Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making
Date
2021-10-25
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Abstract
Background: Recognising that the causes of over half the world’s deaths pass unrecorded,
the World Health Organization (WHO) leads development of Verbal Autopsy (VA): a method
to understand causes of death in otherwise unregistered populations. Recently, VA has been
developed for use outside research environments, supporting countries and communities to
recognise and act on their own health priorities. We developed the Circumstances of
Mortality Categories (COMCATs) system within VA to provide complementary circumstantial
categorisations of deaths.
Objectives: Refine the COMCAT system to (a) support large-scale population assessment and
(b) inform public health decision-making.
Methods: We analysed VA data for 7,980 deaths from two South African Health and SocioDemographic Surveillance Systems (HDSS) from 2012 to 2019: the Agincourt HDSS in
Mpumalanga and the Africa Health Research Institute HDSS in KwaZulu-Natal. We assessed
the COMCAT system’s reliability (consistency over time and similar conditions), validity (the
extent to which COMCATs capture a sufficient range of key circumstances and events at and
around time of death) and relevance (for public health decision-making).
Results: Plausible results were reliably produced, with ‘emergencies’, ‘recognition, ‘accessing
care’ and ‘perceived quality’ characterising the majority of avoidable deaths. We identified
gaps and developed an additional COMCAT ‘referral’, which accounted for a significant
proportion of deaths in sub-group analysis. To support decision-making, data that establish
an impetus for action, that can be operationalised into interventions and that capture deaths
outside facilities are important.
Conclusions: COMCAT is a pragmatic, scalable approach enhancing functionality of VA
providing basic information, not available from other sources, on care seeking and utilisation
at and around time of death. Continued development with stakeholders in health systems,
civil registration, community and research environments will further strengthen the tool to
capture social and health systems drivers of avoidable deaths and promote use in practice
settings.