Using verbal autopsy to ascertain perinatal cause of death: are trained non-physicians adequate?

OBJECTIVES: To develop a standardized verbal autopsy (VA) training program and evaluate whether its implementation resulted in comparable knowledge required to classify perinatal cause of death (COD) by physicians and non-physicians. METHODS: Training materials, case studies, and written and mock scenarios for this VA program were developed using conventional VA and ICD-10 guidelines. This program was used to instruct physicians and non-physicians in VA methodology using a train-the-trainer model. Written tests of cognitive and applied knowledge required to classify perinatal COD were administered before and after training to evaluate the effect of the VA training program. RESULTS: Fifty-three physicians and non-physicians (nurse-midwives/nurses and Community Health Workers [CHW]) from Pakistan, Zambia, the Democratic Republic of Congo, and Guatemala were trained. Cognitive and applied knowledge mean scores among all trainees improved significantly (12.8 and 28.8% respectively, P < 0.001). Cognitive and applied knowledge post-training test scores of nurse-midwives/nurses were comparable to those of physicians. CHW (high-school graduates with 15 months or less formal health/nursing training) had the largest improvements in post-training applied knowledge with scores comparable to those of physicians and nurse-midwives/nurses. However, CHW cognitive knowledge post-training scores were significantly lower than those of physicians and nurses. CONCLUSIONS: With appropriate training in VA, cognitive and applied knowledge required to determine perinatal COD is similar for physicians and nurses-midwives/nurses. This suggests that midwives and nurses may play a useful role in determining COD at the community level, which may be a practical way to improve the accuracy of COD data in rural, remote, geographic areas.

Effect of recall on estimation of non-fatal injury rates: a community based study in Tanzania.

STUDY OBJECTIVE: To investigate the effect of recall on estimation of non-fatal injury rates in Tanzania. DESIGN: Retrospective population based survey. SETTING: Eight branches in an urban area and six villages in a relatively prosperous rural area in Tanzania. SUBJECTS: Individuals of all ages living in households selected by cluster sampling. MAIN OUTCOME MEASURES: Estimated non-fatal injury rates calculated at each of the 12 recall periods (one to 12 months before the interview). RESULTS: Out of a population of 15 223 persons, 509 individuals reported 516 injuries during the preceding year. Of these 313 (61.5%) were males and 196 (38.5%) females. The data showed notable declining incidence rates from 72 per 1000 person-years when based on a one month recall period to 32.7 per 1000 person-years for a 12 month recall period (55% decline). The decline was found for injuries resulting in fewer than 30 days of disability whereas rates for severe injuries (disability of 30 days or more) did not show a consistent variation with recall period. Decline in injury rates by recall period was higher in rural than in urban areas. Age, sex, and education did not notably affect recall. CONCLUSIONS: Longer recall periods underestimate injury rates compared with shorter recall periods. For severe injuries, a recall period of up to 12 months does not affect the rate estimates. It is essential that a recall period of less than three months be used to calculate injury rates for less severe injuries.

Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health research agenda?

There is no doubt that communicable diseases will remain the predominant health problem for the populations in sub-Saharan Africa, including adults, for the next 10-20 years. Concern has been expressed that the available resources to deal with this problem would be reduced by increasing the emphasis on noncommunicable diseases. The latter, however, already present a substantial burden because their overall age-specific rates are currently higher in adults in sub-Saharan Africa than in populations in Established Market Economies. There is also evidence that the prevalence of certain noncommunicable diseases, such as diabetes and hypertension, is increasing rapidly, particularly in the urban areas, and that significant demands are being made on the health services by patients with these diseases. To ignore the noncommunicable diseases would inevitably lead to an increase in their burden; the provision of health services for them would be largely undirected by issues of clinical and cost effectiveness, and their treatment and prevention would be left to the mercy of local and global commercial interests. Improved surveillance of all diseases within sub-Saharan Africa is needed in order to place noncommunicable diseases properly within the context of the overall burden of disease. Research is needed to guide improvements in the clinical and cost effectiveness of resources currently committed to the care of patients with noncommunicable diseases, and to direct and evaluate preventive measures.

Effect of misclassification of causes of death in verbal autopsy: can it be adjusted?

