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  • 1.
    Adcock, Joanna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Overseas Development Institute, London, UK.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    The North-South information highway: case studies of publication access among health researchers in resource-poor countries2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1Article in journal (Refereed)
    Abstract [en]

    Background: Less than 2% of scientific publications originate in low-income countries. Transfer of information from South to North and from South to South is grossly limited and hinders understanding of global health, while Northern-generated information fails to adequately address the needs of a Southern readership.

    Methods: A survey of a new generation of health researchers from nine low-income countries was conducted using a combination of email questionnaires and face-to-face interviews. Data were gathered on personal experiences, use and aspirations regarding access and contribution to published research.

    Results: A total of 23 individuals from 9 countries responded. Preference for journal use over textbooks was apparent, however a preference for print over online formats was described among African respondents compared to respondents from other areas. Almost all respondents (96%) described ambition to publish in international journals, but cited English language as a significant barrier.

    Conclusion: The desire to contribute to and utilise contemporary scientific debate appears to be strong among study respondents. However, longstanding barriers

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    The North-South information highway: case studies of publication access among health researchers in resource-poor countries
  • 2. Bird, J.
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, University of the Witwatersrand, South Africa and University College London, United Kingdom .
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, University of the Witwatersrand, South Africa and University College London, United Kingdom .
    Mee, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, University of the Witwatersrand, South Africa and University College London, United Kingdom .
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. UCL Institute for Global Health, University College London, United Kingdom.
    A matter of life and death: practical and ethical constraints in the development of a mobile verbal autopsy tool2013In: CHI '13 Proceedings of the SIGCHI Conference on Human Factors in Computing SystemsPages 1489-1498, 2013, p. 1489-1498Conference paper (Refereed)
    Abstract [en]

    Verbal autopsy (VA) involves interviewing relatives of the deceased to identify the probable cause of death and is typically used in settings where there is no official system for recording deaths or their causes. Following the interview, physician assessment to determine probable cause can take several years to complete. The World Health Organization (WHO) recognizes that there is a pressing need for a mobile device that combines direct data capture and analysis if this technique is to become part of routine health surveillance. We conducted a field test in rural South Africa to evaluate a mobile system that we designed to meet WHO requirements (namely, simplicity, feasibility, adaptability to local contexts, cost-effectiveness and program relevance). If desired, this system can provide immediate feedback to respondents about the probable cause of death at the end of a VA interview. We assessed the ethical implications of this technological development by interviewing all the stakeholders in the VA process (respondents, fieldworkers, physicians, population scientists, data managers and community engagement managers) and highlight the issues that this community needs to debate and resolve.

  • 3.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chandramohan, Daniel
    Clark, Samuel J.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Graham, Wendy J.
    Herbst, Abraham J.
    Hodgson, Abraham
    Hounton, Sennen
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krishnan, Anand
    Leitao, Jordana
    Odhiambo, Frank
    Sankoh, Osman A.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy (VA) is the only available approach for determining the cause of many deaths, where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHO VA instrument as a new standard, intended both as a research tool and for routine registration of deaths. Objective: A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument. Design: The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version 10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths. Results: The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration dataset from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4. Conclusions: InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration. Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data.

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    Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool
  • 4.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Epidemiologi och folkhälsovetenskap.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Epidemiologi och folkhälsovetenskap.
    Dao, Lan Huong
    Berhane, Yemane
    Corrah, Tumani
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Muhe, Lulu
    Do, Duc Van
    Refining a probabilistic model for interpreting verbal autopsy data.2006In: Scandinavian journal of public health, ISSN 1403-4948, Vol. 34, no 1, p. 26-31Article in journal (Refereed)
  • 5.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; IMMPACT, Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK.
    Herbst, Kobus
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. UCL Institute for Global Health, University College London, London, UK.
    Ali, Mohamed M
    Odhiambo, Frank
    Amek, Nyaguara
    Hamel, Mary J
    Laserson, Kayla F
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kabudula, Chodziwadziwa
    Mee, Paul
    Bird, Jon
    Jakob, Robert
    Sankoh, Osman
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Comparing verbal autopsy cause of death findings as determined by physician coding and probabilistic modelling: a public health analysis of 54 000 deaths in Africa and Asia2015In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 5, no 1, p. 65-73, article id 010402Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Coverage of civil registration and vital statistics varies globally, with most deaths in Africa and Asia remaining either unregistered or registered without cause of death. One important constraint has been a lack of fit-for-purpose tools for registering deaths and assigning causes in situations where no doctor is involved. Verbal autopsy (interviewing care-givers and witnesses to deaths and interpreting their information into causes of death) is the only available solution. Automated interpretation of verbal autopsy data into cause of death information is essential for rapid, consistent and affordable processing.

    METHODS: Verbal autopsy archives covering 54 182 deaths from five African and Asian countries were sourced on the basis of their geographical, epidemiological and methodological diversity, with existing physician-coded causes of death attributed. These data were unified into the WHO 2012 verbal autopsy standard format, and processed using the InterVA-4 model. Cause-specific mortality fractions from InterVA-4 and physician codes were calculated for each of 60 WHO 2012 cause categories, by age group, sex and source. Results from the two approaches were assessed for concordance and ratios of fractions by cause category. As an alternative metric, the Wilcoxon matched-pairs signed ranks test with two one-sided tests for stochastic equivalence was used.

    FINDINGS: The overall concordance correlation coefficient between InterVA-4 and physician codes was 0.83 (95% CI 0.75 to 0.91) and this increased to 0.97 (95% CI 0.96 to 0.99) when HIV/AIDS and pulmonary TB deaths were combined into a single category. Over half (53%) of the cause category ratios between InterVA-4 and physician codes by source were not significantly different from unity at the 99% level, increasing to 62% by age group. Wilcoxon tests for stochastic equivalence also demonstrated equivalence.

