Reducing ignorance about who dies of what: research and innovation to strengthen CRVS systems.

The Sustainable Development Goal (SDG) agenda offers a major impetus to consolidate and accelerate development in civil registration and vital statistics (CRVS) systems. Strengthening CRVS systems is an SDG outcome in itself. Moreover, CRVS systems are the best - if not essential - source of data to monitor and guide health policy debates and to assess progress towards numerous SDG targets and indicators. They also provide the necessary documentation and proof of identity for service access and are critical for disaster preparedness and response. While there has been impressive global momentum to improve CRVS systems over the past decade, several challenges remain. This article collection provides an overview of recent innovations, progress, viewpoints and key areas in which action is still required - notably around the need for better systems and procedures to notify the fact of death and to reliably diagnose its cause, both for deaths in hospital and elsewhere.

Addressing critical knowledge and capacity gaps to sustain CRVS system development.

BACKGROUND: Improving civil registration and vital statistics (CRVS) systems requires strengthening the capacity of the CRVS workforce. The improvement of data collection and diagnostic practices must be accompanied by efforts to ensure that the workforce has the skills and knowledge to assess the quality of, and analyse, CRVS data using demographic and epidemiological techniques. While longer-term measures to improve data collection practices must continue to be implemented, it is important to build capacity in the cautious use of imperfect data. However, a lack of training programmes, guidelines and tools make capacity shortages a common issue in CRVS systems. As such, any strategy to build capacity should be underpinned by (1) a repository of knowledge and body of evidence on CRVS, and (2) targeted strategies to train the CRVS workforce. MAIN TEXT: During the 4 years of the Bloomberg Philanthropies Data for Health (D4H) Initiative at the University of Melbourne, an extensive repository of knowledge and practical tools to support CRVS system improvements was developed for use by various audiences and stakeholders (the 'CRVS Knowledge Gateway'). Complementing this has been a targeted strategy to build CRVS capacity in countries that comprised two approaches - in-country or regional training and a visiting Fellowship Program. These approaches address the need to build competence in countries to collect, analyse and effectively use good quality birth and death data, and a longer-term need to ensure that local staff in countries possess the comprehensive knowledge of CRVS strategies and practices necessary to ensure sustainable CRVS development. CONCLUSION: The Knowledge Gateway is a dynamic, useful and long-lasting repository of CRVS knowledge for countries and development partners to use to formulate and evaluate CRVS development strategies. Capacity-building through in-country or regional training and the University of Melbourne D4H Fellowship Program will ensure that CRVS capacity and knowledge is developed and maintained, facilitating improvements in CRVS data systems that can be used by policymakers to support better decision-making in health.

Better data for better outcomes: the importance of process mapping and management in CRVS systems.

BACKGROUND: Despite attempts to apply standard methods proven to work in high-income nations, nearly all civil registration and vital statistics (CRVS) systems in low- and middle-income countries are failing to achieve adequate levels of registration completeness or produce the high-quality vital statistics needed to support better health outcomes and monitor progress towards the 2030 Sustainable Development Goals. This suggests that, rather than simple technical issues, these countries are facing additional or different systemic challenges, including duplication of roles and responsibilities, inefficient methods of data collection, and a reluctance to change. APPLYING PROCESS MANAGEMENT: Process management is a valuable tool that strengthens the production of vital statistics by providing a visualisation of data flow from start to finish. It helps identify gaps and bottlenecks in the process, allowing stakeholders to work collaboratively to find solutions and target interventions. As part of the Bloomberg Philanthropies Data for Health Initiative at the University of Melbourne, 16 countries were supported in mapping the varied processes required in registering a birth or death. Comparative analysis exposed several limitations in the design of CRVS systems that hinder their performance - from 'passive' systems, to overly complex and fragmented system design, through to poor collaboration and duplication of efforts. CONCLUSIONS: The experiences from Myanmar, Papua New Guinea and Rwanda reported in this paper illustrate the benefits of process management to improve CRVS. While these three countries are at different stages of system development, each uniquely benefited. Process management is a useful tool for all CRVS systems, from the most rudimentary to the most developed. It can strengthen CRVS systems and improve the quality and completeness of vital statistics, resulting in more robust, reliable and timely vital statistics for health planning and better monitoring of the 2030 Sustainable Development Goal agenda.

