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Lundberg E, Ozanne A, Larsdotter C, Böling S, Dellenborg L, Ensted D, Öhlén J. Place of death among foreign-born individuals: a national population-based register study. Palliat Care Soc Pract 2023; 17:26323524231185157. [PMID: 37465177 PMCID: PMC10350762 DOI: 10.1177/26323524231185157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Background Relatively little is known about where foreign-born individuals die in Sweden and how birth region might influence place of death. Thus, there is a need for population-based studies investigating place of death and associated factors among foreign-born individuals. Objectives The aim of this study was to identify variations in place of death among foreign-born individuals residing in Sweden and to compare place of death between the foreign- and domestic-born population. We also examine the association between place of death, underlying cause of death and sociodemographic characteristics among the foreign-born population. Design A population-based register study. Methods All deceased individuals ⩾18 years of age in Sweden with a registered place of death between 2012 and 2019 (n = 682,697). Among these, 78,466 individuals were foreign-born. Univariable multinomial logistic regression modelling and multivariable multinomial logistic regression analyses were performed. Results Overall, hospital was the most common place of death among the foreign-born population. However, there were variations in place of death related to region of birth. Compared to domestic-born, a higher proportion of foreign-born individuals dies at home, the majority of whom were born on the African continent. Conclusion Region of birth is one of the several factors associated with place of death among foreign-born individuals. Further research is needed to explore both preferences and barriers to place of death among foreign-born individuals.
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Affiliation(s)
| | - Anneli Ozanne
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cecilia Larsdotter
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Susanna Böling
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lisen Dellenborg
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Ensted
- Department of Literature, History of Ideas, and Religion, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Palliative Centre, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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Misganaw A, Worku A. Reliable cause-of-death data for better child health practice in Ethiopia. Lancet Glob Health 2023; 11:e987-e988. [PMID: 37349042 DOI: 10.1016/s2214-109x(23)00266-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Awoke Misganaw
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; National Data Management and Analytics Center, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
| | - Asnake Worku
- National Data Management and Analytics Center, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Siregar KN, Kurniawan R, Nuridzin DZ, BaharuddinNur RJ, Retnowati, Handayani Y, Rohjayanti, Halim L. Strengthening causes of death identification through community-based verbal autopsy during the COVID-19 pandemic. BMC Public Health 2022; 22:1607. [PMID: 35999519 PMCID: PMC9398045 DOI: 10.1186/s12889-022-14014-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Indonesia has not optimally provided complete and reliable civil registration and vital statistics (CRVS). Death certification is one of the elements of the CRVS system. Reliable data on death rates and causes serve as the basis for building a strong evidence base for public health policy, planning, monitoring, and evaluation. This study aims to implement an approach to identifying the cause of death through verbal autopsy by empowering community health workers during the pandemic. Method This study is implementation research with the empowerment of the community, in this case, health cadres and health facilitators/workers, to identify the cause of death through a mobile-based verbal autopsy. This implementation research consisted of four main activities: community-based verbal autopsy, mobile-based verbal autopsy development, data collection, and analysis of the suspected causes of death using InterVA-5. Result From October to November 2020, a total of 143 respondents were willing to do a verbal autopsy interview (response rate of 58%). Of 143 respondents, most of them were women (112 or 78.3%), was the child of the deceased (61 or 42.7%) and lived with the deceased until before he/she died (120 or 83.9%). Based on the characteristics of the deceased, of 143 deceased, 78 (54.5%) were male, 134 (93.7%) were adults, 100 (69.9%) died at home, and 119 (83.2%) did not have a death certificate stating the cause of death. The cause of death of 143 deceased mainly was infectious disease (92 or 64.3%), followed by non-communicable disease (39 or 27.3%), external factors (5 or 3.5%), and unknown factors (4 or 2.8%). In sequence, the top five suspected causes of death are acute respiratory infection, including pneumonia (72 or 50.3%), other and unspecified infectious disease (18 or 12.6%), other and unspecified cardiac disease (17 or 11.9%), acute cardiac disease (4 or 2.8%), and Digestive neoplasms (4 or 2.8%). Conclusion The findings showed that the mobile-based verbal autopsy using a community-based mechanism was feasible during the COVID-19 pandemic.
