Measuring the Vital Events in the Communities of Africa


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  • I would like to recognize and acknowledge co-authors of this presentation from MEASURE Evaluation: Dr. Sian Curtis, Director - MEASURE Evaluation Stirling Cummings, Research Associate – MEASURE Evaluation
  • A quote from the Minister of Justice and Constitutional Affairs, Mr, Mathias Chikawe, on the need for an improved, well functioning vital events registration system in Tanzania in particular, and in Africa as a whole. RITA (Registration, Insolvency and Trustees Agency) program in Tanzania, only 15% of Tanzanians have utilized the services
  • 1 st bullet: gap between mortality information and current VR systems, which lack complete coverage or are otherwise low-functioning 2 nd bullet: … which will be a benefit to both individuals and to communities 3 rd bullet: Recognize there are long-term goals of VR systems, but there are also more immediate needs for information for decision making in Health Programs
  • Having complete and universal Civil / Vital Events Registration is long-term goal…but in the meantime:
  • Evolution of SAVVY: (Lessons learned from  Sample Registration System (India) Disease Surveillance Point System (China) National Sentinel Surveillance System (Tanzania) Health and Demographic Surveillance Systems (INDEPTH Network) Households Surveys (DHS, HBS, LSMS) National Censuses
  • Main difference between SAVVY and HDSS: SAVVY is nationally representative based on sampling techniques at cluster level. Also tools implemented with SAVVY have been extensively reviewed and validated
  • Sources: Improving death registration and statistics in developing countries: Lessons from sub-Saharan Africa (Chalapati Rao, Debbie Bradshaw, Colin Mathers). South African Journal of Demography 9(2): 79-97 SAVVY – MEASURE Evaluation website
  • For example, according to the 2007 INCAM study in Mozambique, roughly 73% of all deaths identified occurred at home. What can be done? Do more to enumerate and register deaths in communities Use appropriate techniques to determine likely causes of death Create and use mortality statistics derived from all available information
  • Steps 3,4 actually recommended by WHO, not everyone does this...
  • Types of VA questionnaires Form 1: Stillbirths, perinatal and neonatal deaths Form 2: Post-neonatal and child deaths Form 3: Adult deaths
  • Death Certification and ICD-10 coding training: DC and ICD-10 coding training (about 2 weeks) Takes place after VA data collection is completed 1 week - review of ICD volumes and processes 1 week - actual death certification and ICD-coding work Physicians review of VAQ Each VA independently reviewed by 2 MDs Write death certificates and ICD-10 codes, with tentative UCOD Reconciliation of death certificates 2 DCs are compared – if agree, UCOD reached If do not agree – 2 MDs sit together to reconcile
  • Direct may speak to issues of providing TREATMENT Underlying may speak to issues of PREVENTION
  • Some of the last items are still in very preliminary stages.
  • Kenya: Snow RW, Winstanley MT, Marsh VM, Newton CRJC, Waruiru C and others, 1992. “Childhood deaths in Africa: uses and limitations of verbal autopsies”. The Lancet Vol 340 Issue 8815, August 1992. Common causes of childhood deaths were detected with specificities >80%, Sensitivity was >75% for measles, neonatal tetanus, malnutrition, and injury-related deaths. However sensitivity less than 50% for malaria, anaemia, ARI, gastroenteritis and meningitis Zimbabwe: Ben Lopman, Adrian Cook, Jennifer Smith, Godwin Chawira, et al, 2009. “VA can consistently measure AIDS mortality: A validity study in Tanzania and Zimbabwe”. The Journal of Epidemiology and Community Health (JECH). October 23, 2009. Results High Sensitivity and Specificity of AIDS death among age group 15-44 (79% or higher) Namibia: Mobley CC, Boerma JT, Titus S, Lohrke B, Shangula K, Black RE, 1996. “Validation study of a verbal autopsy method for causes of childhood mortality in Namibia”. Results:An algorithm for cerebral malaria (fever, loss of consciousness or convulsions) – sensitivity 72%, specificity 85%. All malaria deaths (sensitivity 45%, specificity 87%. Proportion 33/243. Tanzania: Philip Setel, David Whiting, yusuf Hemed, D. Chnadramohan, Lara wolfson, KGMM Alberti and Alan Lopez, 2006 ”Validity of VA procedures for determining cause of death in Tanzania:. Tropical Medicine and International Health, Vol 11, No 5, May 2009.
