MINISTRY OF HEALTH REFK SAYDAM HYGIENE CENTER PRESIDENCY SCHOOL OF PUBLIC HEALTH

BAKENT UNIVERSITY NATIONAL BURDEN OF DISEASE AND COST EFFECTIVENESS PROJECT

VERBAL AUTOPSY SURVEY INTERIM REPORT

24 December 2003 ANKARA

 Refik Saydam Hygiene Center Presidency Refik Saydam School of Public Health Directorate

This report has been written by Bakent University, Ankara for its use, publication and distribution by the Ministry of Health (RSHMB- Refik Saydam Hygiene Center Presidency, the School of Public Health). No other individuals or agencies except for the Ministry of Health (RSHMB- the School of Public Health) can claim for any rights based on this report nor can utilize it. No individuals who have utilized this report can claim for any losses due to its content. The publishing of this report does not undertake any responsibilities for its content. Neither Bakent University and the Ministry of Health ( RSHMB- the School of Public Health) nor any personnel, managers or representatives who are positioned in either of these agencies can be held responsible for any information or statement included in this report and no claims can be made that these two agencies and their above mentioned personnel have undertaken any kind of commitment, given any kind of warranty or will make any kind of written and verbal statements in the future. All rights are reserved. In compliance with the Law no 4110 and FSEK no 5846, a written authorization in compliance with the Article no 52 must be received from the right owner of this report before its use. Otherwise, no use of this report through different kinds of processing, copying, distributing, selling, hiring, lending, representing, presenting and delivering by means of any radio or wireless, technical, digital and / or electronical communication methods is permitted. For Further Information, Please Contact Refik Saydam Hygiene Center Presidency Refik Saydam School of Public Health Directorate Address: brahim Mteferrika Sokak, No:5, 06030, Rzgarl/ Ulus/ Ankara, Turkey Phone : 00-90--312-3091224 e-mail : mektep@hm.saglik.gov.tr

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ACKNOWLEDGEMENTS
This study, as a component of the National Burden of Disease and Cost Effectiveness Project, was financed by the Ministry of Health of the Republic of Turkey. We thank first of all the Ministry of Health, for all kinds of support in the design of the study, especially the Health Project General Coordinators Dr. Mehmet Fettaholu and Haydar Mezarc; the School of Public Healths Director Dr. Salih Mollahalilolu; Dr. Nazan Yardm, Dr. Berrak B. Baara, Dr. mer Varol, Uzm Dr. Vural Dirimee, Dr. Mehtap Kartal, Dr. Halil E. Eriti and all others involved at the Refik Saydam Hygiene Center Presidency School of Public Health, for working closely with us since the planning phases in all aspects of the Study; and the members of the steering and scientific committee of the National Burden of Disease and Cost Effectiveness Project, for their valuable contributions. Further, in evaluation of report before printing we thank to Dr. Engin zkan, Dt. Demet Aksoy, Dr. Esin ener, Dr. Zekiye elebi, Dr. lhan ztrk, Nurse Serap Takaya, Dr. Belgin zhan. The Study was performed by Bakent University. Professor Seval Akgn and Assistant Professor Meri olak carried out the principal work in planning, implementation, analysis and

report writing. Professor Gl Ergr and Assistant Professor Gina Etheredge contributed in the
Studys planning and coordination. Dr. Cihangir zcan and the Household Survey team provided confirmation of deaths in the verbal autopsy questionnaire as well as checking data reliability. In order that this project could be completed and become a fundamental tool for defining appropriate policy and strategy for health services in Turkey, material and moral support was provided from the beginning by Bakent Universitys Rector, Dr. Mehmet Haberal; and for the work of Project Coordinator Dr. Korkut Ersoy, Assistant Project Coordinator Adnan Ksa and everyone who worked with them, we express our thanks.

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NBD-CE PROJECT MONITORING COMMITTEE MEMBERS

MINISTRY OF HEALTH General Directorate of Primary Health Care Systems Dr. . Ercan BAL, Dr. Hlya ALTINYOLLAR, Dr. Nihal BABALIOLU General Directorate of Maternal Child Health and Family Planning Dr. Levent EKER, Dr. Arzu KSEL General Directorate of Treatment Services Dr. Ertan KAVASOLU, Hakime ZAL, Dr.Filiz BOZKURT, Hseyin BYKKAYIKI Agency Directorate of Fight Against Tuberculosis Dr. Binnaz KAYA DURUNAY, Dr. Ayen Melek AYTU KOAN Agency Directorate of Fight Against Malaria, Dr.mer YEDKARDELER General Directorate of Medication and Pharmacology, Ecz. Eda CNDOLU Agency Directorate of Information Systems, Dr. Songl DOAN, Dr. zlem YTBAIOLU Agency Directorate of Fight Against Cancer, Prof.Dr. Murat TUNCER, Dr. Funda TEKN, Dr. Emire ZEN Ministry of Health,Research nciser KAYA, lknur GNEY, Rasim CEYHAN Ankara, Provincial Health Directorate, ubuk State Hospital , Abdullah YILDIZ Ankara Hospital Dr. Mehmet FETTAHOLU Refik Saydam Hygiene Center Presidency School Of Public Health Dr. Salih MOLLAHALLOLU, Dr. Nazan YARDIM, Dr. Berrak BORA BAARA, Dr. Mehtap KARTAL, Dr. Halil Erkan ERT, Dr. mer Varol, Dr. Vural DRMEE

