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Background: The INDEPTH Training & Research Centres of Excellence (INTREC) collaboration developed a training programme to strengthen social determinants of health (SDH) research in low- and middle-income countries (LMICs). It was piloted among health- and demographic researchers from 9 countries in Africa and Asia. The programme followed a blended learning approach and was split into three consecutive teaching blocks over a 12-month period: 1) an online course of 7 video lectures and assignments on the theory of SDH research; 2) a 2-week qualitative and quantitative methods workshop; and 3) a 1-week data analysis workshop. This report aims to summarise the student evaluations of the pilot and to suggest key lessons for future approaches to strengthen SDH research capacity in LMICs. Methods: Semi-structured interviews and questionnaires with 24 students from 9 countries in Africa and Asia were used to evaluate each teaching block. Information was collected about the students’ motivation and interest in studying SDH, any challenges they faced during the consecutive teaching blocks, and suggestions they had for future courses on SDH. Results: Of the 24 students who began the programme, 13 (54%) completed all training activities. The students recognised the need for such a course and its potential to improve their skills as health researchers. The main challenges with the online course were time management, prior knowledge and skills required to participate in the course, and the need to get feedback from teaching staff throughout the learning process. All students found the face-to-face workshops to be of high quality and value for their work, because they offered an opportunity to clarify SDH concepts taught during the online course and to gain practical research skills. After the final teaching block, students felt they had improved their data analysis skills and were better able to develop research proposals, scientific manuscripts, and policy briefs. Conclusions: The INTREC programme has trained a promising cadre of health researchers who live and work in LMICs, which is an essential component of efforts to identify and reduce national and local level health inequities. Time management and technological issues were the greatest challenges, which can inform future attempts to strengthen research capacity on SDH.

Background: As in any measurement process, a certain amount of error may be expected in routine population surveillance operations such as those in demographic surveillance sites (DSSs). Vital events are likely to be missed and errors made no matter what method of data capture is used or what quality control procedures are in place. The extent to which random errors in large, longitudinal datasets affect overall health and demographic profiles has important implications for the role of DSSs as platforms for public health research and clinical trials. Such knowledge is also of particular importance if the outputs of DSSs are to be extrapolated and aggregated with realistic margins of error and validity.Methods: This study uses the first 10-year dataset from the Butajira Rural Health Project (BRHP) DSS, Ethiopia, covering approximately 336,000 person-years of data. Simple programmes were written to introduce random errors and omissions into new versions of the definitive 10-year Butajira dataset. Key parameters of sex, age, death, literacy and roof material (an indicator of poverty) were selected for the introduction of errors based on their obvious importance in demographic and health surveillance and their established significant associations with mortality. Defining the original 10-year dataset as the 'gold standard' for the purposes of this investigation, population, age and sex compositions and Poisson regression models of mortality rate ratios were compared between each of the intentionally erroneous datasets and the original 'gold standard' 10-year data.Results: The composition of the Butajira population was well represented despite introducing random errors, and differences between population pyramids based on the derived datasets were subtle. Regression analyses of well-established mortality risk factors were largely unaffected even by relatively high levels of random errors in the data.Conclusion: The low sensitivity of parameter estimates and regression analyses to significant amounts of randomly introduced errors indicates a high level of robustness of the dataset. This apparent inertia of population parameter estimates to simulated errors is largely due to the size of the dataset. Tolerable margins of random error in DSS data may exceed 20%. While this is not an argument in favour of poor quality data, reducing the time and valuable resources spent on detecting and correcting random errors in routine DSS operations may be justifiable as the returns from such procedures diminish with increasing overall accuracy. The money and effort currently spent on endlessly correcting DSS datasets would perhaps be better spent on increasing the surveillance population size and geographic spread of DSSs and analysing and disseminating research findings. [ABSTRACT FROM AUTHOR]

