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Zhu N, Wahab A, Bartušová M, Ng N, Hussain-Alkhateeb L. Synthesizing a pragmatic and systemized measure of universal health coverage: verifying the circumstances of mortality CATegories of death investigated by verbal autopsy. Front Public Health 2025; 13:1422248. [PMID: 40247880 PMCID: PMC12003401 DOI: 10.3389/fpubh.2025.1422248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 03/19/2025] [Indexed: 04/19/2025] Open
Abstract
Background Vital data on births, deaths, and causes of death are primarily captured by civil registration and vital statistics systems, which are vastly lacking or inadequately operating in resource-constrained settings. Out-of-health facility deaths remain prevalent and often pass without adequate medical certification, leading to gaps in understanding the medical, social, logistical, and health system circumstances contributing to these deaths. Verbal autopsy (VA), as a standardized and scalable method, is well designed to fill gaps by eliciting causes of death information at the population level. Circumstances Of Mortality CATegories (COMCAT) is a newly integrated concept within VA to identify and quantify likely circumstantial factors contributing to deaths, mainly from social and health system aspects. COMCAT, previously tested in South Africa and Saudi Arabia, show potential to systematically categorize circumstances of death at a population scale. This study intends to verify the process of COMCAT by assessing its plausibility and relevance in generating sensible applications in Indonesia. Methods InterVA-5, a machine learning-based VA tool, was used for processing and interpreting medical and non-medical (COMCAT) causes of death for data collected between 2017 and 2021 in the Sleman Health and Demographic Surveillance System. Cause-specific mortality fractions and the corresponding COMCAT categories were derived for each cause of death. Results Lack of recognition of the illness severity among families attributed mostly to deaths in the Sleman region. The proportions and ranks of each COMCAT were consistent with the known health information of the population in the setting, which speaks to the plausibility of these findings. The novel geo-mapping component of this tool application adds value to monitoring "hot spots" and their social and health system determinants. Conclusion Geo-temporal COMCAT information shows sensible applications of the utility of the VA by producing plausible circumstantial information on population mortality in time and space.
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Affiliation(s)
- Ningxin Zhu
- Global Public Health Research Group, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Abdul Wahab
- Sleman HDSS, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Biostatistics, Epidemiology and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Mária Bartušová
- Global Public Health Research Group, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Preventive and Clinical Medicine, Faculty of Public Health, Slovak Medical University, Bratislava, Slovakia
| | - Nawi Ng
- Global Public Health Research Group, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Laith Hussain-Alkhateeb
- Global Public Health Research Group, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Population Health Research Section, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Tunga M, Lungo JH, Chambua J, Kateule R, Lyatuu I. Exploring challenges and recommendations for verbal autopsy implementation in low-/middle-income countries: a cross-sectional study of Iringa Region-Tanzania. BMJ Open 2023; 13:e075399. [PMID: 38086579 PMCID: PMC10729186 DOI: 10.1136/bmjopen-2023-075399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Verbal autopsy (VA) plays a vital role in providing cause-of-death information in places where such information is not available. Many low-/middle-income countries (LMICs) including Tanzania are still struggling to yield quality and adequate cause-of-death data for Civil Registration and Vital Statistics (CRVS). OBJECTIVE To highlight challenges and recommendations for VA implementation to support LMICs yield quality and adequate mortality statistics for informed decisions on healthcare interventions. DESIGN Cross-sectional study. STUDY SETTING Iringa region in Tanzania. PARTICIPANTS 41 people including 33 community health workers, 1 VA national coordinator, 5 national task force members, 1 VA regional coordinator and 1 member of the VA data management team. RESULTS The perceived challenges of key informants include a weak death notification system, lengthy VA questionnaire, poor data quality and inconsistent responses, lack of clarity in the inclusion criteria, poor commitment to roles and responsibilities, poor coordination, poor financial mechanism and no or delayed feedback to VA implementers. Based on these findings, we recommend the following strategies for effective adaptation and use of VAs: (1) reinforce or implement legislative procedures towards the legal requirement for death notification. (2) Engage key stakeholders in the overall implementation of VAs. (3) Build capacity for data collection, monitoring, processing and use of VA data. (4) Improve the VA questionnaire and quality control mechanism for optimal use in data collection. (5) Create sustainable financing mechanisms and institutionalisation of VA implementation. (6) Integrating VA Implementation in CRVS. CONCLUSION Effective VA implementation demands through planning, stakeholder engagement, upskilling of local experts and fair compensation for interviewers. Such coordinated endeavours will overcome systemic, technical and behavioural challenges hindering VA's successful implementation.
