Correction: Mabunda et al. Development, Objectives and Operation of Return-of-Service Bursary Schemes as an Investment to Build Health Workforce Capacity in South Africa: A Multi-Methods Study. Healthcare 2023, 11, 2821.

In the original publication [...].

Risk factors for incident cardiovascular events and their population attributable fractions in rural India: The Rishi Valley Prospective Cohort Study.

OBJECTIVE: We prospectively determined incident cardiovascular events and their association with risk factors in rural India. METHODS: We followed up with 7935 adults from the Rishi Valley Prospective Cohort Study to identify incident cardiovascular events. Using Cox proportional hazards regression, we estimated hazard ratios (HRs) with 95% confidence intervals (95% CI) for associations between potential risk factors and cardiovascular events. Population attributable fractions (PAFs) for risk factors were estimated using R ('averisk' package). RESULTS: Of the 4809 participants without prior cardiovascular disease, 57.7% were women and baseline mean age was 45.3 years. At follow-up (median of 4.9 years, 23,180 person-years [PYs]), 202 participants developed cardiovascular events, equating to an incidence of 8.7 cardiovascular events/1000 PYs. Incidence was greater in those with hypertension (hazard ratio [HR] [95% CI] 1.73 [1.21-2.49], adjusted PAF 18%), diabetes (1.96 [1.15-3.36], 4%) or central obesity (1.77 [1.23, 2.54], 9%) which together accounted for 31% of the PAF. Non-traditional risk factors such as night sleeping hours and number of children accounted for 16% of the PAF. CONCLUSIONS: Both traditional and non-traditional cardiovascular risk factors are important contributors to incident cardiovascular events in rural India. Interventions targeted to these factors could assist in reducing the incidence of cardiovascular events.

CKD is the Major Cause of Death in Uddanam: A Population-Representative Study Using Smart Verbal Autopsy.

Introduction: Uddanam is an agricultural area with a high burden of chronic kidney disease of unknown etiology (CKDu). Despite reports of many deaths due to CKD in the lay press, the exact contribution of CKD to deaths remains uncertain because most deaths occur outside medical care. Methods: We used SmartVA automated verbal autopsy tool to ascertain the cause-specific mortality fractions among a 2419 subject-strong general population cohort of adult subjects in Uddanam between 2018 and 2022. Verbal autopsy interviews were conducted twice with the family members of the deceased. Results: A total of 133 deaths were recorded, giving a crude death rate of 5.5%, 10 times higher than that recorded in national surveys. CKD was responsible for 45% of all deaths, followed by ischemic heart disease (15%) and respiratory disease (6%). Conclusion: This study confirms CKD as the leading cause of mortality in this high CKD burden area and provides crucial data for public health decision-making and resource allocation.

Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019.

PURPOSE: Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality. METHOD: Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index. RESULTS: One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings. DISCUSSION: Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Comparison of the performance of cardiovascular risk prediction tools in rural India: the Rishi Valley Prospective Cohort Study.

AIMS: We compared the performance of cardiovascular risk prediction tools in rural India. METHODS AND RESULTS: We applied the World Health Organization Risk Score (WHO-RS) tools, Australian Risk Score (ARS), and Global risk (Globorisk) prediction tools to participants aged 40-74 years, without prior cardiovascular disease, in the Rishi Valley Prospective Cohort Study, Andhra Pradesh, India. Cardiovascular events during the 5-year follow-up period were identified by verbal autopsy (fatal events) or self-report (non-fatal events). The predictive performance of each tool was assessed by discrimination and calibration. Sensitivity and specificity of each tool for identifying high-risk individuals were assessed using a risk score cut-off of 10% alone or this 10% cut-off plus clinical risk criteria of diabetes in those aged >60 years, high blood pressure, or high cholesterol. Among 2333 participants (10 731 person-years of follow-up), 102 participants developed a cardiovascular event. The 5-year observed risk was 4.4% (95% confidence interval: 3.6-5.3). The WHO-RS tools underestimated cardiovascular risk but the ARS overestimated risk, particularly in men. Both the laboratory-based (C-statistic: 0.68 and χ2: 26.5, P = 0.003) and non-laboratory-based (C-statistic: 0.69 and χ2: 20.29, P = 0.003) Globorisk tools showed relatively good discrimination and agreement. Addition of clinical criteria to a 10% risk score cut-off improved the diagnostic accuracy of all tools. CONCLUSION: Cardiovascular risk prediction tools performed disparately in a setting of disadvantage in rural India, with the Globorisk performing best. Addition of clinical criteria to a 10% risk score cut-off aids assessment of risk of a cardiovascular event in rural India. LAY SUMMARY: In a cohort of people without prior cardiovascular disease, tools used to predict the risk of cardiovascular events varied widely in their ability to accurately predict who would develop a cardiovascular event.The Globorisk, and to a lesser extent the ARS, tools could be appropriate for this setting in rural India.Adding clinical criteria, such as sustained high blood pressure, to a cut-off of 10% risk of a cardiovascular event within 5 years could improve identification of individuals who should be monitored closely and provided with appropriate preventive medications.