Background: Verbal autopsy (VA) is a widely used technique for assigning causes to non-medically certified deaths using information gathered from a close caregiver. Both operational and cultural factors may cause delays in follow-up of deaths. The resulting time lag-from death to VA interview-can influence ways in which terminal events are remembered, and thus affect cause-of-death assignment. This study investigates the impact of recall period on causes of death determined by VA., Methods: A total of 10,882 deaths from the Agincourt Health and Demographic Surveillance System (HDSS) with complete VAs, including recall period, were incorporated in this study. To measure seasonal effect, cause specific mortality fractions (CSMFs) were calculated and compared by every cause for VAs undertaken within six months of death and those undertaken from six to 12 months of death. All causes were classified into eight broad categories and entered in a multiple logistic regression to explore outcome by recall period in relation to covariates., Results: The majority of deaths (83 %) had VAs completed within 12 months. There was a tendency towards longer recall periods for deaths of those under one year or over 65 years of age. Only the acute respiratory, diarrhoeal and other unspecified non-communicable disease groups showed a CSMF ratio significantly different from unity at the 99 % confidence level between the two recall periods. Only neonatal deaths showed significantly different OR for recall exceeding 12 months (OR 1.69; p value = 0.004) and this increased when adjusting for background factors (OR 2.58; p value = 0.000)., Conclusion: A recall period of up to one year between death and VA interview did not have any consequential effects on the cause-of-death patterns derived, with the exception of neonatal causes. This is an important operational consideration given the planned widespread use of the VA approach in civil registration, HDSS sites and occasional surveys.

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.

Background: The 2012 World Health Assembly set a target for Member States to reduce premature non-communicable disease (NCD) mortality by 25% over the period 2010 to 2025. This reflected concerns about increasing NCD mortality burdens among productive adults globally. This article first considers whether the WHO target of a 25% reduction in the unconditional probability of dying between ages of 30 and 70 from NCDs (cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases) has already taken place in Sweden during an equivalent 15-year period. Secondly, it assesses which population sub-groups have been more or less successful in contributing to overall changes in premature NCD mortality in Sweden., Methods: A retrospective dynamic cohort database was constructed from Swedish population registers in the Linnaeus database, covering the entire population in the age range 30 to 69 years for the period 1991 to 2006, which was used directly to measure reductions in premature NCD mortality using a life table method as specified by the WHO. Multivariate Poisson regression models were used to assess the contributions of individual background factors to decreases in premature NCD mortality., Results: A total of 292,320 deaths occurred in the 30 to 69 year age group during the period 1991 to 2006, against 70,768,848 person-years registered. The crude all-cause mortality rate declined from 5.03 to 3.72 per 1,000 person-years, a 26% reduction. Within this, the unconditional probability of dying between the ages of 30 and 70 from NCD causes as defined by the WHO fell by 30.0%. Age was consistently the strongest determinant of NCD mortality. Background determinants of NCD mortality changed significantly over the four time periods 1991-1994, 1995-1998, 1999-2002, and 2003-2006., Conclusions: Sweden, now at a late stage of epidemiological transition, has already exceeded the 25% premature NCD mortality reduction target during an earlier 15-year period. This should be encouraging news for countries currently implementing premature NCD mortality reduction programmes. Our findings suggest, however, that it may be difficult for Sweden and other late-transition countries to reach the current 25 × 25 target, particularly where substantial premature mortality reductions have already been achieved.

Background: In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period., Methods: Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use., Results: There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008-2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003-2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated., Conclusions: There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.

New Global Burden of Disease estimates for liver cirrhosis, published in BMC Medicine, suggest that cirrhosis caused over a million deaths in 2010, with a further million due to liver cancer and acute hepatitis. Cause-specific mortality data were very sparse for some regions, particularly in Africa, with no relevant mortality data for 58/187 countries. Liver disease involves infectious, malignant and chronic aetiologies with overlapping symptoms. Where available mortality data come from verbal autopsies, separating different types of liver disease is challenging. Cirrhosis is a disease of rich and poor alike; key public health risk factors such as alcohol consumption play an important role. Risk-reduction strategies such as controlling the price of alcohol are being widely discussed. Since these estimates used alcohol consumption as a covariate, they cannot be used to explore relationships between alcohol consumption and cirrhosis mortality. There is hope: coming generations of adults will have been vaccinated against hepatitis B, and this is envisaged to reduce the burden of fatal liver disease. But more complete civil registration globally is needed to fully understand the burden of liver disease.Please see related article: http://www.biomedcentral.com/1741-7015/12/145/abstract.

