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1.  Understanding maternal mortality from top–down and bottom–up perspectives: Case of Tigray Region, Ethiopia 
Journal of Global Health  null;5(1):010404.
Unacceptably high levels of preventable maternal mortality persist as a problem across sub–Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.
A community–based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15–49 years retrospectively over a one–year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15–49 years. All pregnancy–related deaths were identified after processing the VA material using the InterVA–4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).
The MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy–related deaths. Haemorrhage was the major cause of pregnancy–related death (34%). District–level MMRs were strongly inversely correlated with population density (r2 = 0.86).
This simple but well–designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub–Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions.
PMCID: PMC4306295
2.  Changing use of traditional healthcare amongst those dying of HIV related disease and TB in rural South Africa from 2003 – 2011: a retrospective cohort study 
In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period.
Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use.
There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008–2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003–2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated.
There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6882-14-504) contains supplementary material, which is available to authorized users.
PMCID: PMC4325963  PMID: 25515165
Traditional medical practitioner; Traditional medicine; Antiretroviral therapy; HIV; AIDS; Mortality; Tuberculosis; Demographic surveillance system; South Africa; Sub-Saharan Africa; Risk factor
3.  Deaths Ascribed to Non-Communicable Diseases among Rural Kenyan Adults Are Proportionately Increasing: Evidence from a Health and Demographic Surveillance System, 2003–2010 
PLoS ONE  2014;9(11):e114010.
Non-communicable diseases (NCDs) result in more deaths globally than other causes. Monitoring systems require strengthening to attribute the NCD burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal.
Methods and Findings
Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya, attributed into broad categories using InterVA-4 computer algorithms; 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% (39% male, 48% female) of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010 (χ2 linear trend 93.4; p<0.001). While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. The substantial fall in CD MRs resulted in similar MRs for CDs and NCDs among all adult females by 2010. NCD MRs for adults aged 15y to <65y fell from 409 to 183 per 100,000 among females and from 517 to 283 per 100,000 population among males. NCD MRs were higher among males than females aged both below, and at or above, 65y.
NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.
PMCID: PMC4245262  PMID: 25426945
4.  Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study 
Global Health Action  2014;7:10.3402/gha.v7.24826.
Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.
This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.
Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007–2008 and 2009–2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.
In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.
PMCID: PMC4245451  PMID: 25416322
HIV; mortality; determinants; global health; population health; healthcare access; South Africa
5.  Mortality from external causes in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System Sites 
Global Health Action  2014;7:10.3402/gha.v7.25366.
Mortality from external causes, of all kinds, is an important component of overall mortality on a global basis. However, these deaths, like others in Africa and Asia, are often not counted or documented on an individual basis. Overviews of the state of external cause mortality in Africa and Asia are therefore based on uncertain information. The INDEPTH Network maintains longitudinal surveillance, including cause of death, at population sites across Africa and Asia, which offers important opportunities to document external cause mortality at the population level across a range of settings.
To describe patterns of mortality from external causes at INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories.
All deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates.
A total of 5,884 deaths due to external causes were documented over 11,828,253 person-years. Approximately one-quarter of those deaths were to children younger than 15 years. Causes of death were dominated by childhood drowning in Bangladesh, and by transport-related deaths and intentional injuries elsewhere. Detailed mortality rates are presented by cause of death, age group, and sex.
The patterns of external cause mortality found here generally corresponded with expectations and other sources of information, but they fill some important gaps in population-based mortality data. They provide an important source of information to inform potentially preventive intervention designs.
PMCID: PMC4220124  PMID: 25377327
external causes; accidents; suicide; assault; transport; drowning; Africa; Asia; mortality; INDEPTH Network; verbal autopsy; InterVA
6.  Cause-specific childhood mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites 
Global Health Action  2014;7:10.3402/gha.v7.25363.
Childhood mortality, particularly in the first 5 years of life, is a major global concern and the target of Millennium Development Goal 4. Although the majority of childhood deaths occur in Africa and Asia, these are also the regions where such deaths are least likely to be registered. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.
To present a description of cause-specific mortality rates and fractions over the first 15 years of life as documented by INDEPTH Network sites in sub-Saharan Africa and south-east Asia.