Development, Objectives and Operation of Return-of-Service Bursary Schemes as an Investment to Build Health Workforce Capacity in South Africa: A Multi-Methods Study.

BACKGROUND: South Africa uses government-funded return-of-service (RoS) schemes to train, recruit and retain skilled health professionals in underserved areas. These educate health professionals locally or internationally in return for a commitment to serve in a specified area for an agreed period. While such schemes are used widely and are funded by substantial public funds, their exact makeup differs across jurisdictions, and little is known about why these differences have emerged or how they influence their effectiveness or impact on the health system. We aimed to fill these gaps through an analysis of the origins, architecture, and evolution of RoS schemes in South Africa. METHODS: A multimethod research study including a policy review, a literature review, and semi-structured interviews of policymakers was undertaken between October 2020 and August 2022. The included policy documents and literature were analysed using the Walt and Gilson framework and narrative synthesis. Qualitative data were analysed using inductive, thematic analysis in NVIVO 12. RESULTS: RoS schemes are used as a recruitment and retention strategy and a mechanism to address equity in access to medical education. Whilst there is evidence of RoS schemes existing in 1950, no evidence of beneficiaries was found in databases until 1989. The impact of these schemes is likely being limited by sub-optimal institutional arrangements and poor transparency in their design and implementation. CONCLUSION: Despite rigorous research methods, the origins of RoS policies in South Africa could not be established due to poor preservation of institutional memory. Opportunities to monitor the value of public investment into RoS programs are being missed and often the underlying objective of the programs has not been well-specified. Policies were found to have been developed and operate in isolation from other health workforce planning activities and thus may not be maximising their impact as a retention and training tool.

Prioritising and planning scale-up research projects targeting non-communicable diseases: a mixed-method study by the Global Alliance for Chronic Diseases upscaling working group.

INTRODUCTION: Governments must scale-up evidence-based interventions to reduce the burden of non-communicable diseases (NCDs). Implementation research can help develop contextually appropriate strategies and optimise interventions for scale-up. We aimed to determine the priorities of the Global Alliance for Chronic Diseases (GACD) 2019 funding round for scale-up research targeting NCD interventions. The research questions were: (a) What was the purpose of the call and what were the specific issues considered by funders when supporting the selected projects? (b) How did the selected research projects align with the objectives of GACD scale-up call? METHODS: We undertook a mixed-methods study to examine the projects funded by the GACD in 2019. We completed semistructured interviews with representatives from 5 out of 8 funding agencies and complemented this by reviewing project documents from 21 (78%) of the 27 funded studies. A literature review of scale-up frameworks informed the interview guide and data extraction template. The transcripts were open-coded using thematic analysis to identify critical issues for funders. Data were extracted to identify the common elements considered when planning, implementing and evaluating interventions for scale-up. RESULTS: Interviews with the funders revealed three enabling themes related to scale-up: local research priorities (contextualisation through engagement), capacity building (developing knowledge base) and connections (networking opportunities). We further identified that timelines (more flexibility) and equity (funding low-income and middle-income researchers) could be considered for future funding investments. Multidisciplinary international research teams led the development of diverse studies to address funder's priorities. The detailed plans included a range of implementation frameworks to help develop contextual scale-up strategies. CONCLUSIONS: Fundamental to NCD scale-up research are (1) funding opportunities that reflect the complexity and time necessary to enable contextualisation; (2) investment in building multidisciplinary research capacity and leadership and (3) better networking to encourage cohesive action and align NCD-related scale-up research activities globally.

Testing the effectiveness and acceptability of online supportive supervision for mental health practitioners in humanitarian settings: a study protocol for the caring for carers project.

BACKGROUND: Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project. METHOD: A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress (Professional Quality of Life Scale), perceived injustice, clinical self-efficacy (Counseling Activity Self-Efficacy Scale), service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention. DISCUSSION: There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.

Effectiveness of return-of-service schemes for human resources for health retention: a retrospective cohort study of four Southern African countries.