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Affiliation(s)
- Kemal Nazarudin Siregar
- Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Indonesia, Depok City, Indonesia. .,Health Informatics Research Cluster (HIRC) Faculty of Public Health, Universitas Indonesia, Depok City, Indonesia.
| | - Rico Kurniawan
- Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Indonesia, Depok City, Indonesia
| | - Dion Zein Nuridzin
- Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Diponegoro, Semarang City, Indonesia
| | - Ryza Jazid BaharuddinNur
- Center of Biostatistics and Health Informatics, Faculty of Public Health, Universitas Indonesia, Depok City, Indonesia.,Department Epidemiology, Faculty of Public Health, Universitas Hasanuddin, Makassar City, Indonesia
| | - Retnowati
- Medical Record and Health Information Department, Semarang Health Polytechnic Ministry of Health, Semarang City, Indonesia
| | - Yolanda Handayani
- Health Informatics Research Cluster (HIRC) Faculty of Public Health, Universitas Indonesia, Depok City, Indonesia
| | - Rohjayanti
- Head of NCD Prevention and Control Section, Bogor District Health Office, Bogor District, Indonesia
| | - Lindawati Halim
- Health Center Coordinator in Babakan Madang Sub-District, Bogor District, Indonesia
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4
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Mebrahtom S, Worku A, Gage DJ. Causes of infant deaths and patterns of associated factors in Eastern Ethiopia: Results of verbal autopsy (InterVA-4) study. PLoS One 2022; 17:e0270245. [PMID: 35925957 PMCID: PMC9352103 DOI: 10.1371/journal.pone.0270245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background In a range of setting, detecting and generate empirical information on the cause of infant death and contributing risk factors at population level is basically utmost essential to take evidence-based measures in reducing infant morbidity and mortality. An electronic verbal autopsy is suitable tool and best alternative solution to determine individuals’ cause of death in a setting where the majority of deaths occur at home and civil registration systems do not exist. The present study was undertaken to find out cause of infant death, applying computer-based probabilistic model (InterVA-4) and analyze the patterns of association factors of mother’s and the deceased infant’s characteristics to the leading cause-specific infant mortality in Eastern Ethiopia. Methods The study employed a community-based prospective longitudinal survey, which was conducted with routinely enumeration of reported infant deaths for a period of two years (from September 2016 to August 2018) in Eastern part of Ethiopia. Using the two-stage cluster sampling technique, the study was undertaken in four randomly selected districts of West Hararghe zone and two districts of zone 3 in Oromia and Afar regional state, respectively. The study included a total of 362 infants who were deceased during the study period. Data was collected by trained enumerators by interviewing the mothers or guardians of the deceased infant using a 2014 standardize World Health Organization (WHO) Verbal Autopsy questionnaire. InterVA-4 model were used for processing and interpreting verbal autopsy data in order to arrive at the most likely causes of infant death. SPSS version 23 was also used for statistical analysis of frequency distribution and logistic regression for the association between covariates and outcomes. Findings Of the overall (362) deceased infants’ during the study period, 53.0% of deaths occurred during neonatal time while 47.0% died in the post-neonatal period. Acute respiratory infection including neonatal and post-neonatal pneumonia (38.4%), birth asphyxia (16.4%), diarrheal diseases (16.3%), prematurity (7.4%) and malaria (4.3%) were found to be the leading causes of infant mortality in the study area. The independent factors strongly associated with probable ARI, including pneumonia related mortality as compared to all-causes of death were infants with maternal age lower than 20 years old (p = 0.001, AOR: 4.82, 95% CI: 1.88, 12.3) and infant being died outside of heath facilities (P = 0.007, AOR: 2.85, 95% CI: 1.33, 6.12). The post-neonatal period (P = 0.000, AOR: 15.5, 95% CI: 6.35, 37.8) and infant died in the wet season (P = 0.006, AOR: 2.38, 95% CI: 1.28, 4.44) had strong relationship with dying from diarrhea-related death than those infants died from all non-diarrhea. The death due to malaria robustly associated with infants whose mothers age between 20–35 years old (P = 0.024, AOR: 4.44, 95% CI: 1.22, 16.2) and infant who was dwelled in the districts of Afar region (P = 0.013, AOR: 4.08, 95% CI: 1.35, 12.4). Conclusion The highest cause of infant mortality was associated with disease of respiratory system, particularly acute respiratory infection, including both neonates and post-neonatal pneumonia. Most of the infant deaths existed are as a result of diseases and conditions that are readily preventable or treatable cause, similar to those reported in worldwide, which have needs of further attention. The patterns of significant associated factors across cause-specific mortality against all-cause of death were dissimilar. Therefore, strengthen maternal and child health program with effective preventive interventions emphasizing on the most common cause of infant deaths and those factors contributing in raising mortality risk are required.