All childhood deaths at INDEPTH sites are routinely registered and followed up with verbal autopsy (VA) interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provided person-time denominators for mortality rates. Cause-specific mortality rates and cause-specific mortality fractions are presented according to WHO 2012 VA cause groups for neonatal, infant, 1–4 year and 5–14 year age groups.
A total of 28,751 childhood deaths were documented during 4,387,824 person-years over 18 sites. Infant mortality ranged from 11 to 78 per 1,000 live births, with under-5 mortality from 15 to 152 per 1,000 live births. Sites in Vietnam and Kenya accounted for the lowest and highest mortality rates reported.
Many children continue to die from relatively preventable causes, particularly in areas with high rates of malaria and HIV/AIDS. Neonatal mortality persists at relatively high, and perhaps sometimes under-documented, rates. External causes of death are a significant childhood problem in some settings.
PMCID: PMC4220125  PMID: 25377325
Childhood; Africa; Asia; mortality; INDEPTH Network; verbal autopsy; InterVA
7.  Cause-specific mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites 
Global Health Action  2014;7:10.3402/gha.v7.25362.
Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.
To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns.
Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death.
A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths.
This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis.
PMCID: PMC4220126  PMID: 25377324
mortality; cause of death; Africa; Asia; verbal autopsy; INDEPTH Network
8.  Who died of what in rural KwaZulu-Natal, South Africa: a cause of death analysis using InterVA-4 
Global Health Action  2014;7:10.3402/gha.v7.25496.
For public health purposes, it is important to see whether men and women in different age groups die of the same causes in South Africa.
We explored sex- and age-specific patterns of causes of deaths in a rural demographic surveillance site in northern KwaZulu-Natal in South Africa over the period 2000–2011.
Deaths reported through the demographic surveillance were followed up by a verbal autopsy (VA) interview using a standardised questionnaire. Causes of death were assigned likelihoods using the publicly available tool InterVA-4. Cause-specific mortality fractions were determined by age and sex.
Over the study period, a total of 5,416 (47%) and 6,081 (53%) deaths were recorded in men and women, respectively. Major causes of death proportionally affecting more women than men were (all p<0.0001): human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (20.1% vs. 13.6%), other and unspecified cardiac disease (5.9% vs. 3.2%), stroke (4.5% vs. 2.7%), reproductive neoplasms (1.7% vs. 0.4%), diabetes (2.4% vs. 1.2%), and breast neoplasms (0.4% vs. 0%). Major causes of deaths proportionally affecting more men than women were (all p<0.0001) assault (6.1% vs. 1.7%), pulmonary tuberculosis (34.5% vs. 30.2%), road traffic accidents (3.0% vs. 1.0%), intentional self-harm (1.3% vs. 0.3%), and respiratory neoplasms (2.5% vs. 1.5%). Causes of death due to communicable diseases predominated in all age groups except in older persons.
While mortality during the 2000s was dominated by tuberculosis and HIV/AIDS, we found substantial sex-specific differences both for communicable and non-communicable causes of death, some which can be explained by a differing sex-specific age structure. InterVA-4 is likely to be a valuable tool for investigating causes of death patterns in other similar Southern African settings.
PMCID: PMC4220127  PMID: 25377332
mortality; cause of death; demographic surveillance; South Africa; HIV/AIDS; tuberculosis; verbal autopsy
9.  Adult non-communicable disease mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites 
Global Health Action  2014;7:10.3402/gha.v7.25365.
Mortality from non-communicable diseases (NCDs) is a major global issue, as other categories of mortality have diminished and life expectancy has increased. The World Health Organization's Member States have called for a 25% reduction in premature NCD mortality by 2025, which can only be achieved by substantial reductions in risk factors and improvements in the management of chronic conditions. A high burden of NCD mortality among much older people, who have survived other hazards, is inevitable. The INDEPTH Network collects detailed individual data within defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.
To describe patterns of adult NCD mortality from INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories, with separate consideration of premature (15–64 years) and older (65+ years) NCD mortality.
All adult deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates.
A total of 80,726 adult (over 15 years) deaths were documented over 7,423,497 person-years of observation. NCDs were attributed as the cause for 35.6% of these deaths. Slightly less than half of adult NCD deaths occurred in the 15–64 age group. Detailed results are presented by age and sex for leading causes of NCD mortality. Per-site rates of NCD mortality were significantly correlated with rates of HIV/AIDS-related mortality.