NBD-CE PROJECT STEERING COMMITTEE MEMBERS

REPUBLIC OF TURKEY, MINISTRY OF INTERNAL AFFAIRS

General Directorate of Population and Citizenship Affairs, Orhan AKKAYA, Dner TETK
REPUBLIC OF TURKEY, HEADQUARTERS TURKISH GENERAL STAFF Turkish Armed Forces Health Command, Muharrem UAR

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REPUBLIC OF TURKEY, PRIME MINISTRY, UNDERSECRETERIAT OF TREASURY

Public Economic Ventures, General Directorate, A. Tuncay TEKSZ Foreign Economic Relations, General Directorate Aye AKKRAZ
REPUBLIC OF TURKEY, PRIME MINISTRY STATE PLANNING ORGANIZATION, General Directorate of Social Sectors and Coordination

Muharrem VARLIK, Nihan KIRCALIAL

REPUBLIC OF TURKEY, PRIME MINISTRY CHAIRMANSHIP OF STATE STATISTIC INSTITUTE Agency Directorate of National Calculations; Glay ERDEN, A. rfan TRKOLU, Sevim ETKESEN

Directorate of Social Sectors and Coordination; engl ARSLAN, Nevin UYSAL

Agency Directorate of Research, Investigation and Statistics Techniques

Ylmaz ERAHN, Muharrem GR

REPUBLIC OF TURKEY, MINISTRY OF FINANCE,

General Directorate of Budget and Financial Control, Abdurrahman VARGN,

REPUBLIC OF TURKEY, GENERAL DIRECTORATE OF SOCIAL SECURITY ORGANIZATION FOR ARTISANS, CRAFTSMAN, TRADEMAN AND THE OTHER SELF-EMPLOYED, Chairmanship Of Health Affaires, Merih DZC REPUBLIC OF TURKEY, GENERAL DIRECTORATE OF RETIREMENT FUND Agency Directorate of Health Care Services Tark KANGAL REPUBLIC OF TURKEY, MINISTRY OF LABOUR AND SOCIAL SECURITY Chairmanship of Social Security Institution, General Directorate of Health Affaires

Hseyin Bykkayk, Nuri AMAZ NBD-CE PROJECT SCIENTIFIC COMMITTEE MEMBERS

HACETTEPE UNIVERSITY PRESIDENCY Faculty of Medicine, Department of Public Health Associate Professor Dr. Nesrin LNGROLU, Associate Professor. Dr. Bahar GZ DOAN, Dr. Banu AKIR, Dr. Sarp NER, Associate Professor.Dr. Hilal ZCEBE Faculty of Medicine Department of Biostatistics, Assistant Professor Pnar ZDEMR GEYK Institution of Population Studies, Professor. Dr. Sabahat TEZCAN, Research Assistant Elif KURTULU YT,

Faculty of Economic and Administrative Science, Economy Department Zafer ALIKAN ANKARA UNIVERSITY PRESIDENCY Directory of Health Education Faculty Assistant Professor Dr. smail AIRBA, Associate Professor Dr.Efsun Ezel ESATOLU School of Political Sciences, Assistant Professor Hasan AHN GAZ UNIVERSITY

Faculty of Medicine, Department of Public Health, Associate Professor Il MARAL

Directorate of Investigation and Prevention of Accidents Institution Dr. Elif DURUKAN

Faculty of Economic and Administrative Science, Proffessor Metin Kamil ERCAN

MARMARA UNIVERSITY Directory of Health Education Faculty, Assistant Professor Metin ATE DOKUZ EYLL UNIVERSITY Directory of Faculty of Economic and Administrative Science Assistant Professor Yasemin YENBOY KARADENZ TEKNK UNIVERSITY Faculty of Medicine, Department of Public Health, Assistant Professor Murat TOPBA ERCYES UNIVERSITY Faculty of Medicine, Department of Public Health, Professor Osman GNAY KOCAEL UNIVERSITY PRESIDENCY Faculty of Medicine, Department of Public Health, Assistant Professor Nilay ETLER ASSOCIATIONS Association of Thorax, Dr. Osman RSEL Association of Public Health Experts, Aassosciate Professor Dr. Hilal ZCEBE Association of Clinical Microbiology and Infection Diseases Professor Dr. Halil KURT Association of Internal Diseases Experts, Dr. Glay SAHN GVEN