Where there is no hospital: improving the notification of community deaths.

BACKGROUND: Globally, an estimated two-thirds of all deaths occur in the community, the majority of which are not attended by a physician and remain unregistered. Identifying and registering these deaths in civil registration and vital statistics (CRVS) systems, and ascertaining the cause of death, is thus a critical challenge to ensure that policy benefits from reliable evidence on mortality levels and patterns in populations. In contrast to traditional processes for registration, death notification can be faster and more efficient at informing responsible government agencies about the event and at triggering a verbal autopsy for ascertaining cause of death. Thus, innovative approaches to death notification, tailored to suit the setting, can improve the availability and quality of information on community deaths in CRVS systems. IMPROVING THE NOTIFICATION OF COMMUNITY DEATHS: Here, we present case studies in four countries (Bangladesh, Colombia, Myanmar and Papua New Guinea) that were part of the initial phases of the Bloomberg Data for Health Initiative at the University of Melbourne, each of which faces unique challenges to community death registration. The approaches taken promote improved notification of community deaths through a combination of interventions, including integration with the health sector, using various notifying agents and methods, and the application of information and communication technologies. One key factor for success has been the smoothing of processes linking notification, registration and initiation of a verbal autopsy interview. The processes implemented champion more active notification systems in relation to the passive systems commonly in place in these countries. CONCLUSIONS: The case studies demonstrate the significant potential for improving death reporting through the implementation of notification practices tailored to a country's specific circumstances, including geography, cultural factors, structure of the existing CRVS system, and available human, information and communication technology resources. Strategic deployment of some, or all, of these innovations can result in rapid improvements to death notification systems and should be trialled in other settings.

Improving medical certification of cause of death: effective strategies and approaches based on experiences from the Data for Health Initiative.

BACKGROUND: Accurate and timely cause of death (COD) data are essential for informed public health policymaking. Medical certification of COD generally provides the majority of COD data in a population and is an essential component of civil registration and vital statistics (CRVS) systems. Accurate completion of the medical certificate of cause of death (MCCOD) should be a relatively straightforward procedure for physicians, but mistakes are common. Here, we present three training strategies implemented in five countries supported by the Bloomberg Philanthropies Data for Health (D4H) Initiative at the University of Melbourne (UoM) and evaluate the impact on the quality of certification. METHODS: The three training strategies evaluated were (1) training of trainers (TOT) in the Philippines, Myanmar, and Sri Lanka; (2) direct training of physicians by the UoM D4H in Papua New Guinea (PNG); and (3) the implementation of an online and basic training strategy in Peru. The evaluation involved an assessment of MCCODs before and after training using an assessment tool developed by the University of Melbourne. RESULTS: The TOT strategy led to reductions in incorrectly completed certificates of between 28% in Sri Lanka and 40% in the Philippines. Following direct training of physicians in PNG, the reduction in incorrectly completed certificates was 30%. In Peru, the reduction in incorrect certificates was 30% after implementation and training on an online system only and 43% after training on both the online system and basic medical certification principles. CONCLUSIONS: The results of this study indicate that a variety of training strategies can produce benefits in the quality of certification, but further improvements are possible. The experiences of D4H suggest several aspects of the strategies that should be further developed to improve outcomes, particularly key stakeholder engagement from early in the intervention and local committees to oversee activities and support an improved culture in hospitals to support better diagnostic skills and practices.

Assessment of the quality of cause-of-death data in Greenland, 2006-2015.

