Mortality rate and cause of death pattern in Thai Nguyen and Quang Ninh provinces

Cause of deaths reflects the burden of diseases in the community and is important information for evidence-based health policy. Objectives of the study were to determine mortality rates and cause of death pattern in Thai Nguyen and Quang Ninh.

MORTALITY RATE AND CAUSE OF DEATH PATTERN IN THAI NGUYEN AND QUANG NINH PROVINCES

Pham Ngan Giang, Nguyen Phuong Hoa, Thanh Ngoc Tien, Nguyen Thi Tuyet Nhung

Department of Family Medicine, Hanoi Medical University Cause of deaths reflects the burden of diseases in the community and is important information for evidence-based health policy Objectives of the study were to determine mortality rates and cause of death pattern in Thai Nguyen and Quang Ninh A cross - sectional study was conducted One thousand four hundred and seventy seven deaths were recorded at 26 communes in 2014 The survey was used WHO standard verbal autopsy questionnaire The results showed that overall mortality rate was 4.94‰, mortality rate among males was higher than among females (6.09‰ versus 4.91‰, p < 0.05), urban population had lower rate of death than the rural population (4.73‰ versus 5.56‰, p < 0,05) The results showed that most of the deaths occurred at home (88%), only 4.8% of deaths in health facilities There was a transition in the cause of death pattern while the leading causes were cardiovascular diseases, cancer and injury In particular, death from stroke was 20.6%, lung cancer 8.3% and traffic accident 3.7% In conclusion, it is necessary to collect information about the deaths, which are outside health fa-cilities (at home) and an intervention programs need to prioritize for some of the leading causes of death.

Keywords: mortality rate, cause of death, burden of diseases

I INTRODUCTION

Mortality statistics and causes of death

(COD) information are important to measure

population health status, identify key public

health issues, set priorities, and improve

health outcomes through effective resource

allocation [1 - 3] However, an estimated 2/3

of all deaths were not reported globally

Mil-lions of people in Africa and Asia die without

leaving any trace in legal records or official

statistics [4]

Mortality data on causes of death for Vietnam have not been reported to the World Health Organization (WHO) to date [5; 6] With a population of over 91 million [6], there is a critical need for such data for the above stated purposes At the national level, due to limitations in the availability of data, cause of death patterns in Vietnam has been estimated based on mortality data from Chinese, Thai and Indian populations [7]

The absence of complete and valid na-tional mortality data limits the evidence base to estimate the burden of disease in

Corresponding author: Nguyen Phuong Hoa,

Depart-ment of Family Medicine,, Hanoi Medical University

Email: nguyenphuonghoa@hmu.edu.vn

Received: 05 June 2017

Accepted: 16 November 2017

Vietnam At the national level, three

organi-zations within the Government of Vietnam

collect national mortality data: the Ministry

of Health (MOH), the Ministry of Justice

(MOJ), and the General Statistics Office

(GSO) GSO data provide important

indi-cators such as life expectancy and crude

death rates [8] However, this source does

not collect detailed information about COD,

which is urgently required by the health

sec-tor for developing health interventions,

prior-ity setting, and policy formulation The MOJ

has legal responsibility over the national

civil registration and vital statistics system

For deaths, this system only collects

infor-mation about the numbers of deaths by sex

and age However, the registration of deaths

recorded in this system is low for different

areas Also, the MOJ system does not have

any procedures for formal reporting of the

causes of death (COD)

In order to meet the information needs

of the health sector, the MOH operates a

routine death register system at commune

health stations (CHS) Local commune

health staffs identify deaths in the

commu-nity and record basic demographic data and

information on the cause of death for each

death in an official MOH log-book named

the “A6 register” Frankly, data from the A6

registers are not used effectively at different

levels in the health sector because there is

no consistent process for compiling data

from A6 registers at district, province, and

national levels; therefore the MOH mortality

database now in the Statistical Handbook

of Vietnam MoH was based on mortality

data from hospitals only However, currently

in Vietnam, the majority of deaths occur at

home

Therefore, by using verbal autopsy (VA), this study was conducted to determine mor-tality rates and cause of death pattern in Thai Nguyen and Quang Ninh in 2014

II SUBJECTS AND METHODS

1 Study sites and sample

The study was implemented in two prov-inces, Quang Ninh and Thai Nguyen, which are located in the Northern region of Viet-nam In each province, one urban district and one rural district were chosen to as-sess likely differences between those two areas Within each selected district, 6-7 communes were chosen as study sites by simple random method

