This combination of information provides unique insights into the complex interplay of burden of disease, SES and health care service use.
The historical imbalances in health care delivery in South Africa, coupled with the changing patterns of disease and the complex burden of communicable and non-communicable disease places a huge strain on the public health service.
Several studies demonstrated how in households the care, illnesses, and deaths of family members create a complex burden of care [ 20, 23, 28, 30, 36].
Therefore, it may be the complex burden of pain, more than the specific condition that is associated with EDS.
What then is the potential for preventing and managing this large and complex burden of mental health problems in the working population?
Concerns about workload are further exacerbated by staff shortages in South Africa and the complex burden of disease (communicable, noncommunicable, perinatal and maternal conditions, and injury-related complications) which have a negative influence on nurses' job satisfaction [ 67, 68].
India shows a high and complex burden of tobacco consumption, as also reported in tobacco surveillance studies. 2 12 13 This paper uses empirical evidence to show that India is currently between stages II and III of the Cigarette Epidemic model on the basis of estimates of smoking for men, but distinctly differs from the model on the patterns seen for women.
It is possible that this level of support from healthcare providers is perhaps even more important for patients of low socio-economic status who, as with our sample, often lack the health literacy, material resources and self-efficacy to cope with the complex burden of self-care.
These challenges create a complex burden of psychosocial, functional, and physical health risks which can obstruct their access to material resources and health care, and in turn put them at high risk for poor health outcomes and poor quality of life [ 2- 4].
The key question here is about the strategic direction of healthcare services: what kinds of changes are necessary to improve patient experiences of complex and cumulative burdens?
Furthermore, transformation efforts have been undermined by the country's crippling, complex disease burden of HIV/AIDS, TB, non-communicable disease (NCD) and violence [ 5].