Background: Sickle cell disease (SCD) is common in many parts of sub-Saharan Africa (SSA), where it is associated with high early mortality. In the absence of newborn screening, most deaths among children with SCD go unrecognized and unrecorded. As a result, SCD does not receive the attention it deserves as a leading cause of death among children in SSA. In the current study, we explored the potential utility of verbal autopsy (VA) as a tool for attributing underlying cause of death (COD) in children to SCD., Methods: We used the 2007 WHO Sample Vital Registration with Verbal Autopsy (SAVVY) VA tool to determine COD among child residents of the Kilifi Health and Demographic Surveillance System (KHDSS), Kenya, who died between January 2008 and April 2011. VAs were coded both by physician review (physician coded verbal autopsy, PCVA) using COD categories based on the WHO International Classification of Diseases 10th Edition (ICD-10) and by using the InterVA-4 probabilistic model after extracting data according to the 2012 WHO VA standard. Both of these methods were validated against one of two gold standards: hospital ICD-10 physician-assigned COD for children who died in Kilifi District Hospital (KDH) and, where available, laboratory confirmed SCD status for those who died in the community., Results: Overall, 6% and 5% of deaths were attributed to SCD on the basis of PCVA and the InterVA-4 model, respectively. Of the total deaths, 22% occurred in hospital, where the agreement coefficient (AC1) for SCD between PCVA and hospital physician diagnosis was 95.5%, and agreement between InterVA-4 and hospital physician diagnosis was 96.9%. Confirmatory laboratory evidence of SCD status was available for 15% of deaths, in which the AC1 against PCVA was 87.5%., Conclusions: Other recent studies and provisional data from this study, outlining the importance of SCD as a cause of death in children in many parts of the developing world, contributed to the inclusion of specific SCD questions in the 2012 version of the WHO VA instruments, and a specific code for SCD has now been included in the WHO and InterVA-4 COD listings. With these modifications, VA may provide a useful approach to quantifying the contribution of SCD to childhood mortality in rural African communities. Further studies will be needed to evaluate the generalizability of our findings beyond our local context.

Background: Maternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India., Results: Using training datasets, it was possible to create a probabilistic tool that handled uncertainty of women's self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified., Conclusion: The probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women's self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.

Background: Verbal Autopsy (VA) is widely viewed as the only immediate strategy for registering cause of death in much of Africa and Asia, where routine physician certification of deaths is not widely practiced. VA involves a lay interview with family or friends after a death, to record essential details of the circumstances. These data can then be processed automatically to arrive at standardized cause of death information., Methods: The Population Health Metrics Research Consortium (PHMRC) undertook a study at six tertiary hospitals in low- and middle-income countries which documented over 12,000 deaths clinically and subsequently undertook VA interviews. This dataset, now in the public domain, was compared with the WHO 2012 VA standard and the InterVA-4 interpretative model., Results: The PHMRC data covered 70% of the WHO 2012 VA input indicators, and categorized cause of death according to PHMRC definitions. After eliminating some problematic or incomplete records, 11,984 VAs were compared. Some of the PHMRC cause definitions, such as 'preterm delivery', differed substantially from the International Classification of Diseases, version 10 equivalent. There were some appreciable inconsistencies between the hospital and VA data, including 20% of the hospital maternal deaths being described as non-pregnant in the VA data. A high proportion of VA cases (66%) reported respiratory symptoms, but only 18% of assigned hospital causes were respiratory-related. Despite these issues, the concordance correlation coefficient between hospital and InterVA-4 cause of death categories was 0.61., Conclusions: The PHMRC dataset is a valuable reference source for VA methods, but has to be interpreted with care. Inherently inconsistent cases should not be included when using these data to build other VA models. Conversely, models built from these data should be independently evaluated. It is important to distinguish between the internal and external validity of VA models. The effects of using tertiary hospital data, rather than the more usual application of VA to all-community deaths, are hard to evaluate. However, it would still be of value for VA method development to have further studies of population-based post-mortem examinations.