Background: While the system of registration of mortality and cause of death (COD) in Greenland was established several decades ago, reporting procedures follow a complicated administrative process. Timely and reliable reporting on mortality and COD is of high importance for the usability of the collected data for research, health planning and decision making. Methods: COD data collected by the Chief Medical Office in Greenland from 2006 to 2015 (4490 registered deaths) were analysed with the software Analysis of National Causes of Death for Action (ANACONDA) v4.0. Unusable or insufficiently specified ICD codes are identified. The Vital Statistics Performance Index for Quality (VSPI(Q)) is estimated for the overall quality conclusions of the register's usability. Results: Sixty-eight per cent of the input data for Greenland was coded with a usable underlying COD, 24% with an unusable cause and 8% of deaths with an insufficiently specified cause. Almost 700 deaths were coded to an unusable code of 'very high impact'. The most prevalent unusable underlying causes were other ill-defined and unspecified causes, including no death certificate available, followed by senility, heart failure, sepsis and shock and cardiac arrest. The VSPI(Q) score was 66%, representing medium quality. Conclusions: In the 10 years' worth of data analysed, the true underlying COD in many cases was unknown. Several likely explanations for this include lack of systematic COD training for physicians, logistic and capacity challenges in Greenland that potentially could reduce the quality of the collected data and its usability in providing essential information about the true pattern of mortality in Greenland.

Maximizing Telerehabilitation for Patients With Visual Loss After Stroke: Interview and Focus Group Study With Stroke Survivors, Carers, and Occupational Therapists.

BACKGROUND: Visual field defects are a common consequence of stroke, and compensatory eye movement strategies have been identified as the most promising rehabilitation option. There has been a move toward compensatory telerehabilitation options, such as the Durham Reading and Exploration (DREX) training app, which significantly improves visual exploration, reading, and self-reported quality of life. OBJECTIVE: This study details an iterative process of liaising with stroke survivors, carers, and health care professionals to identify barriers and facilitators to using rehabilitation tools, as well as elements of good practice in telerehabilitation, with a focus on how the DREX package can be maximized. METHODS: Survey data from 75 stroke survivors informed 12 semistructured engagement activities (7 focus groups and 5 interviews) with 32 stroke survivors, 10 carers, and 24 occupational therapists. RESULTS: Thematic analysis identified key themes within the data. Themes identified problems associated with poststroke health care from both patients' and occupational therapists' perspectives that need to be addressed to improve uptake of this rehabilitation tool and telerehabilitation options generally. This included identifying additional materials or assistance that were required to boost the impact of training packages. The acute rehabilitation setting was an identified barrier, and perceptions of technology were considered a barrier by some but a facilitator by others. In addition, 4 key features of telerehabilitation were identified: additional materials, the importance of goal setting, repetition, and feedback. CONCLUSIONS: The data were used to try to overcome some barriers to the DREX training and are further discussed as considerations for telerehabilitation in general moving forward.

Saving lives through certifying deaths: assessing the impact of two interventions to improve cause of death data in Perú.

BACKGROUND: Mortality statistics derived from cause of death data are an important source of information for population health monitoring, priority setting and planning. In Perú, almost all death certificates are issued by doctors because it is a legal requirement. However, the quality of cause of death data is poor. In August 2016, the Ministry of Health of Perú decided to make two specific interventions to improve cause of death data: to introduce an online death certification system and to train doctors in standard death certification practices. METHODS: The study comprised a random sample of 300 pre-intervention death certificates, 900 death certificates that were part of the online intervention, and 900 death certificates that were part of both the online and training interventions. All the deaths had occurred between January and September 2017. We used the Assessing the quality of death certification tool from the University of Melbourne for the assessment. We examined the frequency of common errors in death certificates, the frequency of any error and the average error score for each category of: age group, sex, doctor's seniority, doctor's speciality, level of health facility and broad cause of death. RESULTS: The average error score declined by 38% due to the online intervention and by a further 26% due to the training intervention. Improved certification practices remained after controlling for potentially confounding factors. Main improvements were reductions in the absence of a time interval (66% of certificates), incorrect sequence of causes (22%), and ill-defined conditions (13%). CONCLUSIONS: This study demonstrates how the two interventions introduced by the Ministry of Health in Perú improved the correctness of death certificates. The study also provides evidence on necessary changes to the training program to address the poor certification practices that have remained after implementation of the online system.