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Affiliation(s)
- Samuel Mebrahtom
- Ethiopian Institute of Water Resources, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Alemayehu Worku
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel J. Gage
- Department of Molecular and Cell Biology, University of Connecticut, Storrs, Connecticut, United States of America
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Memirie ST, Dagnaw WW, Habtemariam MK, Bekele A, Yadeta D, Bekele A, Bekele W, Gedefaw M, Assefa M, Tolla MT, Misganaw A, Gupta N, Bukhman G, Norheim OF. Addressing the Impact of Noncommunicable Diseases and Injuries (NCDIs) in Ethiopia: Findings and Recommendations from the Ethiopia NCDI Commission. Ethiop J Health Sci 2022; 32:161-180. [PMID: 35250228 PMCID: PMC8864405 DOI: 10.4314/ejhs.v32i1.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/15/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Noncommunicable diseases and injuries (NCDIs) are the leading causes of premature mortality globally. Ethiopia is experiencing a rapid increase in NCDI burden. The Ethiopia NCDI Commission aimed to determine the burden of NCDIs, prioritize health sector interventions for NCDIs and estimate the cost and available fiscal-space for NCDI interventions. METHODS We retrieved data on NCDI disease burden and concomitant risk factors from the Global Burden of Disease (GBD) Study, complemented by systematic review of published literature from Ethiopia. Cost-effective interventions were identified through a structured priority-setting process and costed using the One Health tool. We conducted fiscal-space analysis to identify an affordable package of NCDI services in Ethiopia. RESULTS We find that there is a large and diverse NCDI disease burden and their risk factors such as hypertension and diabetes (these conditions are NCDIs themselves and could be risk factors to other NCDIs), including less common but more severe NCDIs such as rheumatic heart disease and cancers in women. Mental, neurological, chronic respiratory and surgical conditions also contribute to a substantial proportion of NCDI disease burden in Ethiopia. Among an initial list of 235 interventions, the commission recommended 90 top-priority NCDI interventions (including essential surgery) for implementation. The additional annual cost for scaling up of these interventions was estimated at US$550m (about US$4.7 per capita). CONCLUSIONS A targeted investment in cost-effective interventions could result in substantial reduction in premature mortality and may be within the projected fiscal space of Ethiopia. Innovative financing mechanisms, multi-sectoral governance, regional implementation, and an integrated service delivery approach mainly using primary health care are required to achieve these goals.
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Affiliation(s)
- Solomon Tessema Memirie
- Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | | | | | - Dejuma Yadeta
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amsalu Bekele
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondu Bekele
- Mathiwos Wondu-YeEthiopia Cancer Society, Addis Ababa, Ethiopia
| | - Molla Gedefaw
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Mathewos Assefa
- Departement of Oncology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mieraf Taddese Tolla
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Neil Gupta
- Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- NCD Synergies, Partners in Health, Boston, MA, USA
| | - Gene Bukhman
- Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- NCD Synergies, Partners in Health, Boston, MA, USA
| | - Ole F Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Ali S, Misganaw A, Worku A, Destaw Z, Negash L, Bekele A, Briant PS, Johnson CO, Alam T, Odell C, Roth GA, Naghavi M, Abate E, Mirkuzie AH. The burden of cardiovascular diseases in Ethiopia from 1990 to 2017: evidence from the Global Burden of Disease Study. Int Health 2021; 13:318-326. [PMID: 32945840 PMCID: PMC8253991 DOI: 10.1093/inthealth/ihaa069] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/14/2020] [Accepted: 08/29/2020] [Indexed: 12/11/2022] Open
Abstract
In Ethiopia, evidence on the national burden of cardiovascular diseases (CVDs) is limited. To address this gap, this systematic analysis estimated the burden of CVDs in Ethiopia using the Global Burden of Disease (GBD) 2017 study data. The age-standardized CVD prevalence, disability-adjusted life years (DALYs) and mortality rates in Ethiopia were 5534 (95% uncertainty interval [UI] 5310.09 - 5774.0), 3549.6 (95% UI 3229.0 - 3911.9) and 182.63 (95% UI 165.49 - 203.9) per 100 000 population, respectively. Compared with 1990, the age-standardized CVD prevalence rate in 2017 showed no change. But significant reductions were observed in CVD mortality (54.7%), CVD DALYs (57.7%) and all-cause mortality (53.4%). The top three prevalent CVDs were ischaemic heart disease, rheumatic heart disease and stroke in descending order. The reduction in the mortality rate due to CVDs is slower than for communicable, maternal, neonatal and nutritional disease mortalities. As a result, CVDs are the leading cause of mortality in Ethiopia. These findings urge Ethiopia to consider CVDs as a priority public health problem.