  • Uganda: Field work conducted between March and April 2007. Analyzed sample = 541 of 641 Ghana: Field work conducted between September and November 2008. Analyzed sample = 199 of 226 Rwanda: Field work conducted between May and June 2008. Analyzed sample = 431 of 462 wanda
  • One of the highest child mortality rates in the world: under-5 mortality rates of 168 per 1,000 live births, the infant mortality rate of 115 per 1,000 live births.
  • Response Rates Uganda Initial count in the death frame = 724 including 83 stillbirths identified by the 2006 UDHS Stillbirths were excluded and hence remained with 641 child deaths in the death frame. Of the 641 deaths: VAs were not completed for 87 cases Also, in the process of coding, 13 deaths were identified by medical coders to have been stillbirths, and hence excluded in the analysis. Final count in the death frame complete with VA and ICD codes was 541. This is equivalent to a response rate of 84.4%
  • Formal health services in Uganda include: Government and private hospitals, health centers, clinics and dispensaries
  • Response Rates Ghana 226 in the death frame. VA completed – 199. VA not completed – 27 This is equivalent to a response-rate of 88.1%.
  • Formal health services in Ghana include: government, private, and faith-based hospitals, health centers and clinics
  • Verbal autopsy methods are a crude but replicable and moderately reliable method for estimating cause-specific mortality. The validity of verbal autopsy methods to identify specific causes of mortality in children and adults is influenced by prevalence data which can differ from one area to the other. Although the point estimates of cause-specific mortality data requires some type of adjustments, verbal autopsy methods offers reliable estimates for ascertaining mortality trends. VA presents the best option for assessing and responding to deaths deaths and theirs causes in many African countries where there is a paucity of reliable information and most deaths occur away from health facilities, or without formal health care contact in the period before death. This is especially true for deaths occurring in poorer communities. The use of validated verbal autopsy procedures in assessing the impact of burden of disease is an emerging procedure, and produces results that can be validated, and are useful for informing policies and monitoring interventions at all levels. Verbal autopsy methods are indispensable in monitoring the progress toward the achievement of global and local initiatives.
  • Measuring the Vital Events in the Communities of Africa

    1. 1. Measuring Vital Events in the Communities in Africa ROBERT MSWIA, MEASURE Evaluation GHC International Conference June 14-18, 2010, Omni Shoreham Hotel, Washington, DC
    2. 2. <ul><li>“ Millions of people in Africa are born and dying without any records that can be referred to, and it becomes even difficult to understand whether one happened to live and eventually die in the region” </li></ul><ul><li>Tanzanian Minister for Justice and Constitutional Affairs, Daily News May 26, 2010 </li></ul>
    3. 3. Demand for Better Data on Vital Events <ul><li>How to measure impact when there is a gap between information needs and vital events data in many countries in Africa? </li></ul><ul><li>Long-term goal of having a complete and sustainable vital registration system in the region. </li></ul><ul><li>How can we bridge the information gap? </li></ul><ul><ul><li>Current interim measures, i.e. surveys, census </li></ul></ul><ul><ul><li>Global initiatives committing to long-term goals </li></ul></ul>
    4. 4. Demand for VE data <ul><li>M&E is central to global and local initiatives (MDGs, Millennium Challenge Account, PEPFAR Strategic Information, PMI strategies, etc) </li></ul><ul><li>Several millennium commitments to do better with investments in population health and development </li></ul><ul><li>Increased realization of need for information systems (NOT just data from surveys) that are: </li></ul><ul><ul><li>Sustainable, longitudinal, community-based, and </li></ul></ul><ul><ul><li>Multi-level and multi-purpose </li></ul></ul>
    5. 5. Monitoring and Evaluation of Programs, National and International Indicators <ul><li>To assess progress in health sector reform and intervention programs </li></ul><ul><li>Serve as a means for measuring the impact of scaled-up health initiatives that aim at reducing morbidity and mortality </li></ul><ul><ul><li>MDGs; UNGASS; UNAIDS; PEPFAR; Global Fund to Fight AIDS, Tuberculosis; PMI; RBM; Poverty Reduction Strategies; Stop TB; SMI; etc </li></ul></ul><ul><li>National burden of disease estimates for appropriate budgeting, planning and resource allocation </li></ul>
