Core Verbal Autopsy Procedures with Comparative Validation Results from Two Countries

BACKGROUND: Cause-specific mortality statistics remain scarce for the majority of low-income countries, where the highest disease burdens are experienced. Neither facility-based information systems nor vital registration provide adequate or representative data. The expansion of sample vital registration with verbal autopsy procedures represents the most promising interim solution for this problem. The development and validation of core verbal autopsy forms and suitable coding and tabulation procedures are an essential first step to extending the benefits of this method. METHODS AND FINDINGS: Core forms for peri- and neonatal, child, and adult deaths were developed and revised over 12 y through a project of the Tanzanian Ministry of Health and were applied to over 50,000 deaths. The contents of the core forms draw upon and are generally comparable with previously proposed verbal autopsy procedures. The core forms and coding procedures based on the International Statistical Classification of Diseases (ICD) were further adapted for use in China. These forms, the ICD tabulation list, the summary validation protocol, and the summary validation results from Tanzania and China are presented here. CONCLUSIONS: The procedures are capable of providing reasonable mortality estimates as adjudged against stated performance criteria for several common causes of death in two countries with radically different cause structures of mortality. However, the specific causes for which the procedures perform well varied between the two settings because of differences in the underlying prevalence of the main causes of death. These differences serve to emphasize the need to undertake validation studies of verbal autopsy procedures when they are applied in new epidemiological settings

“It's all the time in my mind”: Facilitators of adherence to antiretroviral therapy in a Tanzanian setting

Although HIV-positive patients’ adherence to antiretroviral therapy (ART) is relatively high in African nations, as compared with industrialized nations, few studies have explored why. In the research presented here we aimed to understand the dynamics of good adherence to ART among patients receiving free ART and HIV-related services from a clinic in Arusha, Tanzania. We conducted individual semi-structured interviews with 6 health care providers and 36 patients at the study site. Interviews were conducted in Swahili using interview guides informed by social cognitive theory. All interviews were audio-recorded, transcribed in Kiswahili, translated into English and coded for themes and patterns with Atlas t.i. Of the 36 patients interviewed (mean time on ART 9.8 months; range 1–23 months), 32 reported perfect adherence in the previous month. Self-reported adherence was high despite economic hardship, depression, low rates of HIV disclosure and high perceived HIV-associated stigma. Five factors emerged to explain excellent adherence in the face of such barriers. First, all respondents experienced substantial improvements in their health after starting ART; this supported their confidence in the medication and motivated them to adhere. Second, their perceived need to be able to meet their family responsibilities motivated respondents to stay healthy. Third, respondents developed specific strategies to remember to take pills, particularly routinizing pill-taking by linking it with daily activities or events. Fourth, material and emotional support received from others facilitated adherence. Finally, respondents trusted the advice and instructions of their health care providers, who regularly emphasized adherence. The facilitating factors identified were consistent with the constructs of social cognitive theory and highlighted the importance of interventions that address multiple levels of influence on adherence

Core Verbal Autopsy Procedures with Comparative Validation Results from Two Countries

Cause-specific mortality statistics remain scarce for the majority of low-income countries, where the highest disease burdens are experienced. Neither facility-based information systems nor vital registration provide adequate or representative data. The expansion of sample vital registration with verbal autopsy procedures represents the most promising interim solution for this problem. The development and validation of core verbal autopsy forms and suitable coding and tabulation procedures are an essential first step to extending the benefits of this method

The WHO 2016 verbal autopsy instrument: An international standard suitable for automated analysis by InterVA, InSilicoVA, and Tariff 2.0

Background Verbal autopsy (VA) is a practical method for determining probable causes of death at the population level in places where systems for medical certification of cause of death are weak. VA methods suitable for use in routine settings, such as civil registration and vital statistics (CRVS) systems, have developed rapidly in the last decade. These developments have been part of a growing global momentum to strengthen CRVS systems in low-income countries. With this momentum have come pressure for continued research and development of VA methods and the need for a single standard VA instrument on which multiple automated diagnostic methods can be developed. Methods and findings In 2016, partners harmonized a WHO VA standard instrument that fully incorporates the indicators necessary to run currently available automated diagnostic algorithms. The WHO 2016 VA instrument, together with validated approaches to analyzing VA data, offers countries solutions to improving information about patterns of cause-specific mortality. This VA instrument offers the opportunity to harmonize the automated diagnostic algorithms in the future. Conclusions Despite all improvements in design and technology, VA is only recommended where medical certification of cause of death is not possible. The method can nevertheless provide sufficient information to guide public health priorities in communities in which physician certification of deaths is largely unavailable. The WHO 2016 VA instrument, together with validated approaches to analyzing VA data, offers countries solutions to improving information about patterns of cause-specific mortality.The World Health Organization, Bill & Melinda Gates Foundation, and Bloomberg Philanthropies, under the Data for Health Initiative, funded the technical work and making the work publicly available. NM was partially supported by the World Health Organization under an Agreement of Performance of Work grant number 2015/ 535961 awarded to the Swiss Tropical and Public Health Institute, Basel, Switzerland. SJC was partially supported by the Bill & Melinda Gates Foundation grant number OPP1082114 awarded to the London School of Hygiene & Tropical Medicine, London, UK, with a subcontract to the University of Washington, Seattle, US. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Neonatal mortality in two districts in Indonesia: Findings from Neonatal Verbal and Social Autopsy (VASA)