    CONCLUSIONS: These findings show strong concordance between InterVA-4 and physician-coded findings over this large and diverse data set. Although these analyses cannot prove that either approach constitutes absolute truth, there was high public health equivalence between the findings. Given the urgent need for adequate cause of death data from settings where deaths currently pass unregistered, and since the WHO 2012 verbal autopsy standard and InterVA-4 tools represent relatively simple, cheap and available methods for determining cause of death on a large scale, they should be used as current tools of choice to fill gaps in cause of death data.

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  • 6.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hounton, Sennen
    Ouédraogo, Moctar
    Somé, Henri
    Diallo, Ibrahima
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Emmelin, Axel
    Meda, Nicolas
    Direct data capture using hand-held computers in rural Burkina Faso: experiences, benefits and lessons learnt.2008In: Trop Med Int Health, ISSN 1365-3156, Vol. 13 Suppl 1, p. 25-30Article in journal (Refereed)
  • 7.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Moving from data on deaths to public health policy in Agincourt, South Africa: approaches to analysing and understanding verbal autopsy findings2010In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 7, no 8, p. e1000325-Article in journal (Refereed)
    Abstract [en]

    There were no differences between physician interpretation and probabilistic modelling that might have led to substantially different public health policy conclusions at the population level. Physician interpretation was more nuanced than the model, for example in identifying cancers at particular sites, but did not capture the uncertainty associated with individual cases. Probabilistic modelling was substantially cheaper and faster, and completely internally consistent. Both approaches characterised the rise of HIV-related mortality in this population during the period observed, and reached similar findings on other major causes of mortality. For many purposes probabilistic modelling appears to be the best available means of moving from data on deaths to public health actions. Please see later in the article for the Editors' Summary.

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    Moving from data on deaths to public health policy in Agincourt, South Africa: approaches to analysing and understanding verbal autopsy findings
  • 8.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and Centre for International Health and Development, Institute of Child Health, University College London, London, UK.
    Mee, Paul
    MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Using verbal autopsy to track epidemic dynamics: the case of HIV-related mortality in South Africa.2011In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 9, p. 46-Article in journal (Refereed)
    Abstract [en]

    Background Verbal autopsy (VA) has often been used for point estimates of cause-specific mortality, but seldom to characterize long-term changes in epidemic patterns. Monitoring emerging causes of death involves practitioners' developing perceptions of diseases and demands consistent methods and practices. Here we retrospectively analyze HIV-related mortality in South Africa, using physician and modeled interpretation.

    Methods Between 1992 and 2005, 94% of 6,153 deaths which occurred in the Agincourt subdistrict had VAs completed, and coded by two physicians and the InterVA model. The physician causes of death were consolidated into a single consensus underlying cause per case, with an additional physician arbitrating where different diagnoses persisted. HIV-related mortality rates and proportions of deaths coded as HIV-related by individual physicians, physician consensus, and the InterVA model were compared over time.

    Results Approximately 20% of deaths were HIV-related, ranging from early low levels to tenfold-higher later population rates (2.5 per 1,000 person-years). Rates were higher among children under 5 years and adults 20 to 64 years. Adult mortality shifted to older ages as the epidemic progressed, with a noticeable number of HIV-related deaths in the over-65 year age group latterly. Early InterVA results suggested slightly higher initial HIV-related mortality than physician consensus found. Overall, physician consensus and InterVA results characterized the epidemic very similarly. Individual physicians showed marked interobserver variation, with consensus findings generally reflecting slightly lower proportions of HIV-related deaths. Aggregated findings for first versus second physician did not differ appreciably.

    Conclusions VA effectively detected a very significant epidemic of HIV-related mortality. Using either physicians or InterVA gave closely comparable findings regarding the epidemic. The consistency between two physician coders per case (from a pool of 14) suggests that double coding may be unnecessary, although the consensus rate of HIV-related mortality was approximately 8% lower than by individual physicians. Consistency within and between individual physicians, individual perceptions of epidemic dynamics, and the inherent consistency of models are important considerations here. The ability of the InterVA model to track a more than tenfold increase in HIV-related mortality over time suggests that finely tuned "local" versions of models for VA interpretation are not necessary.

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  • 9.
    Fantahun, Mesganaw
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Berhane, Yemane
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Assessing a new approach to verbal autopsy interpretation in a rural Ethiopian community: the InterVA model2006In: Bulletin of the World Health Organization, ISSN 0042-9686, E-ISSN 1564-0604, Vol. 84, no 3, p. 204-210Article in journal (Refereed)
  • 10. Filippi, Véronique
    et al.
    Goufodji, Sourou
    Sismanidis, Charalambos
    Kanhonou, Lydie
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ronsmans, Carine
    Alihonou, Eusèbe
    Patel, Vikram
    Effects of severe obstetric complications on women's health and infant mortality in Benin2010In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 15, no 6, p. 733-742Article in journal (Refereed)
    Abstract [en]

    Women in developing countries face a high risk of severe complications during pregnancy and delivery. These can lead to adverse consequences for their own health and that of their offspring. Resources are needed to ensure that pregnant women receive adequate care before, during and after discharge from hospital. Near-miss women with a perinatal death appear a particularly high-risk group.

  • 11.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Advances in verbal autopsy: pragmatic optimism or optimistic theory?2011In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 9, p. 24-Article in journal (Refereed)
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  • 12.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Dying to count: mortality surveillance in resource-poor settings2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Article in journal (Refereed)
    Abstract [en]

    Reliable cause-specific mortality data constitute a crucial resource for health monitoring, service planning and prioritisation. However, in the majority of the world's poorest settings, systematic health and vital event surveillance systems are weak or non-existent. As such, deaths are not counted and causes of death remain unregistered for more than two-thirds of the world's population.For researchers, health workers and policy makers in resource-poor settings, therefore, attempts to measure mortality have to be implemented from first principles. As a result, there is wide variation in mortality surveillance methodologies in different settings, and lack of standardisation and rigorous validation of these methods hinder meaningful comparison of mortality data between settings and over time.With a particular focus on Health and Demographic Surveillance Systems (HDSSs), this paper summarises recent research and conceptual development of certain methodological aspects of mortality surveillance stemming from a series of empirical investigations. The paper describes the advantages and limitations of various methods in particular contexts, and argues that there is no single methodology to satisfy all data needs. Rather, methodological decisions about mortality measurement should be a synthesis of all available knowledge relating to clearly defined concepts of why data are being collected, how they can be used and when they are of good enough quality to inform public health action.

