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  • 51.
    Byass, Peter
    et al.
    Immpact, University of Aberdeen, Aberdeen, AB25 2ZD, UK .
    D'Ambruoso, Lucia
    Immpact, University of Aberdeen, Aberdeen, AB25 2ZD, UK .
    Ouédraogo, Moctar
    GREFSaD, Bobo-Dioulasso, Burkina Faso .
    Qomariyah, S Nurul
    Immpact, Center for Family Welfare, Faculty of Public Health, University of Indonesia, Jakarta, Indonesia .
    Assessing the repeatability of verbal autopsy for determining cause of death: two case studies among women of reproductive age in Burkina Faso and Indonesia2009In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 7, no 1, p. 6-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Verbal autopsy (VA) is an established tool for assessing cause-specific mortality patterns in communities where deaths are not routinely medically certified, and is an important source of data on deaths among the poorer half of the world's population. However, the repeatability of the VA process has never been investigated, even though it is an important factor in its overall validity. This study analyses repeatability in terms of the overall VA process (from interview to cause-specific mortality fractions (CSMF)), as well as specifically for interview material and individual causes of death, using data from Burkina Faso and Indonesia.

    METHODS: Two series of repeated VA interviews relating to women of reproductive age in Burkina Faso (n = 91) and Indonesia (n = 116) were analysed for repeatability in terms of interview material, individual causes of death and CSMFs. All the VA data were interpreted using the InterVA-M model, which provides 100% intrinsic repeatability for interpretation, and thus eliminated the need to consider variations or repeatability in physician coding.

    RESULTS: The repeatability of the overall VA process from interview to CSMFs was good in both countries. Repeatability was moderate in the interview material, and lower in terms of individual causes of death. Burkinabé data were less repeatable than Indonesian, and repeatability also declined with longer recall periods between the death and interview, particularly after two years.

    CONCLUSION: While these analyses do not address the validity of the VA process in absolute terms, repeatability is a prerequisite for intrinsic validity. This study thus adds new understanding to the quest for reliable cause of death assessment in communities lacking routine medical certification of deaths, and confirms the status of VA as an important and reliable tool at the community level, but perhaps less so at the individual level.

  • 52.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    de Courten, Maximilian
    Graham, Wendy J
    Laflamme, Lucie
    McCaw-Binns, Affette
    Sankoh, Osman A
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Zaba, Basia
    Reflections on the global burden of disease 2010 estimates2013In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 10, no 7, p. e1001477-Article in journal (Refereed)
  • 53.
    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, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    de Savigny, Don
    Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland and University of Basel, Basel, Switzerland.
    Lopez, Alan D
    Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia.
    Essential evidence for guiding health system priorities and policies: anticipating epidemiological transition in Africa2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 158-168Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way.

    PROPOSALS: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers.

    CONCLUSION: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services.

  • 54.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fantahun, Mesganaw
    Emmelin, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Molla, Mitike
    Berhane, Yemane
    Spatio-temporal clustering of mortality in Butajira HDSS, Ethiopia, from 1987 to 20082010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. 26-31Article in journal (Refereed)
    Abstract [en]

    Background: Mortality in a population may be clustered in space and time for a variety of reasons, including geography, socio-economics, environment and demographics. Analysing mortality clusters can therefore reveal important insights into patterns and risks of mortality in a particular setting. Objective and design: To investigate the extent of spatio-temporal clustering of mortality in the Butajira District, Ethiopia, from 1987 to 2008. The Health and Demographic Surveillance System (HDSS) dataset recorded 10,696 deaths among 951,842 person-years of observation, with each death located by household, in which population time at risk was also recorded. The surveyed population increased from 28,614 in 1987 to 62,322 in 2008, in an area approximately 25 km in diameter. Spatio-temporal clustering analyses were conducted for overall mortality and by specific age groups, grouping the population into a 0.01° latitude-longitude grid. Results: A number of significantly high- and low-mortality clusters were identified at various times and places. Butajira town was characterised by significantly low mortality throughout the period. A previously documented major mortality crisis in 1998-1999, largely resulting from malaria and diarrhoea, dominated the clustering analysis. Other local high-mortality clusters, appreciably attributable to meningitis, malaria and diarrhoea, occurred in the earlier part of the period. In the later years, a more homogeneous distribution of mortality at lower rates was observed. Conclusions: Mortality was by no means randomly distributed in this community during the period of observation. The clustering analyses revealed a clear epidemiological transition, away from localised infectious epidemics, over a generation.