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NBD-CE PROJECT NATIONAL VERBAL AUTOPSY SURVEY TEAM

Dr. Seval Akgn, Professor of Public Health, Bakent University Dr. Meri olak, Assistant Professor, Bakent University Dr. Gl Ergr, Professor of Public Health, 9 Eyll University Dr. Gina Etheredge, Associate Professor ,Tulane University Erin Karakan, MBA, Bakent University

NBD-CE PROJECT BAKENT UNIVERSITY EPIDEMIOLOGY TEAM

Dr. Alan Lopez, Professor of Public Health, The University of Quinsland /Australia, Senior Science Advisor, Department on Evidence and Information for Policy, World Health Organization, Geneva Dr. Seval Akgn, Professor of Public Health, Bakent University Dr. Rao Chalapati, Lecturer, The University of Quinsland /Australia Dr. Mithat oruh, Prof., Director of Board of Trustees,Bakent University Dr. Gl Ergr, Professor of Public Health, 9 Eyll University Dr.Elena Andresen, Associate Professor, Saint Louis University Dr. Gina Etheredge, Associate Professor ,Tulane University Dr. Rengin Erdal, Professor of Public Health ,Bakent University Dr. Meri olak, Assistant Professor, Bakent University Dr. zlem Aydn, Bakent University Erin Karakan, MBA, Bakent University

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HIGHLIGTS
The verbal autopsy study was conducted as a necessary part of the National Burden of Disease and Cost Effectiveness Project in order to confirm the causes of death reported in the routine registration systems. This study, is a component of the National Burden of Disease and Cost Effectiveness Project, and it could be completed and become a fundamental tool for defining appropriate policy and strategy for health services in Turkey. This was a cross-sectional survey, which identified the causes of death using the verbal autopsy method and based on a representative sampling according to age and sex in Turkey. In addition, there was also a methodological study, which determined the validity of the verbal autopsy method. With the Verbal Autopsy Survey prepared by Project team, data were collected on deaths occurring in the last one year in the primary sampled household and in two neighboring households on each side of the primary household (two on the left and two on the right). In addition to these deaths, data were also collected on respondents siblings who died during the last one year but who were away from the house. In addition, we contacted the hospital for all of those who died in hospitals, and conducted a validity analysis comparing the Verbal Autopsy and hospital-based records in terms of causes of death. In this study, for the application of VA in terms of determining the number of deaths that occurred in hospitals and which reached hospital records, the sampling method below was used in order to determine the number of deaths. Short term objectives of this study is to identify the national, rural and urban, age and sex specific mortality rates in Turkey, define the medical causes of death for the 0-28 days and 29 days-5 years age groups, as well as adult mortality in Turkey overall by applying the verbal autopsy method conducted by physicians, use these findings as data sources to show the demographic structure of Turkey and to design life tables, identify the Turkish national, urban, rural and regional number of deaths for each disease and condition using the verbal autopsy results; and with all other data sources concerning Turkeys demographic structure and causes of death, calculate YLL of burden of disease and DALYs in accordance with these estimations, verify the physician interviewers verbal autopsy diagnoses by checking hospital records, and identify the sensitivity and specificity of these diagnoses. Long term objectives of his study is to determine the number and causes of death in Turkey and provide the appropriate selection of health programs that lead towards reduction of these causes of death, is to be a source and pioneer for future verbal autopsy studies in our country and show the applicability of the method for our society, supplement and improve the existing system for compiling deathrelated data. At the end of the study, death causes and age and sex specific death rates from this study were obtained and used in deriving life tables. At the same time, the studys results were also important for the calculations of the mortality component of years of life lost (YLL) and subsequently the final DALYs. Death causes are defined by verbal autopsy interviewer. In this study, in order to compare other countries studies, ICD 10 coding system was used in death causes classification. Validity and reliability (within interviewer) of verbal autopsy were tested by hospital records for death causes. For the validity of verbal autopsy diagnoses, sensitivity and specificity tests were used. Causes of death obtained by interviewers and in hospital records were coded in accordance with the ICD 10 coding system and they were evaluated separately for deaths of infants aged 0-28 days, infants and children aged 29 days to 5 years, and for adult age groups. Diseases coded to systems were grouped and validity and reliability analysis were done with this grouped disease. A total of 12. 000 households were selected from 480 blocks to provide representative data for Turkey, and those 12.000 households and their two neighboring households on each side (two on the left, two on the right) were visited for a total of 60,000 households and the deaths occurred inside the household and syblings of the respondent which is in the sample occurred within last one year outside the household was also questioned. In neighbors totally, 165.085 people were identified. In this

