Guidelines^ for Investigating Suspected Starvation Deaths
Item
- Title
-
Guidelines^ for Investigating
Suspected Starvation Deaths - extracted text
-
Guidelines^ for Investigating
Suspected Starvation Deaths
(Document prepared by the JSA Hunger Watch Group)
1
A
Contents
Section I: Introduction
Section II: Outline of Investigation Methodology
Section III: Assessment of Death Rates
Section IV: Anthropometry to assess nutritional status of the community
Section V: Assessing ‘Food Security’ related schemes and parameters
Section VI: Verbal Autopsy procedure
Section VII: How to prepare the final report and draw the ‘Hunger Pyramid’
Section VIII: Entitlements for a population facing Food Insecurity
Annexures
1.
Verbal Autopsy questionnaires
2.
Expected Weight for Age (NCHS Standard)
3.
LAP classification of Weight for Age
4.
Details of food security schemes
2
Section I
Introduction
During the last few years, news items of drought, crop failure, suicides by farmers, and
reports of starvation and hunger deaths have come in from various parts of the country. The
stark contrast between deaths in situations of severe food deficit on one hand, and
government godowns overflowing with food grains on the other hand is mind-boggling.
Governments routinely shrug off reports of starvation deaths either by pointing out that
people have been eating some inedible items (like mango kernels), or by blaming some
illness immediately preceding the death. Often the only steps taken by the government are to
hide the cause of mortality when there is uproar over starvation deaths. The reluctance of the
Government to formulate and disseminate a coherent definition of starvation and starvation
deaths is regrettable. It is surprising that even the academic community of nutritionists and
public health professionals has not taken interest in clarifying this area of considerable social
significance. This is a major hindrance for people’s organisations who try to answer distress
calls of the affected citizens.
In this context, during the NWG meeting of Jan Swasthya Abhiyan on 4 January 2003, it
was decided to form a ‘Hunger Watch’ group as a response to high levels of undemutrition,
growing instances of hunger deaths and government apathy towards them. The aim was to
arrive at a scientific protocol to investigate and document hunger related mortality. This
protocol could be employed across the country to assess undemutrition and document
starvation deaths.
Subsequently, a group of activists from the Jan Swasthya Abhiyan, met on the 22nd and
23rd February 2003 in Mumbai to constitute the ‘Hunger Watch’ and to concretise the
methodology to investigate hunger related deaths.*
One of the ideas behind constituting such a group has been that while the situation of
silent hunger hardly seems to draw any action for relief, instances of suspected starvation
deaths send the government machinery into overdrive to vehemently deny their occurrence.
Therefore it was thought that efforts must be made to systematically investigate and
document starvation deaths, at the same time keeping a focus on a community diagnosis of a
starving population and to advocate for relief to the entire community. The occurrence of a
starvation death could be used as an advocacy tool to highlight the omnipresent
undemutrition, and could help establish the Right to Food for chronically starved populations
especially in case of severe drought or crop failure.
We are acutely aware that the issue of starvation is ultimately not primarily a technical
issue, but is rather related to deep-rooted socio-economic inequities, which require radical
and systemic solutions. While the Hunger Watch group can perhaps only help point out the
larger changes necessary, our dream would remain an India where no one goes to sleep
hungry, no child remains undernourished, and no shame of a starvation death burdens our
conscience.
Those attending the Mumbai meeting included Veena Shatrughna (Deputy Director, National
Institute of Nutrition, Hyderabad), Vandana Prasad (Paediatrician), Narendra Gupta (Prayas), Sunita Abraham
(Christian Medical Association of India), Sarojini (SAMA and Convenor of MFC), C. S. Kapse (Professor,
Department of Forensic Medicine, D. Y. Patil Medical College), Neeraj Hatekar (Professor, Department of
Economics, University of Mumbai), Sanjay Rode (Ph. D. student. Department of Economics, University of
Mumbai), Abhay Shukla (Co-ordinator, SATHI Cell, CEHAT), Neelangi Nanai, Amita Pitre and Qudsiya (all
researchers at CEHAT).
3
Section II
Outline of Investigation Methodology
While approaching the issue of hunger related deaths, we should start with the basic fact
that starvation and malnutrition related deaths are public health problems requiring
community diagnosis. In this sense they differ from classical ‘disease related mortality’. The
diagnosis of a death due to tuberculosis may be approached as an individual diagnosis. But the
diagnosis of a ‘malnutrition death" cannot be just an individual diagnosis; we have to
document the circumstances prevailing in the family and community along with the individual
to reach such a conclusion.
When we look at the scale and depth of malnutrition in tribal and rural areas of our
country, making individual diagnosis of a few 'malnutrition deaths' may seem almost
peripheral to the main issue. These deaths, though tragic and extremely unfortunate especially
since they could have been so easily prevented, are just the tip of the iceberg of a situation of
near universal undemutrition in most tribal and backward rural areas. However, the paradox is
that the Government can ignore or downplay the fact that millions of children and adults lead
lives of severe, chronic undemutrition since it does not provoke any public outcry. But a few
malnutrition deaths reported in the press make the entire Government machinery go into
overdrive to 'deny' such an event and take some emergency measures. Even civil society and
middle class opinion which starts wringing hands at the mention of starvation deaths, remains
impervious to the implications of findings such as NIN data according to which around 90%
of children in rural areas are undernourished! So what do we do - focus on the widespread
community undemutrition / starvation or on the few starvation deaths? The first emerges as
the main problem from a public health perspective while the second has certain urgency and
carries the advocacy impact of moving public opinion and the Govt, system. Our approach
needs to adequately understand and document both.
Another issue we need to keep in mind is that generally prevalent 'baseline' malnutrition,
gradually worsening severe malnutrition and definite starvation merge with each other along
a seamless continuum. In a community which is used to barely subsistence intake, three years
of drought reduces this further and then some families start eating once a day, a few poorest
families eat on alternate days ... where exactly is the dividing line between malnutrition and
starvation? When exactly does the situation change from 'a chronic problem' to 'an alarming
situation'?
Keeping these considerations in mind, we have tried to evolve a methodology to
document starvation / malnutrition related deaths within a public health framework.
To establish adult starvation deaths in a particular conununity, we suggest the
following criteria:
♦ Documentation of recent increased death rates (monthly, tri-monthly) in the community
compared to state averages
♦ Anthropometric indicators below state averages
♦ No mass disasters or other accidents
♦ Reduced food off-take from PDS and other indicators of reduced food security like eating
unusual foods, increased indebtedness, large-scale outmigration for work etc.
♦ Sample dietary histories to assess daily calorie intake, show starvation diets (<850 Kcal
per day in adults)
4
L
♦ Verbal autopsies reveal at least a few deaths in which starvation is an underlying cause of
death (irrespective of the immediate cause, which may often be infections etc.)
Verbal autopsies should be used only in conjunction with the first five criteria, to
document specific starvation deaths. Individual starvation deaths are only extreme examples
of the severe nutritional deprivation being suffered by the entire community, and should
always be presented in the larger context of community starvation.
For children, the following criteria may tentatively be used to establish malnutrition
deaths ♦ Increased death rates among under-five children compared to state U5MR. An exercise
must be done to calculate age specific death rates, and compare this with the state averages
to define increased death rates.
♦ Siblings of children who have died of suspected malnutrition can be assessed. Their
anthropometry may show very poor nutritional status and this would be supportive
evidence.
♦ Access ICDS records/ records from other sources for weight of the deceased child shortly
before death if possible
♦ High mortality from minor infections (e.g. diarrhea, measles) is itself an indicator that the
underlying cause of death is malnutrition. We need to compare mortality rates due to the
infection in the sample community with ‘standard’ mortality rates for that illness. If say
the case fatality rate for measles in a community is 20% compared to the known case
fatality rate of 2% then the 'measles deaths' in the community are actually malnutrition
deaths in which the terminal event is measles.
Keeping these broad criteria in mind, the following activities would need to be
carried out for the investigation:
(a) Initial contact with the community, coming to know about villages affected and anecdotal
reports of starvation deaths
(b) Selection of village (s) / hamlet(s) to be taken up for the study
(c) Assessment of deaths rates in these communities during a specific recent period
(d) Anthropometric measurements on a sample of adults and children
(e) Dietary survey to assess adequacy of food intake in sample families (can be combined
with anthropometric survey)
(f) Assessment of any deterioration in food security in the community, based on data about
off take from PDS etc.
(g) Accessing ICDS weight-for-age records for recently deceased children if available
(h) Verbal autopsy in case of selected suspected starvation deaths
5
I
Section III
Assessment of Death Rates
An important component of investigating suspected starvation deaths is the calculation
of death rates, in a specific area and pertaining to a specified period during which suspected
starvation deaths have been reported.
Identifying the area for investigation - Anecdotal reports may be received about unusually
high number of deaths from certain villages. A cluster of such villages, from where there have
been reports of suspected starvation deaths, may be taken up for investigation. All the deaths
that have taken place in these villages during the period of serious food deficit (say a period of
at least three months, may be six months or one year) would need to be documented.
Once the villages and the period have been finalised, all the deaths during the period
should be recorded by means of small group enquiries throughout the area (covering all
hamlets and house clusters)/ house to house survey in that area to document deaths in that
particular period of time. The families of all the deceased would need to be visited, the date /
month of death should be verified for all deaths being investigated. Deaths whose timing falls
outside the study period should be excluded from the calculation.
To confirm the timing of all deaths, and in order not to miss any deaths, an attempt
should be made to compare this data with the mortality records maintained by the ANM for
the area. Our experience is that the ANM may be better at recording neonatal and infant
deaths, since she does antenatal registration, but she may not record certain deaths esp. of
adults in remote hamlets, which she visits infrequently.
Local calendar, local festivals, phases of the moon and local market days may be used
to ascertain the date of death in case of all deaths in the specified period. The exact number of
deaths in this period should be used for the calculation of death rates. The shorter the recall
period, greater will be the accuracy in assessing the date of deaths.
A parallel important exercise is to assess the exact population of all the villages /
hamlets in the cluster, which would form the denominator. The Gram Panchayat would
usually have figures and voter lists, yet this may be cross-checked by actual estimation of
number of households based on information from local people.
How to check whether the number of deaths in this particular area are significantly
higher or not?