These findings present important evidence on the distribution of NCD mortality across a wide range of African and Asian settings. This comes against a background of global concern about the burden of NCD mortality, especially among adults aged under 70, and provides an important baseline for future work.
PMCID: PMC4220128  PMID: 25377326
adults; non-communicable disease; Africa; Asia; mortality; INDEPTH Network; verbal autopsy; InterVA
10.  Malaria mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites 
Global Health Action  2014;7:10.3402/gha.v7.25369.
Malaria continues to be a major cause of infectious disease mortality in tropical regions. However, deaths from malaria are most often not individually documented, and as a result overall understanding of malaria epidemiology is inadequate. INDEPTH Network members maintain population surveillance in Health and Demographic Surveillance System sites across Africa and Asia, in which individual deaths are followed up with verbal autopsies.
To present patterns of malaria mortality determined by verbal autopsy from INDEPTH sites across Africa and Asia, comparing these findings with other relevant information on malaria in the same regions.
From a database covering 111,910 deaths over 12,204,043 person-years in 22 sites, in which verbal autopsy data were handled according to the WHO 2012 standard and processed using the InterVA-4 model, over 6,000 deaths were attributed to malaria. The overall period covered was 1992–2012, but two-thirds of the observations related to 2006–2012. These deaths were analysed by site, time period, age group and sex to investigate epidemiological differences in malaria mortality.
Rates of malaria mortality varied by 1:10,000 across the sites, with generally low rates in Asia (one site recording no malaria deaths over 0.5 million person-years) and some of the highest rates in West Africa (Nouna, Burkina Faso: 2.47 per 1,000 person-years). Childhood malaria mortality rates were strongly correlated with Malaria Atlas Project estimates of Plasmodium falciparum parasite rates for the same locations. Adult malaria mortality rates, while lower than corresponding childhood rates, were strongly correlated with childhood rates at the site level.
The wide variations observed in malaria mortality, which were nevertheless consistent with various other estimates, suggest that population-based registration of deaths using verbal autopsy is a useful approach to understanding the details of malaria epidemiology.
PMCID: PMC4220130  PMID: 25377329
malaria; Africa; Asia; mortality; INDEPTH Network; verbal autopsy; InterVA
11.  HIV/AIDS-related mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites 
Global Health Action  2014;7:10.3402/gha.v7.25370.
As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data.
To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia.
Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population.
The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates.
Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS.
PMCID: PMC4220131  PMID: 25377330
HIV/AIDS; tuberculosis; Africa; Asia; Mortality; INDEPTH Network; Verbal Autopsy; InterVA
12.  Cause-specific mortality at INDEPTH Health and Demographic Surveillance System Sites in Africa and Asia: concluding synthesis 
Global Health Action  2014;7:10.3402/gha.v7.25590.
This synthesis brings together findings on cause-specific mortality documented by means of verbal autopsies applied to over 110,000 deaths across Africa and Asia, within INDEPTH Network sites.
Developments in computerised methods to assign causes of death on the basis of data from verbal autopsy (VA) interviews have made possible these standardised analyses of over 110,000 deaths from 22 African and Asian Health and Demographic Surveillance System sites in the INDEPTH Network. In addition to previous validations of the InterVA-4 probabilistic model, these wide-ranging analyses provide further evidence of the applicability of this approach to assigning the cause of death. Plausible comparisons with existing knowledge of disease patterns, as well as substantial correlations with out-of-model parameters such as time period, country, and other independent data sources were observed.
Substantial variations in mortality between sites, and in some cases within countries, were observed. A number of the mortality burdens revealed clearly constitute grounds for public health actions. At an overall level, these included high maternal and neonatal mortality rates. More specific examples were childhood drowning in Bangladesh and homicide among adult males in eastern and southern Africa. Mortality from non-communicable diseases, particularly in younger adulthood, is an emerging cause for concern. INDEPTH’s approach of documenting all deaths in particular populations, and successfully assigning causes to the majority, is important for formulating health policies.