BACKGROUND: Verbal autopsy (VA) is an indirect method of ascertaining cause of death from information about symptoms and signs obtained from bereaved relatives. This method has been used in several settings to assess cause-specific mortality. However, cause-specific mortality estimates obtained by VA are susceptible to bias due to misclassification of causes of death. One way of overcoming this limitation of VA is to adjust the crude VA estimate of cause-specific mortality fractions (CSMF) using the sensitivity and specificity of the VA tool. This paper explores the application of sensitivity and specificity of VA data obtained from a hospital-based validation study for adjusting the effect of misclassification error in VA data obtained from a demographic surveillance system. METHOD: Data from a multi-centre validation study of 796 adult VA, conducted in Tanzania, Ethiopia and Ghana, were used to explore the effect of distribution of causes of death in the validation study population and the pattern of misclassification on the sensitivity and specificity of VA. VA estimates of CSMF for six causes (acute febrile illness, diarrhoeal diseases, TB/AIDS, cardiovascular disorders, direct maternal causes and injures) were obtained from a demographic surveillance system in Morogoro Rural District in Tanzania. These were adjusted for misclassification error by using sensitivity and specificity values of VA obtained from the validation study in a model proposed for correcting the effect of misclassification error in morbidity prevalence surveys. RESULTS: Sensitivity and specificity of VA differed between the three validation study sites depending on the distribution of causes of death. These differences were explained by variations in the level and pattern of misclassification between sites. When these estimates of sensitivity and specificity were applied to data from the demographic surveillance system with a comparable structure of causes of death the difference between crude and adjusted VA estimates of CSMF ranged from 3 to 83%. CONCLUSION: Estimates of sensitivity and specificity obtained from hospital-based validation studies must be used cautiously as a de facto 'gold standard' for adjusting the misclassification error in CSMF derived from VA. It is not possible to use sensitivity and specificity estimates derived from a location-specific validation study to adjust for misclassification in VA data from populations with substantially different patterns of cause-specific mortality.

Validity of data-derived algorithms for ascertaining causes of adult death in two African sites using verbal autopsy.

background Verbal autopsy (VA) is used to ascertain causes of death using information obtained from bereaved relatives. Causes of death can be ascertained from VA questionnaires by a panel of physicians or from predefined algorithms. In a previous study, we developed data-derived algorithms using VA data from 796 adult deaths in hospitals in Tanzania, Ethiopia, and Ghana (primary sites). These computerized algorithms accurately estimated the cause-specific mortality fractions (CSMFs) for deaths due to injuries, meningitis, TB/AIDS and diarrhoeal diseases in the primary sites. Since the same data were used to generate and to validate the algorithms, the accuracy of our algorithms may have been overestimated. We report here on the validity of the algorithms when they were applied to VA data from two secondary sites in Ghana and Tanzania. Here, 'validity' is taken to mean the degree to which the algorithms replicated the physician-generated CSMF for major causes of death, when applied to the same VA data. methods VA interviews were conducted in two secondary sites: in Navrongo, Ghana, on 406 adult deaths, where three local physicians independently reviewed the questionnaires and assigned a cause of death. In Morogoro, Tanzania, VA interviews were conducted on 209 adult deaths, and a panel of physicians independently reviewed the VA questionnaires together with the hospital death certificates or hospital records to determine the cause of death. The CSMF obtained using each algorithm was compared with the CSMF obtained using physician review. results For injuries and meningitis, the algorithms and physician review estimated a similar CSMF in the Morogoro and Navrongo data. For TB/AIDS, the algorithm estimated a similar CSMF as the physicians in Morogoro. The algorithm for diarrhoeal diseases did not agree closely with the physicians in Morogoro or Navrongo. conclusions In general, our data-derived algorithms for assigning causes of death due to injuries, meningitis, and TB/AIDS estimated a similar CSMF as the physicians in the secondary sites. Recommendations for further validation and refinement are discussed. Computerized algorithms offer a potentially quick, affordable, and feasible method for assigning causes of death in mortality surveillance or studies using VA.

Introduction. Sexual networking, knowledge, and risk: contextual social research for confronting AIDS and STDs in eastern and southern Africa.

PIP: The Workshop on Multipartnered Sexuality and Sexual Networking in Southern and Eastern Africa transpired at the University of Natal, Durban, South Africa, during February 7-8, 1997. 22 young researchers involved in behavioral and cultural studies related to the spread of HIV/AIDS from 9 countries in the region met to assess the current state of research upon multipartnered sexuality and sexual networking in the region; discuss the significance of regional dynamics of multipartnered sexuality and sexual networking in relation to HIV/AIDS, sexual and reproductive health, fertility, and gender; and consider how to coordinate a regional program of research and support for junior African scholars working on such topics. Conference organizers noted that an inadequate amount of social research is being conducted upon AIDS in Africa, while workshop participants created SafeSexNet, a facilitating body designed to maintain open communication among regional scholars conducting behavioral and cultural studies on sexuality and risk in the context of AIDS.^ieng

AIDS as a paradox of manhood and development in Kilimanjaro, Tanzania.