Monitoring and accountability for the Pacific response to the non-communicable diseases crisis.

BACKGROUND: Non-communicable diseases (NCD) are the leading cause of premature death and disability in the Pacific. In 2011, Pacific Forum Leaders declared "a human, social and economic crisis" due to the significant and growing burden of NCDs in the region. In 2013, Pacific Health Ministers' commitment to 'whole of government' strategy prompted calls for the development of a robust, sustainable, collaborative NCD monitoring and accountability system to track, review and propose remedial action to ensure progress towards the NCD goals and targets. The purpose of this paper is to describe a regional, collaborative framework for coordination, innovation and application of NCD monitoring activities at scale, and to show how they can strengthen accountability for action on NCDs in the Pacific. A key component is the Dashboard for NCD Action which aims to strengthen mutual accountability by demonstrating national and regional progress towards agreed NCD policies and actions. DISCUSSION: The framework for the Pacific Monitoring Alliance for NCD Action (MANA) draws together core country-level components of NCD monitoring data (mortality, morbidity, risk factors, health system responses, environments, and policies) and identifies key cross-cutting issues for strengthening national and regional monitoring systems. These include: capacity building; a regional knowledge exchange hub; innovations (monitoring childhood obesity and food environments); and a robust regional accountability system. The MANA framework is governed by the Heads of Health and operationalised by a multi-agency technical Coordination Team. Alliance membership is voluntary and non-conditional, and aims to support the 22 Pacific Island countries and territories to improve the quality of NCD monitoring data across the region. In establishing a common vision for NCD monitoring, the framework combines data collected under the WHO Global Framework for NCDs with a set of action-orientated indicators captured in a NCD Dashboard for Action. Viewing NCD monitoring as a multi-component system and providing a robust, transparent mutual accountability mechanism helps align agendas, roles and responsibilities of countries and support organisations. The dashboard provides a succinct communication tool for reporting progress on implementation of agreed policies and actions and its flexible methodology can be easily expanded, or adapted for other regions.

Health information systems and disability in the Lao PDR: a qualitative study.

The Convention on the Rights of Persons with Disabilities provides an opportunity to strengthen disability-related health information. This study analysed the health information system in Lao PDR and sought evidence of interventions to improve disability-related health information. The study was based on a literature review and key informant interviews (N = 17) informed by the Health Metrics Network's Framework and Standards and the Performance of Routine Information System Management framework. The Lao health information system is in an embryonic stage with health data often incomplete, inaccurate and poorly used. Indicators related to disability or functioning are not included, and capacity to diagnose the health condition of disability is limited. No studies of health information interventions were found. As a State Party to the CRPD, the Lao PDR has a legal obligation to collect health-related information on people with disabilities. Given the nascent stage of development of the health information system in the Lao PDR and diagnostic capacity, indicators related to basic functioning and access to services should be integrated into household level surveys. As the health information system further develops, small, incremental changes in the type of disability information and rehabilitation and the way it is collected can be implemented. Copyright © 2015 John Wiley & Sons, Ltd.

Health information priorities for more effective implementation and monitoring of non-communicable disease programs in low- and middle-income countries: lessons from the Pacific.

BACKGROUND: Non-communicable diseases (NCDs) place enormous burdens on individuals and health systems. While there has been significant global progress to guide the development of national NCD monitoring programs, many countries still struggle to adequately establish critical information systems to prioritise NCD control approaches. DISCUSSION: In this paper, we use the recent experience of the Pacific as a case study to highlight four key lessons about prioritising strategies for health information system development for monitoring NCDs: first, NCD interventions must be chosen strategically, taking into account local disease burden and capacities; second, NCD monitoring efforts must align with those interventions so as to be capable of evaluating progress; third, in order to ensure efficiency and sustainability, NCD monitoring strategies must be integrated into existing health information systems; finally, countries should monitor the implementation of key policies to control food and tobacco industries. Prioritising NCD interventions to suit local needs is critical and should be accompanied by careful consideration of the most appropriate and feasible monitoring strategies to track and evaluate progress.