There are two major issues involved if we calculate the death rates for a
comparatively shorter period (e.g. three months) and in a small sample, and then extrapolate
it to the whole year and compare it with the state figures. Firstly, there is seasonal variation in
deaths. For e.g. there may be more deaths in rainy season due to water bom diseases like
diarrhoea. If the death rate we have calculated in our study coincides with the period in which
there are seasonally higher deaths in that region, and then we extrapolate to the whole year,
then definitely the death rate that we have calculated will be an overestimate compared to the
annual death rate. Thus it is essential to consider the seasonal variation in deaths while
calculating death rates for a shorter period. One way of doing this is to compare death rate in
a specific season this year with the death rate during the same season last year. A higher rate
this year indicates a definite and significant increase.
A second important issue related to calculating death rates in this manner is that if the
sample population we have covered is too small in size, and then if we compare it with the
rates of the state, it will may give an inaccurate estimate of death rates for that sample
6
4
population being higher than the total state. For that we need to take certain minimum
population while calculating death rates (to be estimated), and perform a statistical
comparison ofproportions, which will take into account the difference in sample size.
To see whether the number of deaths in the area we are investigating are significantly
higher than the previous year in the same area or than that of the nearby villages in the same
year, we will have to follow certain steps:
1. Document all the deaths in the area we are investigating in the specified period of time
in which we are suspecting that the starvation deaths have occurred.
2. Find out the number of deaths in the same area in the same period in the previous year
through Gram Panchayat data.
3. The data for deaths in that District in the same period can be collected from the NSS
records.
4. Find out the number of deaths for the district in that period.
To overcome the problem of seasonal variation in deaths, here we are comparing the
deaths in the same period during last year in the same population. To calculate whether
the deaths in the area we are investigating are significantly higher, we can apply the
comparison of proportions test or chi-square test. For comparison, age specific deaths
should be compared.
For e.g. total number of deaths in the age group of 0 to 5 years in the village we are
investigating are 17 in the year of investigation and the total number of children in this
age group is 138.
In the previous year in the same village the total number of children in the same age
group were 154 and the total deaths that took place were 13. Then to find out whether the
number of deaths in this year is significantly higher or not, apply the proportion test.
Pl=17
Ql=121
Nl=138
P2=13
Ql=141
N2=154
Standard error of difference\|piQl/Nl+ P2Q2/N2
= 17X121/138 + 13X141/154
26.80839
= 5.1776
= 5
Actual difference - less than 10 that is less than 2 SD therefore not significant
7
4
Section IV
Anthropometry to assess nutritional status of the community
An effective nutritional survey involves an assessment of nutritional status of children
and adults in the area based on anthropometric measurements, assessment of specific
deficiencies, socio-economic status, along with current sources of income, availability of
food and social security measures such as Fair price shop, Ration shop and Anganwadis etc.
The following strategies could help in an accurate estimation of nutritional status based on
anthropometric measurements. The other parameters could be tackled with the help of a short
questionnaire answered by people in a village meeting.
At the outset explain what you are going to do to the activists who are helping you.
Repeat this when you go to the actual villages. Explain the procedure patiently to each person
involved in the study. Take their oral consent after informing them about the nature of the
study, what is the objective behind it and where will the results be used. Assure them that the
names of all participants will be strictly confidential in case they are alarmed about this.
Lastly tell them that they can withdraw from the study at any stage.
Sampling- It is the method of choosing a part of the study population, rather than the
entire population, for participation in the study. It should be representative of all the strata in
the population. Sampling makes the study easier, economical and enables us to study a larger
area.
Various methods can be employed for this according to our needs. In case of the
present study we can study two or three hamlets in the area, which will give us a good idea of
the nutritional status in the whole area.
In order to take a representation from all the groups in the population we can
select hamlets such that:
♦ Hamlets close to the road and away from road are covered.
♦ Hamlets of different tribes, and or backward castes/ classes/ areas we are interested in
working with are covered
♦ Hamlets with and without an Anganwadi facility are covered.
We can choose 2-3 hamlets, which cover these aspects. This would be a representative
sample of the people we would like to work with. Within the hamlet we need not choose a
further sub-sample if the hamlet is as small as of 30-40 households. In case it is as large as
that of 100-200 households, we can take a 50% sample, i.e. we can choose every alternate
house. This will give us a good representation of that hamlet. We can study the children in
the age group of 1-5 yrs and adults above the age of 18 years in the chosen households. This
sampling scheme will be repeated in each area we want to study.
Nutritional survey of children- The weight of a child is a sensitive indicator of its
nutritional status. NCHS standards for ideal body weights for children, both male and female
are available to us. (Annexurel) Classification systems based on these standards enable us to
decide from the age of the child and its weight if the child has a normal nutritional status or is
either undernourished or overweight. The IAP standards (Indian Academy of Paediatrics) are
most commonly used as they are also the standards used by the ICDS (Integrated Child
Development Scheme). In order to use this classification the weight of the child in Kilograms
(Kg) and the age of the child in months should be available. It is also desirable to measure the
height of the child to know the Height for age and whether there is 'stunting' which shows
chronic/ long term undernutrition.
8
Tools required-
Weighing scale
1.
2.
Height measuring tape
3.
Indian / local Calendar to ascertain the exact date of birth.
Weighing children above the age of 2 years is not a problem as they can stand on the
weighing scale. To weigh children between the ages of 12 months to 24 months, ask any
responsible adult to hold the child in her arms. Weigh them both together. Then weigh the
adult alone and calculate the difference between the two weights.
Precautions to be taken while measuring weight:
(a) The zero error of the weighing scale should be checked before taking the weight and
corrected as and when required.
(b) The individual should wear minimum clothing, and be without shoes.
(c) The individual should not lean against or hold anything , while the weight is recorded.
For accurate measurement of height, ask the person to stand against a straight wall. The
position should be as such that both the feet are together, heels to wall and chin parallel to
ground looking straight ahead.
As record of vital statistics is very poor in rural India, many times there is no reliable
record of the child’s age. Hence make sure that you are acquainted with the local festivals or
landmark events, and take an Indian Calendar while recording the date of birth of the child.
Make as accurate an estimation in months of the child’s age. This is important for the
following calculation.
The weight of the child should be compared to the ideal weight for that age mentioned in
the NCHS standards. Calculate what percentage of the NCHS standard is the child’s weight,
using the formula-
Weight of the child
Percentage of the NCHS standards =
x 100
Expected weight for that age (NCHS std)
IAP classification of Nutritional Status
Grade of Nutrition
Normal_____
Mild
to
moderate
undernutrition
I
II__________
Severe undernutrition
HI
IV
Weight as Percentage of NCHS
weight stds
>80%
71-80%
61-71%
51-60%
50% <
Tabulate the number of children falling in each category of nutrition status.
9
Nutritional Status of Adults- This is assessed based on the Body Mass Index or the
BMI. BMI is the ratio of the weight of the adult in Kgs to the square of her/his height in
meters.
BMI = Weight in Kgs
Height in meters
This is a very good indicator of adult nutritional status as it is age independent. It
measures the person’s weight for her height. Values of BMI between 20 to 25 are normal.
Undemutrition is measured using the following parameters.
Nutritional Status using BMI
Grade
undernutrition
HI degree CEP*
1. BMI <16
II degree CED
2. BMI 16-17
I degree CEP
3. BMI 17-18.5
Low normal
4. BMI 18.5 to
20________________
Normal
5. BMI 20 to 25
Overweight
6. BMI >25
BMI analysis
of
*CED - Chronic Energy Deficiency
Criteria to define starvation in Adults - An important issue is that malnutrition,
starvation and starvation deaths seem to lie along a continuum. How is it possible to
demarcate one from the other? A significant research finding is that in adults, below BMI of
19, mortality rates start rising. Mortality rates among adults with BMI below 16 are nearly
triple compared to rates for normal adults.
Thus in adults a B.M.I of 16 and less should be used as a cut off point to demarcate
starvation from undemutrition. Based on a requirement of 0.7 Kcal / kg / hour, a 50 Kg person
needs about 850 Kcal per day to maintain oneself at Basal Metabolic Rate, without any
physical activity. Thus any food intake that is sustainedly lower than 850 Kcal per day
would be incompatible with life in due course and is an indication of starvation.
10
Section V
Assessing ‘Food Security9 related schemes and parameters
The issue of food security has gained importance in India in the decade of 90s when
India clearly established self reliance in food production required to meet the food needs of
its total population. In fact, in late 1990s the country accumulated huge stocks of food
sufficient to feed the country even if there were no crops for three years. However the
paradox is that inspite of overflowing graneries, a large number ofpersons and families still
sleep hungry for certain periods in a year, leave aside getting food in balanced quantity.
There are about 800 million children undernourished in the world, out of it 400 million
children are in India. A majority of adults in the country have less than the optimum body
mass index. Reasons for prevailing chronic under nutrition both among children and adults
range from inability to purchase food due to poverty to non-availability of affordable food
owing to improper functioning of the public distribution system.
What is Food Security :
The concept of food security implies that all people, at all times, have physical and
economic access to sufficient, safe and nutritious food to meet their dietary needs and food
preferences for an active and healthy life. But unfortunately, this is not happening in India
today for the vast majority.
Food security in India, particularly for the vulnerable sections of the population, has
always been closely linked with the Public Distribution System (PDS) where from basic food
item the cereal was available at subsidised cost.
However, in recent years the prices have risen very rapidly. Also, in 1997, the Union
government drastically reduced the off take from the PDS when it introduced the Targeted
PDS (TPDS), which divided consumers into those below poverty level (BPL), and those
above poverty level (APL). APL consumers were to purchase grain from the PDS at a price
equal to the market rates, while the BPL consumers were expected to pay half the APL price.
This resulted in the total withdrawal of the APL consumers from the PDS, while the BPL
consumers found the prices beyond their purchasing power. The off-take of rice and wheat
taken together fell by about 10 million tonnes in 2000-01, adding further to the already
burgeoning grains stockpiled with the Food Corporation of India (FCI).
And today we witness this paradox in our country- about 70 million tonnes of wheat and
rice in Government go downs and over 200 million children, women and men chronically
undernourished.
The process of globalisation has further sharpened the threat to food security of many
people living in India and many developing countries. Chronic hunger is increasing in several
parts of the country. Improving food security at the household level is an issue of great
importance.