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population when the number that age and sex were not defined was excluded, this population is reached to 163.495. The total number of households interviewed by verbal autopsy was about 48.057. When the populations were combined with neighbors and the number that age and sex are not defined was excluded, total populations were 211.552. Age and sex specific death rates were calculated according to this population in verbal autopsy. In this manner a total of 1185 deaths were identified, but death rates by age and sex were calculated from 1170 deaths because 15 deaths either occurred more than one year ago or were not identified properly in terms of age and sex. For some of these 1170 deaths, there was no one who could supply information even after four visits. In these 1170 deaths, 81 siblings death who were living at outside the household were subtracted because, their household was not visited. Therefore age and sex specific death rates were calculated from these 1089 deaths. For cause of death analysis, in these 1170 death, verbal autopsy were applied to 1089 deaths, because for some of the deaths, any person were found or addresses were not identified. But in the course of data checking, five deaths were found to be stillbirths. Analysis and results are provided for these stillbirths separately in the report. Therefore, the evaluation of verbal autopsy questionnaires was done for 1084 deaths. During the application of VA, the questionnaires were coded as 0-28 days, 29 days- 5 years and adult. Of 1084 deaths, 35 deaths (3.2 %) were among infants aged 0-28 days, 68 deaths (6.3%) were among children aged 29 days -5 years, and 981 deaths (90.5%) were among adults. There were 28 deaths for which causes could not be identified by a physician, due to lack of information. All deaths were categorized as household deaths, sibling deaths or two right household/ two left household deaths. Household deaths in all identified deaths are 326 (27,9%), sibling deaths are 87 (7,4%), neighboring household deaths are 751 (64,2%). For 6 deaths (0,5%) there is no information. These amounted to 301 household deaths (27,6%), 87 sibling deaths (8,0%), and 701 neighboring household deaths (64,4%) for the deaths in verbal autopsy survey. Respondents were defined that their siblings deaths who were living outside the household in last one year were 87. But in siblings deaths, 6 deaths were excluded from analysis because their ages were not defined. 81 siblings deaths were not included in the analysis of age and sex specific death rates. As a result, the number valid in the analysis of age and sex specific death rates was 1089. Deaths were divided into 3 region after screening for deaths. Among cases identified, hospital records were analyzed for all deaths occurred at hospitals. 30,2% of the total 1084 deaths occurred in hospitals. Cause of death information of all 327 hospital deaths was coded from existing hospital records. One physician from each region who was independent of those who conducted the verbal autopsy completed these hospital record forms. A total of 255 deaths were completed of the 327 (78.0%). The validity and reliability of verbal autopsy were done at pre test study. The validity and reliability of verbal autopsy were tested by observing hospital records. In order to test the mortality module and the verbal autopsy questionnaire introduced by some parts in this module for use in WHS, 63 cases were completed during the pretest. We selected a sample size of 63 deaths to obtain an adequately precise confidence interval. For reliability, 30 verbal autopsy survey and for validity, 63 verbal autopsy surveys were taken evaluation and kappa statistics were used in calculations. Of the hospital deaths, 15 are 0-28 day infant deaths, 15 of them are 29 day-5 day child death, and 225 of them are 5 years above deaths. In last on year, totally, 35 0-28 day infant deaths were obtained, of these 35 infant deaths, 57,1% (20) were at hospital deaths. Of these 20 hospital deaths, 15 were determined. Hospital records of 5 deaths were not obtained. In this age group, totally, 68 child deaths were occurred. The number of hospital deaths are 18 (26,5%). Of the 18 hospital deaths, 15 (83,3 %) were obtained. The number of 5 year above deaths are 981 and of them 289 ( 29,4%) are hospital deaths. But just 225 (77,9 %) of them were obtained. The first part of the analysis is introduced with descriptive tables. In the NBD-CE Verbal Autopsy study, infant mortality rates in Turkey were found to be 20,2/1000 for males and 22,9/1000 for females. By evaluating the crude death rates for Turkey according to the results of NBD-CE study, the crude death rate is found to be 5.1/1000. This rate is 6.0/1000 for males and 4.2/1000 for females. The crude death rate in urban areas in Turkey is 4,7/1000. For urban areas, according to the results of verbal autopsy, the crude death rate for males is 5,9/1000 and 3,7/1000 for females. If death rates in urban areas are evaluated by age and sex the number of deaths in the 0 age group in females is 15 and death rate is 12,7/1000, and the corresponding number of deaths for males is 21, with a death rate of