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  • 13.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    The value of verbal autopsies for determining the causes of maternal deaths2011In: Special Issue: Abstracts of the 7th European Congress on Tropical Medicine and International Health. 3-6 October 2011 Barcelona, Spain., Oxford, England: Blackwell Science , 2011, Vol. 16, p. 32-32Conference paper (Refereed)
  • 14. Fottrell, Edward
    et al.
    Azad, Kishwar
    Kuddus, Abdul
    Younes, Layla
    Shaha, Sanjit
    Nahar, Tasmin
    Aumon, Bedowra Haq
    Hossen, Munir
    Beard, James
    Hossain, Tanvir
    Pulkki-Brännström, Anni-Maria
    Skordis-Worrall, Jolene
    Prost, Audrey
    Costello, Anthony
    Houweling, Tanja A J
    The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh: A cluster randomized trial2013In: JAMA pediatrics, ISSN 2168-6211, Vol. 167, no 9, p. 816-25Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Community-based interventions can reduce neonatal mortality when health systems are weak. Population coverage of target groups may be an important determinant of their effect on behavior and mortality. A women's group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality, despite a similar intervention having a significant effect on neonatal and maternal death in comparable settings.

    OBJECTIVE: To assess the effect of a participatory women's group intervention with higher population coverage on neonatal mortality in Bangladesh.

    DESIGN: A cluster randomized controlled trial in 9 intervention and 9 control clusters.

    SETTING: Rural Bangladesh.

    PARTICIPANTS: Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention.

    INTERVENTIONS: Women's groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues.

    MAIN OUTCOMES AND MEASURES: Neonatal mortality rate.

    RESULTS: Analysis included 19 301 births during the final 24 months of the intervention. More than one-third of newly pregnant women joined the groups. The neonatal mortality rate was significantly lower in the intervention arm (21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas), a reduction in neonatal mortality of 38% (risk ratio, 0.62 [95% CI, 0.43-0.89]) when adjusted for socioeconomic factors. The cost-effectiveness was US $220 to $393 per year of life lost averted. Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight. Improvements were seen in hygienic home delivery practices, newborn thermal care, and breastfeeding practices.

    CONCLUSIONS AND RELEVANCE: Women's group community mobilization, delivered at adequate population coverage, is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh.

    TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN01805825.

  • 15.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Identifying humanitarian crises in population surveillance field sites: simple procedures and ethical imperatives.2009In: Public Health, ISSN 0033-3506, E-ISSN 1476-5616, Vol. 123, no 2, p. 151-155Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Effective early warning systems of humanitarian crises may help to avert substantial increases in mortality and morbidity, and prevent major population movements. The Butajira Rural Health Programme (BRHP) in Ethiopia has maintained a programme of epidemiological surveillance since 1987. Inspection of the BRHP data revealed large peaks of mortality in 1998 and 1999, well in excess of the normally observed year-to-year variation. Further investigation and enquiry revealed that these peaks related to a measles epidemic, and a serious episode of drought and consequent food insecurity that went undetected by the BRHP. This paper applies international humanitarian crisis threshold definitions to the BRHP data in an attempt to identify suitable mortality thresholds that may be used for the prospective detection of humanitarian crises in population surveillance sites in developing countries.

    STUDY DESIGN: Empirical investigation using secondary analysis of longitudinal population-based cohort data.

    METHODS: The daily, weekly and monthly thresholds for crises in Butajira were applied to mortality data for the 5-year period incorporating the crisis periods of 1998-1999. Days, weeks and months in which mortality exceeded each threshold level were identified. Each threshold level was assessed in terms of prospectively identifying the true crisis periods in a timely manner whilst avoiding false alarms.

    RESULTS: The daily threshold definition is too sensitive to accurately detect impending or real crises in the population surveillance setting of the BRHP. However, the weekly threshold level is useful in identifying important increases in mortality in a timely manner without the excessive sensitivity of the daily threshold. The weekly threshold level detects the crisis periods approximately 2 weeks before the monthly threshold level.

    CONCLUSION: Mortality measures are highly specific indicators of the health status of populations, and simple procedures can be used to apply international crisis threshold definitions in population surveillance settings for the prospective detection of important changes in mortality rate. Standards for the timely use of surveillance data and ethical responsibilities of those responsible for the data should be made explicit to improve the public health functioning of current sentinel surveillance methodologies.

  • 16.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Immpact, University of Aberdeen, Scotland, UK.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Immpact, University of Aberdeen, Scotland, UK.
    Population survey sampling methods in a rural African setting: measuring mortality2008In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 6, p. Article nr 2-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Population-based sample surveys and sentinel surveillance methods are commonly used as substitutes for more widespread health and demographic monitoring and intervention studies in resource-poor settings. Such methods have been criticised as only being worthwhile if the results can be extrapolated to the surrounding 100-fold population. With an emphasis on measuring mortality, this study explores the extent to which choice of sampling method affects the representativeness of 1% sample data in relation to various demographic and health parameters in a rural, developing-country setting.

    METHODS: Data from a large community based census and health survey conducted in rural Burkina Faso were used as a basis for modelling. Twenty 1% samples incorporating a range of health and demographic parameters were drawn at random from the overall dataset for each of seven different sampling procedures at two different levels of local administrative units. Each sample was compared with the overall 'gold standard' survey results, thus enabling comparisons between the different sampling procedures.