An estimated 400 million Indians do not have access to regular and adequate quantities
of food. Hunger, malnutrition and under nourishment are widespread. Many parts of the
country, particularly Orissa are stalked by death due to starvation. Recently there had been
reports of hunger related deaths in tribal pockets of Rajasthan and M.P. Such unusual hunger
amidst plenty can be attributed to a host of reasons, many of which are direct or indirect
consequences of the structural adjustment as a part of globalisation. Some of the features of
11
globalisation are the government set out to reduce subsidies and fiscal deficit by cutting state
expenditure on rural development, cutting food subsidies, reducing priority credit to
agriculture and allowing Indian agricultural prices to move closer to world prices which led
to increased food prices.
All of this however meant falling rural employment and real wages for the landless, and
more insecure and volatile incomes from cultivation for small farmers. Simultaneously food
prices in the Public Distribution System went up because of the reduction in food subsidies.
Very few could purchase foodgrains at such high prices. The government was left with huge
stocks, and it ran up enormous storage costs.
Repeated years of drought in states like Rajasthan and M.P. have led to extreme threat to
the food security of poor people. Not only food but, water and fodder for animals have been
an issue. In such situations, the government should not weaken the Public Distribution
System (PDS), rather it needs to universalise PDS, make the PDS effective in the rural areas
and create more employment opportunities for the rural people.
Inability and insensitive attitude of Government to ensure food security to its people in
many states of the country particularly in states like Rajasthan which is experiencing drought
for many years, the PUCL (People's Union for Civil Liberties), Rajasthan branch filed a writ
petition in the Supreme Court in 2001. The court after hearing arguments passed on interim
orders, which were applicable to the entire country. To ensure that court orders are followed,
the Supreme Court also appointed two commissioners - Shri N.C. Saxena and and Shri S.R.
Shankaran as the commissioners to undertake periodic review and submit reports about the
status of implementation by different state Governments.
In a significant interim order dated 28 November 2001, the Supreme Court issued
directions pertaining to 8 food-related schemes sponsored by the central government. Briefly,
the order directs the Union and State governments to implement these schemes fully as per
official guidelines. (See Annexure - 4 for outline of each scheme and a summary of the
corresponding Supreme Court directions)
How do we assess the implementation of food security schemes in our areas :
The eligibility criteria for each scheme are clearly laid out. We should obtain the list of
beneficiaries under various schemes from the local panchayat/block development or local
revenue office. A separate department generally implements ICDS scheme.
From the point of view of Food security, collecting information about PDS (including
Antyodaya Yojana), Annapurna Yojana, Mid-day meal scheme and ICDS should be a
priority. The information collected ought to be verified in the villages where we are working
with people. By verification we should try to ascertain whether selection of beneficiary
families/individuals is appropriate, and if there are more eligible families, which are left out.
We should also verify whether the selected families are receiving benefits in time and in full
quantity. A people’s monitoring team with advice of activists may develop monitoring
framework to undertake fortnightly verification exercise. A suggestive monitoring schedule is
attached.
12
I
Section VI
Verbal Autopsy procedure
Verbal Autopsy is a scientific method of proven validity used for establishing the cause
of death of individuals in a community, where forensic autopsies have not been or cannot be
conducted for any reason. This is particularly useful in situations where the proportion of
deaths occurring under medical care are low and where no autopsies are routinely carried out.
This method has been successfully employed in India, Bangladesh, Kenya, Nigeria,
Philippines, Indonesia, Egypt, and several other countries to determine the cause of death of
individuals in various circumstances, especially to identify causes of maternal and infant
mortality. At the Bhopal Peoples' Health and Documentation Clinic run by the Sambhavna
Trust, Verbal Autopsy (VA) was used as a method for monitoring mortality related to the
December 1984 Union Carbide disaster in Bhopal.
Sampling- Ideally, all the recent deaths in the area should be considered for VA, so there
is no sampling involved. All deaths during a specified period (from one to three months)
should be taken. Recall of details becomes poorer with respect to deaths prior to 3 months
before the time of VA, and should be avoided.
A less demanding method is to conduct VA only on suspected starvation deaths during a
specified recent period. However, here a working definition of ‘suspected starvation deaths’
needs to be used, for example ‘any death where family members report that the deceased had
significantly reduced food intake due to non-availability of food, during the month prior to
death’. This option would thus involve a two-stage survey process, first identification of
suspected starvation deaths and then VA on the selected suspected starvation deaths.
Technique of Verbal Autopsy-This method is based on the assumption that most causes
of death have distinct symptom complexes and these features can be recognized, remembered
and reported by lay people. It involves trained workers administering a questionnaire to the
carer / close family member of the deceased. Information thus collected on the symptoms
suffered and signs observed is given individually and independently to a panel of experts for
ascertaining the probable cause of death.
Steps in carrying out the Verbal autopsy
♦ Training- The questionnaire to conduct a VA is somewhat medicalised in nature and
hence we recommend that a person with some experience of health work be given
appropriate training in administering it, familiarity of the local language would be
necessary. However given the circumstances in which it has been successfully used
earlier, a well-trained fieldworker with good knowledge of the local language can also be
suited for the job. The section wise details of the questionnaire will be provided later. All
fieldworkers have to be given the background for conducting this VA, and be trained in
interviewing skills, administration of the questionnaire and signs and symptoms of
diseases.
♦ Identification of households- The fieldworkers would conduct a survey to identify and
list households where deaths have taken place during the specified time period. Then for
the VA, they would question carer of the deceased on the medical history and clinical
symptoms suffered. It is best to identify a single carer who has been with the deceased
13
X
and nursed her/him through the illness, and get all the information through this person. In
case of children, the mother is the best person, though this would depend entirely on the
circumstances. Using culturally appropriate language, the fieldworkers, should apply
stringent criteria in the collection and recording of information. Information would be
recorded on a questionnaire designed to elicit details of the last illness, bodily appearance
at the time of death, details of food availability in the house, medical examinations and
their results, treatment including duration etc.
The VA questionnaire- At the outset, the interviewer must explain to the carer, the
purpose of conducting the VA, and take an informed consent to proceed. This may be written
or oral in case of non-literate carer, but this should be explicitly recorded. The verbal autopsy
questionnaire (VAQ) begins with general, introductory questions to determine the lifecycle of
the deceased. An instruction sheet is used by the field workers as a guideline for
administration of the questionnaire. The instruction sheet should be translated into the local
language where it is to be administered. The health workers would also confirm which
medical records of the deceased are in the possession of the carer. General questioning
familiarizes the carer with the type of information to be collected and enables the interviewer
to create favorable conditions for the carer to speak openly, regarding personal and often
traumatic details concerning the deceased.
The health worker then begins an open section in which the interviewee is invited to
explain what happened in their own words, details of food security, subsequent illness/es, and
responses to treatment received till the death of the deceased. The statement is recorded
verbatim. With the use of filter questions, specific recordings of the symptoms related to
different body systems are then made. While the interviewer should be cautioned against
asking leading questions, the questionnaire consists of all important symptoms and signs
relating to the major body systems, which should not be left out in case their importance is
not realized by the carer. Thus the health worker identifies a body system, e.g. the respiratory
system and encourages the carer to provide voluntary information on any particular
symptoms, e.g. breathlessness, cough, expectoration tightness in chest etc. Care is taken to
ensure that the interviewer does not provide any direct or indirect suggestions during
questioning. Information on medical treatment received and documents related are also
gathered.
A special section is devoted to collecting information concerning family food security.
Another section elicits the dietary history relating to the deceased, during the week and
during the month prior to death.
Assessment of Completed Verbal Autopsy Questionnaires- The filled VAQ is then
sent to a panel of three independent physicians along with available medical records of the
deceased. The physicians in the verbal autopsy assessment panel (who do not communicate
with each other about their opinions) fill in a VA analysis table for their convenience, and
then write their opinions on the probable immediate, underlying and contributory causes of
death of the individual.
The final opinion is arrived at on the basis of the level of agreement among the three
independent medical opinions. In case all the three doctors in the assessment panel opine that
the underlying cause of death has been ‘Starvation’, then the final opinion states that the
’most probable' cause of death is attributable to ‘Starvation’. The final opinion states
'probable' in case two of the three doctors agree on the nexus between starvation and
subsequent death and 'possible' if only one of the doctors in the panel mentions starvation as a
probable cause of death. In case all three doctors opine that the disease or condition of death
14
is not related to ‘Starvation’, the final opinion states that the cause of death is unrelated to
‘Starvation’.
Validity of the method of Verbal Autopsy in ascertaining cause of death - Through
numerous studies carried out in different parts of the world, the method of Verbal Autopsy
has been found to have a positive predictive value in the range of 70% to 80% depending on
the cause of death and age of the deceased. This range of validity has been confirmed through
comparison of opinions on cause of death as ascertained through usual autopsies (post
mortem examinations) and that through Verbal Autopsy.
Appropriateness of VA in ascertaining starvation as a cause of death- The areas
where Verbal Autopsy is going to be used to assess starvation as a cause of death are also the
areas where availability of medical care is poor. This includes reasons related to extreme
poverty and physical lack of access to any government or private medical facility. Also, an
overwhelming majority of these deaths occur in people's homes resulting in autopsies rarely
being conducted and often there being no competent doctor to certify the cause of death.
Although some care may have been available, medical records of the deceased prior to death
are often unavailable or where available, these are often incomplete. Given such a situation,
VA appears to be the most appropriate method to assess the cause of death.
The VA has to be supplemented in these circumstances by a thorough recording of the
conditions of 'Food Security" prevailing in the community in general, including natural disasters of
drought, famines, rain and crop failure or conditions of gross/sudden unemployment, indebtedness
etc, similar conditions in the individual household, any signs of desperation to find food such as
borrowing, begging, stealing, consumption of unusual foods and incidents of suicide etc. Also an
analysis of the ‘Calorific value’ of whatever food is available and eaten should be undertaken, to see
whether the deceased was getting enough calories through food. To further strengthen the findings
anthropometric measurements of the living siblings in case of children and the Body Mass Index of
the living adults in the same household should be obtained.
Dietary Survey and Calorific Value of Locally Eaten Foods
Dietary survey is an essential part of the verbal autopsy process, which gives idea about
whether starvation / insufficient food intake is a cause of death or not.
Whenever a dietary survey is carried out in any community to investigate starvation
deaths, we first identify major local staple foods (basically cereals) eaten in that community.