Background: Computer-coded verbal autopsy (CCVA) methods to assign causes of death (CODs) for medically unattended deaths have been proposed as an alternative to physician-certified verbal autopsy (PCVA). We conducted a systematic review of 19 published comparison studies (from 684 evaluated), most of which used hospital-based deaths as the reference standard. We assessed the performance of PCVA and five CCVA methods: Random Forest, Tariff, InterVA, King-Lu, and Simplified Symptom Pattern., Methods: The reviewed studies assessed methods' performance through various metrics: sensitivity, specificity, and chance-corrected concordance for coding individual deaths, and cause-specific mortality fraction (CSMF) error and CSMF accuracy at the population level. These results were summarized into means, medians, and ranges., Results: The 19 studies ranged from 200 to 50,000 deaths per study (total over 116,000 deaths). Sensitivity of PCVA versus hospital-assigned COD varied widely by cause, but showed consistently high specificity. PCVA and CCVA methods had an overall chance-corrected concordance of about 50% or lower, across all ages and CODs. At the population level, the relative CSMF error between PCVA and hospital-based deaths indicated good performance for most CODs. Random Forest had the best CSMF accuracy performance, followed closely by PCVA and the other CCVA methods, but with lower values for InterVA-3., Conclusions: There is no single best-performing coding method for verbal autopsies across various studies and metrics. There is little current justification for CCVA to replace PCVA, particularly as physician diagnosis remains the worldwide standard for clinical diagnosis on live patients. Further assessments and large accessible datasets on which to train and test combinations of methods are required, particularly for rural deaths without medical attention.

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.

Introduction: Haryana was the first state in India to launch a conditional cash transfer (CCT) scheme in 1994. Initially it targeted all disadvantaged girls but was revised in 2005 to restrict it to second girl children of all groups. The benefit which accrued at girl attaining 18 years and subject to conditionalities of being fully immunized, studying till class 10 and remaining unmarried, was increased from about US$ 500 to US$ 2000. Using a mixed methods approach, we evaluated the implementation and possible impact of these two schemes., Methods: A survey was conducted among 200 randomly selected respondents of Ballabgarh Block in Haryana to assess their perceptions of girl children and related schemes. A cohort of births during this period was assembled from population database of 28 villages in this block and changes in sex ratio at birth and in immunization coverage at one year of age among boys and girls was measured. Education levels and mean age at marriage of daughters were compared with daughters-in-law from outside Haryana. In-depth interviews were conducted among district level implementers of these schemes to assess their perceptions of programs' implementation and impact. These were analyzed using a thematic approach., Results: The perceptions of girls as a liability and poor (9% to 15%) awareness of the schemes was noted. The cohort analysis showed that while there has been an improvement in the indicators studied, these were similar to those seen among the control groups. Qualitative analysis identified a "conspiracy of silence" - an underplaying of the pervasiveness of the problem coupled with a passive implementation of the program and a clash between political culture of giving subsidies and a bureaucratic approach that imposed many conditionalities and documentary needs for availing of benefits., Conclusion: The apparent lack of impact on the societal mindset calls for a revision in the current approach of addressing a social issue by a purely conditional cash transfer program.

Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR ≤ 30 per 100,000 by 2030).

