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 Table of Contents  
Year : 2013  |  Volume : 57  |  Issue : 2  |  Page : 78-83  

Causes of death in rural adult population of North India (2002-2007), using verbal autopsy tool

1 Assistant Professor, Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Assistant Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Assistant Professor, Department of Epidemiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
4 Additional Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
5 Associate Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication15-Jul-2013

Correspondence Address:
Anand Krishnan
Associate Professor, Centre for Community Medicine, Old OT Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.114988

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Background: With the on-going epidemiological transition, information on the pattern of mortality is important for health planning. Verbal autopsy (VA) is an established tool to ascertain the cause of death in areas where routine registration systems are incomplete or inaccurate. We estimated cause-specific mortality rates in rural adult population of 28 villages of Ballabgarh in North India using VA. Materials and Methods: During 2002-2007, trained multi-purpose health workers conducted 2294 VA interviews and underlying cause of death was coded by physicians. Proportional mortality (%) was calculated by dividing the number of deaths attributed to a specific cause by the total number of deaths for which a VA was carried out. Findings: 61% of deaths occurred among males and 59% occurred among those aged ≥60 years. The leading causes of death were diseases of the respiratory system (18.7%) and the circulatory system (18.1%). Infectious causes and injuries and other external causes, each accounted for around 15% of total deaths followed by neoplasms (6.8%) and diseases of the digestive system (4%). Among those 45 years of age, more than half of deaths were attributed to non-communicable diseases (NCDs) alone. Accidents and injuries were responsible for one-fourth of deaths in 15-30 years age group. Conclusion: NCDs and injuries are emerging as major causes of death in this region thereby posing newer challenges to public health system.

Keywords: Adults, Cause of death, Epidemiology, Mortality, Surveillance, Verbal autopsy

How to cite this article:
Palanivel C, Yadav K, Gupta V, Rai SK, Misra P, Krishnan A. Causes of death in rural adult population of North India (2002-2007), using verbal autopsy tool. Indian J Public Health 2013;57:78-83

How to cite this URL:
Palanivel C, Yadav K, Gupta V, Rai SK, Misra P, Krishnan A. Causes of death in rural adult population of North India (2002-2007), using verbal autopsy tool. Indian J Public Health [serial online] 2013 [cited 2023 Feb 6];57:78-83. Available from:

   Introduction Top

Knowledge about causes of death is vital for public health planning and resource allocation. [1] In developing countries like India, this information is not routinely available for the rural population where maximum deaths occur at home (especially in villages) and the available information is often incomplete and of poor quality. While attaining good quality vital registration data should be a long-term goal, alternative methods of ascertaining and estimating cause-of death distributions at the population level must be used in the interim. Reliable, representative, routine, low-cost and long-term mortality measurements are the key to monitoring trends in health conditions of the population leading research into avoidable causes of death and improving accountability for expenditures on disease control. [2],[3] Mortality information becomes especially important in view of the epidemiological transition that developing countries are witnessing.

The World Health Organization estimates that nearly 52% of deaths and 38% of total disease burden in the South-East Asian Region are related to non-communicable diseases (NCDs) underscoring the need for reliable country data in the region. [4] However, the burden of NCDs in developing countries has received much less policy attention and development assistance than maternal mortality, human immunodeficiency virus and tuberculosis. [5] This lack of focus on NCDs has been due to lack of data and its ineffective utilization for program planning. Verbal autopsy (VA) methods have been utilized world-wide with an aim of supplementing mortality information. [6],[7],[8] This paper attempts to provide the reliable information on causes of death in adults by using VA methods.

   Materials and Methods Top

Study setting

This study was performed in 28 villages of Ballabgarh block of Haryana, India. These 28 villages come under Ballabgarh health and demographic surveillance site (HDSS), also known as comprehensive rural health services project. The demographic and health information resides in electronic databases as previously described. [9] Under the project, there exist two primary health centers (PHCs) and one secondary level hospital at Ballabgarh. Each PHC has 6 sub-centers (total 12 sub-centers) and together they include 28 villages. The health-care in these villages is provided by paramedical multi-purpose health workers (MPHWs). VA was introduced in the villages in 1999 for under-five deaths and in 2002 for adult deaths. [10] The population age and sex structure is derived from an annual census conducted by the MPHWs and supervised by health supervisors and medical officers. The main economic activity of majority of the population is agriculture or agriculture dependent trades.