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Affiliation(s)
- Solomon Ali
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia.,Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Awoke Misganaw
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia.,Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Asnake Worku
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Zelalem Destaw
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Legesse Negash
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Abebe Bekele
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Paul S Briant
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Catherine O Johnson
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Tahiya Alam
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Chris Odell
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Gregory A Roth
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA 98121, USA
| | - Ebba Abate
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Alemnesh H Mirkuzie
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia.,University of Bergen, Norway
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Anteneh A, Endris BS. Injury related adult deaths in Addis Ababa, Ethiopia: analysis of data from verbal autopsy. BMC Public Health 2020; 20:926. [PMID: 32539824 PMCID: PMC7294602 DOI: 10.1186/s12889-020-08944-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Injury related deaths are causing huge impact on families and communities throughout the world. Reports show that developing countries are highly affected by injury deaths. Ethiopia is among the countries that are highly affected by injury deaths especially road traffic accident. Previous studies in Ethiopia concerning injury deaths were mostly based on hospital records. However, in the context of Ethiopia, where majority of the deaths are happening outside health facilities, hospital-based studies cannot give the exact proportion of injury deaths. This study aimed to assess the proportion and types of injury deaths in Addis Ababa and the distribution with different socio-demographic characteristics using data from verbal autopsy. Methods We used verbal autopsy data of Addis Ababa Mortality Surveillance Program. The basic source of data for Addis Ababa Mortality Surveillance is burial surveillance from all cemeteries of Addis Ababa. We analyzed causes of injury mortality by different characteristics and tried to show the trends. Results Over the 8 years period of time injury has contributed about 7 % of the total deaths. Majority of injury related deaths were among males. Traffic accidents were the major injury related deaths for both sexes; intentional self-harm was highly observed among males compared with females. The findings of this study showed that the proportion of injury related deaths decreased with increasing age. Conclusions This study witnessed that deaths resulting from injuries are substantial health challenges in Addis Ababa. Road traffic accident is the most common cause of injury related deaths in the study area. The findings also indicated that males and the productive age groups are highly affected by injury deaths.
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Affiliation(s)
- Aderaw Anteneh
- Population Services International-Ethiopia, Addis Ababa, Ethiopia.
| | - Bilal Shikur Endris
- PI of AAMSP, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
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8
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Neergaard MA, Brunoe AH, Skorstengaard MH, Nielsen MK. What socio-economic factors determine place of death for people with life-limiting illness? A systematic review and appraisal of methodological rigour. Palliat Med 2019; 33:900-925. [PMID: 31187687 DOI: 10.1177/0269216319847089] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Socio-economic factors play important roles in place of death. However, up-to-date knowledge on socio-economic determinants for place of death is warranted including analysis of collinearity between socio-economic determinants. AIM To examine associations between socio-economic determinants (social class, deprivation level in area of residence, income, education, occupation, urbanisation) and place of death among adult patients with life-limiting illnesses. Furthermore, to describe how these factors are operationalised and examined for collinearity. DESIGN A systematic review was performed (PROSPERO, record: CRD42018091218) and quality was assessed using the Newcastle-Ottawa Scale. DATA SOURCES A comprehensive search of PubMed, Embase, CINAHL, Scopus and PsycINFO was conducted for studies published from 1 January 2008 until the date of the search (23 March 2018) in English or Scandinavian languages. RESULTS Of the 1599 unique citations identified, 34 studies were eligible. Dying at home was to a high degree associated with better financial situation and living in rural areas. Furthermore, hospital death was associated with a high level of deprivation in the area of residence and being employed. Regarding educational level, we found mixed and inconclusive results. CONCLUSION Inequalities concerning place of death were found, and attention towards socio-economic inequality concerning place of death is necessary, especially in patients with a poor financial status, patients living in deprived and metropolitan areas and patients who are employed. Furthermore, we found a low degree of assessment for collinearity and adjustment of socio-economic variables. These issues should be considered in planning of future studies of socio-economic determinants for place of death.