Background: There is an urgent need to protect children against dengue since this age group is particularly sensitive to the disease. Since dengue vectors are active mainly during the day, a potential target for control should be schools where children spend a considerable amount of their day. School uniforms are the cultural norm in most developing countries, worn throughout the day. We hypothesise that insecticide-treated school uniforms will reduce the incidence of dengue infection in school-aged children. Our objective is to determine the impact of impregnated school uniforms on dengue incidence., Methods: A randomised controlled trial will be conducted in eastern Thailand in a group of schools with approximately 2,000 students aged 7-18 years. Pre-fabricated school uniforms will be commercially treated to ensure consistent, high-quality insecticide impregnation with permethrin. A double-blind, randomised, crossover trial at the school level will cover two dengue transmission seasons., Discussion: Practical issues and plans concerning intervention implementation, evaluation, analysing and interpreting the data, and possible policy implications arising from the trial are discussed., Trial Registration: clinicaltrial.gov., Registration Number: NCT01563640.

Background: Financial barriers are a recognized major bottleneck of access and use of health services. The aim of this study was to assess effectiveness of a community based health insurance (CBHI) scheme on utilization of health services as well as on mortality and morbidity., Methods: Data were collected from April to December 2007 from the Nouna's Demographic Surveillance System on overall mortality, utilization of health services, household characteristics, distance to health facilities, membership in the Nouna CBHI. We analyzed differentials in overall mortality and selected maternal health process measures between members and non-members of the insurance scheme., Results: After adjusting for covariates there was no significant difference in overall mortality between households who could not have been members (because their area was yet to be covered by the stepped-wedged scheme), non-members but whose households could have been members (areas covered but not enrolled), and members of the insurance scheme. The risk of overall mortality increased significantly with distance to health facility (35% more outside Nouna town) and with education level (37% lower when at least primary school education achieved in households)., Conclusion: There was no statistically significant difference in overall mortality between members and non-members. The enrolment rates remain low, with selection bias. It is important that community based health insurances, exemptions fees policy and national health insurances be evaluated on prevention of deaths and severe morbidities instead of on drop-out rates, selection bias, adverse selection and catastrophic payments for health care only. Effective social protection will require national health insurance.

Background: Relating Information on causes of deaths to implementation of health interventions provides vital information for program planning and evaluation. This paper from Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India looks at temporal trends and gender differentials in the causes of death among under-five children., Methods: Data on causes of death for 1972-74, 1982-84, 1992-94, 2002-04 were taken from existing HDSS publications and database. Physicians' assigned causes of death were based on narratives by lay health worker till 1994 and later by verbal autopsy. Cause Specific Mortality Fractions (CSMF) and Cause Specific Mortality Rates (CSMR) per 1000 live births were calculated for neonatal (<1 month) and childhood (1-59 months) period. Gender difference was estimated by calculating ratio of CSMR between girls and boys. Available information on coverage of childhood interventions in the HDSS was retrieved and compiled., Results: The CSMF of prematurity and sepsis was 32% and 17.6% during neonatal period in 2002-04. The share of infections in all childhood deaths decreased from 55.2% in 1972-74 to 43.6% in 2002-04. All major causes of mortality (malnutrition, diarrhea and acute lower respiratory infection) except injuries showed a steep decline among children and seem to have plateued in last decade. Most of disease specific public health interventions were launched in mid eighties. . Girls reported significantly higher mortality rates for prematurity (RR 1.52; 95% CI 1.01-2.29); diarrhea (2.29; 1.59 - 3.29), and malnutrition (3.37; 2.05 - 5.53)., Conclusions: The findings of the study point out to the need to move away from disease-specific to a comprehensive approach and to address gender inequity in child survival through socio-behavioural approaches.