BACKGROUND: Governments use return-of-service (RoS) schemes to train, employ and retain health professionals in the public sector. We determined the effectiveness of RoS schemes in four Southern African countries. METHODS: This retrospective cohort study used databases of RoS beneficiaries from South Africa, Botswana, Eswatini and Lesotho. We ascertained the period of funding for beneficiaries between 2000 and 2010, study programme, selection criteria, study country and if they completed their studies. Records were sought to track beneficiaries' service and fulfilment of their RoS obligations. Data were sought at the provincial level in South Africa and nationally for the other three countries. Binomial logistics regression and Kaplan-Meier survival estimates were used to determine risk factors and predictors of defaulting. RESULTS: Most beneficiary enrolment (eg, decision on why they were funded, socioeconomic status, disability status, high school results) and service data (eg, health facilities where they worked, how long they worked at each health facility, movement between health facilities) were not available. A total of 5616 beneficiaries were drawn from the four countries' databases. Of those with full data available, 21.7% (229/1056) were retained/served beyond their obligatory period and 20.2% (213/1056) were still serving. A total of 24.3% (95% CI: 21.7% to 26.9%; n=257/1056) of beneficiaries in the final subanalysis of two South African provinces fulfilled their contractual obligations. Only 32.2% (277/861) of beneficiaries undertook internship within their funding provinces. Governments needed to fund six beneficiaries to have one beneficiary complete their contractual obligation if they undertook internship outside their province. CONCLUSION: Record keeping in all countries was poor, hampering the effectiveness of RoS schemes. Of the units with full data available, the retention rate was below 25%, and internship being undertaken outside the funding province was associated with higher defaulter rates, calling for a policy overhaul.

Promoting equitable health workforce distribution through improved migration governance: A mixed methods study of African health professionals' perceptions in Australia.

BACKGROUND: This study examined skilled health worker (SHW) migration governance in African countries and Australia, with an emphasis on areas of influence for achieving an equitable global health workforce distribution. METHODS: We used a mixed-methods research design with African SHW migrants in Australia. An institutional and rights-based framing of governance guided thematic analysis of the interviews, which was mapped to survey findings from a Bayesian Exploratory Factor Analysis. RESULTS: The findings imply that Australian state actors enforce laws that attract SHW migrants and promote safe clinical practice, but do not adequately address their integration concerns or role in health system strengthening. Non-state actors in Australia make donations to African health institutions but rarely promote health workforce equity. African state actors respond to increased SHW migration trends by increasing health worker training and limiting migration, but they lack a comprehensive governance framework for involving citizens and engaging foreign governments. There is limited evidence of a shared community definition of SHW migration governance in many African countries. CONCLUSION: When stakeholders in both sending and receiving countries recognise the indivisibility of the rights at stake (for example, SHW rights as migrants and the right to health), support for an equity-focused SHW migration governance system may increase. Promoting these rights can result in policies that enhance health system strengthening in destination and source countries. Similarly, growing adoption of these rights in sending countries should help inspire a coordinated plan for strengthening health system and SHW migration governance.

How Were Return-of-Service Schemes Developed and Implemented in Botswana, Eswatini and Lesotho?

Botswana, Eswatini and Lesotho are three Southern African countries that make use of return-of-service (RoS) schemes to increase human resources for health in their countries. These initiatives bind beneficiaries to a pre-defined period of service upon the completion of their studies based on the length of funding support received. We aimed to review the history of these policies to understand the conceptualisation, intent and implementation of these schemes. We used a multi-methods research design which consisted of a literature review, a policy review and semi-structured interviews with policymakers and implementors. All three governments have a combination of grant-loan schemes and full bursaries or scholarships. The policies have all been operating for over 20 years, with Eswatini's pre-service policy being the oldest since it was introduced in 1977, followed by Lesotho's 1978 policy and Botswana's 1995 pre-service policy. These policies have never been reviewed or updated. RoS schemes in these countries were introduced to address critical skills shortages, to improve employability prospects for citizens, to have competent public sector employees by global standards and to aid the career progress of government employees. Ministries of Health are passive role players. However, these schemes can only be efficient if there is clear cooperation and coordination between all stakeholders.

Combining general and central measures of adiposity to identify risk of hypertension: a cross-sectional survey in rural India.