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Abate AT, Amdie FZ, Bayu NH, Gebeyehu D, G/Mariam T. Knowledge, attitude and associated factors towards end of life care among nurses' working in Amhara Referral Hospitals, Northwest Ethiopia: a cross-sectional study. BMC Res Notes 2019; 12:521. [PMID: 31426854 PMCID: PMC6700991 DOI: 10.1186/s13104-019-4567-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
Objective The aim of this study was to assess nurses’ Knowledge, Attitude and Associated Factors towards end of life care in Amhara Referral Hospitals, Northwest Ethiopia, 2017. Results A total of 331 participants were included with a response rate of 93.2%. From these, 129 (39.0%) of them had good knowledge and 234 (70.7%) had favorable attitude towards end of life care. Being Bachelor of Science holder and above in nursing (AOR = 4.261, 95% CI 1.524–11.912), working in Emergency department (AOR = 4.911, 95% CI 1.796–13.426), having daily experience of caring for chronically ill patients (AOR = 2.764, 95% CI 1.366–5.591) and taking training on end of life care (AOR = 10.269, 95% CI 4.730–22.296) were significantly associated with good knowledge of nurses towards end of life care. On the other hand, having 6–10 years of working experience in nursing (AOR = 2.199, 95% CI 1.147–4.215), being trained in end of life care (AOR = 3.027, 95% CI 1.285–7.13), Bachelor of Science holder and above in nursing (AOR = 4.414, 95% CI 2.230–8.738) were found to be statistically significant with more positive attitude of nurses towards end of life care. Electronic supplementary material The online version of this article (10.1186/s13104-019-4567-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Addisu Taye Abate
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Fisseha Zewdu Amdie
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Netsanet Habte Bayu
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Dawit Gebeyehu
- Department of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tesfamichael G/Mariam
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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10
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Blanchard CL, Ayeni O, O'Neil DS, Prigerson HG, Jacobson JS, Neugut AI, Joffe M, Mmoledi K, Ratshikana-Moloko M, Sackstein PE, Ruff P. A Prospective Cohort Study of Factors Associated With Place of Death Among Patients With Late-Stage Cancer in Southern Africa. J Pain Symptom Manage 2019; 57:923-932. [PMID: 30708125 PMCID: PMC6531674 DOI: 10.1016/j.jpainsymman.2019.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 11/17/2022]
Abstract
CONTEXT Identifying factors that affect terminally ill patients' preferences for and actual place of death may assist patients to die wherever they wish. OBJECTIVE The objective of this study was to investigate factors associated with preferred and actual place of death for cancer patients in Johannesburg, South Africa. METHODS In a prospective cohort study at a tertiary hospital in Johannesburg, South Africa, adult patients with advanced cancer and their caregivers were enrolled from 2016 to 2018. Study nurses interviewed the patients at enrollment and conducted postmortem interviews with the caregivers. RESULTS Of 324 patients enrolled, 191 died during follow-up. Preferred place of death was home for 127 (66.4%) and a facility for 64 (33.5%) patients; 91 (47.6%) patients died in their preferred setting, with a kappa value of congruence of 0.016 (95% CI = -0.107, 0.139). Factors associated with congruence were increasing age (odds ratio [OR]: 1.03, 95% CI: 1.00-1.05), use of morphine (OR: 1.87, 95% CI: 1.04-3.36), and wanting to die at home (OR: 0.44, 95% CI: 0.24-0.82). Dying at home was associated with increasing age (OR 1.03, 95% CI 1.00-1.05) and with the patient wishing to have family and/or friends present at death (OR 6.73, 95% CI 2.97-15.30). CONCLUSION Most patients preferred to die at home, but most died in hospital and fewer than half died in their preferred setting. Further research on modifiable factors, such as effective communication, access to palliative care and morphine, may ensure that more cancer patients in South Africa die wherever they wish.
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Affiliation(s)
- Charmaine L Blanchard
- Centre for Palliative Care, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Non Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa.
| | - Oluwatosin Ayeni
- MRC Developmental Pathways to Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Non Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Daniel S O'Neil
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA
| | - Judith S Jacobson
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Maureen Joffe
- MRC Developmental Pathways to Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Non Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Keletso Mmoledi
- Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa; Centre for Palliative Care, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Non Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Mpho Ratshikana-Moloko
- Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa; Centre for Palliative Care, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Non Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Paul E Sackstein
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Paul Ruff
- Division of Medical Oncology, Department of Internal Medicine, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa; Non Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
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11
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Lankoandé B, Duthé G, Soura A, Pison G. Returning home to die or leaving home to seek health care? Location of death of urban and rural residents in Burkina Faso and Senegal. Glob Health Action 2018; 11:1475040. [PMID: 29869949 PMCID: PMC5990939 DOI: 10.1080/16549716.2018.1475040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: In sub-Saharan Africa, the literature on end of life is limited and focuses on place of death as an indicator of access and utilization of health-care resources. Little is known about population mobility at the end of life. Objective: To document the magnitude, motivations and associated factors of short-term mobility before death among adults over 15 years of age in Burkina Faso and Senegal. Methods: The study was based on deaths of adult residents reported in three Health and Demographic Surveillance System (HDSS) sites in urban (Ouagadougou) and semi-rural areas (Kaya) of Burkina Faso, and rural areas of Senegal (Mlomp). After excluding deaths from external causes, the analysis covered, respectively, 536 and 695 deaths recorded during the period 2012–2015 in Ouagadougou and Kaya. The period was extended to 2000–2015 in Mlomp, with a sample of 708 deaths. Binary logistic regressions were used to examine the effects of socio-demographic characteristics on place of death (health facility or not) and location of death (within or outside the HDSS). Results: In Mlomp, Kaya and Ouagadougou, respectively 20.6%, 5.3% and 5.9% of adults died outside the HDSS site. In Mlomp and Kaya, these deaths were more likely to occur in a health facility than deaths that occurred within the site. The reverse situation was found in Ouagadougou. Age is the strongest determinant of mobility before death in Mlomp and Kaya. In Mlomp, young adults (15–39) were 10 times more likely to die outside the site than adults in the 60–79 age group. In Ouagadougou, non-natives were three times more likely to die outside the city than natives. Conclusions: At the end of life, some rural residents move to urban areas for medical treatment while some urban dwellers return to their village for supportive care. These movements of dying individuals may affect the estimation of urban/rural mortality differentials.