  • 55.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Fantahun, Mesganaw
    Mekonnen, Wubegzier
    Emmelin, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Berhane, Yemane
    From birth to adulthood in rural Ethiopia: the Butajira Birth Cohort of 1987.2008In: Paediatr Perinat Epidemiol, ISSN 1365-3016, Vol. 22, no 6, p. 569-74Article in journal (Refereed)
  • 56.
    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)
  • 57.
    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, Umeå University.
    Friberg, Peter
    Sahlgrenska University Hospital, Gothenburg.
    A proposal to add patient safety to the Stockholm Declaration - Authors'reply2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 382, no 9894, p. 765-766Article in journal (Refereed)
  • 58.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Friberg, Peter
    Swedish Society of Medicine and Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Gothenburg.
    A proposal to add patient safety to the Stockholm Declaration Reply2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 382, no 9894, p. 765-766Article in journal (Refereed)
  • 59.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Friberg, Peter
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Beyond 2015: time to reposition Scandinavia in global health?2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6Article in journal (Refereed)
    Abstract [en]

    Global health currently finds itself in an exciting, almost bewildering, state of flux. A plethora of initiatives, statements, high-level meetings, and other activities are generating a continuous flow of new ideas, with the impetus at least partly driven by the advent of the 2015 target date set for the Millennium Development Goals that were adopted in 2000. Whatever shape the post-2015 global health landscape may eventually take, it is already clear that there will be new targets of some kind as the world tries to make further progress on some of the less tractable health issues.

  • 60.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Ghebreyesus, Tedros A
    Making the world's children count.2005In: Lancet, ISSN 1474-547X, Vol. 365, no 9465, p. 1114-6Article in journal (Refereed)
  • 61.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Graham, Wendy J.
    Grappling with uncertainties along the MDG trail2011In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 378, no 9797, p. 1119-1120Article in journal (Refereed)
  • 62.
    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.

  • 63.
    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)
  • 64.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; 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; Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa.
    Hussain-Alkhateeb, Laith
    D'Ambruoso, Lucia
    Clark, Samuel
    Davies, Justine
    Fottrell, Edward
    Bird, Jon
    Kabudula, Chodziwadziwa
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; INDEPTH Network, Accra, Ghana.
    Schiöler, Linus
    Petzold, Max
    An integrated approach to processing WHO-2016 verbal autopsy data: the InterVA-5 model2019In: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 17, article id 102Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy is an increasingly important methodology for assigning causes to otherwise uncertified deaths, which amount to around 50% of global mortality and cause much uncertainty for health planning. The World Health Organization sets international standards for the structure of verbal autopsy interviews and for cause categories that can reasonably be derived from verbal autopsy data. In addition, computer models are needed to efficiently process large quantities of verbal autopsy interviews to assign causes of death in a standardised manner. Here, we present the InterVA-5 model, developed to align with the WHO-2016 verbal autopsy standard. This is a harmonising model that can process input data from WHO-2016, as well as earlier WHO-2012 and Tariff-2 formats, to generate standardised cause-specific mortality profiles for diverse contexts.

    The software development involved building on the earlier InterVA-4 model, and the expanded knowledge base required for InterVA-5 was informed by analyses from a training dataset drawn from the Population Health Metrics Research Collaboration verbal autopsy reference dataset, as well as expert input.

    Results: The new model was evaluated against a test dataset of 6130 cases from the Population Health Metrics Research Collaboration and 4009 cases from the Afghanistan National Mortality Survey dataset. Both of these sources contained around three quarters of the input items from the WHO-2016, WHO-2012 and Tariff-2 formats. Cause-specific mortality fractions across all applicable WHO cause categories were compared between causes assigned in participating tertiary hospitals and InterVA-5 in the test dataset, with concordance correlation coefficients of 0.92 for children and 0.86 for adults.

    The InterVA-5 model’s capacity to handle different input formats was evaluated in the Afghanistan dataset, with concordance correlation coefficients of 0.97 and 0.96 between the WHO-2016 and the WHO-2012 format for children and adults respectively, and 0.92 and 0.87 between the WHO-2016 and the Tariff-2 format respectively.

    Conclusions: Despite the inherent difficulties of determining “truth” in assigning cause of death, these findings suggest that the InterVA-5 model performs well and succeeds in harmonising across a range of input formats. As more primary data collected under WHO-2016 become available, it is likely that InterVA-5 will undergo minor re-versioning in the light of practical experience. The model is an important resource for measuring and evaluating cause-specific mortality globally.

  • 65.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa.
    Jackson Cole, Catherine
    Davies, Justine I.
    Geldsetzer, Pascal
    Witham, Miles D.
    Wu, Yan
    Collaboration for impact in global health2018In: The Lancet Global Health, E-ISSN 2214-109X, Vol. 6, no 8, p. e836-e837Article in journal (Refereed)
  • 66.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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.
    Kabudula, Chodziwadziwa W.
    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; INDEPTH Network, Accra, Ghana.
    Mee, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Ngobeni, Sizzy
    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;.
    Silaule, Bernard
    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;.
    Gomez-Olive, F. Xavier
    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; INDEPTH Network, Accra, Ghana.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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; INDEPTH Network, Accra, Ghana.
    Tugendhaft, Aviva
    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; PRICELESS/PEECHi, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa .
    Wagner, Ryan G.
    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; .
    Twine, Rhian
    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; .
    Hofman, Karen
    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; PRICELESS/PEECHi, 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. 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; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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; INDEPTH Network, Accra, Ghana.
    A Successful Failure: missing the MDG4 Target for Under-Five Mortality in South Africa2015In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 12, no 12, article id e1001926Article in journal (Refereed)
  • 67.
    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.