Future directions
The pooled dataset underlying these analyses is available at the INDEPTH Data Repository for further analysis. INDEPTH will continue to fill cause-specific mortality knowledge gaps across Africa and Asia, which will also serve as a baseline for post-2015 development goals. The more widespread use of similar VA methods within routine civil registration systems is likely to become an important medium-term strategy in many countries.
PMCID: PMC4220138  PMID: 25377341
mortality; cause of death; Africa; Asia; verbal autopsy; INDEPTH Network
13.  Pregnancy-related mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites 
Global Health Action  2014;7:10.3402/gha.v7.25368.
Women continue to die in unacceptably large numbers around the world as a result of pregnancy, particularly in sub-Saharan Africa and Asia. Part of the problem is a lack of accurate, population-based information characterising the issues and informing solutions. Population surveillance sites, such as those operated within the INDEPTH Network, have the potential to contribute to bridging the information gaps.
To describe patterns of pregnancy-related mortality at INDEPTH Network Health and Demographic Surveillance System sites in sub-Saharan Africa and southeast Asia in terms of maternal mortality ratio (MMR) and cause-specific mortality rates.
Data on individual deaths among women of reproductive age (WRA) (15–49) resident in INDEPTH sites were collated into a standardised database using the INDEPTH 2013 population standard, the WHO 2012 verbal autopsy (VA) standard, and the InterVA model for assigning cause of death.
These analyses are based on reports from 14 INDEPTH sites, covering 14,198 deaths among WRA over 2,595,605 person-years observed. MMRs varied between 128 and 461 per 100,000 live births, while maternal mortality rates ranged from 0.11 to 0.74 per 1,000 person-years. Detailed rates per cause are tabulated, including analyses of direct maternal, indirect maternal, and incidental pregnancy-related deaths across the 14 sites.
As expected, these findings confirmed unacceptably high continuing levels of maternal mortality. However, they also demonstrate the effectiveness of INDEPTH sites and of the VA methods applied to arrive at measurements of maternal mortality that are essential for planning effective solutions and monitoring programmatic impacts.
PMCID: PMC4220143  PMID: 25377328
maternal mortality; cause of death; Africa; Asia; verbal autopsy; INDEPTH Network
14.  Causes of death among persons of all ages within the Kilifi Health and Demographic Surveillance System, Kenya, determined from verbal autopsies interpreted using the InterVA-4 model 
Global Health Action  2014;7:10.3402/gha.v7.25593.
The vast majority of deaths in the Kilifi study area are not recorded through official systems of vital registration. As a result, few data are available regarding causes of death in this population.
To describe the causes of death (CODs) among residents of all ages within the Kilifi Health and Demographic Surveillance System (KHDSS) on the coast of Kenya.
Verbal autopsies (VAs) were conducted using the 2007 World Health Organization (WHO) standard VA questionnaires, and VA data further transformed to align with the 2012 WHO VA instrument. CODs were then determined using the InterVA-4 computer-based probabilistic model.
Five thousand one hundred and eighty seven deaths were recorded between January 2008 and December 2011. VA interviews were completed for 4,460 (86%) deaths. Neonatal pneumonia and birth asphyxia were the main CODs in neonates; pneumonia and malaria were the main CODs among infants and children aged 1–4, respectively, while HIV/AIDS was the main COD for adult women of reproductive age. Road traffic accidents were more commonly observed among men than women. Stroke and neoplasms were common CODs among the elderly over the age of 65.
We have established the main CODs among people of all ages within the area served by the KHDSS on the coast of Kenya using the 2007 WHO VA questionnaire coded using InterVA-4. We hope that our data will allow local health planners to estimate the burden of various diseases and to allocate their limited resources more appropriately.
PMCID: PMC4220144  PMID: 25377342
verbal autopsy; InterVA-4; cause-specific mortality fraction; Kenya
15.  Two decades of mortality change in rural northeast South Africa 
Global Health Action  2014;7:10.3402/gha.v7.25596.
The MRC/Wits University Agincourt research centre, part of the INDEPTH Network, has documented mortality in a defined population in the rural northeast of South Africa for 20 years (1992–2011) using long-term health and socio-demographic surveillance. Detail on the unfolding, at times unpredicted, mortality pattern has been published. This experience is reviewed here and updated using more recent data.
To present a review and summary of mortality patterns across all age-sex groups in the Agincourt sub-district population for the period 1992–2011 as a comprehensive basis for public health action.