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Affiliation(s)
- Bruno Lankoandé
- a Center for Demographic Research , Université catholique de Louvain , Louvain-la-Neuve , Belgium
| | | | - Abdramane Soura
- c Institut supérieur des sciences de la population , Université de Ouagadougou , Ouagadougou , Burkina Faso
| | - Gilles Pison
- b French Institute for Demographic Studies , Paris , France.,d Museum national d'histoire naturelle , Paris , France
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12
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Mai TTX, Lee E, Cho H, Chang YJ. Increasing Trend in Hospital Deaths Consistent among Older Decedents in Korea: A Population-based Study Using Death Registration Database, 2001-2014. BMC Palliat Care 2018; 17:16. [PMID: 29325534 PMCID: PMC5765638 DOI: 10.1186/s12904-017-0269-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background With improvement in hospice palliative care services and long-term care, Republic of Korea (hereafter South Korea) has recorded significant changes in places of death (e.g., hospital, home), especially among older adults. Over the last few decades, the most common places of death in South Korea were hospitals. However, Koreans, especially older adults, reportedly prefer to receive terminal care and eventually die at home. This study was conducted to investigate trends in places of death among older Korean adults and factors associated therewith. Methods Data were obtained from the Korean Death Registration Database maintained by the National Statistical Office. Decedents who died after the age of 65 years from 2001 to 2014 were included in the analysis. For descriptive analysis, proportions of places of death were analyzed and were used to plot graphs for visualizing trends during 13-year period. Logistic regression model was used to evaluate factors associated with places of death (hospital versus home). Results Two million three hundred fifty eight thousand two hundred eleven older adult decedents were included in final analysis. Hospitals were the most common places of death (57.82%), followed by homes (32.12%). Dying at social welfare facilities was rare (2.61%). A gradual increase in hospital deaths (31.38% in 2001 to 75.30% in 2014) and a subsequent decrease in home deaths (60.44% to 15.95% over the same period) were noted. Hospital deaths were more likely for younger patients (ORs 1.28, 95% CI 1.27-1.29), females (ORs 1.28, 95% CI 1.27-1.29), and single/divorced or widowed individuals (ORs 1.77, 1.49 and 1.03 respectively). A higher education level and living in urban areas were strongly associated with a higher likelihood of dying in a hospital. Conclusion Over the study period, there was a consistent increasing trend in hospital deaths in South Korea. Trends in place of death and factors associated therewith should be more intensely investigated and monitored. Resources and facilities should be increased to fulfill end-of-life care preferences and the needs of an increasingly older population in South Korea.
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Affiliation(s)
- Tran Thi Xuan Mai
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea
| | - Eunsook Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.,Department of Cancer Biomedical Science, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea
| | - Hyunsoon Cho
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea. .,Division of Cancer Registration and Surveillance, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea.
| | - Yoon Jung Chang
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea. .,Hospice and Palliative Care Branch, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea.
