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      Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring

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      1 , 1 ,   2 , # , 3 , * , 4 , 5 , 6 ,   7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 23 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35
      Global Health Action
      Co-Action Publishing
      verbal autopsy, cause of death, vital registration, civil registration, vital statistics, World Health Organization, InterVA

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          Abstract

          Objective

          Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems.

          Methods

          A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification.

          Findings

          A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach.

          Conclusions

          The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians.

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          Most cited references49

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          Verbal autopsy: methods in transition.

          Understanding of global health and changing morbidity and mortality is limited by inadequate measurement of population health. With fewer than one-third of deaths worldwide being assigned a cause, this long-standing dearth of information, almost exclusively in the world's poorest countries, hinders understanding of population health and limits opportunities for planning, monitoring, and evaluating interventions. In the absence of routine death registration, verbal autopsy (VA) methods are used to derive probable causes of death. Much effort has been put into refining the approach for specific purposes; however, there has been a lack of harmony regarding such efforts. Subsequently, a variety of methods and principles have been developed, often focusing on a single aspect of VA, and the resulting literature provides an inconsistent picture. By reviewing methodological and conceptual issues in VA, it is evident that VA cannot be reduced to a single one-size-fits-all tool. VA must be contextualized; given the lack of "gold standards," methodological developments should not be considered in terms of absolute validity but rather in terms of consistency, comparability, and adequacy for the intended purpose. There is an urgent need for clarified thinking about the overall objectives of population-level cause-of-death measurement and harmonized efforts in empirical methodological research.
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            Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool

            Background Verbal autopsy (VA) is the only available approach for determining the cause of many deaths, where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHO VA instrument as a new standard, intended both as a research tool and for routine registration of deaths. Objective A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument. Design The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version 10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths. Results The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration dataset from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4. Conclusions InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration. Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data.
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              Population Health Metrics Research Consortium gold standard verbal autopsy validation study: design, implementation, and development of analysis datasets

              Background Verbal autopsy methods are critically important for evaluating the leading causes of death in populations without adequate vital registration systems. With a myriad of analytical and data collection approaches, it is essential to create a high quality validation dataset from different populations to evaluate comparative method performance and make recommendations for future verbal autopsy implementation. This study was undertaken to compile a set of strictly defined gold standard deaths for which verbal autopsies were collected to validate the accuracy of different methods of verbal autopsy cause of death assignment. Methods Data collection was implemented in six sites in four countries: Andhra Pradesh, India; Bohol, Philippines; Dar es Salaam, Tanzania; Mexico City, Mexico; Pemba Island, Tanzania; and Uttar Pradesh, India. The Population Health Metrics Research Consortium (PHMRC) developed stringent diagnostic criteria including laboratory, pathology, and medical imaging findings to identify gold standard deaths in health facilities as well as an enhanced verbal autopsy instrument based on World Health Organization (WHO) standards. A cause list was constructed based on the WHO Global Burden of Disease estimates of the leading causes of death, potential to identify unique signs and symptoms, and the likely existence of sufficient medical technology to ascertain gold standard cases. Blinded verbal autopsies were collected on all gold standard deaths. Results Over 12,000 verbal autopsies on deaths with gold standard diagnoses were collected (7,836 adults, 2,075 children, 1,629 neonates, and 1,002 stillbirths). Difficulties in finding sufficient cases to meet gold standard criteria as well as problems with misclassification for certain causes meant that the target list of causes for analysis was reduced to 34 for adults, 21 for children, and 10 for neonates, excluding stillbirths. To ensure strict independence for the validation of methods and assessment of comparative performance, 500 test-train datasets were created from the universe of cases, covering a range of cause-specific compositions. Conclusions This unique, robust validation dataset will allow scholars to evaluate the performance of different verbal autopsy analytic methods as well as instrument design. This dataset can be used to inform the implementation of verbal autopsies to more reliably ascertain cause of death in national health information systems.
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                Author and article information