Vital events in the Agincourt population have been updated in annual surveys undertaken since 1992. All deaths have been rigorously recorded and followed by verbal autopsy interviews. Responses to questions from these interviews have been processed retrospectively using the WHO 2012 verbal autopsy standard and the InterVA-4 model for assigning causes of death in a standardised manner.
Between 1992 and 2011, a total of 12,209 deaths were registered over 1,436,195 person-years of follow-up, giving a crude mortality rate of 8.5 per 1,000 person-years. During the 20-year period, the population experienced a major HIV epidemic, which resulted in more than doubling of overall mortality for an extended period. Recent years show signs of declining mortality, but levels remain above the 1992 baseline recorded using the surveillance system.
The Agincourt population has experienced a major mortality shock over the past two decades from which it will take time to recover. The basic epidemic patterns are consistent with generalised mortality patterns observed in South Africa as a whole, but the detailed individual surveillance behind these analyses allows finer-grained analyses of specific causes, age-related risks, and trends over time. These demonstrate the complex, somewhat unpredicted course of mortality transition over the years since the dawn of South Africa's democratic era in 1994.
PMCID: PMC4220148  PMID: 25377343
Africa; Agincourt; rural; mortality; HIV/AIDS; tuberculosis; INDEPTH Network; verbal autopsy; InterVA; non-communicable diseases
16.  Assessing the impact of mHealth interventions in low- and middle-income countries – what has been shown to work? 
Global Health Action  2014;7:10.3402/gha.v7.25606.
Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders.
Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications.
There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects.
Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.
PMCID: PMC4216389  PMID: 25361730
mHealth; low- and middle-income countries; health systems; interventions; mobile data
17.  The global burden of liver disease: a challenge for methods and for public health 
BMC Medicine  2014;12(1):159.
New Global Burden of Disease estimates for liver cirrhosis, published in BMC Medicine, suggest that cirrhosis caused over a million deaths in 2010, with a further million due to liver cancer and acute hepatitis. Cause-specific mortality data were very sparse for some regions, particularly in Africa, with no relevant mortality data for 58/187 countries. Liver disease involves infectious, malignant and chronic aetiologies with overlapping symptoms. Where available mortality data come from verbal autopsies, separating different types of liver disease is challenging.
Cirrhosis is a disease of rich and poor alike; key public health risk factors such as alcohol consumption play an important role. Risk-reduction strategies such as controlling the price of alcohol are being widely discussed. Since these estimates used alcohol consumption as a covariate, they cannot be used to explore relationships between alcohol consumption and cirrhosis mortality.
There is hope: coming generations of adults will have been vaccinated against hepatitis B, and this is envisaged to reduce the burden of fatal liver disease. But more complete civil registration globally is needed to fully understand the burden of liver disease.
Please see related article:
PMCID: PMC4168048  PMID: 25286285
Liver disease; Cirrhosis; Mortality; Verbal autopsy; Alcohol consumption; Hepatitis; Global estimates; Vaccination; Risk factors; Civil registration
18.  Undertaking cause-specific mortality measurement in an unregistered population: an example from Tigray Region, Ethiopia 
Global Health Action  2014;7:10.3402/gha.v7.25264.
The lack of adequate documentation of deaths, and particularly their cause, is often noted in African and Asian settings, but practical solutions for addressing the problem are not always clear. Verbal autopsy methods (interviewing witnesses after a death) have developed rapidly, but there remains a lack of clarity as to how these methods can be effectively applied to large unregistered populations. This paper sets out practical details for undertaking a representative survey of cause-specific mortality in a population of several million, taking Tigray Region in Ethiopia as a prototype.
Sampling was designed around an expected level of maternal mortality ratio of 400 per 100,000 live births, which needed measuring within a 95% confidence interval of approximately ±100. Taking a stratified cluster sample within the region at the district level for logistic reasons, and allowing for a design effect of 2, this required a population of around 900,000 people, equating to six typical districts. Since the region is administered in six geographic zones, one district per zone was randomly selected.
The survey was implemented as a two-stage process: first, to trace deaths that occurred in the sampled districts within the preceding year, and second to follow them up with verbal autopsy interviews. The field work for both stages was undertaken by health extension workers, working in their normally assigned areas. Most of the work was associated with tracing the deaths, rather than undertaking the verbal autopsy interviews.
