Cause of deaths reflects the burden of diseases in the community and is important information for evidence-based health policy. Objectives of the study were to determine mortality rates and cause of death pattern in Thai Nguyen and Quang Ninh.
JOURNAL OF MEDICAL RESEARCH MORTALITY RATE AND CAUSE OF DEATH PATTERN IN THAI NGUYEN AND QUANG NINH PROVINCES Pham Ngan Giang, Nguyen Phuong Hoa, Thanh Ngoc Tien, Nguyen Thi Tuyet Nhung Department of Family Medicine, Hanoi Medical University Cause of deaths reflects the burden of diseases in the community and is important information for evidence-based health policy Objectives of the study were to determine mortality rates and cause of death pattern in Thai Nguyen and Quang Ninh A cross - sectional study was conducted One thousand four hundred and seventy seven deaths were recorded at 26 communes in 2014 The survey was used WHO standard verbal autopsy questionnaire The results showed that overall mortality rate was 4.94‰, mortality rate among males was higher than among females (6.09‰ versus 4.91‰, p < 0.05), urban population had lower rate of death than the rural population (4.73‰ versus 5.56‰, p < 0,05) The results showed that most of the deaths occurred at home (88%), only 4.8% of deaths in health facilities There was a transition in the cause of death pattern while the leading causes were cardiovascular diseases, cancer and injury In particular, death from stroke was 20.6%, lung cancer 8.3% and traffic accident 3.7% In conclusion, it is necessary to collect information about the deaths, which are outside health facilities (at home) and an intervention programs need to prioritize for some of the leading causes of death Keywords: mortality rate, cause of death, burden of diseases I INTRODUCTION Mortality statistics and causes of death (COD) information are important to measure population health status, identify key public health issues, set priorities, and improve health outcomes through effective resource allocation [1 - 3] However, an estimated 2/3 of all deaths were not reported globally Millions of people in Africa and Asia die without leaving any trace in legal records or official Corresponding author: Nguyen Phuong Hoa, Department of Family Medicine,, Hanoi Medical University Email: nguyenphuonghoa@hmu.edu.vn Received: 05 June 2017 Accepted: 16 November 2017 JMR 111 E2 (2) - 2018 statistics [4] Mortality data on causes of death for Vietnam have not been reported to the World Health Organization (WHO) to date [5; 6] With a population of over 91 million [6], there is a critical need for such data for the above stated purposes At the national level, due to limitations in the availability of data, cause of death patterns in Vietnam has been estimated based on mortality data from Chinese, Thai and Indian populations [7] The absence of complete and valid national mortality data limits the evidence base to estimate the burden of disease in 85 JOURNAL OF MEDICAL RESEARCH Vietnam At the national level, three organizations within the Government of Vietnam collect national mortality data: the Ministry of Health (MOH), the Ministry of Justice (MOJ), and the General Statistics Office (GSO) GSO data provide important indicators such as life expectancy and crude death rates [8] However, this source does not collect detailed information about COD, which is urgently required by the health sector for developing health interventions, priority setting, and policy formulation The MOJ has legal responsibility over the national civil registration and vital statistics system For deaths, this system only collects information about the numbers of deaths by sex and age However, the registration of deaths recorded in this system is low for different areas Also, the MOJ system does not have any procedures for formal reporting of the causes of death (COD) In order to meet the information needs of the health sector, the MOH operates a routine death register system at commune health stations (CHS) Local commune health staffs identify deaths in the community and record basic demographic data and information on the cause of death for each death in an official MOH log-book named the “A6 register” Frankly, data from the A6 registers are not used effectively at different levels in the health sector because there is no consistent process for compiling data from A6 registers at district, province, and national levels; therefore the MOH mortality database now in the Statistical Handbook of Vietnam MoH was based on mortality data from hospitals only However, currently in Vietnam, the majority of deaths occur at 86 home Therefore, by using verbal autopsy (VA), this study was conducted to determine mortality rates and cause of death pattern in Thai Nguyen and Quang Ninh in 2014 II SUBJECTS