Causes of Death of Adults and Elderly and Healthcare-Seeking before Death in Rural Bangladesh

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INTRODUCTION

In 2004, an estimated 58.8 million deaths occurred globally, of which 27.7 million were among females and 31.1 million among males (1). Of every 10 deaths, six were due to non-communicable conditions; three due to communicable, reproductive, or nutrition-related conditions; and one due to injuries. In countries with developing and transitional economies, non-communicable diseases (NCDs), along with a few emerging and re-emerging diseases, such as malaria and tuberculosis, show increasing trends, and other infectious diseases show decreasing trends (2,3). Results of studies on mortality in South Asian countries indicate a transition in patterns of mortality with increase in share of NCDs. Studies on mortality in rural India and Bangladesh also revealed an increased prominence of NCDs (4,5).

An increase in the proportion of NCDs and injuries in recent years has drawn the attention of international organizations. The World Health Organization (WHO) (2008) projected that NCDs would account for at least seven of 10 deaths occurring in developing regions by 2020. The WHO also stated that injuries--both unintentional and intentional--would become more prevalent and were projected to show rates equal to those of mortality due to infectious diseases by 2020 (6).

In developing countries, NCDs not only tend to increase but also appear earlier in life (7). Chronic NCDs, including diabetes and hypertension, and chronic obstructive pulmonary disorder (COPD) require continuous care. Care costs money and time. Unmet needs for medical care are critically higher for chronic illnesses than for acute illnesses in rural Bangladesh (8). Both prolonged ill-health and premature death of main income-earners of households lead to erosion of income with consequences at both micro- and macro-levels (9). Death of young adults is shown to have deepened the spiral of household poverty in rural Bangladesh (10). Thus, control of NCDs has an important role to alleviate poverty.

Planning logistics for controlling NCDs requires up-to-date and reliable population-based statistics of morbidity and mortality by cause. Such statistics, to our knowledge, are lacking, particularly for adolescents, adults, and the elderly in Bangladesh. Most (90%) deaths in rural areas occur in the home and have no death certificate from which one can derive cause of death (11). The national sample vital registration system records cause of death (COD) reported by family members of the deceased (12). Reliance on lay reports of COD, however, coupled with a high proportion of unspecified cause (such as old age), limits the use of national data on COD for planning health services and logistics.

In developing countries where registration of deaths is incomplete and real autopsies are not feasible, verbal autopsy (VA) is a surrogate for population-based death certificates to derive COD. Studies in India, China, and South Africa validated VA for the assessment of COD for adults and the elderly and concluded that VA-derived COD is reliable with respect to the broader cause categories (13-15). VA is increasingly used for deriving COD for setting priorities, planning health services, and monitoring and evaluating the performance of the health system (16). In Bangladesh, where registration of deaths is incomplete and death certificate does not exist, VA is a practical low-cost option to generate population-based death certificate and COD. To generate a database of COD and healthcare responses to fatal illnesses in a well-defined rural population, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) introduced a standard VA in 2003 in Matlab, a rural area of Bangladesh. A rigorous and dynamic health and demographic surveillance system (HDSS) has been operating in Matlab since 1966. The objectives of the present study were to estimate the health burdens of adults and the elderly due to broad disease categories and to assess the healthcare-seeking patterns before death in rural Bangladesh using VA data. …