Then we give a fixed amount (say 1 kg.) of flour or grains of that cereal in any two houses of
that community. We ask them to prepare their usual preparations out of the raw material
given. We then calculate the amount of flour used to make one roti or amount of pulse used
to prepare one Katori of dal. Then prepare a master chart indicating nutritive value of locally
available foods. For eg. In Badwani district of Madhya Pradesh where verbal autopsies were
conducted, one kilogram of maize flour was given to two families each and they were asked
to prepare roti. Out of one kg. flour, six roties were made which means each roti contains
approximately 170 gms. of flour. Since 100 gms of maize gives 342 calories, it was
concluded that one roti in this area gives 580 Kcal approximately.
In case of calculating calorie intake of the deceased, information should be elicited
regarding the food eaten by the deceased one week and one month prior to death. Note the
number of meals eaten by him /her in a day. List the food items and their ingredients in
details. In case of children, note the history of food intake up to three months prior to death.
With the help of the master chart of calorific value of locally available foods, then calculate
the total calorie intake of the deceased per day prior to death.
Based on a requirement of 0.7 Kcal / kg / hour, a 50 Kg person needs about 850 Kcal per
day to maintain oneself at Basal Metabolic Rate, without any physical activity. Thus any food
15
intake that is sustainedly lower than 850 Kcal per day would be incompatible with life in
due course and is an indication of starvation
It may be noted here that the intake during the week prior to death may be reduced due to
the illness itself, and is less significant to identify starvation compared to the intake one
month prior to death. The data on intake has to be combined with data on Food availability
for the family to come to a conclusion about lack offood intake due to non-availability of
food, in other words, starvation.
History of consumption of unusual or ‘famine’ foods like toxic roots, leaves, tubers etc.
or consumption of substances eaten to suppress hunger should also be noted. It indicates the
non availability of other edible food items like pulses, grains etc.
Confirming the date of death
To determine the exact date of death, local events calendar should be used. A local
events calendar shows all the dates on which important events took place during a past one
year period. It shows the different seasons, months, phases of moon, local festivals and events
in the agricultural cycle.
It is important to accurately determine the date of each death also in the context of
calculation of death rates (section III).
Mode and Causes of Death
Even medical professionals are often not very clear about the difference between mode of death
and cause ofdeath, and types of causes of death. Hence the need for us to be clear about these terms
when we talk of starvation as a cause of death.
The Death Certificate issued by a doctor should contain the followingCause of death: A disease or injury that results in the death of the individual. If there is
a time delay between the onset of the disease or injury and the time of death, then the cause
can be divided into the following categories:
(a) Immediate cause of death: This is the disease or injury that developed just before the
death and resulted in the death. E.g. Pneumonia, Diarrhoea, Ischaemic Heart Disease,
Bums, Accident.
(b) Underlying cause of death: When there is a delay between the onset of the disease or
injury and the ultimate death, this is the process that started the chain of events that
eventually resulted in the death. E.g Measles could be the underlying cause of
Pneumonia which resulted in death of the individual, Atheromatous or narrowed blood
vessels could be the underlying cause of Ischaemic Heart Disease. In the same way,
severe malnutrition or starvation could be the underlying cause of death in a case where
the immediate cause is diarrhea.
(c) Contributory cause of death is inherently one not related to the principal cause, but it
must be shown that it contributed substantially or materially; that it aided or lent
assistance to the production of death. It must be shown that there was a causal connection.
E.g Undemutition in death due Pneumonia, High blood pressure in Ischaemic Heart
Disease.
To illustrate the difference, take the case of a woman who is severely anemic during pregnancy.
Her severe anemia remains untreated, and immediately after delivery she has moderate amount of
bleeding and dies. (A healthy, non-anemic woman with similar amount of bleeding may have
survived.) In this case, immediate cause of death is post-delivery bleeding, while underlying cause is
severe anemia.
16
Mode of death: A pathophysiologic derangement that is incompatible with life. It is a
common final pathway to death for a number of disease processes. Modes of dying include
organ failure (e.g. ‘heart failure’, ‘renal failure’, multi-organ failure’), cardiac or respiratory
arrest, coma, cachexia, debility, uraemia and shock.
Therefore it is important to recognize that ‘Cardio-respiratory arrest’, which is often
erroneously mentioned as the immediate cause of death is in fact the mode of death in a
person. To state ‘cardio-respiratory arrest’ as a cause of death is not only factually erroneous,
it may also be a deliberate subterfuge by a medical official, to avoid commenting on the
actual cause of death, such as starvation.
As a general rule, a number of pathways can be responsible for a mechanism or mode of
death, but causes of death are specific. For example, shock has a number of causes and
therefore is a mode of death. However the post-partum sepsis that resulted in shock is the
cause of death.
Another way of looking at it is, if all dead people have the entity that you would like to
list as a cause of death, then it is likely to be a mode of death. All dead people suffer from
low blood pressure (shock), cardiac arrest and pulmonary arrest.
Starvation and Undernutrition as a cause of death- It is obvious that Starvation and
Undemutrition would generally occur as the underlying or contributory cause of death in an
individual. The final clinical event before death may be a minor infection such as diarrhea or
measles, which may become the immediate cause of death.
As we are going to deal with actual human beings in real life situations, the individuals
would suffer from gradual reduction in the calorie intake while having to keep up desperate
efforts to find work and food for the family. The children would have to cope with demands
for their growth. Rather than an absolute deprivation of food leading directly to death, we
would have a chain of events where starvation (<850 Kcal daily intake) is the underlying
cause, and an infection becomes the immediate cause of death.
Ethical issues related to conducting VA
There are certain serious ethical issues, which come up during the process of conducting
a verbal autopsy in such a social situation. Some of the issues encountered and how they may
be addressed are outlined below(a) Distress to relatives caused by the verbal autopsy procedure
The verbal autopsy process involves a detailed questioning of the relatives about the
illness, food intake, treatment and various other aspects of the deceased prior to death. This is
a process, which is liable to cause distress among the relatives of the deceased when they are
questioned.
To deal with this issue, an attempt should be made to carefully explain the purpose of the
study to the relatives. Also, the option of not participating in the study should be kept open
for the respondents. In some situations, where the respondents are not in a mental frame to
answer the questions, a second visit may be made to conduct the questioning at a later stage,
or the asking of information may be spread over two visits. Of course, the interviewer must
properly introduce himself / herself, state the purpose of his / her visit, and thank the
respondents for their co-operation etc.
(b) Possible raising of false expectations among respondents
Measuring of nutritional status of children and adults and detailed questioning of
relatives of the deceased might lead to generation of expectation of some immediate benefit
17
to be given by the interviewers to the respondents. This is especially likely if the interviewer
is a person from outside the area, of apparently better socio-economic background etc.
This problem may be partly avoided if the basis of contact is by means of a local
organisation or person who is already known to the people. If possible, the verbal autopsy
should be done by a person who is known to the community or linked with a local
organisation. People may be already aware of the method of working of the local organisation
and would not expect any personal preferential ‘dole’ from a person who is linked to the
organisation. Rather it should be made clear that the findings of the survey would be used to
generate pressure for better implementation of relief measures in the area, which would
benefit everyone, provided that such an attempt is planned.
(c) Need to share the results of the study with the people in their language
Such a study should preferably be conducted on the demand of a local organisation, and
should help to strengthen their demand for relief facilities. In the same spirit, the results of the
survey should be communicated to the people in their own language, in village meetings and
also by means of a simply written note in the local language.
18
Section VII
Method ofpreparing the final report and drawing the 6Hunger Pyramid^
The methodology of investigation as described in previous chapters has been devised to
ensure a thorough, factual and relatively objective investigation of a death as well as its
context.
However, the report is not a mere collation of the facts thus collected. The report is a
statement of our opinion on the basis of the facts collected along with corroborative
arguments and evidence. It is, therefore, an analytical document carefully arguing a case once
our investigation is complete and has led us to an opinion.
If the investigation convinces us that the death concerned is not a starvation death we
must make our report accordingly if asked to do so by any agency. However, henceforth, this
chapter assumes that we are making the report of what we consider to be starvation death(s),
either of children or adults, in the setting of a starving community.
The objectives of the report are twofold:
1. To verify and certify starvation death(s)
2. To clearly detail the prevailing community conditions of malnutrition and starvation
leading to morbidity (sickness) and further mortality (death) if action is not immediately
taken.
Such a report can be used for demanding immediate action such as compensation and
appropriate state action to ensure food security for the entire community, as well as build
evidence and pressure for long term policy changes.
The report should have the following sections, at least 1. Introduction
2. Under five mortality rates of the given community and comparison with state underfive mortality rates
3. Death rates within the community and comparison with state crude death rates
4. Estimation of malnourished children based on weight for age
5. Estimation of severely malnourished adults based on BMI
6. Details of starvation / malnutrition deaths among children
7. Details of starvation deaths among adults
8. Community situation of food security
9. Hunger pyramid for the community and overall assessment
10. Recommendations
1. Introduction
This section should outline the initial information (press reports, personal
communication), which originally led the team to investigate starvation deaths in this
particular community. It should also contain some information about the area (district, taluka,
villages), organisations and individuals involved in the investigation, and overall setting of
food insecurity in the state / region (drought, failure of food security schemes etc.)
19
2. Under five mortality rates of the given community and comparison with state
under-five mortality rates
3. Death rates within the community and comparison with state crude death rates
These death rates should be calculated and compared with the relevant state mortality
rates. Then the number of excess deaths (actual deaths minus deaths expected according to
state mortality rates) can be calculated. All excess deaths taking place in a situation of serious
food insecurity may be regarded as malnutrition deaths unless proved otherwise. Here the
absence of any major disasters or accidents may be quoted to rule out other causes of excess
deaths.
4. Estimation of malnourished children based on weight for age
All children with weight for height less than -3SD should be enumerated and listed
individually also. The number should be expressed as a percentage of all children and
compared with the state/block average as per ICDS records / NFHS II records, whichever
available. ICDS records are preferable. Increase should be shown as percentage increase and
it has to be argued that according to the WHO any child with -3SD or less weight for age
is considered in need of emergency treatment.
It has been documented that mortality rates among children increase several fold and
drastically when the weight for age is below 60% of the expected weight. Hence these
children are at very high risk of mortality. Any increase in numbers of such children indicates
that the entire community of children is at risk. Therefore, emergency measures must apply to
all children in that particular community.
According to the WHO criteria, if more than 30% of children in a community have low weightfor-age, it is a very high prevalence level. Although practically all poor rural communities in India
have higher than this level of malnutrition, this too may be cited as evidence of very high level of
malnutrition.