    RESULTS: All sampling methods and parameters tested performed reasonably well in representing the overall population. Nevertheless, a degree of variation could be observed both between sampling approaches and between different parameters, relating to their overall distribution in the total population.

    CONCLUSION: Sample surveys are able to provide useful demographic and health profiles of local populations. However, various parameters being measured and their distribution within the sampling unit of interest may not all be best represented by a particular sampling method. It is likely therefore that compromises may have to be made in choosing a sampling strategy, with costs, logistics the intended use of the data being important considerations.

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    Population survey sampling methods in a rural African setting: measuring mortality
  • 17.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Verbal autopsy: methods in transition2010In: Epidemiologic reviews, ISSN 0193-936X, E-ISSN 1478-6729, Vol. 32, no 1, p. 38-55Article in journal (Refereed)
    Abstract [en]

    Understanding of global health and changing morbidity and mortality is limited by inadequate measurement of population health. With fewer than one-third of deaths worldwide being assigned a cause, this long-standing dearth of information, almost exclusively in the world's poorest countries, hinders understanding of population health and limits opportunities for planning, monitoring, and evaluating interventions. In the absence of routine death registration, verbal autopsy (VA) methods are used to derive probable causes of death. Much effort has been put into refining the approach for specific purposes; however, there has been a lack of harmony regarding such efforts. Subsequently, a variety of methods and principles have been developed, often focusing on a single aspect of VA, and the resulting literature provides an inconsistent picture. By reviewing methodological and conceptual issues in VA, it is evident that VA cannot be reduced to a single one-size-fits-all tool. VA must be contextualized; given the lack of "gold standards," methodological developments should not be considered in terms of absolute validity but rather in terms of consistency, comparability, and adequacy for the intended purpose. There is an urgent need for clarified thinking about the overall objectives of population-level cause-of-death measurement and harmonized efforts in empirical methodological research.

  • 18.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Berhane, Yemane
    Addis Continental Inst Publ Hlth, Addis Ababa, Ethiopia.
    Demonstrating the robustness of population surveillance data: implications of error rates on demographic and mortality estimates2008In: BMC Medical Research Methodology, ISSN 1471-2288, E-ISSN 1471-2288, Vol. 8, p. Article nr 13-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: As in any measurement process, a certain amount of error may be expected in routine population surveillance operations such as those in demographic surveillance sites (DSSs). Vital events are likely to be missed and errors made no matter what method of data capture is used or what quality control procedures are in place. The extent to which random errors in large, longitudinal datasets affect overall health and demographic profiles has important implications for the role of DSSs as platforms for public health research and clinical trials. Such knowledge is also of particular importance if the outputs of DSSs are to be extrapolated and aggregated with realistic margins of error and validity.

    METHODS: This study uses the first 10-year dataset from the Butajira Rural Health Project (BRHP) DSS, Ethiopia, covering approximately 336,000 person-years of data. Simple programmes were written to introduce random errors and omissions into new versions of the definitive 10-year Butajira dataset. Key parameters of sex, age, death, literacy and roof material (an indicator of poverty) were selected for the introduction of errors based on their obvious importance in demographic and health surveillance and their established significant associations with mortality. Defining the original 10-year dataset as the 'gold standard' for the purposes of this investigation, population, age and sex compositions and Poisson regression models of mortality rate ratios were compared between each of the intentionally erroneous datasets and the original 'gold standard' 10-year data.

    RESULTS: The composition of the Butajira population was well represented despite introducing random errors, and differences between population pyramids based on the derived datasets were subtle. Regression analyses of well-established mortality risk factors were largely unaffected even by relatively high levels of random errors in the data.

    CONCLUSION: The low sensitivity of parameter estimates and regression analyses to significant amounts of randomly introduced errors indicates a high level of robustness of the dataset. This apparent inertia of population parameter estimates to simulated errors is largely due to the size of the dataset. Tolerable margins of random error in DSS data may exceed 20%. While this is not an argument in favour of poor quality data, reducing the time and valuable resources spent on detecting and correcting random errors in routine DSS operations may be justifiable as the returns from such procedures diminish with increasing overall accuracy. The money and effort currently spent on endlessly correcting DSS datasets would perhaps be better spent on increasing the surveillance population size and geographic spread of DSSs and analysing and disseminating research findings.

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    Demonstrating the robustness of population surveillance data: implications of error rates on demographic and mortality estimates
  • 19.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ouedraogo, Thomas W
    Tamini, Cecile
    Gbangou, Adjima
    Sombié, Issiaka
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Witten, Karen H
    Bhattacharya, Sohinee
    Desta, Teklay
    Deganus, Sylvia
    Tornui, Janet
    Fitzmaurice, Ann E
    Meda, Nicolas
    Graham, Wendy J
    Revealing the burden of maternal mortality: a probabilistic model for determining pregnancy-related causes of death from verbal autopsies2007In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 5, no 1Article in journal (Refereed)
    Abstract [en]

    Background: Substantial reductions in maternal mortality are called for in Millennium Development Goal 5 (MDG-5), thus assuming that maternal mortality is measurable. A key difficulty is attributing causes of death for the many women who die unaided in developing countries. Verbal autopsy (VA) can elicit circumstances of death, but data need to be interpreted reliably and consistently to serve as global indicators. Recent developments in probabilistic modelling of VA interpretation are adapted and assessed here for the specific circumstances of pregnancy-related death.

    Methods: A preliminary version of the InterVA-M probabilistic VA interpretation model was developed and refined with adult female VA data from several sources, and then assessed against 258 additional VA interviews from Burkina Faso. Likely causes of death produced by the model were compared with causes previously determined by local physicians. Distinction was made between free-text and closed-question data in the VA interviews, to assess the added value of free-text material on the model's output.

