Enhancing both notification and registration practices is crucial for generating stronger evidence to guide population health policy and planning. Strengthening civil registration systems for death reporting is therefore a vital first step toward improving the evidence base for effective health interventions. This case study for Zambia examines how integrating digital and mobile technologies into death reporting can improve timeliness, efficiency, and accuracy compared to traditional manual practices. The study focused on burial offices in high-mortality provinces and districts, where improvements could yield substantial gains in reporting completeness. An electronic version of Form 13, the official death notification form, was developed to capture facility and community-based deaths in real time, before mortuary admission. A dashboard was created to track data collection progress, provide real-time access, and support analysis for policy action. Over the course of six months, the electronic platform captured approximately 100,000 deaths, with daily data streaming. Children under one year accounted for the largest proportion of deaths reported (18,884; 16.34%), while deaths among those aged 5–9 (1,977; 1.7%) and 10–14 (1,758; 1.5%) were the least common. The electronic system reduced reporting delays by 80% (e-reporting: 3 days; manual system: 24 days; p < 0.001). Completing a form electronically took an average of 4.6 minutes (median: 4.0). Digitizing CRVS death reporting in Zambia significantly improved the timeliness, completeness, and quality of mortality data, enabling rapid analysis and policy response. The system also eased administrative burdens for bereaved families by reducing delays and unnecessary steps in the reporting process. These findings highlight the potential of digital platforms to strengthen death reporting, improve disease surveillance, and support data-driven interventions.

Previous work from this laboratory has shown that both macrophages and microglia phagocytize relatively little myelin in vitro under basal conditions. In an effort to better simulate the conditions within the central nervous system (CNS), we have co-cultured these cells with astrocytes, the most numerous of the neural cells in the CNS, and have compared myelin phagocytosis in the co-cultures with that in cells cultured alone. Both macrophages and microglia in company with astrocytes phagocytized about three times as much myelin as controls, as measured by the formation of cholesterol ester, while astrocytes alone showed little evidence of myelin phagocytosis. Astrocyte-conditioned medium increased phagocytic activity in macrophages by 2.3-fold, and by 3.5-fold in microglia. A number of adhesion molecules and extracellular matrices were tested for their effects on myelin phagocytosis. Matrigel was most effective in activating the macrophages, and in the presence of conditioned medium, stimulated these cells to phagocytize as much myelin as when co-cultured with astrocytes. On the other hand, Matrigel inhibited myelin phagocytosis in microglia. These results indicate that activation of macrophages by astrocytes may be due to an adhesion component, as well as to soluble factors secreted by the astrocytes. While microglia were also stimulated by conditioned medium, adhesion to astrocytes or Matrigel induced a downregulation in phagocytic activity.

Background Use of a standardized verbal autopsy (VA) questionnaire, such as the World Health Organization (WHO) instrument, can improve the consistency and reliability of the data it collects. Systematically revising a questionnaire, however, requires evidence about the performance of its questions. The purpose of this investigation was to use a mixed methods approach to evaluate the performance of questions related to 14 previously reported issues in the 2016 version of the WHO questionnaire, where there were concerns of potential confusion, redundancy, or inability of the respondent to answer the question. The results from this mixed methods analysis are discussed across common themes that may have contributed to the underperformance of questions and have been compiled to inform decisions around the revision of the current VA instrument. Methods Quantitative analysis of 19,150 VAs for neonates, children, and adults from five project teams implementing VAs predominately in Sub-Saharan Africa included frequency distributions and cross-tabulations to evaluate response patterns among related questions. The association of respondent characteristics and response patterns was evaluated using prevalence ratios. Qualitative analysis included results from cognitive interviewing, an approach that provides a detailed understanding of the meanings and processes that respondents use to answer interview questions. Cognitive interviews were conducted among 149 participants in Morocco and Zambia. Findings from the qualitative and quantitative analyses were triangulated to identify common themes. Results Four broad themes contributing to the underperformance or redundancy within the instrument were identified: question sequence, overlap within the question series, questions outside the frame of reference of the respondent, and questions needing clarification. The series of questions associated with one of the 14 identified issues (the series of questions on injuries) related to question sequence; seven (tobacco use, sores, breast swelling, abdominal problem, vomiting, vaccination, and baby size) demonstrated similar response patterns among questions within each series capturing overlapping information. Respondent characteristics, including relationship to the deceased and whether or not the respondent lived with the deceased, were associated with differing frequencies of non-substantive responses in three question series (female health related issues, tobacco use, and baby size). An inconsistent understanding of related constructs was observed between questions related to sores/ulcers, birth weight/baby size, and diagnosis of dementia/presence of mental confusion. An incorrect association of the intended construct with that which was interpreted by the respondent was observed in the medical diagnosis question series. Conclusions In this mixed methods analysis, we identified series of questions which could be shortened through elimination of redundancy, series of questions requiring clarification due to unclear constructs, and the impact of respondent characteristics on the quality of responses. These changes can lead to a better understanding of the question constructs by the respondents, increase the acceptance of the tool, and improve the overall accuracy of the VA instrument.