    6. 6. ‘ Stepping Stones’ to better vital statistics: with focus on mortality data <ul><ul><li>Stepping Stones to better vital statistics: </li></ul></ul><ul><ul><ul><li>Health and Demographic Surveillance Systems (HDSS) – geographically defined area </li></ul></ul></ul><ul><ul><ul><li>Sentinel and Sample Vital Registration ( example: India SRS, China DSP) </li></ul></ul></ul><ul><ul><ul><li>Implementing SAVVY – nationally representative </li></ul></ul></ul><ul><ul><ul><li>Mortality Surveys (Post-Census mortality follow-up in Mozambique, VA with DHS for < 5yrs mortality follow-up in PMI countries) </li></ul></ul></ul><ul><ul><ul><li>HMN: Monitoring of Vital Events (MoVE) Task Group </li></ul></ul></ul>
    7. 7. What is SAVVY <ul><li>A sample registration surveillance system built around vital events monitoring (births, deaths, migration, etc) </li></ul><ul><li>Assumes a nationally representative sample of clusters </li></ul><ul><li>Purpose is to provide improved monitoring and measurement of vital events on a routine basis </li></ul><ul><ul><li>Not available from vital registration, household surveys, etc </li></ul></ul><ul><ul><li>Includes cause of death ascertainment </li></ul></ul><ul><li>SAVVY consolidates and adapts best practice in </li></ul><ul><ul><li>Sample and demographic surveillance techniques </li></ul></ul><ul><ul><li>Survey sampling methods </li></ul></ul><ul><ul><li>Validated verbal autopsy methods </li></ul></ul>
    8. 8. Possibilities with SAVVY <ul><li>SAVVY addresses the need for better vital events and cause of death data, at national and sub-national level – critical path towards strengthening vital events systems </li></ul><ul><li>Able to produce longitudinal data as from other HDSS operations, including: </li></ul><ul><ul><li>Births, fertility levels and patterns </li></ul></ul><ul><ul><li>Levels, patterns and causes of mortality </li></ul></ul><ul><ul><li>Income poverty and food security </li></ul></ul><ul><ul><li>Population structures and components of change </li></ul></ul><ul><ul><li>Behavioral and biological risk factors </li></ul></ul><ul><ul><li>Major causes of non-fatal morbidity </li></ul></ul><ul><ul><li>Health service utilization </li></ul></ul>
    9. 9. Main Components of the SAVVY System <ul><li>Demographic Surveillance (DSS) </li></ul><ul><ul><li>Baseline enumeration of households, vital events (births, deaths, migration) in sampled population, </li></ul></ul><ul><ul><li>Followed by periodic update of vital events. </li></ul></ul><ul><ul><li>Provide accurate denominators for rates and platform for nested surveys </li></ul></ul><ul><li>Mortality Surveillance (MSS) </li></ul><ul><ul><li>Reporting of deaths in sampled areas and follow-up with ‘verbal autopsy’ interviews </li></ul></ul><ul><ul><li>Provides accurate cause of death data at community-level, by age and sex, for entire population </li></ul></ul><ul><li>Nested / Rider Surveys </li></ul><ul><ul><li>Poverty, equity and health; health and social service coverage; surveys with biomarkers; surveys on Behavior and Attitudes, Environment; etc </li></ul></ul><ul><li>DSS + MSS + Periodic Surveys = SAVVY </li></ul>
    10. 10. Mortality Surveillance with Verbal Autopsy <ul><li>Purpose is to provide improved monitoring and measurement of mortality and their causes. </li></ul><ul><li>Identification of deaths at household level (death frame) in a nationally representative sample (national sentinel areas). </li></ul><ul><li>Followed by application of Verbal Autopsy (VA) and ICD procedures to determine causes of death. </li></ul><ul><li>Innovative approach is to adapt tools to different platforms. </li></ul>
    11. 11. What happens to mortality information? <ul><li>Large number of deaths occur outside of health facilities, few are registered, and fewer still end up tabulated </li></ul>
    12. 12. Verbal Autopsy Process <ul><li>VA is an indirect, community-based, method of ascertaining cause of death. </li></ul><ul><li>Deaths identified through surveillance, household surveys, national census. </li></ul><ul><li>VA interview occurs - respondents are asked about the circumstances and events leading to death of a person, including signs and symptoms and their durations in the period before death. </li></ul><ul><li>‘ Death certificates’ produced by a panel of physicians, and UCOD coded to ICD-10. </li></ul><ul><li>Mortality statistics tabulated using approved list. </li></ul>