IX

17.2/1000. The number of deaths for females is 30 and death rate is 38.1/1000 in rural, whereas the number of deaths for males is 22 and death rate is 24.1/1000 in rural. Crude overall death rate in rural areas was 5.5/1000. Crude overall death rate in rural areas is 4.9/1000 for females and 6.3/1000 for males. Crude death rates were also evaluated by region. As a result of these evaluations, in the Marmara and Aegean the crude death rates are 4.5/1000 overall, 2.9/1000 for females and 6.0/1000 for males. In the Mediterranean region, the corresponding crude death rates are 3.6/1000 overall, 3.6/1000 for females and 4.9/1000 for males. In the Central Anatolia region, crude death rates are 7,5/1000 overall, 6.7/1000 for females and 8.2/1000 for males. In the Black sea region crude death rates are 5,5 in Turkey, 4.5 in females and 5.5 in males respectively. In Eastern and Southeastern Anatolia, crude death rates are 5,0/1000, 4.5/1000 and 5.5/1000 respectively. Life expectancy for males is 72.6 and 77.19 for females. When sexes are evaluated together, life expectancy is 74.80 and infant death mortality is found to be 22/1000. For urban areas, life expectancy at birth for males is 71.82 and for females are 77.78. In rural areas, these values are 73.32 and 76.10 at birth respectively. In rural areas, these values are 73.32 and 76.10 at birth respectively. Overall infant mortality rates for both sexes are 15/1000 and life expectancy is 74.60. In urban areas, In rural Turkey, according to life table calculated by combining the two sexes, the infant death rate is 31/1000 and life expectancy at birth is 74,74 For overall Turkey, the death rate for under-5 age accepted for 5q0 value for males is 27/1000 and for females is 32.8/1000. In urban areas these values are 20.0/1000 for males and 20.0/1000 for females. In rural areas, the calculated rates are 35.5/1000 for males and 50.5/1000 for females. Between ages 15-60, 45q15 values which indicate the probability of death are similar across urban, rural and overall Turkey and also for females and males. 45q15 for Turkey in general is 163.4/1000 for males and 60.0/1000 for females. The corresponding values are 176,5/1000 for urban males and 62.0/100 for urban females, and 145.9/1000 for rural males and 59.8/1000 for rural females. 63,0 % of deaths in urban areas were among males and 37,0% among females; in rural areas, male deaths amounted to 54,2%, and female deaths to 45,8%. By age groups, 3,2 % of deaths occurred among 0-28 day old infants, 6,3 % occurred among 29 day - 5-year-old children, and 90,5% occurred among adults. In urban areas, 92,9 % of deaths occurred among adults, 4,5% among 29 day-5 year old children and 2,5 % among 0-28 day old infants. These proportions were 87.5 %, 8.4 % and 4.1 % in rural areas. In 0-28 day old infants, 51.4 % of deaths were among males and 48.6 % among females. In 29 day-5 year old children, 45.6 % of deaths were among males and 54.4 % among females. In adults, 60,2 % of deaths was among males and 39,8% among females. Overall, 59,0 % of deaths were among males and 41,0 % among females. When the informations belong to 15-49 age female deaths examined, total 40 female deaths were found between 15-49 age. If the values of 15-49 age women are analyzed, 9,5 % had hypertension edema in lower limbs and / or over loss of weight during pregnancy. Any deaths during birth were identified. 13,6 % had continuous fever. In the NBD-CE Verbal Autopsy Study, two mother deaths occurred. One of them is pregnant when she died and the other is maternal death occurred after 6 weeks from birth. 45,7 % of 0-28 day infant deaths occurred in Eastern and Southeastern Anatolia region, 20.0 % in Central Anatolia and 14,3 % in Marmara, Aegean, 11,4% in Black Sea regions. The lowest proportion for infant deaths is identified in the Mediterranean Region (8.6%). Distribution of 29 day-5 year old children deaths comprises 70.6% deaths in Eastern and Southeastern Anatolia and ranked in the first line, 11.8 % deaths in Marmara and Aegean regions and 10.3 % deaths in the Central Anatolia region. One death (1,5%) was identified in the Mediterranean region concerning 29 day-5 year old children. Marmara and Aegean regions take the first place in adult deaths (31.6 %). Death proportions are 23.9 % for Central Anatolia, 22,1 % for Eastern and South Eastern Anatolia, 12.2 % for Black Sea Region and 10.2 % for Mediterranean Region.