Low
% of children with
low weight-for-age (below -2 SD scores)
<10
Medium
High
Very High
10-19
20-29______________________________
>30
Prevalence group
(Criteria laid down in the WHO expert committee report on Anthropometry - WHO TRS 854, 1995)
For effective advocacy, the weights of the children in the affected area should be
compared with those of middle class children in the same age group. This would bring out the
differences more sharply than do figures of percentages in the various categories of
undemutrition.
5. Estimation of severely malnourished adults based on BMI
The number and percentage of adults with BMI less than 18.5 and BMI less than 16
should be computed and presented. Adults with BMI less than 16 are at high risk of mortality
from starvation. If over 40% of adults in the community have a BMI of < 18.5, the
community may be termed at ‘critical risk for mortality from starvation’ or a starving
community.
Low prevalence
5-9% population with BMI< 18.5
20
Medium prevalence
10-19% population with BMI< 18.5
20-39% population with BMI< 18.5
High prevalence
(serious situation)
>= 40% population with BMI< 18.5
Very high prevalence
(critical situation)_______________________________________________
(Criteria laid down in the WHO expert committee report on Anthropometry - WHO TRS 854, 1995)
6. Details of starvation / malnutrition deaths among children
This part of the report is based upon
1. Verbal autopsy
2. Anthropometry of siblings and family members
3. Community Situation of Food Security
4. Community Child Death Rates
These are used to argue the following points 1. Evidence that the dead child was already malnourished ( description of physical
appearance, hair, skin, nails, previous anthropometric /medical records, siblings and other
family members being malnourished - by anthropometry)
2. Evidence that there was acute shortage of food to the individual. This is done by relating
dietary history for the last few days to caloric intake. Since this is relatively difficult for a
child, specially a breast feeding child, this part of the report should be commented upon by
the technical support team (nutritionist / pediatrician)
3. Evidence that there was an acute shortage of food in the household ( dietary history of
other household members, examination of household food supplies, loan taken recently,
recent migration of able bodied family members, eating of unusual food, recent beggary /
crime for food, failure to receive food from PDS, ICDS or any other schemes due to non
availability, illness or debility)
4. Evidence that there is an abnormally raised child death rate in the community (section 2
of the report). Even if the terminal event in most of the deaths are infections (diarrhea,
pneumonia, measles) if the death rate is significantly higher than the under five death rate
for rural areas in the state, this is evidence of hunger related deaths provided there is a
community setting of food insecurity.
Infection as the terminal event
When the terminal event is an infectious disease, which is the commonest scenario, such
as pneumonia or diarrhoea, the ‘diagnosis’ of starvation death need not change.
This logical progression to disease, which forms the terminal event, is well documented
in cases of starvation. The last two points suffice to call a death a starvation death.
If there has been an outbreak of a disease (e.g. measles) and all the deaths have been
attributed to the outbreak, the logical argument in the context of starvation would be that
normally speaking the mortality of a disease does not exceed x percent of cases. The fact that
mortality has been so much higher proves that death was due to starvation, not disease.
7. Details of starvation deaths among adults
This part of the report depends upon 1. Verbal autopsy and dietary history
2.
Anthropometry of family members
21
Verbal autopsy
This is to establish that death did not take place due to accident or other physical trauma, and to
document the clinical events preceding death, as also dietary history and body appearance.
The dietary history component should be analysed in terms of caloric value by referring
to the charts of caloric values of local food for assistance or taking the assistance of the
technical support group. Caloric intake of less than 850kcal per day for an adult establishes the
diagnosis of starvation.
Food security of the family - substantiating findings of food stores within the family,
recent loans, migration of able-bodied members, eating of unusual foods, beggary should be
documented.
Anthropometry of surviving family members
BMI of less than 18.5 amongst adults of the family, and weight for age less than 3SD in
the children is supportive evidence that the whole family is in a situation of starvation.
8. Community situation of food security
The provision of supplies,access and uptake from PDS, Food for Work Programmes if
any, ICDS, Mid Day Meal, maternity benefit and other schemes should be described.
9. Hunger pyramid for the community
The above mentioned two objectives are fulfilled by drawing the entire ‘hunger pyramid’
that prevails within a community, of which the starvation death/s are only the tip.
Starvation deaths
Starving population
Severely undernourished^
Mild to Moderately
undernourished
<
Appropriate figures or percentages should be given for each of these categories, to give a
complete idea of the situation, e.g. in a particular village -
Starvation deaths - 6 persons (4 adults, 2 children)
Starving population - 7% families
Severely undernourished - 15% adults, 18% children
Mild to Moderately undernourished -43% adults, 62% children
Starvation deaths are those deaths which have been identified as being due to starvation
/ malnutrition on the basis of the Verbal autopsy process.
Starving population is the proportion of families where adults have a daily caloric
intake of less than 850 Kcal.
22
Severely undernourished population is the proportion of adults with BMI < 16 and in
case of children, those with weight for age less than 60% of expected, (deduct the proportion
of starving population from this to avoid overlap)
Mild to moderately undernourished population is proportion of adults with BMI <
18.5, proportion of children with weight for age less than 80% of expected (deduct the
previous two proportions from this to avoid overlap)
The investigating team along with the Hunger Watch group should express an overall
opinion. This should categorically express an opinion regarding the deaths that have taken
place - starvation deaths or not starvation deaths. It should also make a community diagnosis
- community at risk for further starvation deaths (starving community) or not.
10. Recommendations
Finally, the report should make recommendations for immediate action at the local
level.Recommendations should include compensation for the deceased, measures to feed and
supply food, hospitalization where necessary, arrangements for nutrition rehabilitation,
healthcare including immunization, long term food security measures.
23
Section VIII
Entitlements for a population facing Food Insecurity
1] Mid Day Meal Scheme (MDMS)
The National Programme for Nutritional Support to Primary Education [MDMS] was
started in 1995. Cooked mid-day meals were to be introduced in all government primary
schools within two years. In the meantime, state governments were allowed to distribute
monthly dry-rations to the children instead of cooked mid-day meals.
The centre allocates to each district, through the medium of the PCI, a quantity of grain
@100 gms of grains per child per day. The allocation is made based on the off take of the
previous term. Cooked meals with the content of 300 calories and 18-20 gms of protein is to
be provided on every working day of the school and for at least 200 days a year to students
having a minimum of 80 % attendance in the previous month. Where dry rations are given, 3
Kgs of wheat or rice per month is to be provided to every child with 80% attendance for 10
months in a year.
The Supreme Court order regarding this scheme is that cooked mid-day meal is to be
provided in all the government and government aided primary schools in all the states. In
states, where the scheme is not operational, it is to be started in half the districts of the state
(by order of poverty) by Feb 28th, 2002. By May 28, 2002, it is to be started in the rest of the
districts too.
2] Targeted Public Distribution System (TPDS)
The scheme was introduced in 1997 to replace the earlier universal public distribution
system (PDS). The families are categorized as below poverty line (BPL) and above poverty
line (APL). The two groups have different entitlements with BPL families getting more grain
at a cheaper price than APL families. The total number of BPL families in each State is
chosen by the Planning Commission. BPL families are to be identified on the basis of
household surveys. The BPL families are given a card of a different colour to distinguish
from the APL families.
3] Antyodaya Anna Yojana (AAY)
This scheme was supposed to provide food security to the poorest of the poor. Provision
has been made to identify one crore such families. The selected families are to be given a
special Antyodaya Card, with which they can claim the grain from the local ration shop. 25
Kgs of grains to be provided each month to the selected families at the price of Rs. 2 / Kg for
wheat and Rs. 3/ kg for rice. The identification of families is supposed to be done by Gram
Sabhas.
4] Integrated Child Development Scheme (ICDS)
The scheme is supposed to cover several activities, ranging from nutrition of the
pregnant women to nutrition, healthcare and educational needs of the child till he or she
completes the age of 6. Children up to 6 years are to be provided 300 calories and 8 to 10
gms of protein. Adolescent girls are to be provided 500 calories and 20-25 Gms of protein per
day. Pregnant and nursing mothers are to be provided 500 calories 20-25 gms of protein per
24
day. Malnourished children are entitled to double the daily supplement provided to the other
children [600 calories and/or special nutrients on medical recommendation.
The services to be provided under the scheme include supplementary nutrition,
immunization, health check-up, referral services, and non formal preschool education.
Annexure I
Verbal Autopsy Questionnaire - Adults
(Above 15 years of age)
Preliminary Information
Name of the deceased:
Date of interview:
Age in years at time of death:
Sex:
Male/Female
d. if FemalePregnant / Lactating/ Neither
Age of eldest living child
Marital status
* Married
* Unmarried
*Divorced
* Widowed
* Others
Address:
Name of the informant(s)
Informant’s relation to the deceased Who, among the informants, was present at the time of the fatal illness?
Occupation
(give details of type of work)
i) Working person, active till death
ii) Working person, stopped working for some period before death (specify period)
iii) Not working person
Family structure Total No. of Members
Male adults
Female adults
Children
Nuclear /
Joint
Income and food supply: (Relates to the family)
Agriculture:
Total Land owned
Irrigated land owned
Crop from last harvest was sufficient to adequately feed the family till which month
25
Wages: (In the last six months)
Work as agricultural labour No. of days in last 6 months
Work on Govt, relief works No. of days in last 6 months
Work outside the village (State the type of work)
No. of days in last 6 months
Daily WageDaily Wage-
Daily Wage-
Any other source of income:
Has the total income during last six months been sufficient to adequately feed all family
members?
Yes
No
If not then what was the approximate proportionate decrease (proportion of usual)? -
Which items in the diet specifically were decreased -
Foodgrains (Maize, Wheat, Jowar, Rice etc.)
Pulses
Vegetables
Oil, milk etc.
In the last six months relating to the deceased and family Were any unusual or ‘famine’ foods being eaten (roots, tubers, leaves etc.)
Were other members of the family eating such unusual things ?
Any substances being eaten to suppress hunger?
Was the family purchasing PDS rations ?
Did the family avail of drought relief ?
If so in what form?