    Results: Following rationalisation between the model and physician interpretations, cause-specific mortality fractions were broadly similar. Case-by-case agreement between the model and any of the reviewing physicians reached approximately 60%, rising to approximately 80% when cases with a discrepancy were reviewed by an additional physician. Cardiovascular disease and malaria showed the largest differences between the methods, and the attribution of infections related to pregnancy also varied. The model estimated 30% of deaths to be pregnancy-related, of which half were due to direct causes. Data derived from free-text made no appreciable difference.

    Conclusion: InterVA-M represents a potentially valuable new tool for measuring maternal mortality in an efficient, consistent and standardised way. Further development, refinement and validation are planned. It could become a routine tool in research and service settings where levels and changes in pregnancy-related deaths need to be measured, for example in assessing progress towards MDG-5.

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    Revealing the burden of maternal mortality: a probabilistic model for determining pregnancy-related causes of death from verbal autopsies
  • 20.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Enquselassie, Fikre
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The distribution and effects of child mortality risk factors in Ethiopia: a comparison of estimates from DSS and DHS2009In: Ethiopian Journal of Health Development, ISSN 1021-6790, E-ISSN 2309-7388, Vol. 23, no 2, p. 163-168Article in journal (Refereed)
    Abstract [en]

    Objectives: To conduct a comparative analysis of the distribution and effects of under-five mortality correlates using Demographic and Health Survey (DHS) and Demographic Surveillance System (DSS) data from Ethiopia, and to investigate the methodological bias in DHS-based childhood mortality rates due to the impossibility of including children whose mothers were deceased.

    Methods: Using all-cause under-5 mortality as an outcome variable, the distribution and effects of risk factors were modeled using survival analysis. All live births in rural Ethiopia in the 5-year period before the 2005 DSS+ survey and between 01/01/2000 and 31/12/2004 in the DSS in the Butajira Rural Health Program (in the Southern Nations, Nationalities, and People's (SNNP) region of Ethiopia) were included.

    Results: Overall, similar estimates of hazard rate ratios were derived from both DHS and DSS data and the child mortality risk profile is similar between each data source, with multiple births and living in less populous households being significant risk factors for under-five mortality. Nevertheless, some notable differences were observed. The DSS data was more sensitive to local variations in population composition and health status, whilst the more dispersed DHS approach tended to average out local variation across the country. Excluding children whose mothers were deceased from the DSS analysis had no important effect on risk profiles or estimates of survival functions at age 5 years. DHS survival functions were somewhat lower than DSS estimates (BRHP=0.87, DHS rural Ethiopia=0.67, DHS SNNP=0.66).

    Conclusion: Despite differing methodologies, cross-sectional DHS and longitudinal DSS data produce estimates of the distribution and effects of under-five mortality risk factors that are broadly similar. The differing methodological characteristics of DHS and DSS mean that when combined, these two data sources have the potential to provide a comprehensive picture of national population composition and health status as well as the extent of local variation both of which are important for health monitoring and planning.

  • 21.
    Fottrell, Edward F
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Dying to count: mortality surveillance methods in resource-poor settings2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background

    Mortality data are critical to understanding and monitoring changes in population health status over time. Nevertheless, the majority of people living in the world’s poorest countries, where the burden of disease is highest, remain outside any kind of systematic health surveillance. This lack of routine registration of vital events, such as births and deaths, constitutes a major and longstanding constraint on the understanding of patterns of health and disease and the effectiveness of interventions. Localised sentinel demographic and health surveillance strategies are a useful surrogate for more widespread surveillance in such settings, but rigorous, evidence-based methodologies for sample-based surveillance are weak and by no means standardised. This thesis aims to describe, evaluate and refine methodological approaches to mortality measurement in resource-poor settings.

    Methods

    Through close collaboration with existing community surveillance operations in a range of settings, this work uses existing data from demographic surveillance sites and community-based surveys using various innovative approaches in order to evaluate and refine methodological approaches to mortality measurement and cause-of-death determination. In doing so, this work explores the application of innovative techniques and procedures for mortality surveillance in relation to the differing needs of those who use mortality data, ranging from global health organisations to local health planners.

    Results

    Empirical modelling of sampling procedures in community-based surveys in rural Africa and of random errors in longitudinal data collection sheds light on the effects of various data-capture and quality-control procedures and demonstrates the representativeness and robustness of population surveillance datasets. The development, application and refinement of a probabilistic approach to determining causes of death at the population level in developing countries has shown promise in overcoming the longstanding limitations and issues of standardisation of existing methods. Further adaptation and application of this approach to measure maternal deaths has also been successful. Application of international guidelines on humanitarian crisis detection to mortality surveillance in Ethiopia demonstrates that simple procedures can and, from an ethical perspective, should be applied to sentinel surveillance methods for the prospective detection of important mortality changes in vulnerable populations.

    Conclusion

    Mortality surveillance in sentinel surveillance systems in resource-poor settings is a valuable and worthwhile task. This work contributes to the understanding of the effects of different methods of surveillance and demonstrates that, ultimately, the choice of methods for collecting data, assuring data quality and determining causes of death depends on the specific needs and requirements of end users. Surveillance systems have the potential to contribute substantially to developing health care systems in resource-poor countries and should not only be considered as research-oriented enterprises.

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    FULLTEXT01
  • 22.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and UCL Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, United Kingdom.
    Högberg, Ulf
    Department of Women’s and Children’s Health, Uppsala University, Academic Hospital, 751 85 Uppsala.
    Ronsmans, Carine
    London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
    Osrin, David
    UCL Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, United Kingdom.
    Azad, Kishwar
    Perinatal Care Project, Diabetic Association of Bangladesh (BADAS), BIRDEM 122 Kazi Nazrul Islam Avenue Shahbagh, Dhaka 1000, Bangladesh.
    Nair, Nirmala
    Ekjut, Plot 556B, Potka, Chakradharpur Pin - 833102, West Singhbhum, Jharkhand, India.
    Meda, Nicolas
    Centre MURAZ, Ministry of Health, 01 PO Box 390, Bobo-Dioulasso 01, Burkina Faso.
    Ganaba, Rasmane
    Centre MURAZ, Ministry of Health, 01 PO Box 390, Bobo-Dioulasso 01, Burkina Faso.
    Goufodji, Sourou
    Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research.
    Filippi, Veronique
    London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
    A probabilistic method to estimate the burden of maternal morbidity in resource-poor settings: preliminary development and evaluation2014In: Emerging Themes in Epidemiology, ISSN 1742-7622, E-ISSN 1742-7622, Vol. 11, no 1, p. 3-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India.

