Update of the JHU/IIP Social Autopsy Instrument | Institute for International Programs

Background

The new verbal and social autopsy (VASA) toolkit is a recent update of VASA tools developed by Johns Hopkins University’s Institute for International Programs (JHU/IIP) with support from the Bill & Melinda Gates Foundation.

At the heart of the updated toolkit are long- and short-form versions of the JHU/IIP social autopsy (SA) tool chronologically integrated with the 2016 version of the WHO verbal autopsy (VA) instrument. The chronologically-ordered VASA tool facilitates a more logical and comfortable interview process for both the data collector and respondent that enables the story of the illness events leading up to death to unfold in a natural manner. The goal of the update was to develop a set of standardized tools capable of identifying the biological causes and social determinants of death that can be used to provide timely and relevant information for decision-making for health policy and program improvement. Long- and short-form SA-alone questionnaires are also provided as separate tools that can be implemented immediately following interview with a VA questionnaire of choice. Supplementary qualitative SA tools for maternal, neonatal and child deaths were also developed as an optional component to provide additional information about issues such as quality of care, perceived cause of death and decision making.

The update process consisted of first conducting a literature review to identify existing social autopsy tools. We searched several online databases in addition to the reference list of each included article to identify any additional tools. To be included in the review, studies had to be published after 2004, be written in English, and have used a quantitative social autopsy tool to gather information about deaths occurring among any population in a low- or middle-income country. After completing the literature review, we contacted the studies’ corresponding authors to request a copy of each tool used. Items from each SA tool received were input into an item matrix that catalogued the questions asked in the tools to compare these with the questions in the latest JHU/IIP SA tool.

In February 2020, an expert working group was convened including stakeholders from a range of organizations and institutions. The purpose of the working group meeting was to 1) review the results of the literature review and corresponding social autopsy item matrix, and 2) determine which items were of critical importance in a social autopsy tool. Because the questions asked in a social autopsy interview vary based on the target population, survey items were reviewed by population group (stillbirths and neonates, children, and adults). All items were reviewed, and the working group members voted to include or exclude each item based on its level of importance.

Following the expert working group review, updated SA tools were drafted with content reflecting decisions made by the group. Inclusion of each item was determined by the number of experts who voted for the item, the threshold for which varied for the short- and long-form tools. Expert working group members met again (virtually, due to the Covid-19 pandemic) in February 2021 to review the draft tools and make any additional edits deemed necessary.

Social autopsy tools

Three separate social autopsy tools were developed for stillbirths and neonatal deaths (0-27 days), child deaths (1 month-11 years), and adult deaths (12 years and older) that may be used as the VASA integrated with the 2016 WHO VA; together with the latest (2022) WHO VA or another verbal autopsy tool; or alone. However, it is recommended that the SA tool always be used together with a VA, either integrated or immediately following a VA interview.

There are eight basic SA modules, as well as specialized modules for stillbirths and neonatal and child deaths (Table 1).

Table 1. SA tool modules population and content

SA Module	Population	Description
General information	SN, C, A*	Information on six topics including the prevalence of HIV and malaria, information about the deceased, information about the interview, information about the respondent, information about others at the interview, and the deceased’s sex and age at death.
Background	SN, C, A	Information on the general delivery context (newborn and child), stillbirth/neonatal death determination, generally signs and symptoms for stillbirths (newborn only) and general background.
Maternal history	SN	Information about the maternal history such as antenatal care, pregnancy and birth history.
Maternal symptoms & care seeking	SN	Information about maternal symptoms and careseeking during pregnancy, labor and delivery, and postpartum, decision-making for careseeking, and birth characteristics.
Care of the newborn and signs and symptoms associated with the fatal illness	SN, C, A	Information about birth complications and symptoms of illness at birth (newborn and child only), care of the newborn (newborn only), illness characteristics (all), and pregnancy history and complications for women suspected/possible pregnancy-related deaths.
Preventive care	SN, C	Information about postnatal care of the newborn (newborn only), care of the child before the fatal illness began such as the use of ITN, breastfeeding, and vaccination history (child only).
Care seeking for the fatal illness	N, C, A	Information about the care and treatments received inside and outside the home, decision-making, barriers to careseeking, and referrals.
Treatments received during the fatal illness	SN, C, A	Information about the types of treatments received during the fatal illness.
The household	SN, C, A	Information about parental demographics and background (newborn and child only), and household characteristics.
Social capital and HIV/AIDS	SN, C, A	Information about social capital in the mother’s (newborn and child) or deceased’s community, testing and diagnosis of HIV/AIDS of the deceased or deceased’s mother (newborn and child).
Open-ended response & interviewer comments	SN, C, A	Narrative of deceased’s illness and any additional information provided by respondent.