  • 68.
    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.

  • 69.
    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.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The global burden of childhood coeliac disease: a neglected component of diarrhoeal mortality?2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 7, p. e22774-Article in journal (Refereed)
    Abstract [en]

    Objectives Coeliac disease has emerged as an increasingly recognised public health problem over the last half-century, and is now coming to be seen as a global phenomenon, despite a profound lack of globally representative epidemiological data. Since children with coeliac disease commonly present with chronic diarrhoea and malnutrition, diagnosis is often overlooked, particularly in poorer settings where children often fail to thrive and water-borne infectious diarrhoeas are common. This is the first attempt to make global estimates of the burden of coeliac disease in childhood.

    Methods We built a relatively crude model of childhood coeliac disease, incorporating estimates of population prevalence, probability of non-diagnosis, and likelihood of mortality among the undiagnosed across all countries from 1970 to 2010, based around the few available data. All our assumptions are stated in the paper and the model is available as a supplementary file.

    Findings Our model suggests that in 2010 there were around 2.2 million children under 5 years of age living with coeliac disease. Among these children there could be 42,000 deaths related to coeliac disease annually. In 2008, deaths related to coeliac disease probably accounted for approximately 4% of all childhood diarrhoeal mortality.

    Conclusions Although coeliac disease may only account for a small proportion of diarrhoeal mortality, these deaths are not preventable by applying normal diarrhoea treatment guidelines, which may even involve gluten-based food supplements. As other causes of diarrhoeal mortality decline, coeliac disease will become a proportionately increasing problem unless consideration is given to trying gluten-free diets for children with chronic diarrhoea and malnutrition.

  • 70.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nurturing Global Health Action through its first decade2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1569847Article in journal (Refereed)
  • 71.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sankoh, Osman
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lessons from history for designing and validating epidemiological surveillance in uncounted populations2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 8, p. e22897-Article in journal (Refereed)
    Abstract [en]

    Background

    Due to scanty individual health data in low- and middle-income countries (LMICs), health planners often use imperfect data sources. Frequent national-level data are considered essential, even if their depth and quality are questionable. However, quality in-depth data from local sentinel populations may be better than scanty national data, if such local data can be considered as nationally representative. The difficulty is the lack of any theoretical or empirical basis for demonstrating that local data are representative where data on the wider population are unavailable. Thus these issues can only be explored empirically in a complete individual dataset at national and local levels, relating to a LMIC population profile.

    Methods and Findings

    Swedish national data for 1925 were used, characterised by relatively high mortality, a low proportion of older people and substantial mortality due to infectious causes. Demographic and socioeconomic characteristics of Sweden then and LMICs now are very similar. Rates of livebirths, stillbirths, infant and cause-specific mortality were calculated at national and county levels. Results for six million people in 24 counties showed that most counties had overall mortality rates within 10% of the national level. Other rates by county were mostly within 20% of national levels. Maternal mortality represented too rare an event to give stable results at the county level.

    Conclusions

    After excluding obviously outlying counties (capital city, island, remote areas), any one of the remaining 80% closely reflected the national situation in terms of key demographic and mortality parameters, each county representing approximately 5% of the national population. We conclude that this scenario would probably translate directly to about 40 LMICs with populations under 10 million, and to individual states or provinces within about 40 larger LMICs. Unsubstantiated claims that local sub-national population data are “unrepresentative” or “only local” should not therefore predominate over likely representativity.

  • 72.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Twine, Wayne
    Collinson, Mark
    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.
    Kjellström, Tord
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing a population's exposure to heat and humidity: an empirical approach2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5421-Article in journal (Refereed)
    Abstract [en]

    Background: It is widely accepted that assessing the impact of heat on populations is an important aspect of climate change research. However, this raises questions about how best to measure people’s exposure to heat under everyday living conditions in more detail than is possible by relying on nearby sources of meteorological data. Objective: This study aimed to investigate practical and viable approaches to measuring air temperature and humidity within a population, making comparisons with contemporaneous external data sources. This was done in a rural South African population during the subtropical summer season. Results: Air temperature and humidity were measured indoors and outdoors at three locations over 10 days and the datalogger technology proved reliable and easy to use. There was little variation in measurements over distances of 10 km. Conclusions: Small battery-powered automatic dataloggers proved to be a feasible option for collecting weather data among a rural South African population. These data were consistent with external sources but offered more local detail. Detailed local contemporary data may also allow post hoc modelling of previously unmeasured local weather data in conjunction with global gridded climate models.

