Elsevier

Social Science & Medicine

Volume 184, July 2017, Pages 65-74
Social Science & Medicine

Review article
New challenges for verbal autopsy: Considering the ethical and social implications of verbal autopsy methods in routine health information systems

https://doi.org/10.1016/j.socscimed.2017.05.002Get rights and content

Highlights

  • Countries require cause-of-death (COD) statistics for effective public health planning.

  • Verbal autopsy (VA) can provide COD where medical death certification is absent or weak.

  • VA methods are currently being incorporated into Civil Registration and Vital Statistics systems.

  • Presents a number of social, cultural, legal and ethical issues that should be considered when scaling-up VA.

  • Countries must carefully consider the regulatory structures necessary for VA in routine systems.

Abstract

Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation.

Section snippets

Background

The importance of population health data to global health efforts is widely recognised and has recently been highlighted by the United Nations' call for a ‘Data Revolution’ and the inclusion of a data, monitoring and accountability target in the new Sustainable Development Goals (IEAG, 2014, United Nations, 2015). Cause-of-death (COD) information is some of the most basic and most essential for estimating the burden of disease, planning health services and deciding research priorities. Ideally,

Methods

Firstly, a review of the VA literature was conducted to identify analyses, guidelines and commentaries on the ethical, legal, social, and cultural implications and considerations for quality VA practice. We examined the literature employing a narrative review approach (Mays et al., 2005), iteratively and reflexively discussing emergent findings among the research team. Several of the authors are members of the Bloomberg CRVS Data for Health Initiative and are currently working closely with

Results/discussion

A total of 839 papers published from 1988 onwards were retrieved from the literature search (Fig. 1). After the removal of duplicates and articles in languages other than English, as well as exclusion of articles that did not engage substantially with the ethical, social, cultural or legal aspects surrounding VA methodology, 61 papers remained Supporting information. A further 11 articles that did not appear in the searches or were present in the grey literature were identified, either through

Conclusion

Today, more than two thirds of deaths that occur globally are still not captured by civil registration systems (Mikkelsen et al., 2015a, Mikkelsen et al., 2015b). In these cases, VA can provide crucial data to inform national decisions about disease prioritisation and health service provision. To date, significant efforts have been employed to ensure that the analytical potential of VAs has been comprehensively explored. Current guidelines and standards for VA implementation, however, were

Acknowledgements

The authors would like to thank Professor Don de Savigny for his comments on earlier drafts of the paper. This work was supported by a National Health and Medical Research Council of Australia project grant; Improving methods to measure comparable mortality by cause (Grant no.631494). RJ is funded by a Future Leader Fellowship funded by the Australian National Heart Foundation (Grant number 100484).

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