Background Ascertaining the causes for deaths occurring outside health facilities is a significant problem in many developing countries where civil registration systems are not well developed or non-functional. Standardized and rigorous verbal autopsy methods is a potential solution to determine the cause of death. We conducted a demonstration project in Lusaka District of Zambia where verbal autopsy (VA) method was implemented in routine civil registration system. Methods About 3400 VA interviews were conducted for bodies “brought-in-dead” at Lusaka’s two major teaching hospital mortuaries using a SmartVA questionnaire between October 2017 and September 2018. Probable underlying causes of deaths using VA and cause-specific mortality fractions were determined.. Demographic characteristics were analyzed for each VA-ascertained cause of death. Results Opportunistic infections (OIs) associated with HIV/AIDS such as pneumonia and tuberculosis, and malaria were among leading causes of deaths among bodies “brought-in-dead”. Over 21.6 and 26.9% of deaths were attributable to external causes and non-communicable diseases (NCDs), respectively. The VA-ascertained causes of death varied by age-group and sex. External causes were more prevalent among males in middle ages (put an age range like 30–54 years old) and NCDs highly prevalent among those aged 55 years and older. Conclusions VA application in civil registration system can provide the much-needed cause of death information for non-facility deaths in countries with under-developed or non-functional civil registration systems.

BackgroundCivil registration and vital statistics (CRVS) are essential administrative tools for accurate statistical data on vital events. However, civil registration coverage is particularly poor in low- and middle-income countries. Currently, CRVS are attracting global attention, as their improvement is considered a priority. While health facility is one of the important actors involved in the management of quality CRVS, its function in CRVS remains unclear. Therefore, this work aims to investigate the CRVS performance of the health facility in Zambia, a low-income country, and identify the gaps for effective policy-making.MethodsTo assess the health facilities’ CRVS performance, a questionnaire was developed based on existing assessment tools for the whole CRVS; this comprised 21 multiple-choice questions in 10 areas with four choices awarded between 0 and 3 points according to performance. These questionnaire-based interviews were conducted by information officers in all health facilities per first, secondary, and tertiary-level in five target districts of Zambia, selected via socioeconomic and geographic features. The average points were calculated in each area by each level of healthcare system and summarized in a single chart.ResultsThe results indicated low scores in the following areas: staff compliance with standard reporting procedures, infrastructure, capacity of coding based on International Classification of Diseases among health personnel, documentation of the cause of death in medical records, and absence of a system to identify the cause of death of brought-in-dead cases.ConclusionThe tool developed in this work to evaluate the CRVS performance of health facilities was useful for identifying the gaps that need to be overcome to ensure the quality of CRVS in Zambia. However, its validity should be further investigated in other areas in Zambia as well as in other countries.

Background Over one third of deaths in Zambian health facilities involve someone who has already died before arrival (i.e., brought in dead [BiD]), and in most BiD cases, the causes of death (CoD) have not been fully analyzed. Therefore, this study aimed to analyze the CoD of BiD cases using the Tariff Method 2.0 for automated verbal autopsy (VA), which is called SmartVA.Methods The target site was one third-level hospital in the Republic of Zambia’s capital city. All BiD cases aged 13 years and older at this facility from January to August 2017 were included. The deceased’s closest relatives were interviewed using a structured VA questionnaire (Population Health Metrics Research Consortium Shortened Questionnaire) and the data were analyzed using the SmartVA to determine the CoD at the individual and population level. The CoDs were compared with description on the death notification forms by using t-test and Cohen’s kappa coefficient.Results Approximately 1500 cases were included (average age = 47.2 years, 61.8% males). The top CoD were infectious diseases, including acquired immunodeficiency syndrome, tuberculosis, and malaria, followed by non-communicable diseases, such as stroke, cardiovascular diseases, and diabetes mellitus (DM). The comparison with the CoD distribution among hospital deaths showed that the trends were similar except for DM, which was greater among hospital deaths, and malaria and accident, which were less frequent in the main CoD. The proportion of cases with a determined CoD was significantly higher when using the SmartVA (75%) than the death notification form (61%). A proportion (42.7%) of the CoD-determined cases matched in both sources, with a low concordance rate (kappa coefficient = 0.1385).Conclusions The CoD of the BiD cases were successfully analyzed using the SmartVA for the first time in Zambia. While there many erroneous descriptions on the death notification form, the SmartVA could determine the CoD among more BiD cases. Since the information on the death notification form is reflected in the national vital statistics, more accurate and complete CoD data are required. In order to strengthen the death registration system with accurate CoD, it will be useful to embed the SmartVA in Zambia’s health information system.