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13
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Abera SF, Gebru AA, Biesalski HK, Ejeta G, Wienke A, Scherbaum V, Kantelhardt EJ. Social determinants of adult mortality from non-communicable diseases in northern Ethiopia, 2009-2015: Evidence from health and demographic surveillance site. PLoS One 2017; 12:e0188968. [PMID: 29236741 PMCID: PMC5728486 DOI: 10.1371/journal.pone.0188968] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 11/16/2017] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION In developing countries, mortality and disability from non-communicable diseases (NCDs) is rising considerably. The effect of social determinants of NCDs-attributed mortality, from the context of developing countries, is poorly understood. This study examines the burden and socio-economic determinants of adult mortality attributed to NCDs in eastern Tigray, Ethiopia. METHODS We followed 45,982 adults implementing a community based dynamic cohort design recording mortality events from September 2009 to April 2015. A physician review based Verbal autopsy was used to identify the most probable causes of death. Multivariable Cox proportional hazards regression was performed to identify social determinants of NCD mortality. RESULTS Across the 193,758.7 person-years, we recorded 1,091 adult deaths. Compared to communicable diseases, NCDs accounted for a slightly higher proportion of adult deaths; 33% vs 34.5% respectively. The incidence density rate (IDR) of NCD attributed mortality was 194.1 deaths (IDR = 194.1; 95% CI = 175.4, 214.7) per 100,000 person-years. One hundred fifty-seven (41.8%), 68 (18.1%) and 34 (9%) of the 376 NCD deaths were due to cardiovascular disease, cancer and renal failure, respectively. In the multivariable analysis, age per 5-year increase (HR = 1.35; 95% CI: 1.30, 1.41), and extended family and non-family household members (HR = 2.86; 95% CI: 2.05, 3.98) compared to household heads were associated with a significantly increased hazard of NCD mortality. Although the difference was not statistically significant, compared to poor adults, those who were wealthy had a 15% (HR = 0.85; 95% CI: 0.65, 1.11) lower hazard of mortality from NCDs. On the other hand, literate adults (HR = 0.35; 95% CI: 0.13, 0.9) had a significantly decreased hazard of NCD attributed mortality compared to those adults who were unable to read and write. The effect of literacy was modified by age and its effect reduced by 18% for every 5-year increase of age among literate adults. CONCLUSION In summary, the study indicates that double mortality burden from both NCDs and communicable diseases was evident in northern rural Ethiopia. Public health intervention measures that prioritise disadvantaged NCD patients such as those who are unable to read and write, the elders, the extended family and non-family household co-residents could significantly reduce NCD mortality among the adult population.
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Affiliation(s)
- Semaw Ferede Abera
- Institute of Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany
- Food Security Center, University of Hohenheim, Stuttgart, Germany
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- Kilte Awlaelo- Health and Demographic Surveillance Site, Mekelle, Ethiopia
| | - Alemseged Aregay Gebru
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- Kilte Awlaelo- Health and Demographic Surveillance Site, Mekelle, Ethiopia
| | - Hans Konrad Biesalski
- Institute of Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany
- Food Security Center, University of Hohenheim, Stuttgart, Germany
| | - Gebisa Ejeta
- Department of Agronomy, Purdue University, West Lafayette, Indiana, United States of America
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Faculty of Medicine, Martin-Luther University, Halle, Germany
| | - Veronika Scherbaum
- Institute of Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany
- Food Security Center, University of Hohenheim, Stuttgart, Germany
| | - Eva Johanna Kantelhardt
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Faculty of Medicine, Martin-Luther University, Halle, Germany
- Department of Gynaecology, Faculty of Medicine, Martin-Luther University, Halle, Germany
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14
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Chisumpa VH, Odimegwu CO, De Wet N. Adult mortality in sub-saharan Africa, Zambia: Where do adults die? SSM Popul Health 2017; 3:227-235. [PMID: 29349220 PMCID: PMC5769069 DOI: 10.1016/j.ssmph.2017.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 11/23/2022] Open
Abstract
Place of death remains an issue of growing interest and debate among scholars as an indicator of quality of end-of-life care in developed countries. In sub-Saharan Africa, however, variations in place of death may suggest inequalities in access to and the utilization of health care services that should be addressed by public health interventions. Limited research exists on factors associated with place of death in sub-Saharan Africa. The study examines factors associated with the place of death among Zambian adults aged 15–59 years using the 2010–2012 sample vital registration with verbal autopsy survey (SAVVY) data, descriptive statistics and multivariate logistic regression analysis. Results show that more than half of the adult deaths occurred in a health facility and two-fifths died at home. Higher educational attainment, urban versus rural residence, and being of female gender were significant predictors of the place of death. Improvement in educational attainment and investment in rural health facilities and the health care system as a whole may improve access and utilization of health services among adults. We examined factors associated with place of death among adults aged 15–59 in Zambia. Health facility remains the common place of death in Zambia followed by the deceased's home. High proportion of adults still dying at home indicates a lack of access to and the utilization of health care services. Educational attainment, sex, and urban-rural residence were strong predictors of the place of death. Variations in place of death by population background characteristics among adult decedents may suggest inequalities in access and utilization of health services.