Background: Health promotion is a key component for primary prevention of cardiovascular disease (CVD). This study evaluated the impact of healthy lifestyle promotion campaigns on CVD risk factors (CVDRF) in the general population in the context of a community-based programme on hypertension management., Methods: A quasi-experimental intervention study was carried out in two rural communes of Vietnam from 2006 to 2009. In the intervention commune, a hypertensive-targeted management programme integrated with a community-targeted health promotion was initiated, while no new programme, apart from conventional healthcare services, was provided in the reference commune. Health promotion campaigns focused on smoking cessation, reducing alcohol consumption, encouraging physical activity and reducing salty diets. Repeated cross-sectional surveys in local adult population aged 25 years and over were undertaken to assess changes in blood pressure (BP) and behavioural CVDRFs (smoking, alcohol consumption, physical inactivity and salty diet) in both communes before and after the 3-year intervention., Results: Overall 4,650 adults above 25 years old were surveyed, in four randomly independent samples covering both communes at baseline and after the 3-year intervention. Although physical inactivity and obesity increased over time in the intervention commune, there was a significant reduction in systolic and diastolic BP (3.3 and 4.7 mmHg in women versus 3.0 and 4.6 mmHg in men respectively) in the general population at the intervention commune. Health promotion reduced levels of salty diets but had insignificant impact on the prevalence of daily smoking or heavy alcohol consumption., Conclusion: Community-targeted healthy lifestyle promotion can significantly improve some CVDRFs in the general population in a rural area over a relatively short time span. Limited effects on a context-bound CVDRF like smoking suggested that higher intensity of intervention, a supportive environment or a gender approach are required to maximize the effectiveness and maintain the sustainability of the health intervention.

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.

Background: Verbal autopsy (VA) is a widely used method for analyzing cause of death in absence of vital registration systems. We adapted the InterVA method to extrapolate causes of death for stillbirths and neonatal deaths from verbal autopsy questionnaires, using data from Malawi, Zimbabwe, and Nepal., Methods: We obtained 734 stillbirth and neonatal VAs from recent community studies in rural areas: 169 from Malawi, 385 from Nepal, and 180 from Zimbabwe. Initial refinement of the InterVA model was based on 100 physician-reviewed VAs from Malawi. InterVA indicators and matrix probabilities for cause of death were reviewed for clinical and epidemiological coherence by a pediatrician-researcher and an epidemiologist involved in the development of InterVA. The modified InterVA model was evaluated by comparing population-level cause-specific mortality fractions and individual agreement from two methods of interpretation (physician review and InterVA) for a further 69 VAs from Malawi, 385 from Nepal, and 180 from Zimbabwe., Results: Case-by-case agreement between InterVA and reviewing physician diagnoses for 69 cases from Malawi, 180 cases from Zimbabwe, and 385 cases from Nepal were 83% (kappa 0.76 (0.75 - 0.80)), 71% (kappa 0.41(0.32-0.51)), and 74% (kappa 0.63 (0.60-0.63)), respectively. The proportion of stillbirths identified as fresh or macerated by the different methods of VA interpretation was similar in all three settings. Comparing across countries, the modified InterVA method found that proportions of preterm births and deaths due to infection were higher in Zimbabwe (44%) than in Malawi (28%) or Nepal (20%)., Conclusion: The modified InterVA method provides plausible results for stillbirths and newborn deaths, broadly comparable to physician review but with the advantage of internal consistency. The method allows standardized cross-country comparisons and eliminates the inconsistencies of physician review in such comparisons.

Background: Costly efforts have been invested to control and prevent cardiovascular diseases (CVD) and their risk factors but the ideal solutions for low resource settings remain unclear. This paper aims at summarising our approaches to implementing a programme on hypertension management in a rural commune of Vietnam., Methods: In a rural commune, a programme has been implemented since 2006 to manage hypertensive people at the commune health station and to deliver health education on CVD risk factors to the entire community. An initial cross-sectional survey was used to screen for hypertensives who might enter the management programme. During 17 months of implementation, other people with hypertension were also followed up and treated. Data were collected from all individual medical records, including demographic factors, behavioural CVD risk factors, blood pressure levels, and number of check-ups. These data were analysed to identify factors relating to adherence to the management programme., Results: Both top-down and bottom-up approaches were applied to implement a hypertension management programme. The programme was able to run independently at the commune health station after 17 months. During the implementation phase, 497 people were followed up with an overall regular follow-up of 65.6% and a dropout of 14.3%. Severity of hypertension and effectiveness of treatment were the main factors influencing the decision of people to adhere to the management programme, while being female, having several behavioural CVD risk factors or a history of chronic disease were the predictors for deviating from the programme., Conclusion: Our model showed the feasibility, applicability and future potential of a community-based model of comprehensive hypertension care in a low resource context using both top-down and bottom-up approaches to engage all involved partners. This success also highlighted the important roles of both local authorities and a cardiac care network, led by an outstanding cardiac referral centre.