AND METHODS Study sites and sample The study was implemented in two provinces, Quang Ninh and Thai Nguyen, which are located in the Northern region of Vietnam In each province, one urban district and one rural district were chosen to assess likely differences between those two areas Within each selected district, 6-7 communes were chosen as study sites by simple random method The study sample comprised all deaths that occurred between 01/01/2014 and 31/12/2014 among residents of the 26 selected communes There were 1477 deaths in total, which were listed by combining the A6 registers, the Justice Clerks’ books and some other resources All deaths in each selected commune were re-investigated to ascertain the causes of death, using Verbal Autopsy (VA) surveys There were 1365 Verbal Autopsy (VA) interviews conducted The other 112 cases could not undertake VA mainly due to the movement of population Methods This assessment was based on a cross-sectional study design Data collection - Making the combined death list All deaths recorded in A6 registers, the Justice Clerk books and some other sources during the defined one-year period beJMR 111 E2 (2) - 2018 JOURNAL OF MEDICAL RESEARCH tween 01 January 2014 and 31 December 2014 were extracted onto a separate form Information collected included reported name, age and sex, date of death, address of the deceased Then, a process of matching death cases from these sources was carried out by commune health staffs, who were responsible for mortality recording Variables used for the matching process were name, sex, age, date of death, and address of the deceased - Implementing Verbal Autopsy surveys All deaths identified in the above combined list were followed up to conduct the household verbal autopsy (VA) interview using a standardized questionnaire that elicits information on signs, symptoms, medical history, and circumstances preceding death The VA questionnaire used for this assessment is the updated version of the Vietnamese verbal autopsy questionnaire, accompanied by a manual and guide for fieldworkers The original English version of the VA questionnaires, which was recommended by WHO, were translated into Vietnamese and revised Interviewers were local health workers from commune health stations who have medical related backgrounds (e.g., medical assistants, nurses) working at the commune or village level where the deaths occurred, and who have the responsibility for collecting data and recording it in the A6 registers at commune health stations The training of interviewers emphasized techniques and communication skills to motivate the principal caretaker of the deceased to participate in the survey and encourage them to give accurate and honest answers JMR 111 E2 (2) - 2018 The interviewees were persons who were mainly responsible for taking care of the decedent before he/she died, and who were able to provide information about the symptoms and diseases experienced by the deceased prior to death The supervisors were the principal investigators and staff in the Provincial/ District Health Centre Supervisors provided assistance and monitored the interviewers’ activities to ensure the quality of the VA interviews On completion of all VA interviews were diagnosed and coded of the Underlying cause of death (UCOD), by trained doctors The UCOD then was coded using International Classification of Diseases version 10 (ICD-10) by application of the mortality coding rules and guidelines[9] Data analysis and management Epidata software and SPSS18 were employed to analyse data The proportions were calculated by communes, district, provincial levels, urban/ rural areas, sex, broad age groups (0 - years, - 14 years, 15 - 59 years, and 60+), place of death, type of health facility, and the last treatment method Each proportion was computed for 95% confidence intervals [10] Ethics Respondents of this study were clearly explained all information regarding the objectives of this assessment, the detail of collecting information Respondents have had complete autonomy in regard to participation, as well as freedom to withdraw at any stage during the interview Access to completed questionnaires and data were 87 JOURNAL OF MEDICAL RESEARCH restricted to authorized personnel to ensure the confidentiality of each respondent The collected data was only used for the purpose of research ber of deaths VA interview could not be carried out in 112 cases (7.4% of total deaths) Table describes the death amount and the crude death rate in general according to gender and location identified during the study The mortality rate of general population was calculated 4.94 per 1000 In comparison to female group, the death proportion in male was higher with statistically significance (p < 0.001) In regards to location, the urban population had the lower mortality rate than the rural population (p < 0.001) III RESULTS A total of 1477 deaths were recorded in the reference year, which comprised 746 cases in Quang Ninh province and 731 cases in Thai Nguyen province Out of these 1477 deaths, the COD were re-investigated in 1365 cases using VA household interviews, equivalent to 92.6% of the total num- Table Crude death rate by sex and area in 2014 Characteristic General population Total Number of deaths Rate (‰) 299,237 1477 4.94 Male 152,357 928 6.09 Female 146,880 549 4.91 Urban 226,325 1071 4.73 Rural 72,912 406 5.56 p value Sex < 0.001 Area Table describes the distribution of deaths by age group and some factors relating to death, all the statistics were ascertained by VA In regard to age, over two thirds of the deaths were among the elderly The proportions of deaths recorded in two groups under the age of years and - 14 years old are very low (1.8% and 1.2% respectively) As can be seen, more than 70% of people attended a health facility for the 88 < 0.001 last treatment prior to death Most of them had visited central/ provincial hospitals (80%) and in about 29% of cases, a visit to a district hospital was reported Only 4.7% went to a commune health station, 2.1% saw healers and very few people visited private doctors As shown in table 2, although only 6% of VA respondents kept the last treatment documents provided by hospitals, which would be useful for reporting for JMR 111 E2 (2) - 2018 JOURNAL OF MEDICAL RESEARCH the mortality register at CHS This aspect will be given attention in the recommendations to strengthen the COD reporting system Table Distribution of deaths by age and information before death Characteristic Number of deaths Percent (%) Age group (n = 1365)* 0-4 24 1.8 - 14 17 1.2 15 - 59 455 33.3 60+ 869 63.7 Treatment at health facility in the last sickness leading to the death? (n = 1365) Yes 959 70.3 No 354 26.0 Unsure/Don’t know 35 2.6 Central/Provincial Hospitals 770 80.3 District hospitals 276 28.8 Commune Health Station 45 4.7 Healers (traditional medicine) 20 2.1 Private Doctor 0.6 Others 0.4 Recall information about the diagnosis after discharge from hospital (n = 959) 885 92.3 Kept the documents from hospital about the last treatment (n = 959) 55 5.7 Type of health facility in the last treatment (n = 959) *1365 cases were interviewed by VA questionnaire Figure illustrates the places of deaths Approximately 88.1% of the people died at home and only 5.0% died at a health facility (includes hospitals, commune health station, clinic, etc.) However, as mentioned above, a large number of the decedents who died at home had visited health facilities during their final illness JMR 111 E2 (2) - 2018 89 JOURNAL OF MEDICAL RESEARCH 5% 1.9% 5% At home At Health facility On the way to health facility Others 88.1% Figure Place of death of the study sample Table describes the differentials in mortality pattern by sex Although stroke was the first leading COD in both males and females, the percentage of females who died due to stroke was higher than those in males This is similar to some other causes such as pneumonia, stomach cancer and other CVD The proportion of senility as a cause of death in females was times higher than males, therefore the rate of this cause in male was not listed in the 10 leading COD table However, some causes such as liver cancer, lung cancer, cirrhosis of liver and HIV, had proportions of male deaths that outweighed those in females Beside two common groups as CVD and cancers, injury that was marked mainly by road traffic injury also situated in the list of top as a leading cause of death among both males and females (4.2% and 2.8% respectively) Table Distribution of 10 leading CODs by sex Male (n = 835) Rank 90 Disease Female (n = 530) Rate (%) Disease Rate (%) Stroke 18.7 Stroke 23.6 Lung cancer 10.4 Senility 10.9 Liver cancer 6.7 Lung cancer 4.9 HIV/AIDS 4.3 Pneumonia 4.7 Cirrhosis of liver 4.3 Breast, Cervix and Ovary cancers 4.2 Road traffic Injury 4.2 Stomach cancer 3.0 JMR 111 E2 (2) - 2018 JOURNAL OF MEDICAL RESEARCH Pneumonia 3.5 Other cardiovascular diseases 3.0 Ischaemic heart disease 2.5 Road traffic Injury 2.8 Other malignant neoplasms 2.4 Ischaemic heart disease 2.6 10 Other unintentional injuries 2.3 Diabetes mellitus 2.5 All other diseases/ causes 29.5 All other diseases/ causes 30.2 Ill-defined and unknown COD 9.2 Ill-defined and unknown COD 7.5 Table describes five specific causes with high rate of mortality in both male and female It can be recognized that almost all of these causes represent some large groups of disease such as CVD, cancer, Injury, communicable disease Noticeably, the overall proportion of the non-communicable