  • 73.
    Byass, Peter
    et al.
    Umeå University.
    Wilder-Smith, Annelies
    Umeå University. Nanyang Technol Univ, Lee Kong Chian Sch Med, Singapore .
    Utilising additional sources of information on microcephaly2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10022, p. 940-941Article in journal (Refereed)
  • 74.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Worku, Alemayehu
    Emmelin, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Berhane, Yemane
    DSS and DHS: longitudinal and cross-sectional viewpoints on child and adolescent mortality in Ethiopia2007In: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 5, no 1, p. Article nr 12-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In countries where routine vital registration data are scarce, Demographic Surveillance Sites (DSS: locally defined populations under longitudinal surveillance for vital events and other characteristics) and Demographic and Health Surveys (DHS: periodic national cluster samples responding to cross-sectional surveys) have become standard approaches for gathering at least some data. This paper aims to compare DSS and DHS approaches, seeing how they complement each other in the specific instance of child and adolescent mortality in Ethiopia.

    METHODS: Data from the Butajira DSS 1987-2004 and the Ethiopia DHS rounds for 2000 and 2005 formed the basis of comparative analyses of mortality rates among those aged under 20 years, using Poisson regression models for adjusted rate ratios.

    RESULTS: Patterns of mortality over time were broadly comparable using DSS and DHS approaches. DSS data were more susceptible to local epidemic variations, while DHS data tended to smooth out local variation, and be more subject to recall bias.

    CONCLUSION: Both DSS and DHS approaches to mortality surveillance gave similar overall results, but both showed method-dependent advantages and disadvantages. In many settings, this kind of joint-source data analysis could offer significant added value to results.

  • 75. Coates, Matthew M.
    et al.
    Kamanda, Mamusu
    Kintuc, Alexander
    Arikpo, Iwara
    Chauque, Alberto
    Mengesha, Melkamu Merid
    Price, Alison J.
    Sifuna, Peter
    Wamukoya, Marylene
    Sacoor, Charfudin N.
    Ogwang, Sheila
    Assefa, Nega
    Crampin, Amelia C.
    Macete, Eusebio, V
    Kyobutungi, Catherine
    Meremikwu, Martin M.
    Otieno, Walter
    Adjaye-Gbewonyo, Kafui
    Marx, Andrew
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Sankoh, Osman
    Bukhman, Gene
    A comparison of all-cause and cause-specific mortality by household socioeconomic status across seven INDEPTH network health and demographic surveillance systems in sub-Saharan Africa2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1608013Article in journal (Refereed)
    Abstract [en]

    Background: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies.

    Objectives: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa.

    Methods: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0-8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2-4 and 5-8 deprivations on our poverty index compared to 0-2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups.

    Results: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5-8 deprivations on our poverty index compared to 0-2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34-4.05) and for non-communicable diseases in several sites (1.14-1.93). The disparities in mortality between 5-8 deprivation groups and 0-2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites.

    Conclusions: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.

  • 76.
    Collinson, Mark A
    et al.
    University of Witwatersrand, South Africa; Umeå universitet, Umeåpå.
    Clark, Samuel J
    University of Witwatersrand, South Africa, University of Washington, USA.
    Gerritsen, Annette M
    University of Venda, South Africa.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kahn, Kathleen
    University of Witwatersrand, South Africa.
    Tollman, Stephen
    University of Witwatersrand, South Africa.
    The dynamics of poverty and migration in a rural South African community, 2001-2005In: Article in journal (Other academic)
  • 77.
    Collinson, Mark A
    et al.
    University of Witwatersrand, South Africa; University of Umeå, Sweden.
    White, Michael J
    Brown University, USA.
    Short, Susan
    Brown University, USA.
    Lurie, Mark
    Brown University, SUA.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kahn, Kathleen
    University of Witwatersrand, South Africa; Umeå University, Sweden.
    Clark, Samuel J
    University of Witwatersrand, South Africa.
    Tollman, Stephen M
    University of Witwatersrand,South Africa; University of Umeå, Sweden.
    Child mortality, migration and parental presence in rural South Africa near the border with MozambiqueManuscript (preprint) (Other academic)
  • 78. Cook, Ian
    et al.
    Alberts, Marianne
    Burger, Sandy
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    All-cause mortality trends in Dikgale, rural South Africa, 1996-2003.2008In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 36, no 7, p. 753-60Article in journal (Refereed)
    Abstract [en]

    AIMS: The Dikgale Demographic Surveillance System (DDSS) site, established in 1995, is one of three rural surveillance sites in South Africa. This paper describes detailed mortality patterns of a rural African population in the central region of Limpopo Province. METHODS: These data were based on yearly household visits to collect data on vital events, covering 63, 873 person-years of observation over eight years. RESULTS: Crude mortality was 7.5 per 1,000 person-years (females: 6.9, males: 8.1). Under-1 year and under-5 years mortality was 15.1 and 5.8 per 1,000 person-years, respectively. Life expectancy at birth was 64.3 years (females: 68.1, males: 60.0). For the two four-year periods (1996-9 and 2000-3) under-20 years mortality risk decreased (rate ratio=0.45, 95% CI: 0.25 to 0.80) while 20-49 years mortality risk increased (rate ratio=1.55, 95% CI: 1.10 to 2.20). Multivariate mortality risk for migrants remained relatively constant (0.71, 95% CI: 0.54 to 0.94) across the two four-year periods, but has increased 2.5-fold in all DDSS +50 year-old adults across the two four-year periods. CONCLUSIONS: The DDSS mortality estimates appear to have remained relatively constant while recent mortality estimates for the Agincourt Demographic and Health Surveillance System (ADHSS) site suggest that mortality risk is higher and life expectancy is lower in ADHSS residents. Moreover, DDSS mortality estimates are substantially more favourable compared with provincial and national mortality estimates.