The death causes identified by doctors who performed the verbal autopsy survey were given by 0-28 day infant death, 29 day-5 year child death and 5 years above death in urban, rural and Turkey seperately. Infant Respiratory Distress Syndrome (RDS) takes the first place in evaluation of causes of death among male and female infants in 0-28 day age group with a proportion of 26,5 %. Neonatal sepsis and preterm other babies with 11,8% are second causes. Birth anoxia with 8,8% is third cause. Infant RDS comes in the first place for male infants overall in Turkey with a proportion of 27.8 %, then preterm infants with 16,7% neonatal sepsis and birth anoxia with a percentage of 11.1 %. Female infants comprise infant RDS 25.0 % and neonatal sepsis 12.5%. The most common cause of infant death for urban Turkey is prematurity, Birth Anoxia, neonatal sepsis with 14,3% and septicemia, Disseminated intravascular coagulation (defibrillation syndrome), meningitis, pneumonia, hydrocephalus, pneumonia, respiratory distress syndrome (RDS), neonatal aspiration of meconium, pneumothorax with 7,1 %. In rural Turkey, the largest cause of death was infant Respiratory Distress Syndrome (40,0 %). In urban communities, premature and neonatal sepsis was reported (10,0 %). Pneumonia has a proportion of 13,4 % and meningitis has a proportion of 7,5 %, 6,0% bronchopneumonia and septicemia, in distribution of causes of death among 29 day-5 year old male and female children in Turkey. It is found that pneumonia with 16,7 %, and meningitis with 13,3 % come in the first place among male children; whereas the same distribution for female children is defined as 10,8 % pneumonia, 8,1% septicemia and 5,4 % bronchopneumonia, road traffic accidents, measles and protein- energy malnutrition. In urban Turkey in the age group of children 29 days to 5 years, pneumonia (11,5%), gastroenteritis of presumed infectious origin, and asthma (7,7 %) were the most common causes of death (7,7 %). In rural children aged 29 days to 5 years, when the distribution of causes of death among males and females is examined, pneumonia occurred a rate of 14,6 %, meningitis and septicemia at 9,8 % each, and bronchopneumonia at 7,3%. According to verbal autopsy results, overall in Turkey, hypertension comes in the first place in causes of death among adults, at 12,5 %. Acute myocardial infarction comes second (9.6%), and lung CA takes third place (5,9%). In females, hypertension is first among causes of death, at 17,0%. This is followed by acute myocardial infarction at 8,0% and diabetes mellitus at 5,1%. In males, MI is the most important cause, at 10,7%. Next come hypertension (9,5%), lung CA (8,5%), and cardiovascular disease (6,2%) Based on the verbal autopsy, the most common cause of death among over 5 year old male and females in urban area is hypertension with 12,3% and then MI with 9,1% and lung CA with 6,9%. The most common cause of death among females in urban areas was hypertension (15,7 %). The others major causes are MI (7,3 %) and diabetes mellitus (5,8 %). Other deaths in females are cardiovascular diseases with 5,2%, stomach CA with 4,2% and chronic obstructive pulmonary disease and unspecified atherosclerosis, with 3,1% each. The most common cause of death among urban males was hypertension (10,4 %). Then, MI with 10,1% and malignant tumor of lung, bronchus trachea with 9,3%. According to the verbal autopsy results, in rural areas of Turkey, hypertension takes first rank in the 5+ age group with 12,6%. Then comes MI with 10,3% and cardiovascular diseases with 5,3%. In females, hypertension comes first among causes of death at The most common cause of death in adult females was hypertension (18,4 %). The second most common cause of death was MI with 8,6 % followed by Alzheimer with 5,9 %. For adult males in rural areas, the most common cause of death was MI (11,5 %). The second cause was hypertension (8,1%), followed by chronic obstructive pulmonary disease with 7,7% and bronchus, trachea and lung malignant neoplasm (7,3%). Diabetes Mellitus with 3,4% and traffic accidents with 3,0% are other cause of deaths in male adults

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CONTENTS

Page No
INTRODUCTION........................................................................................................................... 8 OBJECTIVES ................................................................................................................................. 9 2.1 Short Term Objectives............................................................................................................... 9 2.2 Long Term objectives................................................................................................................ 9 GENERAL INFORMATION ......................................................................................................... 10 3.1 Studies on Verbal Autopsy Content .......................................................................................... 10 METHOD........................................................................................................................................ 13 4.1 Overview of the research........................................................................................................... 13 4.2 Determining the reliability of verbal autopsy............................................................................ 13 4.3 Type of the survey..................................................................................................................... 13 4.4 Timing of the survey ................................................................................................................. 14 4.5 Data Collection.......................................................................................................................... 14 4.5.1 National Health Research Verbal Autopsy Questionnaire Form.................................. 14 4.5.2 Identification of Causes of Death ................................................................................. 15 4.5.3 Lag Time of Verbal Autopsy........................................................................................ 17 4.5.4 Selection and Training of Interviewers......................................................................... 17 4.5.5 Monitoring .................................................................................................................... 18 4.5.6 Validity Analyses ......................................................................................................... 19 4.6 Data Analyses............................................................................................................................ 20 4.6.1 Validity and Reliability ................................................................................................... 20 4.6.2 Pre-Test Application........................................................................................................ 20 4.6.3 Main Field Application ................................................................................................... 23 4.6.4 Statistical Methods Used In the Study............................................................................. 23 4.6.5 Limitations of the Research............................................................................................. 24 RESULTS........................................................................................................................................ 25 5.1 Age and Sex Specific Death Rates, Turkey............................................................................... 25 5.2 Evaluation of Verbal Autopsy Results .................................................................................. 35 5.2.1 Distribution of Participants........................................................................................... 36 5.2.2 General Information About the Deceased .................................................................... 38 5.2.3 Medical History Related to Death ................................................................................ 44 5.2.4 Adult Deaths ................................................................................................................. 56 5.2.5 Deaths Among Infants Aged 0-28 Days....................................................................... 59 5.2.6 Deaths Among Children Aged 29 Days - 5 Years........................................................ 63 5.2.7 Findings Related to Stillbirths ...................................................................................... 66 5.2.8 Causes of Death ............................................................................................................ 69 5.2.8.1 Main Causes of Death Among Male and Female Infants Aged 0-28 Days...... 69 5.2.8.2 Main Causes of Death Among Male and Female Children Aged 29 Days - 5 Years.................................................................................. 71 5.2.8.3 Causes of Death Among Males and Females Above 5 Years of Age. 74 5.3 Validity of the Verbal Autopsys Application........................................................................... 87 5.3.1 Deaths Among Infants Aged 0-28 Days........................................................................ 88 5.3.2 Deaths Among Children Aged 29 Days - 5 Years......................................................... 89 5.3.3 Deaths Among the Above 5 Years Age Group ............................................................. 90 CONCLUSION AND SUGGESTIONS ......................................................................................... 95