Yes / No
Deaths of cattle or other animals
Distress sale of cattle, vessels, implements and other belongings to obtain food
Borrowing or begging food from neighbours, relatives or others
Personal habits
i. Smoking
If yes
Duration
Bidi / cigarette per day
Yes
No
26
ii. Alcohol
If yes
Duration
Quantity per day
Date of death
Day
Yes
No
Month
Weather at the time of Death:
Extreme cold
/
Extreme heat
Year
/
Neither
b. Families in immediate neighborhood:
Health centre / Hospital
Yes /
Place of Death
i. Home
Staying alone / With family
No
iii On the way to Health Centre/Hospital
iv. Any other
Whether Death Certificate Available
Yes/No
If not why
_If yes
Mention Cause of Death as certified
2. Medical history related to death
2.1 Was the deceased seeing a health care provider before death: l.yes
2.no
2.2 If yes, specify (name, profession, address.):
2.3 For how long:
years
2.4 For what complaint (specify):
2.5 Was the deceased taking any medication:
l.yes
2.no
2.6 If yes, specify (ask for remaining containers / unused medicines):
2.7 Was the deceased hospitalized before death:
2.8 If yes, specify where (name, address):
2.9 For how long:
2.no
l.yes
days
27
2.10 Did the deceased leave hospital (before death): l.yes 2.no
If yes, how many days before death?
days
2.11 Did the deceased undergo any surgical operation during this hospitalization: l.yes
2.no
2.12 If yes, when (before death):
days
2.13 Do you know what was the operation: l.yes 2.no
2.14 If yes, specify
2.15 Was the deceased or any member of the family ever told the nature (the diagnosis)
of the illness:
l.yes
2.no
2.16 If yes, what was it (specify as clearly as possible):
Was there any accident / poisoning / bite / bum or other unnatural event shortly before
death-
l.yes
2.no
2.17.1 If yes, what was the accident:
2.17.2 If yes, specify hours / days before death:
2.18 Where did the accident occur:
1. at work
2. road (vehicular accident)
3. at home
4. other (specify):
2.19 Organs/part of body injured during
accident
2.20 Other unnatural eventsDrowning
Poisoning
Hanging
Bite by snake or other venomous animal
28
Bums
Violence
Any other (specify)
How long before the death did this event take place?
(Hours /days)
Details of the event (in case of poisoning, what agent was used; in case of violence, what
type of violence etc.)
3. Specific disease related information
3.0 Open ended question about the illness According to what you know what did the deceased die of and how? Please narrate.
(All questions in the sections below pertain to the illness immediately preceding death
unless specified otherwise)
3.1 Cardiovascular system
Did the deceased ever complain of unusual breathlessness? : l.yes 2.no
If yes, was it on:
Exertion: l.yes 2.no
If yes, how much exertion:
1. Walking on level surface
2. Walking up an incline
3. Climbing stairs
2.no
2.no
Breathlessness while lying down flat: l.yes
At night, relieved by sitting up in bed: 1 .yes
2.no
3.1.2 Did the deceased ever complain of chest pain: l.yes
If yes:
3.1.2.1 Was it persistent for several hours:
l.yes
Was it accompanied by excessive sweating: 1. Yes
3.1.2.2 Was it relieved by rest:
2.no
2. No
l.yes 2.no
3.1.2.3. Did the deceased ever complain of cyanosis on the lips, fingers or nails: l.yes
2.no
3.1.2.4 Did the deceased ever complain of swelling on the body (the lower limbs, foot
and leg, eyelids, abdomen, back):
especially if lying down: 1 .yes
2.no
3.1.2.5 Did the deceased ever complain of an episode of palpitations (sudden rapid heart
beats for one hour or more):
l.yes
2.no
29
3.1.2.6 Did the deceased ever complain of recurrent sore throat, joint pain and
inflammation (migrating, fleeting and affecting several joints):
l.yes
2.no
Respiratory system
3.2.1 Did the deceased have cough:
3.2.2 Dry cough / Productive cough
If productive, was the sputum:
3.2.2.1 Clear and sticky:
l.yes
2.no
l.yes
2.no
3.2.2.2 Yellowish or greenish:
l.yes
2.no
3.2.23 Stained with blood:
l.yes
2.no
l.yes
3.2.2.4 Whether large quantity of sputum and offensive smell:
Duration of the cough
Was the cough related to season ? If so, in which season was it worse?
2.no
3.2.5 Chest pain: l.yes 2.no
If yes
3.2.5.1 Was it increased with cough and / or deep breath :
l.yes
3.2.5.2 Was it localized and tender:
l.yes
2.no
3.2.6 Wheezing:
l.yes
2.no
2.no
Digestive system
Did the deceased ever complain of:
3.3.1 Abdominal pain
If yes, since when?
Was the pain
3.3.1.1 Persistent:
3.3.1.2 Localized over one area:
If yes:
3.3.1.2.1 Central abdomen:
I
2.no
l.yes
l.yes
l.yes
2.no
2.no
l.yes
2.no
3.3.1.2.2 Left upper abdomen
l.yes
2.no
3.3.1.2.3.Right upper abdomen
l.yes
2.no
3.3.1.2.4 Lower abdomen
l.yes
2.no
If yes then - left side
right side
entire lower abdomen
30
3.3.1.2.5 Loin radiating to the groin (inguinal region) 1 .yes
2.no
3.3.1.2.6 Relieved by meals (food):
l.yes
2.no
3.3.1.2.7 Aggravated by meals (food):
l.yes
2.no
3.3.2 Persistent heartbum:
l.yes
2.no
3.3.2.1 Was it sometimes accompanied by water brash (belching of sour fluid in the
mouth :
3.3.3 Diarrhoea:
If yes, was it:
3.3.3.1 Acute (less than 15 days)
l.yes
2.no
l.yes
2.no
3.3.3.2 Chronic (more than 15 days)
3.3.3.3 Accompanied by blood
Alternating with constipation:
3.3.4 Vomiting blood: l.yes 2.no
If yes:
3.3.4.1 Was the blood:
l.yes
2.no
l.yes
2.no
1 .bright red
2.dark brown
3.3.4.2 Did this vomiting of blood last until death: l.yes
2.no
3.3.4.3 For how long before death:
month(s)
3.3.4.4 Was the deceased or any member of the family informed of the nature or the
cause of this
vomiting blood:
l.yes
2.no
If yes:
3.3.4.5 What wasnt
3.3.5 Normal stools with blood in the stools:
If yes:
3.3.5.1 Was the blood:
l.yes
2.no
l.red
2.dark brown
3.3.5.2 Did the symptoms last until death:
l.yes
2.no
If yes:
3.3.5.2.1 For how long before death:
months
3.3.5.3 Was the deceased or any member of the family informed of the nature or cause:
l.yes
2.no
If yes:
3.3.5.3.1 What was-rtr
31
| 7-1 1-8
3.3.6 Jaundice:
If yes:
3.3.6.1 For how long before death:
l.yes
2.no
days
3.3.6.2 Did jaundice last until death:
2.no
l.yes
3.3.6.3 Was the deceased or any member of the family told of its nature or cause:
l.yes
2.no
If yes:
3.3.6.3.1 What was it:
3.3.7 Persistent vomiting:
If yes:
3.3.7.1 Did it last until death:
l.yes
2.no
l.yes
2.no
days
3.3.7.1.1 What was the duration: (before death):
days
Urinary system
3.4.1 Did the deceased ever complain of one of the following symptoms:
3.4.2 Blood in urine:
l.yes
If yes:
3.4.2.1 Did blood in urine last until death:
l.yes
If yes:
3.4.2.1.1 For how long (before death):
2.no
2.no
month(s)
3.4.2.1.2 Was Blood in urine ever associated with pain:
l.yes
2.no
3.4.2.2 Was blood in urine: 1.persistent
2. intermittent
3.4.3 Problems in urination:
l.yes
2.no
If yes:
3.4.3.1 Decreased volume of urine: l.yes
2.no
3.4.3.2 Complete retention of urine lasting for more than a few hours:
l.yes
2.no
If yes:
3.4.3.2.1 Was this retention:
1 .recurrent
2.transient
3.4.3.2.2 Did this retention last until death:
1. yes
2. no
3.5 Infectious diseases
32
3.5.1 Did the deceased ever complain of fever in the month prior to death:
1. continuous 2. intermittent 3. never complained
If continuous or intermittent:
3.5.1.1 Did fever last until death: 1. yes 2. no
If yes:
Was the fever on alternate days or every day at a fixed time?
Were there chills / rigors accompanying the fever?
Was there continuous fever for more than one week?
3.5.1.2 Was the deceased or any member of the family ever informed of the nature of the
diagnosis
of this fever:
l.yes
2.no
If yes:
3.5.1.2.1 What was it.
Reproductive mortality
If the deceased is a female aged 12-50 years:
3.6.1 If married and living with her husband OR separated, divorced, or widowed for less
than 3 months,
did she complain before she died of:
3.6.2.1 Continuous fever:
2. no
1. yes
3.6.2.2 Vaginal bleeding:
1. yes
2. no
3.6.2.3 Abortion (up to 42 days (6 weeks) before death): 1. yes
2.
no
3.6.3 Was she pregnant and delivered before her death (up to 6 weeks before death)
regardless of gestation
age:
1. yes
2. no
If yes:
3.6.3.1 Where did the delivery take place:
1. hospital 2. home 3. other
(specify)
Any significant symptoms or events related to the pregnancy or delivery
Unusually large amount of vaginal bleeding before / during / after delivery
Inability to deliver within 24 hours of onset of labour
Severe continuous pain in the abdomen during labour
Pain in lower abdomen with fever / foul discharge after delivery
Malignancies
33
Did the deceased ever complain of:
3.7.1 The presence of any mass or tumour in any part of the body:
2.no
If yes:
3.7.1.1 Where: (specify, if a woman emphasize mass in breast)—
3.7.1.2 Did this tumour persist until death:
2.no
l.yes
l.yes
3.7.2 Continuous loss of weight with no apparent reason
1 .yes
2.no
3.7.3 Abnormal vaginal bleeding aside from the menstrual cycle especially after
menopause
3.7.4 Lump in the cheek / tongue
3.7.5 Was the deceased or any member of the family ever informed of the possible
existence of a malignant tumour or growth:
l.yes
2.no
If yes:
3.7.4.1 Where in the body (specify as clearly as possible).:
3.7.4.2 What was the outlook for the patient:
1 .not mentioned
2. good
3. reserved
4. bad (fatal)
Did the person have obvious loss of weight in the three months prior to death?
3.8 Other
Did the person have paralysis / extreme weakness on one side or a particular part of the
body?-------------------------------------------------------------------------------------------------Did s/he have severe continuous unremitting headache ?
If yes, was there accompanying fever and inability to bend the head forwards?
Did s/he have convulsions? If yes, did these last until death?
Was the body stiff/ arched back for some hours or days before death?
Was the person unconscious before death? if so, for what duration?
