Comparing quantitative and qualitative verbal and social autopsy tools for under-5 deaths in Uganda: a cross-sectional study

Abstract

Background: Understanding biological causes of death and sociocultural factors that influence survival outcomes is crucial to reducing mortality in low-resource settings. Verbal and Social Autopsy instruments (VASAs) query family members about events leading up to an individual's death, resulting in quantitative, categorical data. We aimed to determine the value of a supplemental in-depth interview (known as VASA-QUAL) that generated detailed qualitative data in understanding childhood deaths. Methods: This cross-sectional study was conducted in Kawaala and Nakulabye in Kampala, Uganda between Feb 6 and March 7, 2020, using 20 village health team members to assist in the identification and recruitment of families within which a children younger than 5 years had died within the preceding 6 months. Family members were interviewed by a trained, local researcher who conducted the quantitative VASA and the VASA-QUAL in-depth interview. Quantitative data were analysed using Stata (v16.0), and qualitative data were transcribed into English and analysed using NVivo (v12.0). Three coders compared quantitative variables from the VASA with qualitative variables from the VASA-QUAL using a rubric of eight key indicators related to symptom recognition, decision making, care seeking, and treatments given, derived from the Pathways to Survival framework. Agreement across sources and new insights from qualitative data were recorded. Findings: 48 VASAs were conducted, reflecting 48 deaths of children between the ages of 1 month and 3 days to 52 months. Agreement on key indicators ranged from 77% (for illness recognition) to 100% (for following provider referral recommendations). The qualitative component added or clarified information about pediatric illness and care-seeking across all indicators, including information about recognition of illness (96% of cases), care-seeking decisions (81%), whether home care was provided (75%), and choice of outside care (92%). The qualitative interviews frequently included symptoms that were missing or denied in the quantitative VASA, and they often clarified the chronological order of symptoms identified via VASA. Many qualitative interviews described complicated mechanisms of decision making, involving multiple key players, which were not adequately captured in the quantitative survey. Interpretation: Supplementing quantitative VASA tools with an in-depth VASA-QUAL interview provided important additional information. Supplemental qualitative interviews are an important tool for understanding the complexity of events leading up to childhood deaths. Funding: The Northern Pacific Global Health Research Training Consortium, Fogarty International Center at the National Institutes of Health.