AIM: In three socioeconomically diverse regions of rural India, we determined the optimal cut-offs for definition of overweight, the prevalence of overweight, and the relationships between measures of overweight and risk of hypertension. SUBJECTS AND METHODS: Villages were randomly sampled within rural Trivandrum, West Godavari, and Rishi Valley. Sampling of individuals was stratified by age group and sex. Cut-offs for measures of adiposity were compared using area under the receiver operating characteristic curve. Associations between hypertension and definitions of overweight were assessed by logistic regression. RESULTS: Of 11 657 participants (50 % male; median age 45 years), 29.8 % had hypertension. Large proportions were overweight as defined by body mass index (BMI) ≥ 23 kg/m2 (47.7 %), waist circumference (WC) ≥ 90 cm for men or ≥ 80 cm for women (39.6 %), waist-hip ratio (WHR) ≥ 0.9 for men or ≥ 0.8 for women (65.6 %), waist-height ratio (WHtR) ≥ 0.5 (62.5 %), or by BMI plus either WHR, WC or WHtR (45.0 %). All definitions of overweight were associated with hypertension, with optimal cut-offs being at, or close to, the World Health Organization (WHO) Asia-Pacific standards. Having overweight according to both BMI and a measure of central adiposity was associated with approximately twice the risk of hypertension than overweight defined by only one measure. CONCLUSIONS: Overweight, as assessed by both general and central measures, is prevalent in rural southern India. WHO standard cut-offs are appropriate in this setting for assessing risk of hypertension. However, combining BMI with a measure of central adiposity identifies risk of hypertension better than any single measure. The risk of hypertension is significantly greater in those centrally and generally overweight than those overweight by a single measure.

Scope of health worker migration governance and its impact on emigration intentions among skilled health workers in Nigeria.

The growing trends for skilled health worker (SHW) migration in Nigeria has led to increased concerns about achieving universal health coverage in the country. While a lot is known about drivers of SHW migration, including national/sub-national government's inability to address them, not enough is known about its governance. Underpinning good governance systems is a commitment to human rights norms, that is, principles that enshrine non-discrimination, participation, accountability, and transparency. Hence, this study was aimed at deriving a conceptual framework that captures the scope of SHW migration governance in Nigeria and the extent to which it is human rights based. To describe the scope of SHW migration governance, we conducted an exploratory factor analysis and mapped our findings to themes derived from a qualitative analysis. We also did a multivariate analysis, examining how governance items are related to migration intentions of SHWs. The scope of SHW migration governance in Nigeria can be described across three levels: Constitutional-where policies about the economy and the health workforce are made and often poorly implemented; Collective-which responds to the governance vacuum at the constitutional level by promoting SHW migration or trying to mitigate its impact; Operational-individual SHWs who navigate the tension between the right to health, their right to fair remuneration, living/working conditions, and free movement. Examining these levels revealed opportunities for collaboration through stronger commitment to human right norms. In recognising their role as rights holders and duty bearers at various levels, citizens, health advocates, health workers, community groups and policy makers can work collaboratively towards addressing factors related to SHW migration. Further evidence is needed on how human rights norms can play a visible role in Nigeria's governance system for SHW migration.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria.

Introduction: Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial. Methods: We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders. Results: Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community. Discussion: While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.

Morbidity and utilisation of healthcare services among people with cardiometabolic disease in three diverse regions of rural India.

OBJECTIVES: To assess the prevalence and determinants of cardiometabolic disease (CMD), and the factors associated with healthcare utilisation, among people with CMD. METHODS: Using a cross-sectional design, 11,657 participants were recruited from randomly selected villages in 3 regions located in Kerala and Andhra Pradesh from 2014 to 2016. Multivariable logistic regression was used to identify factors independently associated with CMD and healthcare utilisation (public or private). RESULTS: Thirty-four per cent (n = 3629) of participants reported having ≥1 CMD, including hypertension (21.6%), diabetes (11.6%), heart disease (5.0%) or chronic kidney disease (CKD) (1.6%). The prevalence of CMD was progressively greater in regions of greater socio-economic position (SEP), ranging from 19.1% to 40.9%. Among those with CMD 41% had sought any medical advice in the last month, with only 19% utilising public health facilities. Among people with CMD, those with health insurance utilised more healthcare (age-gender adjusted odds ratio (AOR) (95% confidence interval (CI)): 1.31 (1.13, 1.51)) as did those who reported accessing private rather than public health services (1.43 (1.23, 1.66)). DISCUSSION: The prevalence of CMD is high in these regions of rural India and is positively associated with indices of SEP. The utilisation of outpatient health services, particularly public services, among those with CMD is low.

Does Collaboration between General Practitioners and Pharmacists Improve Risk Factors for Cardiovascular Disease and Diabetes? A Systematic Review and Meta-Analysis.

