title: Local perceptions of causes of death in rural South Africa: a comparison of perceived and verbal autopsy causes of death.
abstract: BACKGROUND
  Understanding how lay people perceive the causes of mortality and their associated risk factors is important for public health. In resource-limited settings, where verbal autopsy (VA) is used as the most expedient method of determining cause of death, it is important to understand how pre-existing concepts of cause of death among VA-informants may influence their VA-responses and the consequential impact on cause of death assessment. This study describes the agreement between VA-derived causes of death and informant-perceived causes and associated influential factors, which also reflects lay health literacy in this setting.
  
  
  METHODS
  Using 20 years of VA data (n=11,228) from the Agincourt Health and Demographic Surveillance System (HDSS) site in rural South Africa, we explored the agreement between the causes of death perceived by the VA-informants and those assigned by the automated Inter-VA tool. Kappa statistics and concordance correlation coefficients were applied to measure agreement at individual and population levels, respectively. Multivariable regression models were used to explore factors associated with recognised lay perceptions of causes of mortality.
  
  
  RESULTS
  Agreement between informant-perceived and VA-derived causes of death at the individual level was limited, but varied substantially by cause of death. However, agreement at the population level, comparing cause-specific mortality fractions was higher, with the notable exception of bewitchment as a cause. More recent deaths, those in adults aged 15-49 years, deaths outside the home, and those associated with external causes showed higher concordance with InterVA.
  
  
  CONCLUSIONS
  Overall, informant perception of causes of death was limited, but depended on informant characteristics and causes of death, and to some extent involved non-biomedical constructs. Understanding discordance between perceived and recognised causes of death is important for public health planning; low community understanding of causes of death may be detrimental to public health. These findings also illustrate the importance of using rigorous and standardised VA methods rather than relying on informants' reported causes of death.
authors.affiliation: Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; laith.hussain@gu.se.
authors.forename: Laith
authors.initials: L
authors.lastname: Hussain-Alkhateeb
authors.affiliation: Institute for Global Health, University College London, London, UK.|WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden.
authors.forename: Edward
authors.initials: E
authors.lastname: Fottrell
authors.affiliation: Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.|Wits University Rural Public Health, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Max
authors.initials: M
authors.lastname: Petzold
authors.affiliation: WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden.|INDEPTH Network, Accra, Ghana.|Medical Research Council, Johannesburg, South Africa.|Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Kahn
authors.affiliation: WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden.|Medical Research Council, Johannesburg, South Africa.|Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Peter
authors.initials: P
authors.lastname: Byass
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D001344:Autopsy / Q000379:methods* / Q000592:standards*; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D010465:Perception; D011159:Population Surveillance; D012424:Rural Population; D012737:Sex Factors; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D055815:Young Adult
keywords: causes of death; community perception; verbal autopsy