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Affiliation(s)
- Vesper H Chisumpa
- Department of Population Studies, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia.,Demography and Population Studies Programme, School of Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clifford O Odimegwu
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicole De Wet
- Demography and Population Studies Programme, School of Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
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15
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Powell RA, Namisango E, Gikaara N, Moyo S, Mwangi-Powell FN, Gomes B, Harding R. Public priorities and preferences for end-of-life care in Namibia. J Pain Symptom Manage 2014; 47:620-30. [PMID: 23870841 DOI: 10.1016/j.jpainsymman.2013.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 04/03/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Although quality end-of-life care provision is an international public health issue, the majority of evidence is not generated in low- and middle-income countries that bear a disproportionate burden of progressive illnesses. OBJECTIVES To identify the priorities and preferences of the Namibian public for end-of-life care. METHODS Using a cross-sectional study design, data were collected in the country's capital, Windhoek, from November to December 2010. RESULTS In total, 200 respondents were recruited. The mean age was 27 years (SD 7.5; range 18-69), with nearly all (n = 199; 99.5%) expressing a religious affiliation. Being in pain was reported as the most concerning of nine common end-of-life symptoms and problems (n = 52; 26.1%), and the most important care-related aspect was having as much information as wanted (n = 144; 72%). The majority (64%) would want their end-of-life care to focus on improving their quality of life rather than extending it, with 40% not wanting to know if they had limited time left to live. Hospital (n = 96; 48%) and home (n = 64; 32%) were the most preferred places of death. The most important end-of-life priority was keeping a positive attitude (n = 128; 64%). Having had a close relative or friend diagnosed with a serious illness was associated with a 2.3 increase in the odds of preference for a hospital death (odds ratio = 2.34, P = 0.009, 95% CI 1.23-4.47). CONCLUSION This study identified a number of areas that need to be pursued in future research to explore factors that may affect patient preferences and priorities in end-of-life care in Namibia.
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Affiliation(s)
- Richard A Powell
- HealthCare Chaplaincy, New York, New York, USA; African Palliative Care Association, Kampala, Uganda.
| | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda
| | - Nancy Gikaara
- African Palliative Care Association, Kampala, Uganda
| | - Sherperd Moyo
- African Palliative Care Association, Kampala, Uganda
| | - Faith N Mwangi-Powell
- African Palliative Care Association, Kampala, Uganda; Open Society Foundations, New York, New York, USA
| | - Barbara Gomes
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
| | - Richard Harding
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
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Causes of mortality for Indonesian Hajj Pilgrims: comparison between routine death certificate and verbal autopsy findings. PLoS One 2013; 8:e73243. [PMID: 23991182 PMCID: PMC3749149 DOI: 10.1371/journal.pone.0073243] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 07/19/2013] [Indexed: 11/19/2022] Open
Abstract
Background Indonesia provides the largest single source of pilgrims for the Hajj (10%). In the last two decades, mortality rates for Indonesian pilgrims ranged between 200–380 deaths per 100,000 pilgrims over the 10-week Hajj period. Reasons for high mortality are not well understood. In 2008, verbal autopsy was introduced to complement routine death certificates to explore cause of death diagnoses. This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings. Methods Public health surveillance was conducted by Indonesian public health authorities accompanying pilgrims to Saudi Arabia, with daily reporting of hospitalizations and deaths. Surveillance data from 2008 were analyzed for timing, geographic location and site of death. Percentages for each cause of death category from death certificates were compared to that from verbal autopsy. Results In 2008, 206,831 Indonesian undertook the Hajj. There were 446 deaths, equivalent to 1,968 deaths per 100,000 pilgrim years. Most pilgrims died in Mecca (68%) and Medinah (24%). There was no statistically discernible difference in the total mortality risk for the two pilgrimage routes (Mecca or Medinah first), but the number of deaths peaked earlier for those traveling to Mecca first (p=0.002). Most deaths were due to cardiovascular (66%) and respiratory (28%) diseases. A greater proportion of deaths were attributed to cardiovascular disease by death certificate compared to the verbal autopsy method (p<0.001). Significantly more deaths had ill-defined cause based on verbal autopsy method (p<0.001). Conclusions Despite pre-departure health screening and other medical services, Indonesian pilgrim mortality rates were very high. Correct classification of cause of death is critical for the development of risk mitigation strategies. Since verbal autopsy classified causes of death differently to death certificates, further studies are needed to assess the method’s utility in this setting.
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