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Affiliation(s)
- Mahadia Tunga
- Computer Science and Engineering, University of Dar es Salaam College of Engineering and Technology, Dar es Salaam, Tanzania
| | - Juma Hemed Lungo
- Computer Science and Engineering, University of Dar es Salaam College of Engineering and Technology, Dar es Salaam, Tanzania
| | - James Chambua
- Computer Science and Engineering, University of Dar es Salaam College of Engineering and Technology, Dar es Salaam, Tanzania
| | - Ruthbetha Kateule
- Computer Science and Engineering, University of Dar es Salaam College of Engineering and Technology, Dar es Salaam, Tanzania
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Knappett M, Hooft A, Maqsood MB, Lavoie PM, Kortz T, Mehta S, Duby J, Akech S, Maina M, Carter R, Popescu CR, Daftary R, Mugisha NK, Mwesigwa D, Kabakyenga J, Kumbakumba E, Ansermino JM, Kissoon N, Mutekanga A, Hau D, Moschovis P, Kangwa M, Chen C, Firnberg M, Glomb N, Argent A, Reid SJ, Bhutta A, Wiens MO. Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda. Pediatrics 2023; 152:e2023062011. [PMID: 37800272 PMCID: PMC11006254 DOI: 10.1542/peds.2023-062011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies. METHODS Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus. RESULTS Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05). CONCLUSIONS Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
| | - Anneka Hooft
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Muhammad Bilal Maqsood
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Pascal M. Lavoie
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
| | - Teresa Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, California
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California
| | - Sonia Mehta
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya
| | - Michuki Maina
- Health Services Research Group, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Rebecca Carter
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Constantin R. Popescu
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
- Division of Neonatology, Department of Pediatrics, Université Laval, Québec, Canada
| | - Rajesh Daftary
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | | | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - J. Mark Ansermino
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - Duncan Hau
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Peter Moschovis
- Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mukuka Kangwa
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Carol Chen
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Maytal Firnberg
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Nicolaus Glomb
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Stephen J. Reid
- Department of Family, Community and Emergency Care, University of Cape Town, Cape Town, South Africa
| | - Adnan Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew O. Wiens
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Walimu, Kampala, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
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Blasini AW, Waiswa P, Wolski A, Wanduru P, Finkbeiner C, Bakari A, Amutuhaire L, Moyer CA. Comparing quantitative and qualitative verbal and social autopsy tools: does a qualitative supplement improve understanding of the social determinants of under-five deaths in the slums of Kampala, Uganda? JOURNAL OF GLOBAL HEALTH REPORTS 2022. [DOI: 10.29392/001c.38743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Understanding biological causes of death and sociocultural factors influencing outcomes is critical to reducing mortality in low-resource settings. Verbal and Social Autopsy instruments (VASAs) query family members about events leading to an individual’s death, resulting in quantitative, categorical data. This study sought to determine the value of a supplemental in-depth qualitative interview (VASA-QUAL). Methods This cross-sectional study was conducted in two slum neighborhoods in Kampala, Uganda, among families who lost a child under five within the preceding six months. A trained, local researcher conducted the quantitative VASA and then administered the VASA-QUAL to family members. Quantitative data were analyzed using Stata V16.0; qualitative data were transcribed into English and analyzed using NVivo V12.0. The biomedical cause of death was determined using a panel of physicians to code verbal autopsy items. Quantitative VASA variables were compared with qualitative variables from the VASA-QUAL using a rubric of indicators derived from the Pathways to Survival framework. Kappa statistics and percent agreement were calculated to compare quantitative and qualitative data. Three coders independently rated whether qualitative data provided additional information that improved understanding of the cause of death. Results 48 VASAs were conducted (child age range: 1 month to 52 months). Agreement on key indicators ranged from 81.2% (place of death) to 93.8% (recognition of illness), with Kappa coefficients ranging from -0.038 to 0.368. The qualitative component added or clarified information about pediatric illness and care-seeking across all indicators, including recognition of illness (94.0%), care-seeking decisions (79.0%), whether home care was provided (73.0%), and choice of outside care (85.0%). Qualitative interviews frequently included symptoms missing or denied in the quantitative VASA and clarified the chronological order of symptoms. Many qualitative interviews described complicated mechanisms of decision-making not captured in the quantitative survey. Both agreement across data types and whether meaningful information was added by the qualitative data varied by cause of death, although our sample size limited our ability to conduct statistical analysis in this regard. Conclusions Supplementing quantitative VASA tools with an in-depth VASA-QUAL interview provided important additional information, but not consistently across indicators or causes of death. Despite challenges associated with feasibility, supplemental qualitative interviews may be an important tool for understanding the complexity of events leading up to childhood deaths.