disease group including stroke, lung cancer and ischemic heart diseases was remarkably higher than the others Pneumonia was the only representative of the communicable disease category in this top five leading causes list with the quite low percentage (4.0%) There were statistically significant differences between male and female in stroke and lung cancer with opposing tendencies While the number of death due to stroke in female was considerably higher than in male, the percentage of lung cancer death among male was more than times higher than those among female Table Comparison of some leading CODs by sex Both sex (n = 1365) Male (n = 835) Female (n = 530) Rate (%) Rate (%) Rate (%) Stroke 20.6 18.7 23.6 0.03 Lung cancer 8.3 10.4 4.9 < 0.001 Road traffic Injury 3.7 4.2 2.8 > 0.05 Pneumonia 4.0 3.5 4.7 > 0.05 Ischaemic heart disease 2.5 2.5 2.6 > 0.05 Disease p value IV DISCUSSION This study provides useful statistics contributing to the formation of an up to date mortality data at national level and reveals an empirical evidence of the current situation of deaths recording in the routine health management information system in Vietnam By combining two steps in data collection: making death lists from traditional resources (A6 registers, Justice Clerk books and others) and then ascertaining this list by implementing verbal autopsy inter- JMR 111 E2 (2) - 2018 91 JOURNAL OF MEDICAL RESEARCH views, the completeness and the reliability of our results are at high level The study also provides useful observations on the utility of VA methods to identify causes for deaths occurring outside public health facilities Previously, this model has been used in several researches and was demonstrated to be a very effective instrument for evaluating mortality patterns in Vietnam [11 - 13] The response rate of this study was 92.6%, which seemed to be lower than those in some foreign reports that found rates reaching nearly 100% [2], but it was similar to previous experiences in use of verbal autopsy surveys in Vietnam [10; 12] There are many reasons for this phenomenon One of them had been mentioned by Hoa et al [10] with missing cases mostly atributable to migration of the household to another district/province after the deaths of their family member This explains why their names were recorded, but the data collectors could not find them Another possible reason for the difference between Vietnam and other countries comes from an insufficient mortality data recording system, as Vietnamese network of primary healthcare has yet to be developed, resulting in a systemic lack of complete medical records [13] Mortality rate and some relating characteristics The overall death rate of both two provinces was 4.94‰, lower than findings from another source of CDR of Vietnam population as National crude death rate in 2014 from GSO which was estimated to be 6.9‰ [8] However, compared with the rate of 3.9‰ reported by Hoa et al in a regional research of death rate in 2012, our rate 92 was markedly higher [14] Possibly, these differences came from the way of choosing sample while estimates of GSO was based on demographic models and projections, in comparison with the locally measure CDR from this study Regarding to location, our findings figured out the significantly higher proportion of death in rural community than in the urban The fact is that our sample population with higher fraction of urban citizens could have led to this disparity since urban communities in Viet Nam probably enjoy better health care and health status than rural ones [11; 13] In terms of gender, as can be seen, the gap of death rates between male and female showed a statistically significant differential, similar to several previous reports [11; 10; 15] Besides, our result also pointed out two third of the deaths occurred in the group of above 60 years old (63,7%), similar to some others studies [14] As mentioned in some other researches, the disease pattern alteration has been happening in recent years in Vietnam, from communicable diseases to non- communicable diseases which occur mainly in the old people [10; 11; 16] In addition, Vietnamese life expectancy tends to rise due to better living conditions and the percentage of elder population in Vietnam society is increasing [6; 15] Apparently, the combination of two above reasons results in the high rate of death among the elderly The low number of reported neonatal and child deaths results in very low estimated under mortality rates for our study population Similar apparent under-reporting of under mortality was also observed in the sample mortality surveillance system [10] JMR 111 E2 (2) - 2018 JOURNAL OF MEDICAL RESEARCH Apropos of the demand of treatment before death, from our analysis, a