Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making

Figures & data

Table 1. Questions/substantive responses on circumstances of mortality (critical limiting circumstances and events at and around the time of death related to the needs and behaviours of individuals and the responsiveness of the health system towards these) from WHO-2012 and WHO-2016 WHO VA standards and circumstances of mortality categories (COMCATs)

(a) WHO-2016 question/item	Explanation of substantive responses
Id10450 In the final days before death, did she/he travel to a hospital or health facility?	A ‘no’ response indicates no contact with hospital-level services in the days before death (defined as a 24/7 service, but noting in some settings 24/7 facilities may not be called ‘hospitals’).
Id10451 Did she/he use motorised transport to get to the hospital or health facility?	A ‘yes’ response indicates that the person who died travelled to a hospital or health facility by means of motorised transport (car, truck, tractor, motorcycle, scooter or ambulance) during the final illness.
Id10452 Were there any problems during admission to the hospital or health facility?	A ‘yes’ response indicates that the person who died travelled to a hospital or health facility, but then had problems on arrival (delays, paperwork, queues, no staff).
Id10453 Were there any problems with the way she/he was treated (medical treatment, procedures, inter personal attitudes, respect, dignity) in the hospital or health facility?	A ‘yes’ response indicates that the person who died travelled to a hospital or health facility, but then had problems with how they were treated (medical treatment, procedures, inter-personal attitudes, respect, dignity).
Id10454 Were there any problems getting medications, or diagnostic tests in the hospital or health facility?	A ‘yes’ response indicates that the person who died travelled to a hospital or health facility, but then had problems obtaining essential items (drugs, medications or other prescriptions, blood products, and/or diagnostic tests such as lab tests and X-rays, either within the facility or needing to be bought elsewhere).
Id10455 Does it take more than 2 hours to get to the nearest hospital or health facility from the deceased’s household?	A ‘yes’ response indicates that the person who died lived in a household from where it would reasonably take more than 2 hours to reach the nearest 24-hour health facility by the means of transport available to the household members.
Id10456 In the final days before death, were there any doubts about whether medical care was needed?	A ‘yes’ response indicates that there were doubts among those assisting in the final illness (family members, etc.) about whether the final illness was sufficiently serious to need treatment at a health facility.
Id10457 In the final days before death, was traditional medicine used?	A ‘yes’ response indicates that a major part of treatment for the final illness was provided by any kind of traditional or alternative practitioner (herbal remedies, massages, drinks, foods, amulets, spells or blessings provided by traditional healers, witch doctors or shamans).
Id10458 In the final days before death, did anyone use a telephone or cell phone to call for help?	A ‘no’ response indicates that no telephone of any kind (working landline, or cell phone charged and with credit) was used by those assisting in the final 24 hours of the illness, for example to call for help or arrange transportation.
Id10459 Over the course of illness, did the total costs of care and treatment prohibit other household payments?	A ‘yes’ response indicates that the total costs incurred in the final illness were sufficiently great to mean that other kinds of household expenses (food, fuel, travel, education etc.) could not be met, or caused debt or sale of household assets.
(b) COMCAT	Description of circumstantial category
Traditions	Traditional practices or beliefs influenced health seeking behaviour and the pathway to death.
Emergencies	Sudden, urgent or unexpected conditions leading to death.
Recognition	Lack of recognition or awareness of serious disease (e.g. symptoms or severity) negatively influenced health seeking behaviour.
Resources	Inability to mobilise and use resources (e.g. material, transport, financial) hindered access to health care.
Health systems	Problems in getting health care despite accessing health facilities (e.g. related to admissions, treatments and medications).
Inevitability	Death occurred in circumstances that could not reasonably have been averted (e.g. very elderly or recognised terminal conditions).
Multiple	A combination of the above categories affected the pathway to death; no single factor predominated.

Table 2. Circumstances of mortality categories (COMCATs), revised

COMCAT	Description of circumstantial category
Traditions	Traditional practices or beliefs influenced health seeking behaviour and the pathway to death.
Emergencies	Sudden, urgent or unexpected conditions leading to death.
Recognition	Lack of recognition or awareness of serious disease (e.g. symptoms or severity) negatively influenced health seeking behaviour.
Accessing care	Inability to mobilise and use resources (e.g. material, transport, financial) hindered access to health care.
Perceived quality	Problems in getting health care despite accessing health facilities (e.g. related to admissions, treatments and medications).
Referral	Problems receiving a referral when required. Problems reaching referral facility after referral made.
Inevitability	Death occurred in circumstances that could not reasonably have been averted (e.g. very elderly or recognised terminal conditions).
Multiple	A combination of the above categories affected the pathway to death; no single factor predominated.

Figure 1. Assigned circumstances of mortality categories (COMCATs) ranked within each major cause of death category for 7980 deaths in the Agincourt and AHRI health and demographic surveillance systems (HDSSs) 2012–19 and 2017–19 respectively.

Figure 2. Number of deaths for cause-specific mortality fractions (CSMFs) and circumstances of mortality categories (COMCATs) stratified by year and age groups for 5924 deaths in the Agincourt HDSS 2012–19.

Figure 3. Assigned circumstances of mortality categories (COMCATs) ranked within top ten causes of those aged 12 and under for 105 deaths in the Agincourt and AHRI health and demographic surveillance systems (HDSSs) 2016–19 and 2017–19 respectively health and demographic surveillance systems (HDSSs) 2016–19.

Figure 4. Number of deaths for health programme areas and circumstances of mortality categories (COMCATs) stratified by year and cause of death category for deaths in the Agincourt HDSS.