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Affiliation(s)
| | - Peter Waiswa
- Health Policy, Planning, and Management, Makerere University School of Public Health; Global Public Health, Karolinska Institute
| | | | - Phillip Wanduru
- Health Policy, Planning, and Management, Makerere University School of Public Health; Global Public Health, Karolinska Institute
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Mebrahtom S, Worku A, Gage DJ. Causes of infant deaths and patterns of associated factors in Eastern Ethiopia: Results of verbal autopsy (InterVA-4) study. PLoS One 2022; 17:e0270245. [PMID: 35925957 PMCID: PMC9352103 DOI: 10.1371/journal.pone.0270245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background In a range of setting, detecting and generate empirical information on the cause of infant death and contributing risk factors at population level is basically utmost essential to take evidence-based measures in reducing infant morbidity and mortality. An electronic verbal autopsy is suitable tool and best alternative solution to determine individuals’ cause of death in a setting where the majority of deaths occur at home and civil registration systems do not exist. The present study was undertaken to find out cause of infant death, applying computer-based probabilistic model (InterVA-4) and analyze the patterns of association factors of mother’s and the deceased infant’s characteristics to the leading cause-specific infant mortality in Eastern Ethiopia. Methods The study employed a community-based prospective longitudinal survey, which was conducted with routinely enumeration of reported infant deaths for a period of two years (from September 2016 to August 2018) in Eastern part of Ethiopia. Using the two-stage cluster sampling technique, the study was undertaken in four randomly selected districts of West Hararghe zone and two districts of zone 3 in Oromia and Afar regional state, respectively. The study included a total of 362 infants who were deceased during the study period. Data was collected by trained enumerators by interviewing the mothers or guardians of the deceased infant using a 2014 standardize World Health Organization (WHO) Verbal Autopsy questionnaire. InterVA-4 model were used for processing and interpreting verbal autopsy data in order to arrive at the most likely causes of infant death. SPSS version 23 was also used for statistical analysis of frequency distribution and logistic regression for the association between covariates and outcomes. Findings Of the overall (362) deceased infants’ during the study period, 53.0% of deaths occurred during neonatal time while 47.0% died in the post-neonatal period. Acute respiratory infection including neonatal and post-neonatal pneumonia (38.4%), birth asphyxia (16.4%), diarrheal diseases (16.3%), prematurity (7.4%) and malaria (4.3%) were found to be the leading causes of infant mortality in the study area. The independent factors strongly associated with probable ARI, including pneumonia related mortality as compared to all-causes of death were infants with maternal age lower than 20 years old (p = 0.001, AOR: 4.82, 95% CI: 1.88, 12.3) and infant being died outside of heath facilities (P = 0.007, AOR: 2.85, 95% CI: 1.33, 6.12). The post-neonatal period (P = 0.000, AOR: 15.5, 95% CI: 6.35, 37.8) and infant died in the wet season (P = 0.006, AOR: 2.38, 95% CI: 1.28, 4.44) had strong relationship with dying from diarrhea-related death than those infants died from all non-diarrhea. The death due to malaria robustly associated with infants whose mothers age between 20–35 years old (P = 0.024, AOR: 4.44, 95% CI: 1.22, 16.2) and infant who was dwelled in the districts of Afar region (P = 0.013, AOR: 4.08, 95% CI: 1.35, 12.4). Conclusion The highest cause of infant mortality was associated with disease of respiratory system, particularly acute respiratory infection, including both neonates and post-neonatal pneumonia. Most of the infant deaths existed are as a result of diseases and conditions that are readily preventable or treatable cause, similar to those reported in worldwide, which have needs of further attention. The patterns of significant associated factors across cause-specific mortality against all-cause of death were dissimilar. Therefore, strengthen maternal and child health program with effective preventive interventions emphasizing on the most common cause of infant deaths and those factors contributing in raising mortality risk are required.
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Affiliation(s)
- Samuel Mebrahtom
- Ethiopian Institute of Water Resources, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Alemayehu Worku
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel J. Gage
- Department of Molecular and Cell Biology, University of Connecticut, Storrs, Connecticut, United States of America
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