majority of the deceased visited at least one health facility at the end stage of life, similar to several previous reports [13; 17] Howerver, the highlight here is the level of medical services, more than 80% of the death went to Central/ Provincial Hospitals This illustrates out several issues in Vietnam such as insufficient capability of diseases treatment of primary healthcare system, the perception of people to put belief in the medical service of high-level hospital This pattern may be different in other provinces in Vietnam where access to higher level hospitals is more difficult and where the patients may rely on traditional healers However, although a few cases still kept medical record after discharge of health facilities, most of the deceased family members could recall the diagnosis in hospital This finding suggests that a good system of discharge documents may help to improve the availability of reliable information to ascertain the cause of death from verbal autopsy Instead of only asking the relatives of the deceased about the COD, the CHS health staffs can ask them to show the discharge documents (if they are available) to get more detailed information to support the recording of the COD Another aspect is the place of death, the mortality rate at home in our study was very high (88.1%), this feature is similar to previous surveys in Vietnam [13; 14] It is common practice in Vietnam for terminally ill patients to go back home for the final period of their lives, even in some cases, the patients are just hospitalized for a very short time JMR 111 E2 (2) - 2018 Causes of death An important part of this study is to investigate the cause of death It can be easily recognized the transition of disease pattern in Vietnam in recent years from communicable diseases to non-communicable diseases (NCD) as being reported in many researches [10; 14; 16] Our result also revealed the same trend when three out of the five leading causes of death were stroke, lung cancer and ischemic heart diseases, which are categorized into the group of NCD A considerable point here is the differentials in COD pattern between male and female While in stroke, senility, or other CVD, the proportions in females were remarkably higher than those in males, a reverse pat-tern was found for in liver cancer, lung cancer, cirrhosis of liver, where the percentages in males outweighed those in females It is possible that this difference stems from habits among Vietnamese higher smoking and drinking males Also, the higher traffic injury among males compared to females can be explained by the prevalence of drunk driving among men The evidence for this is the increasing proportion of traffic accident during big national festivals conducive to alcohol overuse, mostly among males There were also some causes of death related specifically to gender such as breast, cervix and ovary cancers in females, which constitute the fifth cause in the list top ten leading causes of death V CONCLUSION This study identified the mortality pattern of two provinces in the Northern region of Vietnam contributing to the national mortali93 JOURNAL OF MEDICAL RESEARCH ty database With the transition of the cause of death pattern, it is necessary to pay more attention to collecting information of the deaths outside health facilities as well as improving the mortality recording system, especially at primary healthcare network Comprehensive mortality database, and intervention programs need to prioritize these leading causes of death Acknowledgements We would like to thank the Provincial Health Departments of Quang Ninh and Thai Nguyen provinces for their help in data collection activities and all local health workers from commune health stations who directly conducted interview Finally, we profoundly thank all respondents who spent time in sharing information for our research REFERENCES WHO (2012) World Health Statistics Fottrell, E., Byass, P (2010) Verbal autopsy: methods in transition Epidemiol Rev, 32, 38 - 55 Mathers, C.D., Fat, D M., Inoue, M et al (2005) Counting the dead and what they died from: an assessment of the global status of cause of death data Bull World Health Organ, 83(3), 171 - 177 Setel, P.W., Macfarlane, S.B., Szreter,S et al (2007) A scandal of invisibility: making everyone count by counting everyone The Lancet, 370(9598), 1569 1577 Mahapatra, P., Shibuya, K., Lopez, A D et al (2007) Civil registration systems and vital statistics: successes and missed opportunities Lancet, 370(9599), 1653 - 1663 World Population Review (2014) Vietnam Population 2014 94 Rao, C (2013) Mortality estimates for South East Asia, and INDEPTH mortality surveillance: necessary but not sufficient? 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