Specific information related to malnutrition / starvation
Food intake (semi-quantitative) - here the interviewer has to estimate the caloric intake if
possible based on detailed dietary history.
Daily intake during the week prior to death
How many meals did the deceased have in a day ?
Morning
34
Noon
Afternoon / evening
Night
Other meals / snacks
(Quantify exact amounts of roti, rice, ghat / rabdi (porridge), dal etc. as far as
possible)
Was this food enough to satisfy his hunger?
Daily intake during the month prior to death
How many meals did the deceased have in a day ?
Morning
Noon
Afternoon / evening
Night
Other meals / snacks
Was this food enough to satisfy his hunger?
4.2 a.
Water intake - Normal / reduced / increased / do not know
b.
Source of Water -
Did s/he complain of
Constant complaint of hunger
Loss of feeling of Hunger
Dizziness on standing up
Extreme weakness and inability to walk
Inability to see at night
What were the observations of the family members regarding the deceased person:
Eyes: Sunken/ Normal/ Do not know
Skin: Creases, wrinkles over forehead and face as usual
Increased
Do not know
Normal /
Scaling or peeling /
Do not know
Hair: Normal / Dry or discoloured / Do not know
35
*
Cheeks : As usual/ very sunken /Do not know
Ribs: As usual / very prominent/ Do not know
Limb bones : As usual / prominent/ Do not know
Abdomen: As usual/ very sunken /Do not know
Hipbones : As usual/ prominent and projecting /Do not know
Tongue: Dry / coated or fissured / Do not know
Normal pink colour / very pale or whitish / Do not know
Lips: Normal / Dry or cracked / Do not know
Gums : normal / loose teeth, bleeding / do not know
Swelling over Ankle
Y/N
If yes -
unilateral / bilateral
Face
Upper limbs:
Y/N
Y/N
Palms and nails: Normal pink colour / very pale or whitish / do not know
Body temp : Normal / Cold / Do not know
Bed sores : None
If yes, site : Shoulder blade/ Lower back / Hip/Calf /Other part
Behavioral changes: None /Muttering or irrelevant talk / Unconscious
5. Presumed cause of death
5.1 From death certificate if available:
5.2 From verbal autopsy form:
5.21 Immediate cause of death:
36
5.22 Underlying cause(s) of death
5.23 Contributory cause(s) of death:
Questionnaire modified from - Mortality and causes of death in Jordan 199596:assessment by verbal autopsy
S.A. Khoury, D. Massad, T. Fardous,
Bulletin of the World Health Organization, 1999, 77 (8)
37
Verbal Autopsy Questionnaire for Children
Instructions to interviewer: Introduce yourself and explain the purpose ofyour visit. Ask to speak
to the mother or to another adult carer who was present during the illness that lead to death. If this is
not possible, arrange a time to revisit the household when the mother or carer will be home.
Section 1: Background information on child and household
(To be filled in before interview)
1.1 Address of household
1.2 Name of child
1.3 Sex of child: 1. Male
2. Female
Section 2: Background information about the interview
2.1 Language of interview
day/month/year
Date of first interview attempt
Date of second interview attempt
Date of third interview attempt
Date of interview
Section 3: Information about carer/respondent
3.1 What is the name of the main respondent?
3.2 What is the relationship of main respondent to deceased child? (tick relevant box)
Mother
Maternal Grandmother
Paternal Grandmother
Maternal Grandfather
Paternal Grandfather
Paternal Uncle
Maternal Uncle
Maternal Aunt’s Husband
Paternal Aunt’s Husband
Maternal Aunt
Paternal Aunt
Paternal Uncle’s wife
Maternal Uncle’s wife
Elder brother
Elder sister
1.
Other male (specify)
17.Other female (specify)
3.3 What is the age of main respondent (in years)
3.4 How many years of school did the main respondent complete?
3.5 Were other people present at the interview?
l.Yes
2. No
(If “No”,go to question 3.5.3)
3.5.1 Of those present at the interview, which were present at the illness that led to
death/hospitalization?
38
3.5.2 Total number giving information at interview
3.5.3 If mother is not present at the interview, is the mother still alive?
Yes
No
Section 4: Information about the child
4.1 Date of birth of child:
/
/
(dd mm yy)
4.2 What was the date of death?
/
/
(dd mm yy)
4.3 Where did the child die? (tick relevant box)
1. Hospital
2. Other health facility
3. On route to hospital or health facility
4. Home
5. Other (specify
.)
4.3.3 For deaths at hospital or health facility, record facility name and address:
Section 5: Open history question
5.1 Could you tell me about the child’s illness that led to death?
Prompt: Was there anything else?
Instructions to interviewer - Allow the respondent to tell you about the illness in his or her own
words. Do not prompt exceptfor asking whether there was anything else after the respondentfinishes.
Keep prompting until the respondent says there was nothing else. While recording, underline any
unfamiliar terms.
Take a moment to tick all items mentioned spontaneously in the open history questionnaire.
5.3 Was care sought outside the home while he/she had this illness?
1. Yes
2. No
3. Don’t know
(If “No ” or “Don' t know ", go to section 6)
5.3.1 (Ifyes ask:) Where or from whom did you seek care? (Record all responses)
1. Traditional healer
2. Governmental health centre or clinic
3. Government hospital....
4. Community-based practitiioner associated with health system including trained
birth attendants..
5. Private physician
39
*>
6. Pharmacy, drug seller, store, market
7. Other provider
8. Relative, friend (outside household)
After respondent finishes prompt: Did you seek care anywhere else?
Keep using this prompt until respondent replies that they did not seek
care from anyone else.
Note: Above categories should be country-specific.
Section 6: Accident
6.1 Did the child die from an accident, injury, poisoning, bite, burn or drowning?
l.Yes
2. No.
3. Don’t know
(If “No” or lDon’t know”,go to section 7)
6-1 • 1 (Ifyes ask): What kind of injury or accident? Allow respondent to answer
spontaneously. If respondent has difficulty identifying the injury or accident, read the list slowly.
1. Motor vehicle accident
3. Drowning
5. Bite or sting by venomous animals
7. Other injury (specify)
2. Fall
4. Poisoning
6. Bum
6.1.2 How long did the child survive after the injury, poisoning, bite, burn or drowning?
1.
Died within 24 hours
2. Died 1 day later or more
Section 7: Age determination and reconfirmation
7.1 Record the child’s date of birth from question 4
/_
_/__
dd mm yy
Record child’s date of death from question 4.2__
_/
dd min
yy
7.2 Take a moment and calculate the age of the child at the time of death. Read out:
I have calculated that the child was
days (or months or years old as
appropriate) at the time of death. Is this correct?
If the respondent indicates this is not correct, reconcile the inconsistency by re-checkin the child’
s date of birth and date of death. Make the necessary corrections here and in section 4.
>
If child died within 24 hours from injury or accident,go to section 10 - treatment and
records.
>
If child was less than 28 days old do not record any details as that is beyond the
purview of this study.
>
If child was 28 days old or more at the time of death, go to section 8 - post-neonatal
deaths
Section 8: Post-neonatal deaths
8.1
During the illness that led to death, did he/she have a fever?
l.Yes
2. No
(Jf “No” or "Don ’ t know”, go to question 8.2)
3. Don’t know
8.1.1 (Iffever ask): How many days did the fever last?
.
days
40
8.2 During the illness that led to death, did
liquid stools?
have frequent loose or
1. Yes
2. No
3. Don’t know
8.2 During the illness that led to death, did he/she have (local terms for diarrhoea)?
Note: When preparing the country-specific questionnaire, include local terms for
diarrhoea.
2. No 3. Don’t know
1. Yes
(If “No” or “Don* t know”, for both questions 8.2 and 8.3, go to question 8.4)
8.3.1 (Iffrequent or loose stools or local terms for diarrhoea ask):
For how many days did he/she have loose or liquid stools?
days
8.3.2 Was there visible blood in the loose or liquid stools?
1. Yes
2. No
3. Don’t know
8.3.3 During the time with the loose or liquid stools, did the child drink ‘Rabdi’ or
‘Salt and Sugar solution’ or ORS?
1. Yes
2. No
3. Don’t know
8.3.4 During the illness that led to death, did the child have a cough?
l.Yes
2. No
3. Don’t know
(If “No” or “Don’t know”,go to question 8.5)
8.5 During the illness that led to death, did the child have difficult breathing?
l.Yes
2. No
3. Don’t know
(If “No ” or Don ’ t know”,go to question 8.6)
8.6
l.Yes
During the illness that led to death, did the child have fast breathing?
2. No
3. Don’t know
(If “No ” or Don ’ t know ”,go to question 8.7)
(If yes ask): For how many days did the difficult breathing last?
days
8.6.1 (Ifyes ask): For how many days did the fast breathing last?
days
8.7
l.Yes
During the illness that led to death, did he/she have indrawing of the chest?
2. No
3. Don’t know
41
8.8 During the illness that led to death, did he/she have noisy breathing?
(Demonstrate each sound)
8.8.1 Stridor. .
8.8.2 Grunting
1. Yes
1. Yes
2. No
2. No
3. Don’t know
3. Don’t know
8.8.3 Wheezing
1. Yes
2. No
3. Don’t know
8.9
During the illness that led to death, did his/her nostrils flare with breathing?
1. Yes
2. No
3. Don’t know
8.10 During the illness that led to death, did the child have pneumonia?
1. Yes
2. No
3. Don’t know
Note: When preparing country-specific questionnaires include local terms for pneumonia here.
8.11 Did the child experience any generalized convulsions/fits during the illness
that led to death?
8.12 1. Yes
3. Don’t know
2. No
8.13 Was the child unconscious during the illness that led to death?
2. No
1. Yes
3. Don’t know
8.14 At any time during the illness that led to death, did the child stop being able to
grasp?
2. No
1. Yes
3. Don’t know
(If “No " or Don ’ t know ’^go to question 8.14)
8.15 At any time during the illness that led to death, did the child stop being able to
respond to a voice?
1. Yes
2. No
3. Don’t know
(If “No ” or Don' t know ”,go to question 8.15)
8.16 At any time during the illness that led to death, did the child stop being able to
follow movements with their eyes?
1. Yes
2. No
3. Don’t know
(If “No” or Don’t know”,go to question 8.16)
8.15.1 (Ifyes, ask): How long before he/she died did the child stop being able to follow
movements with their eyes?
1.
2.