REFERENCES .............................................................................................................................. 98 APPENDICES................................................................................................................................. 100 APPENDIX 1: National Verbal Autopsy Survey Interviewer Training Program........................... 100 APPENDIX 2: Verbal Autopsy Doctors ......................................................................................... 101 APPENDIX 3: Distribution of Number of Deaths and Verbal Autopsy Results By Regions and Provinces ......................................................................................... 102 APPENDIX 4: National Burden of Disease and Cost Effectiveness Study Verbal Autopsy Control Form ..................................................................................................... 103 APPENDIX 5: Death Statistics Form ............................................................................................. 104 APPENDIX 6: Definitions of Symbols Used in Life Tables .......................................................... 105 APPENDIX 7: Verbal Autopsy Survey .......................................................................................... 107 APPENDIX 8: Verbal Autopsy Survey Manual ............................................................................. 108

ABBREVIATIONS
ARDS: Acute Respiratory Distress Syndrome DALY: Disability Adjusted Life Years SIS: State Institute of Statistics WHS: World Health Survey WHO: World Health Organization CKI: Chronic Kidney Insufficiency CHD: Chronic Heart Disease COPD: Chronic Obstructive Pulmonary Disease RDS: Respiratory Distress Syndrome CVE: Cerebrovascular Events SEARCH: Society for Education Action and Research in Community Health DHS: Demographic Health Survey NBD-CE: National Burden of Disease and Cost Effectiveness Study ILO: International Labor Organization YLL: Years of Life Lost VA: Verbal Autopsy KIBAS: Intracranial Pressure Syndrome

TABLE LIST Page No

Table 3.1 Some Studies Using the Verbal Autopsy Concept ......................................................... 12 Table 5.1 Age and Sex Specific Death Rates for Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 25 Table 5.2 Age and Sex Specific Death Rates for Urban Areas in Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................... 26 Table 5.3 Age and Sex Specific Death Rates for Rural Areas in Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................... 27 Table 5.4 Crude Death Rates of Turkey by Urban vs. Rural Location and Regions (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 28 Table 5.5 National Life Table for Turkey (NBD-CE Study Verbal Autopsy Survey, 2003) ............................................................ 29 Table 5.6 Life Table for Urban Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................... 31 Table 5.7 Life Table for Rural Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 33 Table 5.8 Child and Adult Death Rates (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 34 Table 5.9 Distribution of Interview Results of Verbal Autopsy Survey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 36 Table 5.10 Relationships of Respondents to the Deceased (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 37 Table 5.11 Distributions of Respondents by Age Groups and Sex (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 37 Table 5.12 Respondents Educational Status (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 38 Table 5.13 Urban-Rural Distribution of Place of Death (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 38 Table 5.14 Distribution of Place of Deaths by Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 39 Table 5.15 Distribution of Place of Death by Regions (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 39 Table 5.16 Distribution of At-Home Deaths by Urban-Rural Location and Sex (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 40 Table 5.17 Distribution of At-Home Deaths by Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 40 Table 5.18 Distribution of At-Home Deaths by Region (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 41 Table 5.19 Distribution of Deaths by Urban-Rural Location and Sex (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)............................................... 41 Table 5.20 Distribution of Deaths by Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 42 Table 5.21 Distribution of Deaths by Age Groups and Sex (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 42 Table 5.22 Distribution of Deaths by Age Groups and Regions (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 42 Table 5.23 Distribution of Deaths Among Age 12+ Adults by Marital Status (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 43 Table 5.24 Distribution of Deaths Among Age 12+ Adults by Occupation (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 43 Table 5.25 Distribution of Adult Deaths by Smoking Habits, Alcohol Use, and Substance / Drug Use (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 44