  • 79. D'Ambruoso, Lucia
    et al.
    Boerma, Ties
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Herbst, Kobus
    Källander, Karin
    Mullan, Zoë
    The case for verbal autopsy in health systems strengthening2017In: The Lancet Global Health, E-ISSN 2214-109X, Vol. 5, no 1, p. e20-e21Article in journal (Refereed)
  • 80.
    D'Ambruoso, Lucia
    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 Public Health Sciences.
    Ouedraogo, Moctar
    Maternal death due to postpartum hemorrhage after snakebite2008In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 102, no 1, p. 71-Article in journal (Refereed)
  • 81. D'Ambruoso, Lucia
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Qomariyah, Siti Nurul
    'Maybe it was her fate and maybe she ran out of blood': final caregivers' perspectives on access to care in obstetric emergencies in rural Indonesia.2010In: Journal of Biosocial Science, ISSN 0021-9320, E-ISSN 1469-7599, Vol. 42, no 2, p. 213-241Article in journal (Refereed)
    Abstract [en]

    Maternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect information on the exclusory mechanisms of health systems, important information for equitable health planning.

  • 82. D'Ambruoso, Lucia
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Qomariyah, Siti Nurul
    Ouédraogo, Moctar
    A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 71, no 10, p. 1728-1738Article in journal (Refereed)
    Abstract [en]

    Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.

  • 83.
    D'Ambruoso, Lucia
    et al.
    Immpact, University of Aberdeen, UK.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of Aberdeen, Dept Publ Hlth, Aberdeen, UK.
    Qomariyan, Siti Nurul
    Univ Indonesia, Fac Publ Hlth, Ctr Family Welf, W Java, Indonesia.
    Can the right to health inform public health planning in developing countries?: A case study for maternal healthcare from Indonesia2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1, p. 10-Article in journal (Refereed)
    Abstract [en]

    Background: Maternal mortality remains unacceptably high in developing countries despite international advocacy, development targets, and simple, affordable and effective interventions. Human rights are powerful advocacy tools, which have become prominent in health and development. In recent years, regard for maternal mortality as a human rights issue as well as one that pertains to health, has emerged.

    Objective: We study a case of maternal death using a theoretical framework derived from the right to health to examine access to and quality of maternal healthcare. Our objective was to explore the potential of rights-based frameworks to inform public health planning from a human rights perspective.

    Design: Information was elicited as part of a verbal autopsy survey investigating maternal deaths in rural settings in Indonesia. The deceased's relatives were interviewed to collect information on medical signs, symptoms and the social, cultural and health systems circumstances surrounding the death.

    Results: In this case, a prolonged, severe fever and a complicated series of referrals culminated in the death of a 19-year-old primagravida at 7 months gestation. The cause of death was acute infection. The woman encountered a range of barriers to access; behavioural, socio-cultural, geographic and economic. Several serious health system failures were also apparent.. The theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld.

    Conclusion: The rights-based approach could identify how and where to improve services. However, there are fundamental and inherent conflicts between the public health tradition (collective and preventative) and the right to health (individualistic and curative). As a result, and in practice, the right to health is likely to be ineffective for public health planning from a human rights perspective. Collective rights such as the right to development may provide a more suitable means to achieve equity and social justice in health planning.

  • 84.
    D'Ambruoso, Lucia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; 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.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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.
    Twine, R
    Spies, B
    van der Merwe, M
    Gómez-Olivé, FX
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; 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.
    Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality2016In: Global Health Research and Policy, ISSN 2397-0642, Vol. 1, no 2Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy (VA) is a health surveillance technique used in low and middle-income countries to establish medical causes of death (CODs) for people who die outside hospitals and/or without registration. By virtue of the deaths it investigates, VA is also an opportunity to examine social exclusion from access to health systems. The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA.

    Methods: A short set of questions on care pathways, circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA (SF-VA). Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site (HDSS), South Africa in 2012 and 2013 where the SF-VA had been applied. InterVA and descriptive analysis were used to calculate cause-specific mortality fractions (CSMFs), and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex sub-groups.

    Results: One thousand two hundred forty-nine deaths were recorded in the Agincourt HDSS censuses in 2012–13 of which 1,196 (96 %) had complete VA data. Infectious and non-communicable conditions accounted for the majority of deaths (47 % and 39 % respectively) with smaller proportions attributed to external, neonatal and maternal causes (5 %, 2 % and 1 % respectively). 5 % of deaths were of indeterminable cause. The new indicators revealed multiple problems with access to care at the time of death: 39 % of deaths did not call for help, 36 % found care unaffordable overall, and 33 % did not go to a facility. These problems were reported consistently across age and sex sub-groups. Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility. An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting.