Endosymbiotic candidates for parasitoid defense in exotic and native New Zealand weevils.

Some insects are infected with maternally inherited bacterial endosymbionts that protect them against pathogens or parasitoids. The weevil Sitona obsoletus (=Sitona lepidus) is invasive in New Zealand, and suspected to contain such defensive symbionts, because it is particularly resistant to a Moroccan strain of the parasitoid Microctonus aethiopoides (which successfully attacks many other weevil species), and shows geographic variation in susceptibility to an Irish strain of the same parasitoid. Using 454 pyrosequencing, we investigated the bacterial community associated with S. obsoletus, two other exotic weevils (Sitona discoideus and Listronotus bonariensis) and two endemic New Zealand weevils (Irenimus aequalis and Steriphus variabilis). We found that S. obsoletus was infected by one strain of Wolbachia and two strains of Rickettsia, none of which were found in any other weevil species examined. Using diagnostic PCR, we found that S. obsoletus in the Northland region, where parasitism is highly variable, were primarily infected with Wolbachia and Rickettsia strain 2, indicating that these two symbionts should be investigated for potential defensive properties. In comparison, S. discoideus lacked any apparent maternally inherited bacterial endosymbionts. In the other weevil species, we found a different strain of Wolbachia and two different strains of Spiroplasma. Two weevil species (St. variabilis and L. bonariensis) were infected with distinct strains of Nardonella, the ancestral endosymbiont of weevils, whereas three weevil species (S. obsoletus, S. discoideus, and I. aequalis) lacked evidence for Nardonella infection. However, I. aequalis was consistently infected with a novel Enterobacteriaceae strain, suggesting that a symbiont replacement may have taken place, similar to that described for other weevil clades.

Development and validation of a quick easily used biochemical assay for evaluating the viability of small immobile arthropods.

Quickly, accurately, and easily assessing the efficacy of treatments to control sessile arthropods (e.g., scale insects) and stationary immature life stages (e.g., eggs and pupae) is problematic because it is difficult to tell whether treated organisms are alive or dead. Current approaches usually involve either maintaining organisms in the laboratory to observe them for development, gauging their response to physical stimulation, or assessing morphological characters such as turgidity and color. These can be slow, technically difficult, or subjective, and the validity of methods other than laboratory rearing has seldom been tested. Here, we describe development and validation of a quick easily used biochemical colorimetric assay for measuring the viability of arthropods that is sufficiently sensitive to test even very small organisms such as white fly eggs. The assay was adapted from a technique for staining the enzyme hexokinase to signal the presence of adenosine triphosphate in viable specimens by reducing a tetrazolium salt to formazan. Basic laboratory facilities and skills are required for production of the stain, but no specialist equipment, expertise, or facilities are needed for its use.

Coconut Rhinoceros Beetle in Samoa: Review of a Century-Old Invasion and Prospects for Control in a Changing Future.

It is now more than 100 years since the coconut rhinoceros beetle (CRB: Oryctes rhinoceros L.) was first detected in the Pacific Island state of Samoa. The exotic pest from Asia became the principal pest of coconut palms in Samoa and, from this first point of invasion, spread to several surrounding countries in the South-West Pacific Ocean. An intensive control operation was initiated, but the beetle could not be eliminated. Various pest management strategies were attempted but had limited success until the introduction of a biological control agent (BCA), Oryctes rhinoceros nudivirus (OrNV), during the late 1960s and early 1970s. The biocontrol release was very successful and became the prime example of "classical biological control" of an insect pest by a virus. Changing economic and social conditions in Samoa and other islands of the Pacific require a re-evaluation of the threat of CRB to coconut production to suggest how the IPM system may be modified to meet future needs. Therefore, it is timely to review the history of CRB in Samoa and summarize experiences in development of an integrated pest management (IPM) system limiting the impact of the pest. We also present results from a recent study conducted in 2020 on the island of Upolu to define the current status of the CRB population and its BCA, OrNV. The lessons from Samoa, with its long history of containment and management of CRB, are applicable to more recent invasion sites. Recommendations are provided to modify the IPM programme to enhance the sustainable control of CRB and support the ongoing coconut replantation program promoted by the Samoan government.