Objective: To assess whether inter-professional, bidirectional collaboration between general practitioners (GPs) and pharmacists has an impact on improving cardiovascular risk outcomes among patients in the primary care setting. It also aimed to understand the different types of collaborative care models used. Study design: Systematic review and Hartung-Knapp-Sidik-Jonkman random effects meta-analyses of randomised control trials (RCTs) in inter-professional bidirectional collaboration between GP and pharmacists assessing a change of patient cardiovascular risk in the primary care setting. Data sources: MEDLINE, EMBASE, Cochrane, CINAHL and International Pharmaceutical Abstracts, scanned reference lists of relevant studies, hand searched key journals and key papers until August 2021. Data synthesis: Twenty-eight RCTs were identified. Collaboration was associated with significant reductions in systolic and diastolic blood pressure (23 studies, 5,620 participants) of -6.42 mmHg (95% confidence interval (95%CI) -7.99 to -4.84) and -2.33 mmHg (95%CI -3.76 to -0.91), respectively. Changes in other cardiovascular risk factors included total cholesterol (6 studies, 1,917 participants) -0.26 mmol/L (95%CI -0.49 to -0.03); low-density lipoprotein (8 studies, 1,817 participants) -0.16 mmol/L (95%CI -0.63 to 0.32); high-density lipoprotein (7 studies, 1,525 participants) 0.02 mmol/L (95%CI -0.02 to 0.07). Reduction in haemoglobin A1c (HbA1C) (10 studies, 2,025 participants), body mass index (8 studies, 1,708 participants) and smoking cessation (1 study, 132 participants) was observed with GP-pharmacist collaboration. Meta-analysis was not conducted for these changes. Various models of collaborative care included verbal communication (via phone calls or face to face), and written communication (emails, letters). We found that co-location was associated with positive changes in cardiovascular risk factors. Conclusion: Although it is clear that collaborative care is ideal compared to usual care, greater details in the description of the collaborative model of care in studies is required for a core comprehensive evaluation of the different models of collaboration.

Social networks and skilled health worker migration in Nigeria: An ego network analysis.

BACKGROUND: Nigeria provides a good case study for researchers, activists, and governments seeking to understand how social networks can help mitigate the negative impact of skilled health worker (SHW) migration in low and middle-income countries. This study aimed to map the social networks of SHWs and explore how they influence migration intentions. METHODS: We combined semi-structured qualitative interviews with an ego-network analysis of 22 SHWs living in Nigeria, used R-Studio to display and visualise their networks, and NVivo for thematic analysis of transcribed interviews. RESULTS: The network size and frequency of interaction were smaller among SHWs seeking to remain in Nigeria, however when compared to SHWs seeking to migrate, they had ties with a diverse group of stakeholders interested in improving health services. The influence of social networks on SHW migration intentions was observed within the following themes: access to information on migration opportunities, modelling of migration behaviour, support for decision making, and opportunities for policy engagement. CONCLUSION: The social networks of SHWs can aid the diffusion of norms that are relevant for improving SHW migration governance. Through their social networks, SHWs can improve awareness of the challenges associated with SHW migration among state actors and the public.

Validation studies of verbal autopsy methods: a systematic review.

BACKGROUND: Verbal autopsy (VA) has emerged as an increasingly popular technique to assign cause of death in parts of the world where the majority of deaths occur without proper medical certification. The purpose of this study was to examine the key characteristics of studies that have attempted to validate VA cause of death against an established cause of death. METHODS: A systematic review was conducted by searching the MEDLINE, EMBASE, Cochrane-library, and Scopus electronic databases. Included studies contained 1) a VA component, 2) a validation component, and 3) original analysis or re-analysis. Characteristics of VA studies were extracted. A total of 527 studies were assessed, and 481 studies screened to give 66 studies selected for data extraction. RESULTS: Sixty-six studies were included from multiple countries. Ten studies used an existing database. Sixteen studies used the World Health Organization VA questionnaire and 5 studies used the Population Health Metrics Research Consortium VA questionnaire. Physician certification was used in 36 studies and computer coded methods were used in 14 studies. Thirty-seven studies used high level comparator data with detailed laboratory investigations. CONCLUSION: Most studies found VA to be an effective cause of death assignment method and compared VA cause of death to a high-quality established cause of death. Nonetheless, there were inconsistencies in the methodologies of the validation studies, and many used poor quality comparison cause of death data. Future VA validation studies should adhere to consistent methodological criteria so that policymakers can easily interpret the findings to select the most appropriate VA method. PROSPERO REGISTRATION: CRD42020186886.