    Conclusions: Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning. Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.

  • 85.
    D'Ambruoso, Lucia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa .
    van der Merwe, Maria
    Wariri, Oghenebrume
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa.
    Goosen, Gerhard
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Masinga, Sparara
    Mokoena, Victoria
    Spies, Barry
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Witter, Sophie
    Twine, Rhian
    Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa2019In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 34, no 6, p. 418-429Article in journal (Refereed)
    Abstract [en]

    Following 50 years of apartheid, South Africa introduced visionary health policy committing to the right to health as part of a primary health care (PHC) approach. Implementation is seriously challenged, however, in an often-dysfunctional health system with scarce resources and a complex burden of avoidable mortality persists. Our aim was to develop a process generating evidence of practical relevance on implementation processes among people excluded from access to health systems. Informed by health policy and systems research, we developed a collaborative learning platform in which we worked as co-researchers with health authorities in a rural province. This article reports on the process and insights brought by health systems stakeholders. Evidence gaps on under-five mortality were identified with a provincial Directorate after which we collected quantitative and qualitative data. We applied verbal autopsy to quantify levels, causes and circumstances of deaths and participatory action research to gain community perspectives on the problem and priorities for action. We then re-convened health systems stakeholders to analyse and interpret these data through which several systems issues were identified as contributory to under-five deaths: staff availability and performance; service organization and infrastructure; multiple parallel initiatives; and capacity to address social determinants. Recommendations were developed ranging from immediate low- and no-cost re-organization of services to those where responses from higher levels of the system or outside were required. The process was viewed as acceptable and relevant for an overburdened system operating 'in the dark' in the absence of local data. Institutional infrastructure for evidence-based decision-making does not exist in many health systems. We developed a process connecting research evidence on rural health priorities with the means for action and enabled new partnerships between communities, authorities and researchers. Further development is planned to understand potential in deliberative processes for rural PHC.

  • 86. Davies, Justine Ina
    et al.
    Macnab, Andrew John
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Stellenbosch Institute for Advanced Study, Wallenberg Research Centre at Stellenbosch University, South Africa; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Norris, Shane A.
    Nyirenda, Moffat
    Singhal, Atul
    Sobngwi, Eugene
    Daar, Abdallah S.
    Developmental origins of health and disease in Africa: influencing early life2018In: The Lancet Global Health, E-ISSN 2214-109X, Vol. 6, no 3, p. E244-E245Article in journal (Other academic)
  • 87. de Savigny, Don
    et al.
    Riley, Ian
    Chandramohan, Daniel
    Odhiambo, Frank
    Nichols, Erin
    Notzon, Sam
    AbouZahr, Carla
    Mitra, Raj
    Munoz, Daniel Cobos
    Firth, Sonja
    Maire, Nicolas
    Sankoh, Osman
    Bronson, Gay
    Setel, Philip
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. WHO Collaborating Centre for Verbal Autopsy; MRC-Wits Rural Public Health and Health Transitions Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
    Jakob, Robert
    Boerma, Ties
    Lopez, Alan D.
    Integrating community-based verbal autopsy into civil registration and vital statistics (CRVS): system-level considerations2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1272882Article in journal (Refereed)
    Abstract [en]

    Background: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low-and lowermiddle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death.

    Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance.

    Conclusions: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems.

  • 88. Desai, Meghna
    et al.
    Buff, Ann M
    Khagayi, Sammy
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Amek, Nyaguara
    van Eijk, Annemieke
    Slutsker, Laurence
    Vulule, John
    Odhiambo, Frank O
    Phillips-Howard, Penelope A
    Lindblade, Kimberly A
    Laserson, Kayla F
    Hamel, Mary J
    Age-specific malaria mortality rates in the KEMRI/CDC health and demographic surveillance system in western Kenya, 2003-20102014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 9, article id e106197Article in journal (Refereed)
    Abstract [en]

    Recent global malaria burden modeling efforts have produced significantly different estimates, particularly in adult malaria mortality. To measure malaria control progress, accurate malaria burden estimates across age groups are necessary. We determined age-specific malaria mortality rates in western Kenya to compare with recent global estimates. We collected data from 148,000 persons in a health and demographic surveillance system from 2003-2010. Standardized verbal autopsies were conducted for all deaths; probable cause of death was assigned using the InterVA-4 model. Annual malaria mortality rates per 1,000 person-years were generated by age group. Trends were analyzed using Poisson regression. From 2003-2010, in children <5 years the malaria mortality rate decreased from 13.2 to 3.7 per 1,000 person-years; the declines were greatest in the first three years of life. In children 5-14 years, the malaria mortality rate remained stable at 0.5 per 1,000 person-years. In persons ≥15 years, the malaria mortality rate decreased from 1.5 to 0.4 per 1,000 person-years. The malaria mortality rates in young children and persons aged ≥15 years decreased dramatically from 2003-2010 in western Kenya, but rates in older children have not declined. Sharp declines in some age groups likely reflect the national scale up of malaria control interventions and rapid expansion of HIV prevention services. These data highlight the importance of age-specific malaria mortality ascertainment and support current strategies to include all age groups in malaria control interventions.