    RESULTS: Using training datasets, it was possible to create a probabilistic tool that handled uncertainty of women's self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified.

    CONCLUSION: The probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women's self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.

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  • 23.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sartorius, Benn
    Huong, Dao Lan
    Van Minh, Hoang
    Fantahun, Mesganaw
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mortality measurement in transition: proof of principle for standardised multi-country comparisons2010In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 15, no 10, p. 1256-1265Article in journal (Refereed)
    Abstract [en]

    Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit-for-purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource-poor settings.

  • 24.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Probabilistic methods for verbal autopsy interpretation: InterVA robustness in relation to variations in a priori probabilities2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 11, p. e27200-Article in journal (Refereed)
    Abstract [en]

    Background: InterVA is a probabilistic method for interpreting verbal autopsy (VA) data. It uses a priori approximations of probabilities relating to diseases and symptoms to calculate the probability of specific causes of death given reported symptoms recorded in a VA interview. The extent to which InterVA's ability to characterise a population's mortality composition might be sensitive to variations in these a priori probabilities was investigated.

    Methods: A priori InterVA probabilities were changed by 1, 2 or 3 steps on the logarithmic scale on which the original probabilities were based. These changes were made to a random selection of 25% and 50% of the original probabilities, giving six model variants. A random sample of 1,000 VAs from South Africa, were used as a basis for experimentation and were processed using the original InterVA model and 20 random instances of each of the six InterVA model variants. Rank order of cause of death and cause-specific mortality fractions (CSMFs) from the original InterVA model and the mean, maximum and minimum results from the 20 randomly modified InterVA models for each of the six variants were compared.

    Results: CSMFs were functionally similar between the original InterVA model and the models with modified a priori probabilities such that even the CSMFs based on the InterVA model with the greatest degree of variation in the a priori probabilities would not lead to substantially different public health conclusions. The rank order of causes were also similar between all versions of InterVA.

    Conclusion: InterVA is a robust model for interpreting VA data and even relatively large variations in a priori probabilities do not affect InterVA-derived results to a great degree. The original physician-derived a priori probabilities are likely to be sufficient for the global application of InterVA in settings without routine death certification.

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    Probabilistic methods for verbal autopsy interpretation: InterVA robustness in relation to variations in a priori probabilities
  • 25.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kanhonou, Lydie
    Goufodji, Sourou
    Béhague, Dominique P
    Marshall, Tom
    Patel, Vikram
    Filippi, Véronique
    Risk of psychological distress following severe obstetric complications in Benin: the role of economics, physical health and spousal abuse2010In: British Journal of Psychiatry, ISSN 0007-1250, E-ISSN 1472-1465, Vol. 196, no 1, p. 18-25Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Little is known about the impact of life-threatening obstetric complications ('near miss') on women's mental health in low- and middle-income countries.

    AIMS: To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin. METHOD: One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities.

    RESULTS: In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth.

    CONCLUSIONS: A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

  • 26.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Osrin, David
    Sickle Cell Anaemia in a Changing World2013In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 10, no 7, p. e1001483-Article in journal (Other academic)
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  • 27.
    Fottrell, Edward
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Golooba-Mutebi, Frederick
    Kahn, Kathleen
    The epidemiology of 'bewitchment' as a lay-reported cause of death in rural South Africa2012In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 66, no 8, p. 704-709Article in journal (Refereed)
    Abstract [en]

    Background Cases of premature death in Africa may be attributed to witchcraft. In such settings, medical registration of causes of death is rare. To fill this gap, verbal autopsy (VA) methods record signs and symptoms of the deceased before death as well as lay opinion regarding the cause of death; this information is then interpreted to derive a medical cause of death. In the Agincourt Health and Demographic Surveillance Site, South Africa, around 6% of deaths are believed to be due to ‘bewitchment’ by VA respondents.

    Methods Using 6874 deaths from the Agincourt Health and Socio-Demographic Surveillance System, the epidemiology of deaths reported as bewitchment was explored, and using medical causes of death derived from VA, the association between perceptions of witchcraft and biomedical causes of death was investigated.

    Results The odds of having one's death reported as being due to bewitchment is significantly higher in children and reproductive-aged women (but not in men) than in older adults. Similarly, sudden deaths or those following an acute illness, deaths occurring before 2001 and those where traditional healthcare was sought are more likely to be reported as being due to bewitchment. Compared with all other deaths, deaths due to external causes are significantly less likely to be attributed to bewitchment, while maternal deaths are significantly more likely to be.

    Conclusions Understanding how societies interpret the essential factors that affect their health and how health seeking is influenced by local notions and perceived aetiologies of illness and death could better inform sustainable interventions and health promotion efforts.

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  • 28. Hall, Charles S
    et al.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. UCL Institute for Global Health, London, UK.
    Wilkinson, Sophia
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Assessing the impact of mHealth interventions in low- and middle-income countries: what has been shown to work?2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 1-12, article id 25606Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders.

    DESIGN: Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications.

    RESULTS: There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects.

    CONCLUSIONS: Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.

