title: The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi.
abstract: BACKGROUND
  Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews.
  
  
  METHODS
  During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative.
  
  
  RESULTS
  Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather.
  
  
  CONCLUSIONS
  The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services.
authors.affiliation: Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK. c.king@ucl.ac.uk.
authors.forename: C
authors.initials: C
authors.lastname: King
authors.affiliation: Parent and Child Health Initiative, Lilongwe, Malawi. fzamawe@gmail.com.
authors.forename: C
authors.initials: C
authors.lastname: Zamawe
authors.affiliation: MaiMwana Project, Mchinji, Malawi. masfordbanda@gmail.com.
authors.forename: M
authors.initials: M
authors.lastname: Banda
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi. Naor.Bar-Zeev@liverpool.ac.uk.|Institute of Infection & Global Health, University of Liverpool, Liverpool, UK. Naor.Bar-Zeev@liverpool.ac.uk.
authors.forename: N
authors.initials: N
authors.lastname: Bar-Zeev
authors.affiliation: Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK. james@beard.net.|London School of Hygiene and Tropical Medicine, London, UK. james@beard.net.
authors.forename: J
authors.initials: J
authors.lastname: Beard
authors.affiliation: Department of Computer Science, City University London, London, UK. jon.bird@city.ac.uk.
authors.forename: J
authors.initials: J
authors.lastname: Bird
authors.affiliation: Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK. anthony.costello@ucl.ac.uk.
authors.forename: A
authors.initials: A
authors.lastname: Costello
authors.affiliation: MaiMwana Project, Mchinji, Malawi. pnkazembe@baylor-malawi.org.|Baylor College of Medicine Children's Foundation, Lilongwe, Malawi. pnkazembe@baylor-malawi.org.
authors.forename: P
authors.initials: P
authors.lastname: Kazembe
authors.affiliation: Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK. d.osrin@ucl.ac.uk.
authors.forename: D
authors.initials: D
authors.lastname: Osrin
authors.affiliation: Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK. e.fottrell@ucl.ac.uk.
authors.forename: E
authors.initials: E
authors.lastname: Fottrell
mesh_terms: D001344:Autopsy / Q000379:methods*; D017028:Caregivers; D002423:Cause of Death; D003142:Communication; D019937:Diagnostic Techniques and Procedures; D006801:Humans; D007407:Interviews as Topic / Q000379:methods*; D008295:Malawi; D033262:Narration; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires
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