  • 89. Desai, Nikita
    et al.
    Aleksandrowicz, Lukasz
    Miasnikof, Pierre
    Lu, Ying
    Leitao, Jordana
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå.
    Tollman, Stephen
    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 and International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Mee, Paul
    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.
    Alam, Dewan
    Rathi, Suresh Kumar
    Singh, Abhishek
    Kumar, Rajesh
    Ram, Faujdar
    Jha, Prabhat
    Performance of four computer-coded verbal autopsy methods for cause of death assignment compared with physician coding on 24,000 deaths in low- and middle-income countries2014In: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 12, no 1, p. 20-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Physician-coded verbal autopsy (PCVA) is the most widely used method to determine causes of death (CODs) in countries where medical certification of death is uncommon. Computer-coded verbal autopsy (CCVA) methods have been proposed as a faster and cheaper alternative to PCVA, though they have not been widely compared to PCVA or to each other.

    METHODS: We compared the performance of open-source random forest, open-source tariff method, InterVA-4, and the King-Lu method to PCVA on five datasets comprising over 24,000 verbal autopsies from low- and middle-income countries. Metrics to assess performance were positive predictive value and partial chance-corrected concordance at the individual level, and cause-specific mortality fraction accuracy and cause-specific mortality fraction error at the population level.

    RESULTS: The positive predictive value for the most probable COD predicted by the four CCVA methods averaged about 43% to 44% across the datasets. The average positive predictive value improved for the top three most probable CODs, with greater improvements for open-source random forest (69%) and open-source tariff method (68%) than for InterVA-4 (62%). The average partial chance-corrected concordance for the most probable COD predicted by the open-source random forest, open-source tariff method and InterVA-4 were 41%, 40% and 41%, respectively, with better results for the top three most probable CODs. Performance generally improved with larger datasets. At the population level, the King-Lu method had the highest average cause-specific mortality fraction accuracy across all five datasets (91%), followed by InterVA-4 (72% across three datasets), open-source random forest (71%) and open-source tariff method (54%).

    CONCLUSIONS: On an individual level, no single method was able to replicate the physician assignment of COD more than about half the time. At the population level, the King-Lu method was the best method to estimate cause-specific mortality fractions, though it does not assign individual CODs. Future testing should focus on combining different computer-coded verbal autopsy tools, paired with PCVA strengths. This includes using open-source tools applied to larger and varied datasets (especially those including a random sample of deaths drawn from the population), so as to establish the performance for age- and sex-specific CODs.

  • 90. Edem, Idara J.
    et al.
    Dare, Anna J.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    D'Ambruoso, Lucia
    Kahn, Kathleen
    Leather, Andy J. M.
    Tollman, Stephen
    Whitaker, John
    Davies, Justine
    External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 6, article id e027576Article in journal (Refereed)
    Abstract [en]

    Objective: Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

    Setting: Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

    Participants: Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

    Methods: A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the ‘three delays framework’ (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs—a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

    Results: Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

    Conclusions: A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

  • 91. Ekström, Anna Mia
    et al.
    Clark, Jocalyn
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lopez, Alan
    De Savigny, Don
    Moyer, Cheryl A
    Campbell, Harry
    Gage, Anastasia J
    Bocquier, Philippe
    AbouZahr, Carla
    Sankoh, Osman
    INDEPTH Network: contributing to the data revolution.2016In: The Lancet Diabetes and Endocrinology, ISSN 2213-8587, E-ISSN 2213-8595, Vol. 4, no 2, p. 97-97Article in journal (Refereed)
  • 92.
    Emmelin, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Fantahun, Mesganaw
    Berhane, Yemane
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Trends in under-five mortality in rural Ethiopia: 18 years of follow-up in the Butajira demographic surveillanceManuscript (preprint) (Other academic)
  • 93.
    Emmelin, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Fantahun, Mesganaw
    Berhane, Yemane
    Wall, Stig
    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.
    Vulnerability to episodes of extreme weather: Butajira, Ethiopia, 1998-19992009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 140-148Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: During 1999-2000, great parts of Ethiopia experienced a period of famine which was recognised internationally. The aim of this paper is to characterise the epidemiology of mortality of the period, making use of individual, longitudinal population-based data from the Butajira demographic surveillance site and rainfall data from a local site.

    METHODS: Vital statistics and household data were routinely collected in a cluster sample of 10 sub-communities in the Butajira district in central Ethiopia. These were supplemented by rainfall and agricultural data from the national reporting systems.

    RESULTS: Rainfall was high in 1998 and well below average in 1999 and 2000. In 1998, heavy rains continued from April into October, in 1999 the small rains failed and the big rains lasted into the harvesting period. For the years 1998-1999, the mortality rate was 24.5 per 1,000 person-years, compared with 10.2 in the remainder of the period 1997-2001. Mortality peaks reflect epidemics of malaria and diarrhoeal disease. During these peaks, mortality was significantly higher among the poorer.

