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      Mortality measurement in transition: proof of principle for standardised multi-country comparisons*

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          Abstract

          Objective

          To demonstrate the viability and value of comparing cause-specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation.

          Methods

          Deaths occurring between 1999 and 2004 in Butajira (Ethiopia), Agincourt (South Africa), FilaBavi (Vietnam) and Purworejo (Indonesia) health and socio-demographic surveillance sites were identified. VA interviews were successfully conducted with the caregivers of the deceased to elicit information on signs and symptoms preceding death. The information gathered was interpreted using the InterVA method to derive population cause-specific mortality fractions for each of the four settings.

          Results

          The mortality profiles derived from 4784 deaths using InterVA illustrate the potential of the method to characterise sub-national profiles well. The derived mortality patterns illustrate four populations with plausible, markedly different disease profiles, apparently at different stages of health transition.

          Conclusions

          Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit-for-purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource-poor settings.

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          Most cited references36

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          Validity of verbal autopsy procedures for determining cause of death in Tanzania.

          To validate verbal autopsy (VA) procedures for use in sample vital registration. Verbal autopsy is an important method for deriving cause-specific mortality estimates where disease burdens are greatest and routine cause-specific mortality data do not exist. Verbal autopsies and medical records (MR) were collected for 3123 deaths in the perinatal/neonatal period, post-neonatal <5 age group, and for ages of 5 years and over in Tanzania. Causes of death were assigned by physician panels using the International Classification of Disease, revision 10. Validity was measured by: cause-specific mortality fractions (CSMF); sensitivity; specificity and positive predictive value. Medical record diagnoses were scored for degree of uncertainty, and sensitivity and specificity adjusted. Criteria for evaluating VA performance in generating true proportional mortality were applied. Verbal autopsy produced accurate CSMFs for nine causes in different age groups: birth asphyxia; intrauterine complications; pneumonia; HIV/AIDS; malaria (adults); tuberculosis; cerebrovascular diseases; injuries and direct maternal causes. Results for 20 other causes approached the threshold for good performance. Verbal autopsy reliably estimated CSMFs for diseases of public health importance in all age groups. Further validation is needed to assess reasons for lack of positive results for some conditions.
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            Verbal autopsies for adult deaths: their development and validation in a multicentre study.

            Verbal autopsy (VA) has been widely used to ascertain causes of child deaths, but little is known about the usefulness of VA for adult deaths. This paper describes the process used to develop a VA tool for adult deaths and the results of a multicentre validation of this tool. A mortality classification was developed by including causes of death that might be arrived at by VAs and causes that are responsive to public health interventions. An algorithm was designed for each cause in the classification, based on classifying symptoms into essential, supportive and differential. A structured questionnaire designed to elicit information on these symptoms was developed in English translated into the local languages. The tool was validated on deaths occurring at hospitals in Tanzania (315 deaths), Ethiopia (249) and Ghana (232). Hospital records of all adult deaths occurring at the study hospitals from June 1993 to April 1995 were collected prospectively. Non-medical interviewers with at least 12 years of formal education conducted VA interviews. Causes of death were diagnosed by a panel of physicians and by a computerized algorithm. The validity of the VA was assessed by comparing the VA diagnoses with hospital diagnoses. Specificity of VAs by physicians fell below 95% only for acute febrile illness (AFI) and TB/AIDS. Sensitivity and positive predictive value (PPV), however, varied widely both across the sites and between causes. Sensitivity was > 75% for tetanus, rabies, direct maternal causes, injuries and TB/AIDS and ranged between 60% and 74% for diarrhoea, acute abdominal conditions and AFI. The PPV was > 75% for tetanus, rabies, hepatitis and injuries and ranged between 60 and 74% for meningitis, AFI, TB/AIDS and direct maternal causes. When the communicable diseases were combined in a single group, the sensitivity was 82%, specificity 78% and PPV 85%. For the group of noncommunicable diseases the corresponding sensitivity, specificity and PPV were 71%, 87% and 67%, respectively. Use of an algorithm resulted in lower sensitivity, specificity and PPV than the VAs by physician. VAs by a panel of physicians performed better than an opinion-based algorithm. The validity of VA diagnosis was highest for AFI, direct maternal causes, TB/AIDS, tetanus, rabies and injuries.
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              Research into health, population and social transitions in rural South Africa: data and methods of the Agincourt Health and Demographic Surveillance System.

              Vital registration is generally lacking in infrastructurally weak areas where health and development problems are most pressing. Health and demographic surveillance is a response to the lack of a valid information base that can provide high-quality longitudinal data on population dynamics, health, and social change to inform policy and practice. Continuous demographic monitoring of an entire geographically defined population involves a multi-round, prospective community study, with annual recording of all vital events (births, deaths, migrations). Status observations and special modules add value to particular research areas. A verbal autopsy is conducted on every death to determine its probable cause. A geographic surveillance system supports spatial analyses, and strengthens field management. Health and demographic surveillance covers the Agincourt sub-district population, sited in rural north-eastern South Africa, of some 70,000 people (nearly a third are Mozambican immigrants) in 21 villages and 11,700 households. Data enumerated are consistent or more detailed when compared with national sources; strategies to improve incomplete data, such as counts of perinatal deaths, have been introduced with positive effect. Basic characteristics: A major health and demographic transition was documented over a 12-year period with marked changes in population structure, escalating mortality, declining fertility, and high levels of temporary migration increasing particularly amongst women. A dual burden of infectious and non-communicable disease exists against a background of dramatically progressing HIV/AIDS. Health and demographic surveillance sites - fundamental to the INDEPTH Network - generate research questions and hypotheses from empirical data, highlight health, social and population priorities, provide cost-effective support for diverse study designs, and track population change and the impact of interventions over time.[image omitted].
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                Author and article information

                Journal
                Trop Med Int Health
                tmi
                Tropical Medicine & International Health
                Blackwell Publishing Ltd
                1360-2276
                1365-3156
                October 2010
                : 15
                : 10
                : 1256-1265
                Affiliations
                [1 ]simpleDepartment of Public Health and Clinical Medicine, Division of Epidemiology & Global Health, Umeå Centre for Global Health Research, Umeå University Umeå, Sweden
                [2 ]simpleMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand Johannesburg, South Africa
                [3 ]simplePurworejo Health and Demographic Surveillance Site, Gadjah Mada University Jogjakarta, Indonesia
                [4 ]simpleFilaBavi Health and Demographic Surveillance Site Hanoi, Vietnam
                [5 ]simpleButajira Rural Health Programme, Department of Community Health, Addis Ababa University Addis Ababa, Ethiopia
                Author notes
                Corresponding Author Edward Fottrell, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, 901 85 Umeå, Sweden. Tel.: +46907851079; E-mail: Edward.Fottrell@ 123456epiph.umu.se
                [*]

                Re-use of this article is permitted in accordance with the Terms and Conditions set out at http://wileyonlinelibrary.com/onlineopen#OnlineOpen_Terms

                Article
                10.1111/j.1365-3156.2010.02601.x
                3085122
                20701726
                ca1d2337-b03e-4e19-9299-39cc524d4d8e
                © 2010 Blackwell Publishing Ltd

                Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit commercial exploitation.

                History
                Categories
                Mortality Measurement

                Medicine
                verbal autopsy,health metrics,mortality,health and demographic surveillance systems,epidemiologic transition,developing countries

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