Suicide in England in the COVID-19 pandemic: Early observational data from real time surveillance.

BACKGROUND: There have been concerns that the COVID-19 pandemic may lead to an increase in suicide. The coronial system in England is not suitable for timely monitoring of suicide because of the delay of several months before inquests are held. METHODS: We used data from established systems of "real time surveillance" (RTS) of suspected suicides, in areas covering a total population of around 13 million, to test the hypothesis that the suicide rate rose after the first national lockdown began in England. FINDINGS: The number of suicides in April-October 2020, after the first lockdown began, was 121•3 per month, compared to 125•7 per month in January-March 2020 (-4%; 95% CI-19% to 13%, p = 0•59). Incidence rate ratios did not show a significant rise in individual months after lockdown began and were not raised during the 2-month lockdown period April-May 2020 (IRR: 1•01 [0•81-1•25]) or the 5-month period after the easing of lockdown, June-October 2020 (0•94 [0•81-1•09]). Comparison of the suicide rates after lockdown began in 2020 for the same months in selected areas in 2019 showed no difference. INTERPRETATION: We did not find a rise in suicide rates in England in the months after the first national lockdown began in 2020, despite evidence of greater distress. However, a number of caveats apply. These are early figures and may change. Any effect of the pandemic may vary by population group or geographical area. The use of RTS in this way is new and further development is needed before it can provide full national data. FUNDING: This study was funded by the Healthcare Quality Improvement Partnership (HQIP).The HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programs and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Program (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The program is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations, and crown dependencies.

Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales.

BACKGROUND: Recent evidence on suicide rates among psychiatric patients from minority ethnic backgrounds is scarce. We aimed to examine suicide rates among minority ethnic psychiatric patients and describe their social and clinical characteristics. METHODS: We did a retrospective observational cohort study on a national case-series of patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2007 and 2018. Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates and standardised mortality ratios (SMRs) were estimated for South Asian (Indian, Pakistani, and Bangladeshi), Black African, Black Caribbean, Chinese, and White patients. FINDINGS: A total of 698 patients in the four minority ethnic groups of South Asian, Black Caribbean, Black African, and Chinese were included (482 [69%] men; 216 [31%] women; mean age 41 years [SD 14·9, range 12-91] and compared with 13 567 White patients (9030 [66·6%] men; 4537 [33·4%] women; mean age 48 years [SD 15·8, range 10-100]). Rates and SMRs for suicide among minority ethnic patients were lower than for White patients (2·73 deaths, 95% CI 2·68-2·78) per 100 000 population. Differences were found between ethnic groups with higher suicide rates in Black Caribbean patients (1·89 deaths [95% CI 1·55-2·23] per 100 000 population) and lower rates in South Asian patients (1·49 deaths [1·33-1·64] per 100 000 population). There was an increase in rates among White patients in 2007-12 followed by a fall but no change among other ethnic groups. Schizophrenia was more common among Black African patients (54%) and Black Caribbean patients (44%), while affective disorder was more common among South Asian patients (41%). Minority ethnic patients overall showed markers of social adversity and received higher intensity care yet were viewed by clinicians as at lower risk than White patients. INTERPRETATION: Effective approaches to prevention might differ between minority ethnic groups. Clinicians and the services in which they work should be aware of the common and distinct social and clinical needs of minority ethnic patients with mental illness. FUNDING: The Healthcare Quality Improvement Partnership.