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Measuring the Vital Events in the Communities of Africa


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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>