This approach to measuring cause-specific mortality in an unregistered Ethiopian population proved to be feasible and effective. Although it falls short of the ideal situation of continuous civil registration and vital statistics, a survey-based strategy of this kind may prove to be a useful intermediate step on the road towards full civil registration and vital statistics implementation.
PMCID: PMC4162981  PMID: 25217254
Ethiopia; mortality; verbal autopsy; population survey; civil registration and vital statistics; evidence-based decision making
19.  Age-Specific Malaria Mortality Rates in the KEMRI/CDC Health and Demographic Surveillance System in Western Kenya, 2003–2010 
PLoS ONE  2014;9(9):e106197.
Recent global malaria burden modeling efforts have produced significantly different estimates, particularly in adult malaria mortality. To measure malaria control progress, accurate malaria burden estimates across age groups are necessary. We determined age-specific malaria mortality rates in western Kenya to compare with recent global estimates. We collected data from 148,000 persons in a health and demographic surveillance system from 2003–2010. Standardized verbal autopsies were conducted for all deaths; probable cause of death was assigned using the InterVA-4 model. Annual malaria mortality rates per 1,000 person-years were generated by age group. Trends were analyzed using Poisson regression. From 2003–2010, in children <5 years the malaria mortality rate decreased from 13.2 to 3.7 per 1,000 person-years; the declines were greatest in the first three years of life. In children 5–14 years, the malaria mortality rate remained stable at 0.5 per 1,000 person-years. In persons ≥15 years, the malaria mortality rate decreased from 1.5 to 0.4 per 1,000 person-years. The malaria mortality rates in young children and persons aged ≥15 years decreased dramatically from 2003–2010 in western Kenya, but rates in older children have not declined. Sharp declines in some age groups likely reflect the national scale up of malaria control interventions and rapid expansion of HIV prevention services. These data highlight the importance of age-specific malaria mortality ascertainment and support current strategies to include all age groups in malaria control interventions.
PMCID: PMC4152016  PMID: 25180495
20.  Evidence for localised HIV related micro–epidemics associated with the decentralised provision of antiretroviral treatment in rural South Africa: a spatio–temporal analysis of changing mortality patterns (2007–2010) 
Journal of Global Health  2014;4(1):010403.
In this study we analysed the spatial and temporal changes in patterns of mortality over a period when antiretroviral therapy (ART) was rolled out in a rural region of north–eastern South Africa. Previous studies have identified localised concentrated HIV related sub–epidemics and recommended that micro–level analyses be carried out in order to direct focused interventions.
Data from an ongoing health and socio–demographic surveillance study was used in the analysis. The follow–up was divided into two periods, 2007–2008 and 2009–2010, representing the times immediately before and after the effects on mortality of the decentralised ART provision from a newly established local health centre would be expected to be evident. The study population at the start of the analysis was approximately 73 000 individuals. Data were aggregated by village and also using a 2 × 2 km grid. We identified villages, grid squares and regions in the site where mortality rates within each time period or rate ratios between the periods differed significantly from the overall trends. We used clustering techniques to identify cause–specific mortality hotspots.
Comparing the two periods, there was a 30% decrease in age and gender standardised adult HIV–related and TB (HIV/TB) mortality with no change in mortality due to other causes. There was considerable spatial heterogeneity in the mortality patterns. Areas separated by 2 to 4 km with very different epidemic trajectories were identified. There was evidence that the impact of ART in reducing HIV/TB mortality was greatest in communities with higher mortality rates in the earlier period.
This study shows the value of conducting high resolution spatial analyses in order to understand how local micro–epidemics contribute to changes seen over a wider area. Such analyses can support targeted interventions.
PMCID: PMC4073250  PMID: 24976962
22.  The development and experience of epidemiological transition theory over four decades: a systematic review 
Global Health Action  2014;7:10.3402/gha.v7.23574.
Epidemiological transition (ET) theory, first postulated in 1971, has developed alongside changes in population structures over time. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners. Here, we review the concept and development of ET theory, contextualising this in empirical evidence, which variously supports and contradicts the original theoretical propositions.
