Validation and application of verbal autopsies in a rural area of South Africa

Health Systems Development Unit, Department of Community Health, University of the Witwatersrand, Johannesburg, South Africa.
Tropical Medicine & International Health (Impact Factor: 2.33). 12/2000; 5(11):824-31.
Source: PubMed


Objective : To validate the causes of death determined with a single verbal autopsy instrument covering all age groups in the Agincourt subdistrict of rural South Africa. Methods : Verbal autopsies (VAs) were conducted on all deaths recorded during annual demogrpahic and health surveillance over a 3-year period (1992-95) in a population of about 63,000 people. Trained field-workers elicited signs and symptoms of the terminal illness from a close caregiver, using a comprehensive questionnaire written in the local language. Questionnaires were assessed blind by three clinicians who assigned a probable cause of death using a stepwise consensus process. Validation involved comparison of VA diagnoses with hospital reference diagnoses obtained for those who died in a district hospital ; and calculation of sensitivity, specificity and positive predictive value (PPV) for children under 5 years, and adults 15 years and older. Results : a total of 127 hospital diagnoses satisfied the criteria for inclusion as reference diagnoses. For communicable diseases, sensitivity of VA diagnoses among children was 69%, specificity 96%, and PPV 90% ; among adults the values were 89, 93 and 76%. Lower values were found for non-communicable diseases : 75, 91 and 86% among children ; and 64, 50 and 80% among adults. Most misclassification occurred within the category itself. For deaths due to accidents or violence, sensitivity was 100%, specificity 97%, and PPV 80% among children ; and 75, 98 and 60% among adults. Since causes of death were largely age-specific, few differences in sensitivity, specificity and PPV were found for adults and children. The frequency distribution of causes of death based on VAs closely approximated that of the hospital records used for validation. Conclusion : VA findings need to be validated before they can be applied to district health planning... (D'après résumé d'auteur)

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    • "Predictors. Adverse childhood experiences such as parental AIDS-death and AIDS-illness were determined using verbal autopsy methods [14], validated in South Africa with sensitivity of 89% and specificity 93% [15]. In the present study, determination of HIV/AIDS required reported HIVþ status with CD4 count <350, or a conservative threshold of 3 AIDS-defining illnesses; for example, Kaposi's sarcoma or shingles. "
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    ABSTRACT: This is the first known prospective study of child suicidal behavior in sub-Saharan Africa. Aims were to determine whether (1) cumulative exposure to adverse childhood experiences (ACEs) predicts later suicidality and (2) heightened risks are mediated by mental health disorder and drug/alcohol misuse. Longitudinal repeated interviews were conducted 1 year apart (97% retention) with 3,515 adolescents aged 10-18 years in South Africa (56% female; <2.5% refusal). Random selection of census enumeration areas from urban/rural sites within two provinces and door-to-door sampling included all homes with a resident adolescent. Measures included past-month suicide attempts, planning, and ideation, mental health disorders, drug/alcohol use, and ACE, for example, parental death by AIDS or homicide, abuse, and exposure to community violence. Analyses included multivariate logistic regression and multiple mediation tests. Past-month suicidality rates were 3.2% of adolescents attempting, 5.8% planning, and 7.2% reporting ideation. After controlling for baseline suicidality and sociodemographics, a strong, graded relationship was shown between cumulative ACE and all suicide behaviors 1 year later. Baseline mental health, but not drug/alcohol misuse, mediated relationships between ACE and subsequent suicidality. Suicide attempts rose from 1.9% among adolescents with no ACE to 6.3% among adolescents with >5 ACEs (cumulative odds ratio [OR], 2.46; confidence interval [CI], 1.00-6.05); for suicide planning, from 2.4% to 12.5% (cumulative OR, 4.40; CI, 2.08-9.29); and for suicide ideation, from 4.2% to 15.6% (cumulative OR, 2.99; CI, 1.68-5.53). Preventing and mitigating childhood adversities have the potential to reduce suicidality. Among adolescents already exposed to adversities, effective mental health services may buffer against future suicidality. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of Adolescent Health 04/2015; 57(1). DOI:10.1016/j.jadohealth.2015.03.001 · 3.61 Impact Factor
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    • "There have been various attempts at validating physician reviews to interpret VA data [4-7]. However, the methodology is known to have several limitations. "
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    ABSTRACT: In countries with incomplete or no vital registration systems, verbal autopsy data are often reviewed by physicians in order to assign the probable cause of death. But in addition to being time and energy consuming, the method is liable to produce inconsistent results. The aim of this study is to validate the InterVA model for estimating the burden of mortality from verbal autopsy data by using physician review as a reference standard. A population-based cross-sectional study was conducted from March to April, 2012. All adults aged ≥14 years and died between 01 January, 2010 and 15 February, 2012 were included in the study. The verbal autopsy interviews were reviewed by the InterVA model and physicians to estimate cause-specific mortality fractions. Cohen's kappa statistic, sensitivity, specificity, positive predictive value, and negative predictive value were applied to compare the agreement between the InterVA model and the physician review. A total of 408 adult deaths were studied. There was a general similarity and just slight differences between the InterVA model and the physicians in assigning cause-specific mortality. Both approaches showed an overall agreement in 298 (73%) cases [kappa = 0.49, 95% CI: 0.37-0.60]. The observed sensitivities and specificities across causes of death categories varied from 13.3% to 81.9% and 77.7% to 99.5%, respectively. In understanding the burden of disease and setting health intervention priorities in areas that lack reliable vital registration systems, an accurate analysis of verbal autopsies is essential. Therefore, users should be aware of the suboptimal performance of the InterVA model. Similar validation studies need to be undertaken considering the limitation of the physician review as gold standard since physicians may misinterpret some of the verbal autopsy data and finally reach a wrong conclusion of the cause of death.
    PLoS ONE 09/2013; 8(9):e73463. DOI:10.1371/journal.pone.0073463 · 3.23 Impact Factor
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    • "The specificity of VA in diagnosing non-HIV deaths among those who were HIV negative was 81 percent (29 non-HIV deaths out of 36 HIV negative persons). These findings are consistent with previous studies which have shown that verbal autopsies are considerably valid in detecting HIV deaths especially among adults though underestimation of HIV deaths is not uncommon [43-45]. Generally, the accuracy of verbal autopsies interpreted by physicians is said to have an acceptable level of diagnostic accuracy, at the population level, if sensitivity and specificity are at least 50 percent and 90 percent respectively [46]. "
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    ABSTRACT: Background It has been almost a decade since HIV was declared a national disaster in Kenya. Antiretroviral therapy (ART) provision has been a mainstay of HIV treatment efforts globally. In Kenya, the government started ART provision in 2003 with significantly scale-up after 2006. This study aims to demonstrate changes in population-level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale-up of the national ART program. Methods We used data from 2070 deaths of people aged 15–54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Only deaths for which verbal autopsy was conducted were included in the study. We divided the analysis into two time periods: the “early” period (2003–2006) which coincides with the initiation of ART program in Kenya, and the “late” period (2007–2010) which coincides with the scale up of the program nationally. We calculated the mortality rate per 1000 person years by gender and age for both periods. Poisson regression was used to predict the risk of HIV mortality in the two periods while controlling for age and gender. Results Overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53 percent less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods. Conclusions Population-level HIV mortality in Nairobi’s slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalized slum populations in Kenya.
    BMC Public Health 06/2013; 13(1):588. DOI:10.1186/1471-2458-13-588 · 2.26 Impact Factor
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