Background The Government of Indonesia is determined to follow global commitments to reduce the neonatal mortality rate. Yet, there is a paucity of information on contributing factors and causes of neonatal deaths, particularly at the sub-national level. This study describes care-seeking during neonates’ fatal illnesses and their causes of death. Methods We conducted a cross-sectional community-based study to identify all neonatal deaths in Serang and Jember Districts, Indonesia. Follow-up interviews were conducted with the families of deceased neonates using an adapted verbal and social autopsy instrument. Cause of death was determined using the InSilicoVA algorithm. Results The main causes of death of 259 neonates were prematurity (44%) and intrapartum-related events (IPRE)-mainly birth asphyxia (39%). About 83% and 74% of the 259 neonates were born and died at a health facility, respectively; 79% died within the first week after birth. Of 70 neonates whose fatal illness began at home, 59 (84%) sought care during the fatal illness. Forty-eight of those 59 neonates went to a formal care provider; 36 of those 48 neonates (75%) were moderately or severely ill when the family decided to seek care. One hundred fifteen of 189 neonates (61%) whose fatal illnesses began at health facilities were born at a hospital. Among those 115, only 24 (21%) left the hospital alive–of whom 16 (67%) were referred by the hospital. Conclusions The high proportion of deaths due to prematurity and IPRE suggests the need for improved management of small and asphyxiated newborns. The moderate to severe condition of neonates at the time when care was sought from home highlights the importance of early illness recognition and appropriate management for sick neonates. Among deceased neonates whose fatal illness began at their delivery hospital, the high proportion of referrals may indicate issues with hospital capability, capacity, and/or cost

Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia

Background Despite the increased access to facility-based delivery in Indonesia, the country’s maternal mortality remains unacceptably high. Reducing maternal mortality requires a good understanding of the care-seeking pathways for maternal complications, especially with the government moving toward universal health coverage. This study examined care-seeking practices and health insurance in instances of pregnancy-related deaths in Jember District, East Java, Indonesia. Methods This was a community-based cross-sectional study to identify all pregnancy-related deaths in the district from January 2017 to December 2018. Follow-up verbal and social autopsy interviews were conducted to collect information on care-seeking behavior, health insurance, causes of death, and other factors. Findings Among 103 pregnancy-related deaths, 40% occurred after 24 hours postpartum, 36% during delivery or within the first 24 hours postpartum, and 24% occurred while pregnant. The leading causes of deaths were hemorrhage (38.8%), pregnancy-induced hypertension (20.4%), and sepsis (16.5%). Most deaths occurred in health facilities (81.6%), primarily hospitals (74.8%). Nearly all the deceased sought care from a formal health provider during their fatal illness (93.2%). Seeking any care from an informal provider during the fatal illness was more likely among women who died after 24 hours postpartum (41.0%, OR 7.4, 95% CI 1.9, 28.5, p = 0.049) or during pregnancy (29.2%, OR 4.4, 95% CI 1.0, 19.2, p = 0.003) than among those who died during delivery or within 24 hours postpartum (8.6%). There was no difference in care-seeking patterns between insured and uninsured groups. Conclusions The fact that women sought care and reached health facilities regardless of their insurance status provides opportunities to prevent deaths by ensuring that every woman receives timely and quality care. Accordingly, the increasing demand should be met with balanced readiness of both primary care and hospitals to provide quality care, supported by an effective referral system

A Lean Modeling Protocol for Evaluating Green Project Delivery

The first vital step to leaning an operation is to model or map the processes used to deliver value in that operation. This allows the requisite understanding of where waste and non value-adding activity exists, and provides the foundation for improvement. Current protocols for modeling operations present the basic tenets for lean mapping, but tend to be based in manufacturing language, and are not easily adapted to capital facilities projects.'Green' or 'sustainable' capital projects delivered using current project delivery systems seem to be laden with hidden waste. These projects tend to be more challenging to deliver due increased levels of building system integration, untraditional materials, and requirements such as recycling, total commissioning, and increased project documentation. Penn State's Lean and Green Research Initiative has examined the delivery of multi-million dollar green building projects for clients including the Pentagon, Toyota, and Penn State's Office of Physical Plant. The processes used to complete these projects are difficult to model with current lean techniques.This paper outlines a detailed modeling protocol for evaluating the delivery processes of green projects. Blending existing protocols and the specific needs of green building projects, this protocol will help define the data collection and analysis procedures, as well as the instruments (metrics) of analysis