    13. 13. International VA Questionnaires <ul><li>Types of International VA Forms </li></ul><ul><ul><li>International VA Questionnaire 1 (0 - < 4wks) </li></ul></ul><ul><ul><li>International VA Questionnaire 2 (4 wks - < 15yrs) </li></ul></ul><ul><ul><li>International VA Questionnaire 3 (Adults 15+ yrs) </li></ul></ul><ul><li>Adapted for children under five </li></ul><ul><ul><li>International VA Questionnaire 1 (0 - < 4wks) </li></ul></ul><ul><ul><li>International VA Questionnaire 2 (4 wks - < 5yrs) </li></ul></ul>
    14. 14. General Structure of VAQ <ul><li>Identifying information. </li></ul><ul><li>Open history. </li></ul><ul><li>Symptoms and durations. </li></ul><ul><li>Treatment and health services utilization. </li></ul><ul><li>Confirmatory evidence: summary information from death certificates or other medical documents, if available. </li></ul><ul><li>Interviewers’ observations. </li></ul>
    15. 15. Cause of Death from VA Reviews <ul><li>The event of death is reported by a key informant </li></ul><ul><li>VA interview is conducted and VAQ completed by a trained interviewer </li></ul><ul><li>Cause of death is assigned by a panel of physicians who use all of the information contained in the completed VA form to discern the underlying cause and chain of events which eventually led to death - assign specific cause(s) of death. </li></ul><ul><li>ICD selection and modification rules are applied by coders who are trained in the ICD coding protocol to translate the medical information in the VA death certificate to validate the sequence of events. </li></ul><ul><li>ICD-10 codes are given by coders to each line of the death certificate. </li></ul><ul><li>Cause specific mortality data are tabulated on a suitable periodic basis (e.g. annually) </li></ul>
    16. 16. Direct and Underlying Causes of Death <ul><li>Using VA with ICD-10 permits the tabulation of two causes of death that are not always the same: Direct and Underlying. </li></ul><ul><ul><li>Direct COD: of medical interest (TREATMENT) </li></ul></ul><ul><ul><li>Underlying COD: of interest to policy makers (PREVENTION) </li></ul></ul>
    17. 17. Accuracy of VA <ul><li>Sensitivity and Specificity generally ‘ok’ with physician panel coding. </li></ul><ul><li>Cause-specific error rates favorable: relative error and average relative error generally low. </li></ul><ul><li>Potentially, costs and time could be reduced without affecting accuracy by analyzing VA data with: </li></ul><ul><ul><li>Algorithms </li></ul></ul><ul><ul><li>Mathematical models </li></ul></ul>
    18. 18. Some VA Validation Studies <ul><li>Kenya (Snow RW et al, The Lancet, Aug 1992) </li></ul><ul><li>Zimbabwe (Lopman et al , JECH Online, Oct 2009) </li></ul><ul><li>Namibia (Mobley et al , J Trop Pediatr, Dec 1996) </li></ul><ul><li>Tanzania (Setel et al , Trop Med & Int. Health, May 2006) </li></ul>
    19. 19. Countries where Standard Verbal Autopsy has been implemented (with technical assistance from MEASURE Evaluation) <ul><li>Mozambique – INCAM (in collaboration with US Census Bureau, CDC/MZ, INE and MISAU) </li></ul><ul><li>Kenya – Harmonization of VA tools and methodology, and their implementation in HDSS sites (with APHIA-II Evaluation Project) </li></ul><ul><li>Brazil – Pilot of VA implementation (with MoH, University of Natal). </li></ul><ul><li>Tanzania – Support to HDSS sites (Ifakara Health Institute) </li></ul>
    20. 20. PMI Countries where Verbal Autopsy methods have been applied with DHS <ul><li>MEASURE Evaluation in collaboration with MEASURE DHS, In-country statistical agencies and Ministries of Health </li></ul><ul><li>Uganda (Post-DHS Child VA Survey): with a 3-year recall period. </li></ul><ul><li>Ghana Child VA Survey (embedded with DHS): with a 3-year recall period. </li></ul><ul><li>Rwanda (Post-DHS Child VA Survey): with a 5-year recall period. </li></ul>
    21. 21. VA with DHS Surveys <ul><li>Death frame generated from birth histories (Uganda, Rwanda), or from household questionnaires (Ghana) </li></ul><ul><li>VAQ administered to caregivers: mothers or other family members of deceased child </li></ul><ul><li>Mothers/respondents were asked about the events leading to death of a child: signs and symptoms (and their duration) in the period before death </li></ul><ul><li>International VA Questionnaires adapted for < 5 yrs </li></ul><ul><li>VAs reviewed by trained physicians to obtain UCOD (coded to ICD-10) </li></ul>