The study sample comprised all deaths that occurred between 01/01/2014 and 31/12/2014 among residents of the 26 se-lected communes There were 1477 deaths

in total, which were listed by combining the A6 registers, the Justice Clerks’ books and some other resources All deaths in each selected commune were re-investigated to ascertain the causes of death, using Ver-bal Autopsy (VA) surveys There were 1365 Verbal Autopsy (VA) interviews conducted The other 112 cases could not undertake VA mainly due to the movement of population

2 Methods

This assessment was based on a cross-sectional study design

Data collection

- Making the combined death list All deaths recorded in A6 registers, the Justice Clerk books and some other

sourc-es during the defined one-year period

be-tween 01 January 2014 and 31 December

2014 were extracted onto a separate form

Information collected included reported

name, age and sex, date of death, address

of the deceased Then, a process of

match-ing death cases from these sources was

carried out by commune health staffs, who

were responsible for mortality recording

Variables used for the matching process

were name, sex, age, date of death, and

address of the deceased

- Implementing Verbal Autopsy surveys

All deaths identified in the above

com-bined list were followed up to conduct the

household verbal autopsy (VA) interview

using a standardized questionnaire that

elicits information on signs, symptoms,

medical history, and circumstances

preced-ing death The VA questionnaire used for

this assessment is the updated version of

the Vietnamese verbal autopsy

question-naire, accompanied by a manual and guide

for fieldworkers The original English

ver-sion of the VA questionnaires, which was

recommended by WHO, were translated

into Vietnamese and revised

Interviewers were local health workers

from commune health stations who have

medical related backgrounds (e.g., medical

assistants, nurses) working at the commune

or village level where the deaths occurred,

and who have the responsibility for

collect-ing data and recordcollect-ing it in the A6 registers

at commune health stations The training of

interviewers emphasized techniques and

communication skills to motivate the

princi-pal caretaker of the deceased to participate

in the survey and encourage them to give

accurate and honest answers

The interviewees were persons who were mainly responsible for taking care of the decedent before he/she died, and who were able to provide information about the symptoms and diseases experienced by the deceased prior to death

The supervisors were the principal in-vestigators and staff in the Provincial/ Dis-trict Health Centre Supervisors provided assistance and monitored the interviewers’ activities to ensure the quality of the VA in-terviews On completion of all VA interviews were diagnosed and coded of the Underly-ing cause of death (UCOD), by trained doc-tors The UCOD then was coded using Inter-national Classification of Diseases version

10 (ICD-10) by application of the mortality coding rules and guidelines[9]

Data analysis and management

Epidata software and SPSS18 were em-ployed to analyse data

The proportions were calculated by communes, district, provincial levels, urban/ rural areas, sex, broad age groups (0 - 4 years, 5 - 14 years, 15 - 59 years, and 60+), place of death, type of health facility, and the last treatment method Each proportion was computed for 95% confidence intervals [10]

3 Ethics

Respondents of this study were clearly explained all information regarding the ob-jectives of this assessment, the detail of collecting information Respondents have had complete autonomy in regard to partic-ipation, as well as freedom to withdraw at any stage during the interview Access to completed questionnaires and data were

restricted to authorized personnel to ensure

the confidentiality of each respondent The

collected data was only used for the

pur-pose of research

III RESULTS

A total of 1477 deaths were recorded in

the reference year, which comprised 746

cases in Quang Ninh province and 731

cas-es in Thai Nguyen province Out of thcas-ese

1477 deaths, the COD were re-investigated

in 1365 cases using VA household

inter-views, equivalent to 92.6% of the total

num-ber of deaths VA interview could not be car-ried out in 112 cases (7.4% of total deaths) Table 1 describes the death amount and the crude death rate in general according

to gender and location identified during the study The mortality rate of general population was calculated 4.94 per 1000

In comparison to female group, the death proportion in male was higher with statisti-cally significance (p < 0.001) In regards to location, the urban population had the lower mortality rate than the rural population (p < 0.001)

Table 1 Crude death rate by sex and area in 2014 Characteristic Total Number of deaths Rate (‰) p value

Sex

< 0.001

Area

< 0.001

Table 2 describes the distribution of

deaths by age group and some factors

re-lating to death, all the statistics were

as-certained by VA In regard to age, over two

thirds of the deaths were among the elderly

The proportions of deaths recorded in two

groups under the age of 5 years and 5 - 14

years old are very low (1.8% and 1.2%

re-spectively) As can be seen, more than 70%

of people attended a health facility for the

last treatment prior to death Most of them had visited central/ provincial hospitals (80%) and in about 29% of cases, a visit to

a district hospital was reported Only 4.7% went to a commune health station, 2.1% saw healers and very few people visited pri-vate doctors As shown in table 2, although only 6% of VA respondents kept the last treatment documents provided by hospi-tals, which would be useful for reporting for

the mortality register at CHS This aspect will be given attention in the recommendations to strengthen the COD reporting system