VA methods

The MPHWs identified deaths among village residents during their routine house visits, (each house in the village is visited fortnightly) and through a network of key informants including the village headman, the "Panchayat" (village governing body), priests and cremation staff. For each identified death, the MPHW visited the deceased's household within a month of date of death, but not before 2 weeks for VA. The validated VA tool includes a series of structured questions followed by an open narrative. [11] The structured questions include symptoms, duration, tobacco and alcohol use and treatment sought. The open narrative section related to illness and circumstances preceding death and was completed with the aid of systematic prompting by the MPHW. Any available adult in the family who was knowledgeable about the events at the time of death could be a respondent. Informed consent was obtained from each respondent by MPHW. The information collected by the MPHW by using VA tool was independently confirmed by a paramedical supervisor for all deaths and 5% of these forms were verified by the qualified medical doctors during his visits. MPHWs were provided training in filling up of the VA forms before the study and queries were clarified every month during the monthly meetings by the medical officer of the PHC. Each VA form was independently assessed by two physicians and assigned a single most probable underlying cause of death. If there was a discrepancy between the two physicians, a third physician reviewed the VA form. Causes of death were selected from a condensed list derived from the 10 th revision of the international classification of diseases-10. [12] Deaths for which, a specific underlying cause was not ascertainable were assigned the code R94.


Data were entered in Microsoft excel spreadsheet and analyzed with STATA version 10. Proportional mortality (%) was calculated by dividing the number of deaths attributed to a specific cause by the total number of deaths for which a VA was carried out.

   Results Top

During the 6 years period (January 2002 through December 2007), 2314 adult deaths (≥15 years) were identified in the study area. VA forms were available for 2294 (99%) deaths. 1345 (59%) deaths occurred at ≥60 years age and 61% of deaths were among males. A specific underlying cause of death could be assigned based on VA for 1859 deaths (81% of deaths with VA forms). The probability of non-ascertainment cause of death on VA was higher for deaths among individuals aged ≥60 years (27.8%) as compared to deaths among younger individuals (6.4%).

The leading causes of death were diseases of the respiratory system (18.7%) with chronic lower respiratory disease accounting for more than 90% of deaths within this category [Table 1]. Diseases of the circulatory system (18.1%) were the second most common cause of death with ischemic heart disease and cerebrovascular disease accounting for more than over 80% deaths within the category. Infectious causes and injuries and other external causes, each accounted for around 15% of deaths and were the next common causes followed by neoplasms (6.8%) and diseases of the digestive system (4%). Except for external causes of death and deaths not elsewhere classifiable, there were no major differences in causes of death among males and females. Proportional mortality due to external causes in males exceeds that of females and the difference was statistically significant (16.8% vs. 10%; P value >0.001).
Table 1: Verbal autopsy defi ned causes of death among individuals ≥15 years of age in rural Ballabgarh, North India (2002-2007)

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More than half of deaths were attributed to NCDs (circulatory disorders, respiratory disorders) and injuries and other external causes across all age groups. Among deaths above 45 years of age, more than half of deaths were attributed to NCDs alone [Figure 1]. Accidents and injuries were common among younger age group. Especially in 15-30 years age group, these were responsible for one-fourth of deaths [Figure 1]. Suicides or intentional self-harm alone constituted 4.8% of all deaths. There was an increase in proportion of deaths due to NCDs in the last 2 years of the reference period, i.e., 2005 and 2006 [Figure 2].
Figure 1: Distribution of deaths by major cause groups and age (2002-2007)

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Figure 2: Trends in major cause groups of deaths (2002-2007)

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   Discussion Top

As is evident from the results, this 6 years mortality data shows that chronic diseases, injuries and external causes were the leading causes of death in this rural community among individuals ≥15 years of age. In our population, nearly 40% deaths occurred in individuals aged younger than 60. Our study highlights that more than 50% deaths were due to NCDs and injuries and other external causes across all ages studied. Infectious diseases still accounted for one-fifth of deaths in economically productive age group (15-59 years).