    22. 22. Some Results from MEASURE Evaluation and Collaborators’ VA Efforts <ul><li>Post-Census: Mozambique (2007) </li></ul><ul><li>- All deaths </li></ul><ul><li>- BUCEN, CDC/MZ, INE, MISAU; PEPFAR </li></ul><ul><li>Post-DHS: Uganda (2007), Ghana (2009) </li></ul><ul><li>- Newborn, infant and child deaths (under 5) </li></ul><ul><li>- ICF Macro/DHS; PMI </li></ul>
    23. 23. MZ: Distribution of Deaths by Age, by Sex
    24. 24. Mozambique: Leading Causes of Death
    25. 25. Mozambique: Health Services Utilization
    26. 26. Uganda: Newborn, Infant and Child Deaths Age Group Deaths 0 to < 28 days Deaths 28 days to < 5yrs Sample (n) 122 419 Prop of all deaths (%) 23% 77% Place of death (%) Health facility: 40% Home: 51% Health facility: 39% Home: 48% Top 5 COD (%) Peri. & early neon: 77% Meningitis: 8% Tetanus: 4% Congenital malform.: 2% Malaria: 1% Malaria: 41% Meningitis: 11% Pneumonia: 10% HIV/AIDS: 7% Malnutrition: 6% Sex (%) Male: 64% Female: 36% Male: 53% Female: 47%
    27. 27. Uganda: Health Service Utilization <ul><li>79% of Children received treatment at some point before death. </li></ul><ul><li>Of those who received treatment, what type of health service/facility </li></ul>Type of Health Service Used Formal (gov’t or priv: hosp, health centers ,clinics/dispensary) 94% Traditional Healer 15% Pharmacy 12% Home remedies 5% Other 1%
    28. 28. Ghana: Newborn, Infant and Child Deaths Age Group Deaths 0 to < 28 days Deaths 28 days to < 5yrs Sample (n) 68 131 Prop of all deaths (%) 36% 64% Place of death (%) Hosp: 49% Home: 49% Hosp: 37% Home: 57% Top 5 COD (%) Perin. & early neon.: 79% Birth asphyxia: 7% Tetanus: 5% Birth trauma: 3% Prem & LBW: 2% Malaria: 43% Malnutrition: 12% Diarrhoeal diseases: 8% External causes: 6% Pneumonia: 5% Sex (%) Male: 66% Female: 34% Male: 56% Female: 44%
    29. 29. Ghana: Health Service Utilization <ul><li>61% of children received treatment at some point before death. </li></ul><ul><li>of those who received treatment, what type of health service/facility </li></ul>Type of Health Service Used Formal (govt, priv, faith-based: hosp, health center, clinics) 86% Home remedies 12% Traditional Healer 2% Pharmacy 1% Other 3%
    30. 30. Discussion <ul><li>VA is replicable, crude, but moderately reliable for estimating mortality and their at the community level; better than the alternative, which is nothing. </li></ul><ul><li>Issues of VA limitations, adequate sample size and recall bias for measuring cause-specific mortality using VA needs to be taken into account when interpreting results. Further studies on VAs to investigate the issue of recall bias and sample size could provide some insights </li></ul><ul><li>SVR, VA (as applied in SAVVY, HDSS) are emerging techniques of demonstrated use at district/local, national, and international level </li></ul>
    31. 31. Discussion <ul><li>Use of validated VA possibly best option for assessing and responding to the need for information on causes of death in SSA, and is readily adaptable to different platforms. </li></ul><ul><li>Other approaches (other than use of medical doctors) for ascertaining causes of death from VA reviews could be applied to reduce cost and time associated with using physicians to review VAs. </li></ul><ul><li>Until there is proper registration of causes of death, VA is a useful tool to accurately estimate the proportion of deaths to different causes </li></ul>
    32. 32. Community-Based VE Monitoring Tools Available from MEASURE Evaluation Website <ul><li>Field Manuals and Training Guides covering all aspects of the SAVVY system for VE. </li></ul><ul><li>Baseline Census and Demographic events update questionnaires. </li></ul><ul><li>International standard VA questionnaires. </li></ul><ul><li>Data entry and processing systems (using CSPro) </li></ul>
    33. 33. <ul><li>MEASURE Evaluation is funded by the U.S. Agency for </li></ul><ul><li>International Development through Cooperative Agreement </li></ul><ul><li>GHA-A-00-08-00003-00 and is implemented by the Carolina </li></ul><ul><li>Population Center at the University of North Carolina at </li></ul><ul><li>Chapel Hill, in partnership with Futures Group International, </li></ul><ul><li>ICF Macro, John Snow, Inc., Management Sciences for </li></ul><ul><li>Health, and Tulane University. The views expressed in this </li></ul><ul><li>presentation do not necessarily reflect the views of USAID or </li></ul><ul><li>the United States government. </li></ul>