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: 2.3). 12/2000; 5(11):824-31.
Source: PubMed

ABSTRACT 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.
Verbal autopsies (VAs) were conducted on all deaths recorded during annual demographic and health surveillance over a 3-year period (1992-95) in a population of about 63 000 people. Trained fieldworkers 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.
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.
VA findings need to be validated before they can be applied to district health planning. In Agincourt, a single verbal autopsy instrument provided a reasonable estimate of the frequency of causes of death among adults and children. Findings can be reliably used to inform local health planning and evaluation.

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Available from: Kathleen Kahn, Aug 16, 2015
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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; DOI:10.1016/j.jadohealth.2015.03.001 · 2.75 Impact Factor
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    • "Misclassification of data could thus have occurred with respect to our study, especially with regard to underestimating non-specific HIV/AIDS-related and non-communicable disease. However, a previous validation study of VAs in Agincourt has shown that it performs well in this high-HIV prevalence setting (Kahn et al., 2000). Other studies have also confirmed that VA data can be used to reasonably estimate the distribution of AIDS-and non-AIDS-related deaths, even in a rural population with relatively low levels of education (Doctor and Weinreb, 2003). "
    Geospatial health 05/2013; 7(2):237-249. · 1.00 Impact Factor
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    • "The interpretation of verbal autopsies largely relies on physician review and has an acceptable sensitivity and specificity for cause of death [14]. It involves the interpretation of verbal autopsy data by one or more trained physicians [5] [12] [15]. Coding of verbal autopsy by physicians has several drawbacks. "
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    ABSTRACT: Background: The lack of cause of death information is the main challenge in monitoring the effectiveness of interven-tions aimed at reducing HIV and AIDS-related deaths in countries where the majority of deaths occur at home. Objec-tive: To evaluate the accuracy of physician reviewers of verbal autopsies in diagnosing HIV and AIDS-related deaths in the adult population of Addis Ababa, the capital of Ethiopia. Methods: This study was done within the context of a burial surveillance system in Addis Ababa. Trained interviewers completed a standard verbal autopsy questionnaire and an independent panel of physicians reviewed the completed form to assign cause of death. Physicians' review was compared to a reference standard constructed based on prospectively collected HIV-serostatus and patients' hospital record. Sensitivity and specificity were calculated to validate the physicians' verbal autopsy diagnoses against reference standards. Results: Physicians accurately identified AIDS-related deaths with sensitivity and specificity of 0.88 (95% CI: 0.80 -0.93) and 0.77 (95% CI: 0.64 -0.87), respectively. Generally, there was high level of agreement (Cohen's Kappa Statistic (K > 0.6) between the first two physicians with some yearly variations. In 2008 and 2009 there was an almost perfect agreement (K > 0.80). Conclusion: This study demonstrated the agreement level between two inde-pendent physicians in diagnosing AIDS-related death is very high and thus using a single verbal autopsy coder is prac-tical for programmatic purposes in countries where there is critical shortage of doctors.
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