Africa: 100 years and still circulating. Health Psychol Behav Med 2:34–40

  54. 54.

    Thase ME, Greenhouse JB, Frank E, Reynolds CF, Pilkonis PA, Hurley K, Grochocinski V, Kupfer DJ (1997) Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Arch Gen Psychiatry 54:1009–1015

  55. 55.

    Schneider M, Baron E, Breuer E, Docrat S, Honikman S, Kagee A, Onah M, Skeen S, Sorsdahl K, Tomlinson M, Van der Westhuizen C, Lund C (2016) Integrating mental health into South Africa’s health system: current status and way forward. South Afr Health Rev 2016:153–163

  56. 56.

    Tsai AC, Tomlinson M, Dewing S, Le Roux IM, Harwood JM, Chopra M, Rotheram-Borus MJ (2014) Antenatal depression case finding by community health workers in South Africa: feasibility of a mobile phone application. Arch Womens Ment Health 17:423–431

  57. 57.

    Tomita A, Kandolo KM, Susser E, Burns JK (2016) Use of short messaging services to assess depressive symptoms among refugees in South Africa: Implications for social services providing mental health care in resource-poor settings. J Telemed Telecare 22:369–377

  58. 58.

    Petersen I, Ssebunnya J, Bhana A, Baillie K (2011) Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. Int J Ment Health Syst 5:1

  59. 59.

    Tanser F, Hosegood V, Benzler J, Solarsh G (2001) New approaches to spatially analyse primary health care usage patterns in rural South Africa. Trop Med Int Health 6:826–838

  60. 60.

    Tanser F (2006) Methodology for optimising location of new primary health care facilities in rural communities: a case study in KwaZulu-Natal, South Africa. J Epidemiol Community Health 60:846–850

  61. 61.

    Tanser F, Gijsbertsen B, Herbst K (2006) Modelling and understanding primary health care accessibility and utilization in rural South Africa: an exploration using a geographical information system. Soc Sci Med 63:691–705

  62. 62.

    Statistics South Africa (2004) Concept and definitions. Statistics South Africa, Pretoria

  63. 63.

    Brown K (2000) Coloured and black relations in South Africa: the burden of racialized hierarchy. Macalester Int 9:198–203

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Waves 1–3 Data: Southern Africa Labour and Development Research Unit. National Income Dynamics Study. Cape Town: Southern Africa Labour and Development Research Unit (producer), 2015. Cape Town: DataFirst (distributor), 2015. We thank Lynn Woolfrey at DataFirst at the University of Cape Town. AT was supported by SA MRC Flagship Grant (MRC-RFAUFSP-01-2013/UKZN HIVEPI) and National Institutes of Health Research Training Grant (R25TW009337), funded by the Fogarty International Center and the National Institute of Mental Health. AV was supported by SA MRC Flagship Grant (MRC-RFAUFSP-01-2013/UKZN HIVEPI). FT was supported by South African MRC Flagship (MRC-RFA-UFSP-01-2013/UKZN HIVEPI) and NIH Grants (R01HD084233 and R01AI124389) as well as a UK Academy of Medical Sciences Newton Advanced Fellowship (NA150161). The study was also supported by University of KwaZulu-Natal funding to RS. The content is solely the responsibility of the authors and does not necessarily represent the official views of the SA MRC, UK Academy of Medical Sciences or the NIH. All authors declare that they have no conflicts of interest.

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Correspondence to Andrew Tomita.

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Tomita, A., Vandormael, A.M., Cuadros, D. et al. Proximity to healthcare clinic and depression risk in South Africa: geospatial evidence from a nationally representative longitudinal study. Soc Psychiatry Psychiatr Epidemiol 52, 1023–1030 (2017).

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  • Primary healthcare clinic
  • Depression
  • Social disconnectedness
  • GPS
  • South Africa