Arriving at a consensus between multiple clinical opinions concerning a particular case is a complex issue - and may give rise to manifestations of the democratic fallacy, whereby a majority opinion is misconstrued to represent some kind of "truth" and minority opinions are somehow "wrong". Procedures for handling multiple clinical opinions in epidemiological research are not well established, and care is needed to avoid logical errors. How to handle physicians' opinions on cause of death is one important domain of concern in this respect. Whether multiple opinions are a legal requirement, for example ahead of cremating a body, or used for supposedly greater rigour, for example in verbal autopsy interpretation, it is important to have a clear understanding of what unanimity or disagreement in findings might imply, and of how to aggregate case data accordingly.In many settings where multiple physicians have interpreted verbal autopsy material, an over-riding goal of arriving at a single cause of death per case has been applied. In many instances this desire to constrain findings to a single cause per case has led to methodologically awkward devices such as "TB/AIDS" as a single cause. This has also usually meant that no sense of disagreements or uncertainties at the case level is taken forward into aggregated data analyses, and in many cases an "indeterminate" cause may be recorded which actually reflects a lack of agreement rather than a lack of data on possible cause(s).In preparing verbal autopsy material for epidemiological analyses and public health interpretations, the possibility of multiple causes of death per case, and some sense of any disagreement or uncertainty encountered in interpretation at the case level, need to be captured and incorporated into overall findings, if evidence is not to be lost along the way. Similar considerations may apply in other epidemiological domains.

Background: There remains a lack of research on co-variation of multiple health outcomes and their socio-economic co-patterning, especially among the elderly. This papers aims to 1) examine the effects of different socio-economic factors on physical functioning and psychological well-being among older adults in a rural community in northern Vietnam; and 2) investigate the extent to which the two outcomes variables co-vary within individuals., Methods: We analyzed the data from the WHO/INDEPTH study on global ageing and adult health conducted on 8535 people aged 50 years old and over in Bavi district of Vietnam in 2006. A multivariate response model was constructed to answer our research questions. The model treats the individual as a level two unit and the multiple measurements observed within an individual as a level one unit., Results: Lower physical functioning and psychological well-being were found in 1) women; 2) older people; 3) people with lower education level; 4) people who were currently single; 5) respondents from poorer household; and 6) mountainous dwellers compared to that in those of other category(ies) of the same variable. Socioeconomic factors accounted for about 24% and 7% of variation in physical functioning and psychological well-being scores, respectively. The adjusted correlation coefficient (0.35) indicates that physical functioning and psychological well-being did not strongly co-vary., Conclusions: The present study shows that there exist problems of inequality in health among older adults in the study setting. This finding highlights the importance of analyzing multiple dimensions of health status simultaneously in inequality investigations.

Background: The prevention and control of high blood pressure or other cardiovascular diseases has not received due attention in many developing countries. This study aims to describe the epidemiology of high blood pressure among adults in Addis Ababa, so as to inform policy and lay the ground for surveillance interventions., Methods: Addis Ababa is the largest urban centre and national capital of Ethiopia, hosting about 25% of the urban population in the country. A probabilistic sample of adult males and females, 25-64 years of age residing in Addis Ababa city participated in structured interviews and physical measurements. We employed a population based, cross sectional survey, using the World Health Organization instrument for stepwise surveillance (STEPS) of chronic disease risk factors. Data on selected socio-demographic characteristics and lifestyle behaviours, including physical activity, as well as physical measurements such as weight, height, waist and hip circumference, and blood pressure were collected through standardized procedures. Multiple linear regression analysis was performed to estimate the coefficient of variability of blood pressure due to selected socio-demographic and behavioural characteristics, and physical measurements., Results: A total of 3713 adults participated in the study. About 20% of males and 38% of females were overweight (body-mass-index > or = 25 kg/m2), with 10.8 (9.49, 12.11)% of the females being obese (body-mass-index > or = 30 kg/m2). Similarly, 17% of the males and 31% of the females were classified as having low level of total physical activity. The age-adjusted prevalence (95% confidence interval) of high blood pressure, defined as systolic blood pressure (SBP) > or = 140 mmHg (millimetres of mercury) or diastolic blood pressure (DBP) > or = 90 mmHg or reported use of anti-hypertensive medication, was 31.5% (29.0, 33.9) among males and 28.9% (26.8, 30.9) among females., Conclusion: High blood pressure is widely prevalent in Addis Ababa and may represent a silent epidemic in this population. Overweight, obesity and physical inactivity are important determinants of high blood pressure. There is an urgent need for strategies and programmes to prevent and control high blood pressure, and promote healthy lifestyle behaviours primarily among the urban populations of Ethiopia.