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  • 29. Hussain-Alkhateeb, Laith
    et al.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute for Global Health, University College London, London, UK.
    Petzold, Max
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. INDEPTH Network, Accra, Ghana; Medical Research Council, Johannesburg, South Africa; Medical Research Council, Johannesburg, South Africa; Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council, Johannesburg, South Africa; Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Local perceptions of causes of death in rural South Africa: a comparison of perceived and verbal autopsy causes of death2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-9, article id 28302Article in journal (Refereed)
    Abstract [en]

    Background: Understanding how lay people perceive the causes of mortality and their associated risk factors is important for public health. In resource-limited settings, where verbal autopsy (VA) is used as the most expedient method of determining cause of death, it is important to understand how pre-existing concepts of cause of death among VA-informants may influence their VA-responses and the consequential impact on cause of death assessment. This study describes the agreement between VA-derived causes of death and informant-perceived causes and associated influential factors, which also reflects lay health literacy in this setting. Method: Using 20 years of VA data (n = 11,228) from the Agincourt Health and Demographic Surveillance System (HDSS) site in rural South Africa, we explored the agreement between the causes of death perceived by the VA-informants and those assigned by the automated Inter-VA tool. Kappa statistics and concordance correlation coefficients were applied to measure agreement at individual and population levels, respectively. Multivariable regression models were used to explore factors associated with recognised lay perceptions of causes of mortality. Results: Agreement between informant-perceived and VA-derived causes of death at the individual level was limited, but varied substantially by cause of death. However, agreement at the population level, comparing cause-specific mortality fractions was higher, with the notable exception of bewitchment as a cause. More recent deaths, those in adults aged 15-49 years, deaths outside the home, and those associated with external causes showed higher concordance with InterVA. Conclusion: Overall, informant perception of causes of death was limited, but depended on informant characteristics and causes of death, and to some extent involved non-biomedical constructs. Understanding discordance between perceived and recognised causes of death is important for public health planning; low community understanding of causes of death may be detrimental to public health. These findings also illustrate the importance of using rigorous and standardised VA methods rather than relying on informants' reported causes of death.

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  • 30. Leitao, Jordana
    et al.
    Chandramohan, Daniel
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jakob, Robert
    Bundhamcharoen, Kanitta
    Choprapawon, Chanpen
    de Savigny, Don
    Fottrell, Edward
    França, Elizabeth
    Frøen, Frederik
    Gewaifel, Gihan
    Hodgson, Abraham
    Hounton, Sennen
    Kahn, Kathleen
    Krishnan, Anand
    Kumar, Vishwajeet
    Masanja, Honorati
    Nichols, Erin
    Notzon, Francis
    Rasooly, Mohammad Hafiz
    Sankoh, Osman
    Spiegel, Paul
    AbouZahr, Carla
    Amexo, Marc
    Kebede, Derege
    Alley, William Soumbey
    Marinho, Fatima
    Ali, Mohamed
    Loyola, Enrique
    Chikersal, Jyotsna
    Gao, Jun
    Annunziata, Giuseppe
    Bahl, Rajiv
    Bartolomeus, Kidist
    Boerma, Ties
    Ustun, Bedirhan
    Chou, Doris
    Muhe, Lulu
    Mathai, Matthews
    Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 21518-Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems.

    METHODS: A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification.

    FINDINGS: A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach.

    CONCLUSIONS: The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians.

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  • 31. Lemma, Hailemariam
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Desta, Alem
    Bosman, Andrea
    Costanzo, Gianfranco
    Toma, Luigi
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Marrast, Anne-Claire
    Ambachew, Yohannes
    Getachew, Asefaw
    Mulure, Nathan
    Morrone, Aldo
    Bianchi, Angela
    Barnabas, Gebre Ab
    Deploying artemether-lumefantrine with rapid testing in Ethiopian communities: impact on malaria morbidity, mortality and healthcare resources2010In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 15, no 2, p. 241-250Article in journal (Refereed)
    Abstract [en]

    Objective: To assess the impact and feasibility of artemether-lumefantrine deployment at community level, combined with phased introduction of rapid diagnostic tests (RDTs), on malaria transmission, morbidity, and mortality and health service use in a remote area of Ethiopia.

    Methods: Two-year pilot study in two districts: artemether-lumefantrine was prescribed after parasitological confirmation of malaria in health facilities in both districts. In the intervention district, artemether-lumefantrine was also made available through 33 community health workers (CHWs); of these, 50% were equipped with RDTs in the second year.

    Results: At health facilities; 54 774 patients in the intervention and 100 535 patients in the control district were treated for malaria. In the intervention district, 75 654 patients were treated for malaria by community health workers. Use of RDTs in Year 2 excluded non-Plasmodium falciparumin 89.7% of suspected cases. During the peak of malaria transmission in 2005, the crude parasite prevalence was 7.4% (95% CI: 6.1-8.9%) in the intervention district and 20.8% (95% CI: 18.7-23.0%) in the control district. Multivariate modelling indicated no significant difference in risk of all-cause mortality between the intervention and the control districts [adjusted incidence rate ratio (aIRR) 1.03, 95%CI 0.87-1.21, P = 0.751], but risk of malaria-specific mortality was lower in the intervention district (aIRR 0.60, 95%CI 0.40-0.90, P = 0.013).

    Conclusions: Artemether-lumefantrine deployment through a community-based service in a remote rural population reduced malaria transmission, lowered the malaria case burden for health facilities and reduced malaria morbidity and mortality during a 2-year period which included a major malaria epidemic.

  • 32. Prost, Audrey
    et al.
    Colbourn, Tim
    Seward, Nadine
    Azad, Kishwar
    Coomarasamy, Arri
    Copas, Andrew
    Houweling, Tanja A J
    Fottrell, Edward
    Kuddus, Abdul
    Lewycka, Sonia
    MacArthur, Christine
    Manandhar, Dharma
    Morrison, Joanna
    Mwansambo, Charles
    Nair, Nirmala
    Nambiar, Bejoy
    Osrin, David
    Pagel, Christina
    Phiri, Tambosi
    Pulkki-Brännström, Anni-Maria
    Rosato, Mikey
    Skordis-Worrall, Jolene
    Saville, Naomi
    More, Neena Shah
    Shrestha, Bhim
    Tripathy, Prasanta
    Wilson, Amie
    Costello, Anthony
    Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 381, no 9879, p. 1736-46Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings.