About two-third of deaths in the age group of 60 years or above occurred due to cause groups-cerebrovascular diseases, lower respiratory tract, tuberculosis, intestinal infectious diseases and due to non-ascertainable causes. These results are comparable with Indian Council of Medical Research study on causes of death by VA in five states Assam, Bihar, Maharashtra, Rajasthan and Tamil Nadu, representing different regions of India. [13]

Studies performed in rural Andhra Pradesh and Tamil Nadu also have documented large proportion of deaths from NCDs. [14],[15] More than half of deaths were attributed to NCDs. Similar results of predominance of non-communicable cause of deaths (more than 50% among males and 43-54% among females) have been observed in other states such as Assam, Maharashtra and Tamil Nadu. [13] According to Sample Registration System (SRS) estimates (2001-2003), NCDs were the leading causes of death in the country, constituting 42% of deaths. [16] A recent study based on 18-year mortality surveillance using VA from rural Haryana, reported 47.6% of deaths attributable to NCDs. [17] Their lower proportion of deaths due to NCDs may be because of prior reference period and also inclusion of deaths under 15 years of age. However, a study in urban slums of Kolkata, India reported 66% of deaths due to NCDs. [18]

In conjunction with other studies, our study shows that injuries and chronic diseases predominate in the older years of life in which most of the deaths occur now. The preponderance of deaths due to chronic diseases in these study villages is likely because of rapid economic and social development as well as effective basic health services such as immunization and maternal and child health programs.

Among communicable diseases, tuberculosis and diarrhea were the common causes of deaths. Mortality due to tuberculosis may be overestimated in this study because some deaths due to other respiratory disorders might have been narrated as tuberculosis deaths by family members if the patient had taken treatment for tuberculosis anytime in his life time. Although conditions such as diabetes and hypertension did not contribute much in the individual causes of death, these conditions would have contributed to the number of deaths by ischemic heart disease and cerebrovascular disease. Furthermore, the diagnosis of these two conditions is important in documenting deaths due to these conditions.

More than one-fourth of deaths in economically productive age group were accounted by injuries and other external causes. Injuries accounted for 14.1% of deaths in the present study, which is comparable to 11.4% reported elsewhere in rural Haryana. [17] In our study, falls accounted for 12.5% of all unintentional injuries, whereas million deaths study reported 25% of falls accounting for unintentional injuries. [19] Deaths in the economically productive age group have major effects in the household as well as in the society. [20] Suicides or intentional self-harm alone accounted for two-fifths of deaths within this category of external causes and one-tenth of overall deaths. This high rate of suicidal rates has already been documented in studies conducted in Tamil Nadu and Kerala. [21],[22] Our study has reported a higher percentage of suicidal deaths (4.8% of all deaths) compared with 3% (aged 15 years or older) reported in the million deaths study and 3.7% (aged 35 years or older) reported in Kerala. [21],[23] This emphasizes the fact that we need to focus on mental health issues, which are emerging as important causes of death along with chronic diseases. However, the study from Kolkata slums reported only 5 suicidal deaths (0.9%) of 544 total deaths in all ages. [18]

VA methods have been used in past and remain a cornerstone of mortality surveillance systems in developing countries. [24],[25] Although the method was initially developed for child [26],[27],[28],[29] and maternal deaths [30],[31] extension of the technique for use in deaths occurring across all age groups is now well-established. [17],[18],[32] This study shows that medical colleges attached with rural field practice areas can be useful for the training of medical students and also in generating valuable robust information. In developing countries like India, where routine civil registration systems are incomplete, strengthening of HDSS sites is necessary.

The strength of the study is 6 years of prospectively collected data, which provides stability. Since, there is an existing surveillance system HDSS in place in the study area and it is attached to a research institute, quality control can be assured. Physician coding of cause of deaths further adds strength to the study. In 19% of deaths, cause of death was not ascertained due to the insufficient information in the VA forms, which is a limitation of using VA tool. Other studies in India which used VA methods for ascertaining the cause of deaths also reported 11-18% of deaths due to ill-defined causes, whereas the study from rural Haryana reported 6.9% of deaths where cause was not ascertainable. [13],[14],[17],[18] VA, for all its shortcomings, remains the feasible option for documenting specific causes of death in community settings. This study reports the causes of death for the reference period of 2002-2007 and early reporting of the findings would have been better. Another limitation is the possibility of misclassification of age especially elderly people whose age cannot be ascertained accurately.

   Conclusion Top

The study results show that millions of individuals in rural India are at greater risk of death due to NCDs and accidents than communicable diseases. The economic and societal impacts of premature death are likely to be enormous. The primary health-care system in India appears to be effective in dealing problems of communicable diseases and maternal and child health. Our study clearly shows an epidemiologic transition with an increasing share of NCDs and injuries in mortality. Reorientation of health systems to include promotive, preventive and curative strategies to effectively tackle these problems is thus the need of the hour.

   References Top

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