Table 2 Distribution of deaths by age and information before death

Age group (n = 1365)*

Treatment at health facility in the last sickness leading to the death? (n = 1365)

Type of health facility in the last treatment (n = 959)

Healers (traditional medicine) 20 2.1

Recall information about the diagnosis after

Kept the documents from hospital about the

*1365 cases were interviewed by VA questionnaire

Figure 1 illustrates the places of deaths Approximately 88.1% of the people died at home and only 5.0% died at a health facility (includes hospitals, commune health station, clinic, etc.) However, as mentioned above, a large number of the decedents who died at home had visited health facilities during their final illness

5% 1.9% 5%

At home

At Health facility

On the way to health facility Others

Figure 1 Place of death of the study sample

Table 3 describes the differentials in mortality pattern by sex Although stroke was the first leading COD in both males and females, the percentage of females who died due to stroke was higher than those in males This is similar to some other causes such as pneumonia, stomach cancer and other CVD The proportion of senility as a cause of death in females was 5 times higher than males, therefore the rate of this cause in male was not listed in the

10 leading COD table However, some causes such as liver cancer, lung cancer, cirrhosis of liver and HIV, had proportions of male deaths that outweighed those in females Beside two common groups as CVD and cancers, injury that was marked mainly by road traffic injury also situated in the list of top as a leading cause of death among both males and females (4.2% and 2.8% respectively)

Table 3 Distribution of 10 leading CODs by sex

3 Liver cancer 6.7 Lung cancer 4.9

5 Cirrhosis of liver 4.3 Breast, Cervix and Ovary cancers 4.2

6 Road traffic Injury 4.2 Stomach cancer 3.0

7 Pneumonia 3.5 Other cardiovascular dis-eases 3.0

8 Ischaemic heart disease 2.5 Road traffic Injury 2.8

9 Other malignant neoplasms 2.4 Ischaemic heart disease 2.6

10 Other unintentional injuries 2.3 Diabetes mellitus 2.5 All other diseases/ causes 29.5 All other diseases/ causes 30.2 Ill-defined and unknown COD 9.2 Ill-defined and unknown COD 7.5

Table 4 describes five specific causes with high rate of mortality in both male and female

It can be recognized that almost all of these causes represent some large groups of disease such as CVD, cancer, Injury, communicable disease Noticeably, the overall proportion of the non-communicable disease group including stroke, lung cancer and ischemic heart diseases was remarkably higher than the others Pneumonia was the only representative of the com-municable disease category in this top five leading causes list with the quite low percentage (4.0%) There were statistically significant differences between male and female in stroke and lung cancer with opposing tendencies While the number of death due to stroke in female was considerably higher than in male, the percentage of lung cancer death among male was more than 2 times higher than those among female

Table 4 Comparison of some leading CODs by sex

Disease

Both sex (n = 1365) (n = 835) Male (n = 530) Female p value

Road traffic Injury 3.7 4.2 2.8 > 0.05

Ischaemic heart disease 2.5 2.5 2.6 > 0.05

IV DISCUSSION

This study provides useful statistics contributing to the formation of an up to date mortality data at national level and reveals an empirical evidence of the current situation of deaths re-cording in the routine health management information system in Vietnam By combining two steps in data collection: making death lists from traditional resources (A6 registers, Justice Clerk books and others) and then ascertaining this list by implementing verbal autopsy

inter-views, the completeness and the reliability

of our results are at high level The study

also provides useful observations on the

utility of VA methods to identify causes for

deaths occurring outside public health

facili-ties Previously, this model has been used in

several researches and was demonstrated

to be a very effective instrument for

evalu-ating mortality patterns in Vietnam [11 - 13]

The response rate of this study was

92.6%, which seemed to be lower than

those in some foreign reports that found

rates reaching nearly 100% [2], but it was

similar to previous experiences in use of

verbal autopsy surveys in Vietnam [10; 12]

There are many reasons for this

phenome-non One of them had been mentioned by

Hoa et al [10] with missing cases mostly

atributable to migration of the household to

another district/province after the deaths of

their family member This explains why their

names were recorded, but the data

collec-tors could not find them Another possible

reason for the difference between Vietnam

and other countries comes from an

insuf-ficient mortality data recording system, as

Vietnamese network of primary healthcare

has yet to be developed, resulting in a

sys-temic lack of complete medical records [13]