*SN=stillbirth/neonate, C=child, A=adult

In addition to the long- and short-form VASA and SA-alone questionnaires, also available on the JHU/IIP website are the supplementary qualitative SA tools and interviewer reference manuals for the long- and short-form questionnaires. Descriptions of some VA questions in the interviewer reference manuals were informed by the WHO VA training of interviewers manual.[1]

A short history of the JHU/IIP social autopsy instrument, and contributors

The JHU/IIP social autopsy instrument has its origins in the Pathway Analysis tool developed in the early 2000s by the BASICS Project and Johns Hopkins University. The tool was designed to analyze data collected according to the Pathway to Survival framework that was developed by BASICS and the U.S. Centers for Disease Control (CDC) to support implementation of the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) approach. Rene Salgado at BASICS and Henry Kalter of JHU/IIP led the development of the Pathway Analysis tool.[2]

The Pathway Analysis instrument was later expanded and integrated with the PHMRC[3] verbal autopsy tool and used to conduct multiple VASA studies[4]^{,[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16]} in countries of sub-Saharan Africa; and eventually was integrated with the 2016 WHO VA questionnaire to form the VASA instrument utilized by the COMSA Project[17] (now SIS-COVE) in Mozambique within its ongoing national Sample Registration System with VASA. The COMSA VASA instrument is available at COMSA’s JHU website.[18]

The current update of the social autopsy and its integration with the 2016 WHO VA was led by Henry Kalter. Other members of the social autopsy expert working group included: Agbessi Amouzou of JHU/IIP, Kathryn Banke of the Bill & Melinda Gates Foundation (BMGF), Robert Black of JHU/IIP, Solveig Argeseanu Cunningham of Emory University Rollins School of Public health, Samantha Dolan of BMGF, Debra Jackson of UNICEF, Alain Koffi of JHU/IIP, Cheryl Moyer of the University of Michigan, Robert Mswia of Vital Strategies, Kananura Rornald Muhumuza of Makerere University School of Public Health (representing the INDEPTH Network), Erin Nichols of CDC’s National Center for Health Statistics (representing the WHO Verbal Autopsy Working Group), Kenneth Sherr of Health Alliance International, Emily Weaver of the University of North Carolina, and Danzhen You of UNICEF. In addition to their expert working group participation, Emily Weaver conducted the social autopsy literature review and Cheryl Moyer developed the supplementary qualitative SA tools.

[1] Manual for the training of interviewers on the use of the 2022 WHO VA instrument, Geneva: World Health Organization; 2017; License: CC BY-NC-SA 3.0 IGO.

[2] https://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=10283&lid=3.

[3] Population Health Metrics Research Consortium, consisting of the Institute for Health Metrics and Evaluation, Johns Hopkins University, and Queensland University.

[4] Kalter HD, Yaroh AG, Maina A, Koffi AK, Bensaïd K, Amouzou A, Black RE. Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007-2010. J Glob Health 2016;6(1). doi: 10.7189/jogh.06.010604.

[5] Koffi AK, Maina A, Yaroh AG, Habi O, Bensaid K, Kalter HD. Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study. J Glob Health 2016;6(1). doi: 10.7189/jogh.06.010603.