                Journal
                Glob Health Action
                Glob Health Action
                GHA
                Global Health Action
                Co-Action Publishing
                1654-9716
                1654-9880
                13 September 2013
                2013
                : 6
                : 10.3402/gha.v6i0.21518
                Affiliations
                [1 ]Disease Control and Vector Biology, London School of Hygiene and Tropical Medicine, London, UK
                [2 ]WHO Collaborating Centre for Verbal Autopsy, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
                [3 ]Health Information and Statistics, WHO, Geneva, Switzerland
                [4 ]International Health Policy Program, Thailand Ministry of Public Health, Nonthaburi, Thailand
                [5 ]Health Policy and Strategic Bureau, Ministry of Public Health, Nonthaburi, Thailand
                [6 ]Public Health and Health Systems, Swiss Tropical and Public Health Institute, Basel, Switzerland
                [7 ]UCL Centre for International Health and Development, Institute of Child Health, London, UK
                [8 ]Epidemiology and Health Evaluation Faculty of Medicine, Federal University of Minas Gerais, Minas Gerais, Brazil
                [9 ]Genes and Environment Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
                [10 ]Faculty of Medicine, University of Alexandria, Alexandria, Egypt
                [11 ]Health Research and Development Division, Ghana Health Serfice, Accra, Ghana
                [12 ]Headquarter, United Nations Population Fund (UNFPA), New York, USA
                [13 ]MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
                [14 ]Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
                [15 ]Uttar Pradesh Center, Community Empowerment Lab, Uttar Pradesh, India
                [16 ]Ifakara Health Institute, Dar es Salaam, Tanzania
                [17 ]International Statistics Division, Centers for Disease Control and Prevention, Hyattsville, USA
                [18 ]Afghan Public Health Institute, Afghanistan Ministry of Public Health, Kabul, Afghanistan
                [19 ]INDEPTH Network Secretariat, INDEPTH Network, Accra, Ghana
                [20 ]Public Health and HIV Section, The office of the United Nations High Commissioner for Refugees (UNHCR), Geneva, Switzerland
                [21 ]Independent Consultant
                [22 ]Monitoring of Vital Events, Health Metrics Network, Geneva, Switzerland
                [23 ]Health Information and Analysis, Pan American Health Organization, Washington, DC, USA
                [24 ]Division of Health Systems and Services Development, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
                [25 ]Health Information, Evidence and Research Policy, WHO Regional Office for Europe, Kobenhavn, Denmark
                [26 ]Evidence-Based Health Situation and Trends Assessment, WHO Regional Office for the South Eastern Region, New Dehli, India
                [27 ]Health Information, Evidence and Research Policy, WHO Regional Office for Western Pacific, Manila, Philipines
                [28 ]Mediterranean Centre for Health Risk Reduction, WHO, Geneva, Switzerland
                [29 ]Department of Child and Adolescent Health and Development, WHO, Geneva, Switzerland
                [30 ]Department of Violence and Injury Prevention and Disability, WHO, Geneva, Switzerland
                [31 ]Health Statistics and Informatics, WHO, Geneva, Switzerland
                [32 ]Classification, Terminology and Standards Unit, WHO, Geneva, Switzerland
                [33 ]Department of Reproductive Health and Research, WHO, Geneva, Switzerland
                [34 ]Child and Adolescent Health and Development, WHO, Geneva, Switzerland
                [35 ]Maternal, Newborn, Child and Adolescent Health, WHO, Geneva, Switzerland
                Author notes
                [* ]Correspondence to: Robert Jakob, HSI/CTS, World Health Organization, 20 Av Appia, CH-1211 Geneva 27, Switzerland, Tel:+41 22 791 5877, Email: jakobr@ 123456who.int
                [# ]Peter Byass, Editor, did not participate in the review and decision process for this paper.
                Article
                21518
                10.3402/gha.v6i0.21518
                3774013
                24041439
                82dc383b-a8fa-4580-a82a-bdd0e0a41731
                © 2013 Jordana Leitao et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 27 May 2013
                : 06 August 2013
                : 12 August 2013
                Categories
                Original Article

                Health & Social care
                verbal autopsy,cause of death,vital registration,civil registration,vital statistics,world health organization,interva

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