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.

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 2860 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.

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.

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.

Background: Substantial reductions in maternal mortality are called for in Millennium Development Goal 5 (MDG-5), thus assuming that maternal mortality is measurable. A key difficulty is attributing causes of death for the many women who die unaided in developing countries. Verbal autopsy (VA) can elicit circumstances of death, but data need to be interpreted reliably and consistently to serve as global indicators. Recent developments in probabilistic modelling of VA interpretation are adapted and assessed here for the specific circumstances of pregnancy-related death., Methods: A preliminary version of the InterVA-M probabilistic VA interpretation model was developed and refined with adult female VA data from several sources, and then assessed against 258 additional VA interviews from Burkina Faso. Likely causes of death produced by the model were compared with causes previously determined by local physicians. Distinction was made between free-text and closed-question data in the VA interviews, to assess the added value of free-text material on the model's output., Results: Following rationalisation between the model and physician interpretations, cause-specific mortality fractions were broadly similar. Case-by-case agreement between the model and any of the reviewing physicians reached approximately 60%, rising to approximately 80% when cases with a discrepancy were reviewed by an additional physician. Cardiovascular disease and malaria showed the largest differences between the methods, and the attribution of infections related to pregnancy also varied. The model estimated 30% of deaths to be pregnancy-related, of which half were due to direct causes. Data derived from free-text made no appreciable difference., Conclusion: InterVA-M represents a potentially valuable new tool for measuring maternal mortality in an efficient, consistent and standardised way. Further development, refinement and validation are planned. It could become a routine tool in research and service settings where levels and changes in pregnancy-related deaths need to be measured, for example in assessing progress towards MDG-5.

Background: Assessing the burden of disease contributes towards evidence-based allocation of limited health resources. However, such measures are not yet commonly available in Vietnam. Taking advantage of the FilaBavi Demographic Surveillance Site (FilaBavi DSS) in Vietnam, this study aimed to establish the feasibility of applying the Years of Life Lost (YLL) technique in the context of a defined DSS, and to estimate the importance of the principal causes of premature mortality in a rural area of Vietnam between 1999 and 2003., Methods: Global Burden of Disease methods were applied. Causes of death were ascertained by verbal autopsy., Results: In five years, 1,240 deaths occurred and for 1,220 cases cause of death information from verbal autopsy was available. Life expectancy at birth was 71.0 (95% confidence interval 69.9-72.1) in males and 80.9 (79.9-81.9) in females. The discounted, but not age weighted YLL per 1,000 population was 85 and 55 for males and females, respectively. The leading causes of YLL and death counts were cardiovascular diseases, malignant neoplasms, unintentional injuries, and neonatal causes. Males contributed 54% of total deaths and 59% of YLL. Males experienced higher YLL than women across all causes. Filabavi mortality estimates are considerably lower than 2002 WHO country estimates for Vietnam. Also the FilaBavi cause distribution varies considerably from the WHO result., Conclusion: The combination of localised demographic surveillance, verbal autopsy and the application of YLL methods enable new insights into the magnitude and importance of significant public health issues in settings where evidence for planning is otherwise scarce. Local mortality data vary considerably from the WHO model-based estimates.