Mortality rate and some relating

char-acteristics

The overall death rate of both two

prov-inces was 4.94‰, lower than findings from

another source of CDR of Vietnam

pop-ulation as National crude death rate in

2014 from GSO which was estimated to be

6.9‰ [8] However, compared with the rate

of 3.9‰ reported by Hoa et al in a

region-al research of death rate in 2012, our rate

was markedly higher [14] Possibly, these differences came from the way of choosing sample while estimates of GSO was based

on demographic models and projections, in comparison with the locally measure CDR from this study Regarding to location, our findings figured out the significantly higher proportion of death in rural community than

in the urban The fact is that our sample population with higher fraction of urban cit-izens could have led to this disparity since urban communities in Viet Nam probably enjoy better health care and health status than rural ones [11; 13] In terms of gender,

as can be seen, the gap of death rates be-tween male and female showed a statisti-cally significant differential, similar to

sever-al previous reports [11; 10; 15]

Besides, our result also pointed out two third of the deaths occurred in the group of above 60 years old (63,7%), similar to some others studies [14] As mentioned in some other researches, the disease pattern alter-ation has been happening in recent years

in Vietnam, from communicable diseases to non- communicable diseases which occur mainly in the old people [10; 11; 16] In ad-dition, Vietnamese life expectancy tends to rise due to better living conditions and the percentage of elder population in Vietnam society is increasing [6; 15] Apparently, the combination of two above reasons results

in the high rate of death among the elderly The low number of reported neonatal and child deaths results in very low estimated under 5 mortality rates for our study pop-ulation Similar apparent under-reporting of under 5 mortality was also observed in the sample mortality surveillance system [10]

Apropos of the demand of treatment

before death, from our analysis, a majority

of the deceased visited at least one health

facility at the end stage of life, similar to

several previous reports [13; 17]

Howerv-er, the highlight here is the level of medical

services, more than 80% of the death went

to Central/ Provincial Hospitals This

illus-trates out several issues in Vietnam such as

insufficient capability of diseases treatment

of primary healthcare system, the

percep-tion of people to put belief in the medical

service of high-level hospital This pattern

may be different in other provinces in

Viet-nam where access to higher level

hospi-tals is more difficult and where the patients

may rely on traditional healers However,

although a few cases still kept medical

re-cord after discharge of health facilities, most

of the deceased family members could

re-call the diagnosis in hospital This finding

suggests that a good system of discharge

documents may help to improve the

avail-ability of reliable information to ascertain the

cause of death from verbal autopsy Instead

of only asking the relatives of the deceased

about the COD, the CHS health staffs can

ask them to show the discharge documents

(if they are available) to get more detailed

information to support the recording of the

COD Another aspect is the place of death,

the mortality rate at home in our study was

very high (88.1%), this feature is similar to

previous surveys in Vietnam [13; 14] It is

common practice in Vietnam for terminally

ill patients to go back home for the final

pe-riod of their lives, even in some cases, the

patients are just hospitalized for a very short

time

Causes of death

An important part of this study is to in-vestigate the cause of death It can be easily recognized the transition of disease pattern in Vietnam in recent years from communicable diseases to non-communi-cable diseases (NCD) as being reported in many researches [10; 14; 16] Our result also revealed the same trend when three out of the five leading causes of death were stroke, lung cancer and ischemic heart dis-eases, which are categorized into the group

of NCD A considerable point here is the differentials in COD pattern between male and female While in stroke, senility, or

oth-er CVD, the proportions in females woth-ere remarkably higher than those in males, a reverse pat-tern was found for in liver can-cer, lung cancan-cer, cirrhosis of liver, where the percentages in males outweighed those in females It is possible that this difference stems from habits among Vietnamese

high-er smoking and drinking males Also, the higher traffic injury among males compared

to females can be explained by the preva-lence of drunk driving among men The ev-idence for this is the increasing proportion

of traffic accident during big national festi-vals conducive to alcohol overuse, mostly among males There were also some

caus-es of death related specifically to gender such as breast, cervix and ovary cancers in females, which constitute the fifth cause in the list top ten leading causes of death

V CONCLUSION

This study identified the mortality pattern

of two provinces in the Northern region of Vietnam contributing to the national

mortali-ty database With the transition of the cause

of death pattern, it is necessary to pay more

attention to collecting information of the

deaths outside health facilities as well as

improving the mortality recording system,

especially at primary healthcare network

Comprehensive mortality database, and

in-tervention programs need to prioritize these

leading causes of death

Acknowledgements

We would like to thank the Provincial

Health Departments of Quang Ninh and

Thai Nguyen provinces for their help in

data collection activities and all local health

workers from commune health stations who

directly conducted interview Finally, we

profoundly thank all respondents who spent

time in sharing information for our research

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