    METHODS: We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries.

    FINDINGS: Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries.

    INTERPRETATION: With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.

  • 33. Ramroth, Heribert
    et al.
    Lorenz, Eva
    Rankin, Johanna C.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ye, Maurice
    Neuhann, Florian
    Ssennono, Mark
    Sie, Ali
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Becher, Heiko
    Cause of death distribution with InterVA and physician coding in a rural area of Burkina Faso2012In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 17, no 7, p. 904-913Article in journal (Refereed)
    Abstract [en]

    Objectives To compare the cause of death distribution using the Physician Coded Verbal Autopsy approach versus the Interpreting Verbal Autopsy model, based on information from a French verbal autopsy questionnaire, in rural north-western Burkina Faso. Methods Data from 5649 verbal autopsy questionnaires reviewed by local physicians at the Nouna Health and Demographic Surveillance Site between 1998 and 2007 were considered for analyses. Information from VA interviews was extracted to create a set of standard indicators needed to run the Interpreting Verbal Autopsy model. Cause-specific mortality fractions were used to compare Physician Coded Verbal Autopsy and Interpreting Verbal Autopsy results. Results At the population level, 62.5% of causes of death using the Interpreting Verbal Autopsy model corresponded with those determined by two or three physicians. Although seven of the 10 main causes of death were present in both approaches, the comparison of percentages of single causes of death shows discrepancies, dominated by higher malaria rates found in the Physician Coded Verbal Autopsy approach. Conclusion Our results confirm that national mortality statistics, which are partly based on verbal autopsies, must be carefully interpreted. Difficulties in determining malaria as cause of death in holoendemic malaria regions might result in higher discrepancies than those in non-endemic areas. As neither Physician Coded Verbal Autopsy nor Interpreting Verbal Autopsy results represent a gold standard, uncertainty levels with either procedure are high.

  • 34.
    Santosa, Ailiana
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research.
    Fottrell, Edward
    Institute for Global Health, University College London, London, UK.
    Högberg, Ulf
    Department of Women’s and Children’s Health, Uppsala University, Uppsala.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    The development and experience of epidemiological transition theory over four decades: a systematic review2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 23574Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Epidemiological transition (ET) theory, first postulated in 1971, has developed alongside changes in population structures over time. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners. Here, we review the concept and development of ET theory, contextualising this in empirical evidence, which variously supports and contradicts the original theoretical propositions.

    DESIGN: A Medline literature search covering publications over four decades, from 1971 to 2013, was conducted. Studies were included if they assessed human populations, were original articles, focused on mortality and health or demographic or ET and were in English. The reference lists of the selected articles were checked for additional sources.

    RESULTS: We found that there were changes in emphasis in the research field over the four decades. There was an increasing tendency to study wide-ranging aspects of the determinants of mortality, including risk factors, lifestyle changes, socio-economics, and macro factors such as climate change. Research on ET has focused increasingly on low- and middle-income countries rather than industrialised countries, despite its origins in industrialised countries. Countries have experienced different levels of progress in ET in terms of time, pace, and underlying mechanisms. Elements of ET are described for many countries, but observed transitions have not always followed pathways described in the original theory.

    CONCLUSIONS: The classic ET theory largely neglected the critical role of social determinants, being largely a theoretical generalisation of mortality experience in some countries. This review shows increasing interest in ET all over the world but only partial concordance between established theory and empirical evidence. Empirical evidence suggests that some unconsidered aspects of social determinants contributed to deviations from classic theoretical pathways. A better-constructed, revised ET theory, with a stronger basis in evidence, is needed.

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  • 35. Vergnano, Stefania
    et al.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Osrin, David
    Kazembe, Peter N
    Mwansambo, Charles
    Manandhar, Dharma S
    Munjanja, Stephan P
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lewycka, Sonia
    Costello, Anthony
    Adaptation of a probabilistic method (InterVA) of verbal autopsy to improve the interpretation of cause of stillbirth and neonatal death in Malawi, Nepal, and Zimbabwe.2011In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 9, p. 48-Article in journal (Refereed)
    Abstract [en]

    Background

    Verbal autopsy (VA) is a widely used method for analyzing cause of death in absence of vital registration systems. We adapted the InterVA method to extrapolate causes of death for stillbirths and neonatal deaths from verbal autopsy questionnaires, using data from Malawi, Zimbabwe, and Nepal.

    Methods

    We obtained 734 stillbirth and neonatal VAs from recent community studies in rural areas: 169 from Malawi, 385 from Nepal, and 180 from Zimbabwe. Initial refinement of the InterVA model was based on 100 physician-reviewed VAs from Malawi. InterVA indicators and matrix probabilities for cause of death were reviewed for clinical and epidemiological coherence by a pediatrician-researcher and an epidemiologist involved in the development of InterVA. The modified InterVA model was evaluated by comparing population-level cause-specific mortality fractions and individual agreement from two methods of interpretation (physician review and InterVA) for a further 69 VAs from Malawi, 385 from Nepal, and 180 from Zimbabwe.

    Results

    Case-by-case agreement between InterVA and reviewing physician diagnoses for 69 cases from Malawi, 180 cases from Zimbabwe, and 385 cases from Nepal were 83% (kappa 0.76 (0.75 - 0.80)), 71% (kappa 0.41(0.32-0.51)), and 74% (kappa 0.63 (0.60-0.63)), respectively. The proportion of stillbirths identified as fresh or macerated by the different methods of VA interpretation was similar in all three settings. Comparing across countries, the modified InterVA method found that proportions of preterm births and deaths due to infection were higher in Zimbabwe (44%) than in Malawi (28%) or Nepal (20%).

    Conclusion

    The modified InterVA method provides plausible results for stillbirths and newborn deaths, broadly comparable to physician review but with the advantage of internal consistency. The method allows standardized cross-country comparisons and eliminates the inconsistencies of physician review in such comparisons.

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