When AIDS emerged in Kilimanjaro region in 1984, many Chagga (the predominant ethnic group in the region) viewed it as a 'disease of development'. Whereas AIDS was commonly seen in the West as a form of punishment for non-reproductive and non-productive lifestyles, in East Africa it represented paradoxes in reproductive and productive life--especially for young, mobile men. This article discusses the emergence of the conditions of risk for HIV among young adults in the 1980s and 1990s, and then explores the perceptions of local actors about the historical and demographic processes that have surrounded the symbolic associations of AIDS. The themes that AIDS evoked were different for men and women; from one perspective, AIDS was seen as an attenuated crisis of the productive and reproductive labors of manhood. For people in northern Kilimanjaro, this disease illuminated contested issues in historical dialogues about social change and the moral value of male participation in idealized forms of work and prescribed male/female unions. The implications of these cultural and demographic realities for AIDS prevention are discussed in the conclusion.

Ethnographic results of a community STD study in the Eastern Highlands Province.

This paper reports on women's understanding of diseases believed to be sexually transmitted in the Asaro Valley of the Eastern Highlands Province. Sexually transmitted diseases (STDs) seemed to be a new category of disease as there were no local language terms for them. Women did not associate STDs with infertility. Although some symptoms were recognized and known to be sexually transmitted, STDs sometimes went untreated for years. STDs were thought of as milder than AIDS because they could be treated. Those informants who had good knowledge of AIDS claimed to have known an AIDS patient. It was interesting that those who knew an AIDS patient reported a change in sexual behaviour among people who saw the deteriorating state of their relative who was dying of AIDS.

PIP: Women's perception of STDs in the Asaro Valley of the Eastern Highlands Province of Papua New Guinea was studied along with the local language terms for reproductive tract infections. Considering that there are no known specific local language terms for diseases that are sexually transmitted, women tend to view STDs as a new category of disease. The study emphasizes the women's understanding of the risk factors, as well as signs and symptoms, causes and measures taken, behavior towards treatment, and suggestions concerning treatment and protection. Interviews were conducted with 30 women aged 17-50 years. 14 of those participated in the clinical side of a community- based STD study, while the rest provided information independently. Particular emphasis was given to sources of information on STDs, understanding of risk factors, signs and symptoms, causes and measures taken, attitude towards treatment, and suggestions for treatment and protection. Since the local language does not have a term to refer to any diseases thought to be passed on through sexual intercourse, three terms were used: "sik nogut" (bad sickness), gonorrhea, and syphilis; additionally, signs and symptoms were described rather than named. It was found that rumors and educated relatives were the primary sources of information about "sik nogut." One of the major findings was that women did not link infertility with STDs, even if symptoms were felt in and around the reproductive tract. The paper concludes that sexual intercourse, as identified by women, is the dominant mode of disease transmission in the Valley. Condoms are becoming acceptable but are not used because of their unavailability. An interesting finding in this study is the reported change in sexual behavior among people who have seen their relatives die of AIDS.

The effects of HIV and AIDS on fertility in East and Central Africa.

Concern has been expressed about the fertility of people infected with HIV: the worry has been that on learning of their condition, HIV-affected individuals may attempt to accomplish unmet reproductive goals knowing that they will not live a normal life span. This article addresses the potential effects of AIDS on fertility and reproductive decisions in East and Central Africa. The problem is seen in terms of a tightly knit continuum of biological, epidemiologic and cultural contexts, and the prevailing conditions of response to the epidemic. AIDS can influence fertility among individuals and groups regardless of any awareness of serostatus by increasing death rates among reproductive populations, and damaging the physical capacities of infected men and women to reproduce. In much of the region, high prevalence of STDs may simultaneously impair the fertility of men and women and increase their risk of contracting HIV. These biological conditions are compounded among those for whom fertility is a highly valued marker of adult status, where the social and economic marginality of young women contributes to reliance on commercialized sex, where the mobility of young men leads to instability in sexual partnerships and frequent partner change, or where women lack the ability to negotiate their fertility with spouses. It appears that even focused programs of testing and counselling with HIV-positive women in Europe and in Africa have not motivated a significant change in reproductive action. Were there a demonstrable effect of counselling on the fertility choices of infected persons, there are numerous practical limitations on the role that interventions can play in affecting the fertility of HIV-positive people.

PIP: There is some concern that people infected with HIV, upon learning of their HIV serostatus, may try to accomplish unmet reproductive goals knowing that they will not live a normal lifespan. This concern derives from the centrality of reproduction to life courses, adult identities, and access to social support, especially for women, in many African settings. However, should populations rush to complete their desired fertility in the wake of confirmed HIV-positive serostatus, health care providers, policymakers, communities, and the offspring of these individuals will have to bear the burden of eventual orphanage, being infected perinatally with HIV, and the long- and short-term provision of health care. This paper explores the potential effects of AIDS on fertility and reproductive decisions in East and Central Africa. The issue is seen in an integrated framework of biological, epidemiologic, and cultural contexts, and the prevailing conditions of response to the epidemic. There are many practical limitations to what can be done to affect the fertility of HIV-seropositive people.