    CONCLUSIONS: The analyses reveal a serious humanitarian crisis with the Butajira population during 1998-1999, which met the CDC guideline crisis definition of more than one death per 10,000 per day. No substantial humanitarian relief efforts were triggered, though from the results it seems likely that the poorest in the farming communities are as vulnerable as the pastoralists in the North and East of Ethiopia. Food insecurity and reliance on subsistence agriculture continue to be major issues in this and similar rural communities. Epidemics of traditional infectious diseases can still be devastating, given opportunities in nutritionally challenged populations with little access to health care.

  • 94.
    Emmelin, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Kumie, Abera
    Addis Ababa University, School of Public Health.
    Berhane, Yemane
    Addis Ababa University, Scholl of Public Health.
    Wall, Stig
    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.
    Use of biomass fuel is related to indicators of ARI among children under five in EthiopiaManuscript (preprint) (Other academic)
  • 95.
    Fantahun, Mesganaw
    et al.
    School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
    Berhane, Yemane
    School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Wall, Stig
    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.
    Ageing of a rural Ethiopian population: who are the survivors?2009In: Public health, ISSN 1476-5616Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This study assessed trends in survival to old age and identified the factors associated with longevity among the elderly (age >/=65 years). STUDY DESIGN: Cohort analysis of demographic surveillance data. METHODS: The study was conducted in the Butajira Rural Health Programme Demographic Surveillance Site in Ethiopia. Using data collected between 1987 and 2004, the probability of survival to 65 years and remaining life expectancy for women and men aged 65 years were computed. Cox regression analysis was used to assess survival by different factors. RESULTS: Although the elderly represented 3% of the population, their person-time contribution increased by 48% over the 18-year period. Less than half reached 65 years of age, with remaining life expectancy at 65 years ranging from 15 years in rural men to 19 years in urban women. Rural residence, illiteracy and widowhood were associated with lower survival adjusted for other factors, whereas gender did not show a significant difference. However, the effect of these factors differed between men and women, as demonstrated by survival curves and Cox regression. Widowhood [hazard ratio (HR) 2.02, 95% confidence interval (CI) 1.59-2.57] and illiteracy (HR 2.26, 95% CI 1.86-2.73) affected males to a greater extent than females, and rural residence was associated with poorer female survival (HR 1.68, 95% CI 1.55-1.83). CONCLUSIONS: The number of elderly people is increasing in Ethiopia, with the chance of survival into older age being similar between men and women and approaching that in developed countries. However, rural women and illiterate women and men, particularly widowers, are disadvantaged in terms of survival.

  • 96. Fantahun, Mesganaw
    et al.
    Berhane, Yemane
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Wall, Stig
    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.
    Young adult and middle age mortality in Butajira demographic surveillance site, Ethiopia: lifestyle, gender and household economy2008In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 8, p. Article nr 268-Article in journal (Refereed)
    Abstract [en]

    Background Public health research characterising the course of life through the middle age in developing societies is scarce. The aim of this study is to explore patterns of adult (15–64 years) mortality in an Ethiopian population over time, by gender, urban or rural lifestyle, causes of death and in relation to household economic status and decision-making.

    Methods The study was conducted in Butajira Demographic Surveillance Site (DSS) in south-central Ethiopia among adults 15–64 years old. Cohort analysis of surveillance data was conducted for the years 1987–2004 complemented by a prospective case-referent (case control) study over two years.

    Rate ratios were computed to assess the relationships between mortality and background variables using a Poisson regression model. In the case-referent component, odds ratios (95% confidence intervals) were used to assess the effect of certain risk factors that were not included in the surveillance system.

    Results A total of 367 940 person years were observed in a period of 18 years, in which 2 860 deaths occurred. One hundred sixty two cases and 486 matched for age, sex and place of residence controls were included in the case referent (case control) study. Only a modest downward trend in adult mortality was seen over the 18 year period. Rural lifestyle carried a significant survival disadvantage [mortality rate ratio 1.62 (95% CI 1.44 to 1.82), adjusted for gender, period and age group], while the overall effects of gender were negligible. Communicable disease mortality was appreciably higher in rural areas [rate ratio 2.05 (95% CI 1.73 to 2.44), adjusted for gender, age group and period]. Higher mortality was associated with a lack of literacy in a household, poor economic status and lack of women's decision making.

    Conclusion A complex pattern of adult mortality prevails, still influenced by war, famine and communicable diseases. Individual factors such as a lack of education, low economic status and social disadvantage all contribute to increased risks of mortality.

  • 97. Fantahun, Mesganaw
    et al.
    Berhane, Yemane
    Wall, Stig
    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.
    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 Global Health.
    Women's involvement in household decision-making and strengthening social capital-crucial factors for child survival in Ethiopia.2007In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 96, no 4, p. 582-589Article in journal (Refereed)
  • 98.
    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)
  • 99.
    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.

  • 100.
    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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