A Medline literature search covering publications over four decades, from 1971 to 2013, was conducted. Studies were included if they assessed human populations, were original articles, focused on mortality and health or demographic or ET and were in English. The reference lists of the selected articles were checked for additional sources.
We found that there were changes in emphasis in the research field over the four decades. There was an increasing tendency to study wide-ranging aspects of the determinants of mortality, including risk factors, lifestyle changes, socio-economics, and macro factors such as climate change. Research on ET has focused increasingly on low- and middle-income countries rather than industrialised countries, despite its origins in industrialised countries. Countries have experienced different levels of progress in ET in terms of time, pace, and underlying mechanisms. Elements of ET are described for many countries, but observed transitions have not always followed pathways described in the original theory.
The classic ET theory largely neglected the critical role of social determinants, being largely a theoretical generalisation of mortality experience in some countries. This review shows increasing interest in ET all over the world but only partial concordance between established theory and empirical evidence. Empirical evidence suggests that some unconsidered aspects of social determinants contributed to deviations from classic theoretical pathways. A better-constructed, revised ET theory, with a stronger basis in evidence, is needed.
PMCID: PMC4038769  PMID: 24848657
epidemiological transition; demographic transition; mortality; social determinants
23.  Essential evidence for guiding health system priorities and policies: anticipating epidemiological transition in Africa 
Global Health Action  2014;7:10.3402/gha.v7.23359.
Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way.
We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers.
African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services.
PMCID: PMC4028905  PMID: 24848653
health services; epidemiological transition; health information; sub-Saharan Africa; health policy
24.  Verbal autopsy as a tool for identifying children dying of sickle cell disease: a validation study conducted in Kilifi district, Kenya 
BMC Medicine  2014;12:65.
Sickle cell disease (SCD) is common in many parts of sub-Saharan Africa (SSA), where it is associated with high early mortality. In the absence of newborn screening, most deaths among children with SCD go unrecognized and unrecorded. As a result, SCD does not receive the attention it deserves as a leading cause of death among children in SSA. In the current study, we explored the potential utility of verbal autopsy (VA) as a tool for attributing underlying cause of death (COD) in children to SCD.
We used the 2007 WHO Sample Vital Registration with Verbal Autopsy (SAVVY) VA tool to determine COD among child residents of the Kilifi Health and Demographic Surveillance System (KHDSS), Kenya, who died between January 2008 and April 2011. VAs were coded both by physician review (physician coded verbal autopsy, PCVA) using COD categories based on the WHO International Classification of Diseases 10th Edition (ICD-10) and by using the InterVA-4 probabilistic model after extracting data according to the 2012 WHO VA standard. Both of these methods were validated against one of two gold standards: hospital ICD-10 physician-assigned COD for children who died in Kilifi District Hospital (KDH) and, where available, laboratory confirmed SCD status for those who died in the community.
Overall, 6% and 5% of deaths were attributed to SCD on the basis of PCVA and the InterVA-4 model, respectively. Of the total deaths, 22% occurred in hospital, where the agreement coefficient (AC1) for SCD between PCVA and hospital physician diagnosis was 95.5%, and agreement between InterVA-4 and hospital physician diagnosis was 96.9%. Confirmatory laboratory evidence of SCD status was available for 15% of deaths, in which the AC1 against PCVA was 87.5%.
Other recent studies and provisional data from this study, outlining the importance of SCD as a cause of death in children in many parts of the developing world, contributed to the inclusion of specific SCD questions in the 2012 version of the WHO VA instruments, and a specific code for SCD has now been included in the WHO and InterVA-4 COD listings. With these modifications, VA may provide a useful approach to quantifying the contribution of SCD to childhood mortality in rural African communities. Further studies will be needed to evaluate the generalizability of our findings beyond our local context.
PMCID: PMC4022330  PMID: 24755265
Sickle cell disease; Verbal autopsy; Agreement coefficient; Child mortality; Kenya
25.  A probabilistic method to estimate the burden of maternal morbidity in resource-poor settings: preliminary development and evaluation 
Maternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India.
Using training datasets, it was possible to create a probabilistic tool that handled uncertainty of women’s self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified.
The probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women’s self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.
PMCID: PMC3975153  PMID: 24620784
Maternal health; Morbidity; Developing countries; Pregnancy; Childbirth; Bayesian analysis; Africa; Asia

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