[6] Kalter HD, Roubanatou A-M, Koffi A, Black RE. Direct estimates of national neonatal and child cause-specific mortality proportions in Niger by expert algorithm and physician-coded analysis of verbal autopsy interviews. J Glob Health, 2015;5(1) doi: 10.7189/jogh.05.010415.

[7] Koffi AK, Wounang RS, Nguefack F, Moluh S, Libite P-R, Kalter HD. Sociodemographic, behavioral, and environmental factors of child mortality in Eastern Region of Cameroon: results from a social autopsy study. J Glob Health, 2017;7(1) doi: 10.7189/jogh.07.010601.

[8] Koffi AK, Libite P-R, Moluh S, Wounang R, Kalter HD. Social autopsy study identifies determinants of neonatal mortality in Doume, Nguelemendouka and Abong–Mbang health districts, Eastern Region of Cameroon. J Glob Health, 2015;5(1) doi: 10.7189/jogh.05.010413.

[9] Liu L, Kalter HD, Chu Y, Kazmi N, Koffi A, Amouzou A, Joos O, Munos M, Black RE. Understanding misclassification between neonatal deaths and stillbirths: empirical evidence from Malawi. PLoS ONE 2016;11(12): e0168743.doi:10.1371/journal.pone. 0168743.

[10] Koffi AK, Mleme T, Nsona H, Banda B, Amouzou A, Kalter HD. Social autopsy of neonatal mortality suggests needed improvements in maternal and neonatal interventions in Balaka and Salima districts of Malawi. J Glob Health, 2015;5(1) doi: 10.7189/jogh.05.010416.

[11] Koffi AK, Perin J, Kalter HD, Monehin J, Adewemimo A, Black RE. How fast did newborns die in Nigeria from 2009-2013: a time-to-death analysis using Verbal/Social Autopsy data. J Glob Health, 2019;9(2) doi: 10.7189/jogh.09.020501.

[12] Adewemimo A, Kalter HD, Perin J, Koffi AK, Quinley J, Black RE (2017) Direct estimates of cause-specific mortality fractions and rates of under-five deaths in the northern and southern regions of Nigeria by verbal autopsy interview. PLoS ONE 2017; 12(5): e0178129. doi.org/10.1371/journal.pone.0178129.

[13] Koffi AK, Kalter HD, Loveth EN, Quinley J, Monehin J, Black RE (2017) Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013. PLoS ONE 2017; 12(5): e0177025. doi.org/10.1371/journal.pone.0177025.

[14] Kalter HD, Perin J, Amouzou A, Kwamdera G, Adewemimo WA, Nguefack F, Roubanatou A-M, Black RE. Using health facility deaths to estimate population causes of neonatal and child mortality in four African countries. BMC Med 2020;18, 183. doi.org/10.1186/s12916-020-01639-1.

[15] Perin, J, Koffi, AK, Kalter, HD et al. Using propensity scores to estimate the effectiveness of maternal and newborn interventions to reduce neonatal mortality in Nigeria. BMC Pregnancy Childbirth 20, 534 (2020). https://doi.org/10.1186/s12884-020-03220-3.

[16] Koffi AK*, Kalter HD*, Kamwe MA, Black RE. Verbal/social autopsy analysis of causes and determinants of under-5 mortality in Tanzania from 2010 to 2016. J Glob Health, 2020;10(2) doi: 10.7189/jogh.10.020901. *equal first authorship.

[17] Macicame I, Kante A, Wilson E, Gilbert B, Koffi A, Nhachungue S, Monjane C, Pedro D, Antonio A, Chicumbe S, Jani1 I, Kalter HD, Datta A, Zeger SL, Black RE, Gudo E, Amouzou A and the COMSA-Mozambique study team. Countrywide Mortality Surveillance for Action (COMSA) in Mozambique: Results from a national sample-based vital statistics system for mortality and cause of death. Amer J Trop Med Hyg. 2023; DOI: 10.4269/ajtmh.22-0367.

[18] https://www.jhsph.edu/research/centers-and-institutes/institute-for-international-programs/current-projects/countrywide-mortality-surveillance-for-action-comsa-in-mozambique.