Less than 12 hours
12 hours or more
42
8.17 Did the child have a stiff neck during the illness that led to death?
(Demonstrate) 1. Yes
2. No
3. Don’t know
8.18 Did the child have a bulging fontanelle during the illness that led to death?
l.Yes
2. No
3. Don’t know
8.19 During the month before he/she died, did the child have a skin rash?
l.Yes
2. No
3. Don’t know
(If “No” or Don’t know”,go to question 8.18)
8.18.1 (Ifyes, ask) Was the rash all over the child’s body?
2. No
1. Yes
3. Don’t know
8.18.2 Was the rash also on the child’s face?
l.Yes
2. No
3. Don’t know
8.18.3 How many days did the rash last? ...
days
8.18.4 Did the rash have blisters containing clear fluid?
2. No 3. Don’t know
1. Yes
8.18.5 Did the skin crack/split or peel after the rash started?
1. Yes
2. No
3. Don’t know
8.18.6 Was this illness “measles”?
1. Yes
2. No
3. Don’t know
Note: When preparing country-specific questionnaire include local
term for measles.
8.18 During the illness that led to death, did the child become very thin?
1. Yes
2. No
3. Don’t know
8.20 During the illness that led to death, did the child have swollen legs or feet?
8.21
1. Yes
2. No
3. Don’t know
(If “No” or Don’t know”,go to question 8.21)
8.20.1 (If yes, ask): How long did the swelling last? Number of weeks
8.22 During the illness that led to death, did the child’s skin flake off in patches?
1. Yes
2. No
3. Don’t know
8.23 Did the child’s hair change in colour to a reddish (or yellowish) colour?
I
43
2. No
1. Yes
3. Don’t know
Note: When preparing country-specific questionnaire, terms for colour to be locally
adapted.
Did the child have “marasmus” during the month before he/she died?
1. Yes
2. No
3. Don’t know
Note: When preparing country-specific questionnaire, local terms for marasmus should be
included.
8.24 During the illness that led to death, did the child suffer from “lack of blood”
or “pallor”?
1. Yes
2. No
3. Don’t know
Note: When preparing country-specific questionnaire, local terms for “lack of blood” or
“pallor” should be included .
8.25
During the illness that led to death, did the child have pale palms?
1. Yes
2. No
3. Don’t know
Note: When preparing country-specific questionnaire, local terms for “pale palms” should be
included.
8.2.7 During the illness that led to death, did the child have white nails? (Show photo if
possible)
1. Yes
2. No
3. Don’t know
Note: When preparing country-specific questionnaire local terms for “white nails” should be
included here.
8.26
armpits?
During the illness that led to death, did the child have swellings in the
1. Yes
8.27
2. No
3. Don’t know
During the illness that led to death, did the child have swellings in the groin?
1. Yes
2. No
3. Don’t know
8.28 During the illness that led to death, did the child have a whitish rash inside the
mouth or on the tongue?
1. Yes
2. No
3. Don’t know
9. Information about the Nutritional status of the child
9.1 What and how much was the child eating about one week before death?
9.1.1 How many meals did the child have in a day?
9.1.2 Approximately what and how much was the child eating in the
44
Morning
Afternoon
Evening
Night
Other
(Try to quantify approximately how much each of Roti, Ghat, Raabdi. Etc)
9.1.3 Was this food enough to satisfy the child’s hunger?
9.2 What and how much was the child eating about one month before death?
9.2.1 How many meals did the child have in a day?
9.2 2.Approximately what and how much was the child eating in the
_
Morning
Afternoon
Evening
___________________________________________
Night
Other
(Try to quantify approximately how much each of Roti, Ghat, Raabdi. Etc)
9.2.3 Was this food enough to satisfy the child’s hunger?
9.3 What and how much was the child eating about three months before death?
9.3.1 How many meals did the child have in a day?
9.3.2 Approximately what and how much was the child eating in the
Morning
Afternoon
______________________________________________
Evening
Night
Other
_________
(Try to quantify approximately how much each of Roti, Ghat, Raabdi. Etc)
9.3.3 Was this food enough to satisfy the child’s hunger?
45
9.4 Was the child being given any unusual foods apart from what is usually given? (e.g.
leaves, roots, tubers)
Were others in the family also eating such unusual foods?
Were any foods being eaten to suppress hunger?
9.5
Information about the Income and Food security of the family.
9.5.1
Agriculture
Total land ownedTotal irrigated land owned
Harvest of the previous year was sufficient to feed the family for how many months?
9.5.2
Labour
Work in the form of agricultural labourer- No. of days in the last six months
Work as daily labourer■
Work obtained in the relief work started by the GovernmentHow many days in the last six monthsDaily wages■
Work obtained outside the villageHow many days in the last six monthsDaily wages9.5.6 Was the income in the last six months enough to adequately feed the family?
9.5.7 If not then how much was the decrease ? (Approximately estimate what
proportionate paise of a rupee)
The decrease was seen in which eatables
1.
Main food (Maize, Jowar, Rice, Wheat)
2.
Pulses
3.
Vegetables
4.
Oil. Milk etc
5.
Meat, Fish, Eggs etc
9.6
1.
2.
3.
4.
9.7
1. Yes
How much water was the child drinking in the week before death ?
Usual quantity
Less than usual
More than usual
Do not know
Did the child suffer from ‘Night Blindness’ ?
2. No
3. Do not know
46
9.8
Were the comers of the child’s mouth cracked, or did he/she have
ulcers in the mouth/ tongue?
l.Yes
2. No
3. Do not know
9.9
1. Yes
Did the child have problems such as bleeding gums or loose teeth?
2. No
3. Do not know
9.10
Did the child have ‘bow legs’ ?
l.Yes
2. No
3. Do not know
Section 10: Treatment and records
I would now like to ask a few questions about any drugs the child may have received
during the illness that led to death.
10.2 Do you have any prescriptions, case papers or other health records that belonged to
the child ?
l.Yes
2. No
3. Don’t know
(If “No” or Don't know”,go to question 10.5)
10.2.1 (If yes ask): Can I see the health records?
1. Yes
2. No
3. Don’t know
(If “No” or Don't know ”,go to question 10.5)
If respondent allows you to see the health records, transcribe all the entries within the
12 months before the child died.
10.3 Weights (most recent two)
10.3.1 Record the dates of the most recent weight, two weights
2._
/_
/_
/_
/
(dd/mm/yy)
(dd/mm/yy)
10.3.2 Record the most recent two weights .
1
2
10.4 Medical notes
10.4.1 Record the date of the last note...
10.4.2 Transcribe the note
(dd/mm/yy)
10.5 Was a death certificate issued?
1. Yes
2. No
3. Don’t know
(If “No ” or Don' t know ”,go to question 10.7)
INSTRUCTIONS TO INTERVIEWER - Ask to see the death certificate and record
whether you have been able to see it.
47
10.5.1 Able to see death certificate?
l.Yes
2. No
(If “No”,go to question 10.7)
10.6
Record the immediate cause of death from the certificate
Record the first underlying cause of death from the
certificate
Record the contributing cause(s) of death from the certificate
Now I would like to ask a few questions about the child’s mother.
10.7
Has the child’s mother ever been tested for “HIV”?
1. Yes
2. No
3. Don’t know
(If “No” or Don’t know”,go to question 10.8)
10.7.1 {Ifyes ask): Was the “HIV” test ever positive?
1. Yes
2. No
3. Don’t know
10.8
Has the child’s (biological) mother ever been told she had “AIDS” by a
health worker?
1. Yes
2. No
3. Don’t know
11.
form:
From verbal autopsy
11.1
death:
Immediate cause of
11.2
death:
Underlying cause(s) of
11.3
death:
Contributory cause(s) of
END OF INTERVIEW
THANK RESPONDENT(S) FOR THEIR COOPERATION
(Modifiedfrom - WHO/CDS/CSR/ISR/99.4; A STANDARD VERBAL AUTOPSY METHOD FOR
INVESTIGATING CA USES OF DEATH IN INFANTS AND CHILDREN)
48
1
Annexure II
Expected Weight for Age
(NCHS Standard)
Weights in Kg.
Age in
months
12
15
18
21
24
27
30
33
36
39
42
45
48
51
54
57
60
63
66
69
72
75
Male
10.2
10.8
11.5
12.5
12.6
13.1
13.7
14.2
14.7
15.2
15.7
16.2
16.7
17.2
17.7
18.2
18.7
19.2
19.7
20.2
20.7
21.2
Female
9.5
10.1
10.8
11.3
11.9
12.4
12.9
13.4
13.9
14.5
15.1
15.5
16
16.4
16.8
17.2
17.7
18.1
18.6
19.5
19.5
20
Reference- Weight in Kg are 50th percentiles of Boys and Girls;
NCHS growth curves for children, Birth-18 yrs. National Centre for Health Statistics,
Publ No. DHS 878-1650, 1977. Hyattsville MD, USA
49
, '...I
Annexure III
IAP classification for weight for age
Weight for Age
Years
A
B
G
oys iris
ge
1
1
1
9
2
0.2
.5
1.3 m
1
1
1
5
0.8
0.1
1 1/2
1
1
1
8
1.5
0.8
1.9 m
2
1
1
1
2.5
1.3
2
2
1
1
4
2.6
1.9
2.3 m
2
1
1
7 3.1 2.4
2 1/2
3
1
1
0
3.7
2.9
2.9 m
3
1
1
4.2
3.4
3
3
1
3
1
6
4,7
3.9
3.3 m
3
1
1
9
5.2
4.5
3 1/2
4
1
1
5.1
_2_ 5.7
4‘
3.9 m
1
1
5
6.2
5.5
4‘
4
1
1
8
6.7
6
5‘
4.3 m
1
1
1
7.2
6.4
5‘
4 1/2
1
1
4
7.7
6.8
5’
4.9 m
1
1
7
8.2
7.2
6‘
5
1
1
0
8.7
7.7
6"
5.3 m
1
1
3
9.2
8.1
6‘
5 1/2
1
1
9.7
6
8.6
6"
5.9 m
2
1
9
0.2
9.5
2 ‘
7"
6
1
2
0.7
9.5
50
6.3 m
7
5
2
1.2
2
0
Annexure IV
Suggested reading material
1.
Physical Status: The Use And Interpretation Of Anthropometry
Report Of A WHO Expert Committee
WHO technical report series 854
2.
51
(W T - ) ^-5
] 0-) 7-2
- Media
12128.pdf
Position: 981 (8 views)