Table 5.26 Presence of Pre-Death Symptoms/ Complaints in the Deceased (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003 ............................................... 44 Table 5.27 Distribution of Pre-Death Complaints (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 45 Table 5.28 Distribution of the Deceased According to Whether They Were Seen by a Health Professional in Their Last One Year (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 47 Table 5.29 Distribution of the Deceased Who Received Inpatient Treatment in a Hospital in Their Last One Year, by Age and Sex (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 48 Table 5.30 Distribution of Reported Operations, by Type (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 48 Table 5.31 Distribution of Organs Operated On (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 49 Table 5.32 Distribution of Death Diagnoses Reported by Respondents (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003). ........................................ 50 Table 5.33 Distribution of Deaths in Terms of Whether a Physician Provided a Diagnosis, by Sex and Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 52 Table 5.34 Distribution of Whether Deaths Were Due to Injury, by Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 52 Table 5.35 Distribution of Types of Injury Causing Death, by Sex and Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 53 Table 5.36 Distribution of Events Causing Injury, by Sex and Age Groups (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 54 Table 5.37 Distribution of Injuries by Place of Occurrence (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 55 Table 5.38 Distribution of Situations at the Time of Injury (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 55 Table 5.39 Distribution of Injuries by Body-Part Injured (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 56 Table 5.40 Distribution of Medical Conditions Caused by Injury (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 56 Table 5.41 Distribution of Reported Tumors by Location (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................... 57 Table 5.42 Distribution of Symptoms and Conditions Before Death, by Organ Systems (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 58 Table 5.43 Distribution of Pre-Death Findings Among 15-49 Year Old Females, as Reported by Respondents (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 59 Table 5.44 Distribution of Mothers Health Conditions before Giving Birth, During the Birth and After the Birth, as Reported by Respondents (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 60 Table 5.45 Distribution of Situations Encountered During and After Delivery Prior to Deaths Among of 0-28 Day Old Infants (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .......................................... 61 Table 5.46 Distribution of Deaths Among 0-28 Day Old Infants by Post-Delivery Complications (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 62 Table 5.47 Distribution of Deaths Among 29 Day-5 year Old Children, by Complications and Breastfeeding Status (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 64

Table 5.48 Distribution of Deaths Among 29 Day-5 Year Children, by Immunization Status and Presence of Rash or Skin Diseases (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 64 Table 5.49 Distribution of Deaths Among 29 Day-5 Year Old Children, by Selected Symptoms (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 65 Table 5.50 General Information About Respondents Who Reported Stillbirths (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 66 Table 5.51 Distribution of General Characteristics of Stillbirths (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 67 Table 5.52 Distribution of Findings Associated With Stillbirths, Before, During and After Delivery (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ..........................................67 Table 5.53 Distribution of Main Causes of Death Among 0-28 Day Old Infants, by Sex and Physician Diagnosis (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 69 Table 5.54 Distribution of Main Causes of Death Among 0-28 Day Old Infants, by Sex and Physician Diagnosis: Turkey, Urban Region (NBD-CE Study Verbal Autopsy, Turkey, 2003)........................................................ 70 Table 5.55 Distribution of Main Causes of Death Among 0-28 Day Old Infants, by Sex and Physician Diagnosis: Turkey, Rural Region (NBD-CE Study Verbal Autopsy, Turkey, 2003)........................................................ 71 Table 5.56 Distribution of Main Causes of Death Among Male and Female Children Aged 29 Days - 5 Years, by Sex and Physician Diagnosis: Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 72 Table 5.57 Distribution of Main Causes of Death Among Male and Female Children Aged 29 Days - 5 Years, by Sex and Physician Diagnosis: Turkey, Urban Region NBD-CE Study Verbal Autopsy, Turkey, 2003)........................................................... 73 Table 5.58 Distribution of Main Causes of Death Among Male and Female Children Aged 29 Days - 5 Years, by Sex and Physician Diagnosis: Turkey, Rural Region (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 74 Table 5.59 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 75 Table 5.60 Distribution of the Top 10 Causes of Death in the Over-5 Age Group,

by Sex and Physician Diagnosis

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 79 Table 5.61 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Urban Region (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 80 Table 5.62 Distribution of the Top 10 Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Urban Region (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 83 Table 5.63 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Rural Region (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 84 Table 5.64 Distribution of the Top 10 Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Rural Region (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 87 Table 5.65 Table 5.65 Comparison of Causes of Death Diagnosed by Physicians in the Verbal Autopsy Survey and Hospital Records, for Deaths Among Infants Aged 0-28 Days (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 88

Table 5.66 Comparison of Causes of Death Diagnosed by Physicians in the Verbal Autopsy Survey and Hospital Records For Deaths Among Children Aged 29 Days - 5 Years (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 89 Table 5.67 Distribution of Grouped Main Causes of Death in the Over-5 Age Group According to Physician Diagnoses in Verbal Autopsy Survey and Hospital Records (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ........................................... 91 Table 5.68 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey Records (Cancer) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) .............................................. 92 Table 5.69 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Lung CA) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 92 Table 5.70 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Ischemic Heart Disease) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 92 Table 5.71 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Cerebrovascular Events-CVE) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................. 93 Table 5.72 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Hypertension) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 93 Table 5.73 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Diabetes Mellitus) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 93 Table 5.74 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Chronic Kidney Insufficiency-CKI) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 94 Table 5.75 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (COPD) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 94 Table 5.76 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (MI) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) ............................................ 94

INTRODUCTION
Information on births and deaths are important for estimating a societys health needs and necessary health services. In this information, particularly national-level death rates and causes of death should be included, given their great importance for planning and supporting necessary preventive and therapeutic services. As it known, there is no information gathering system to forecast correctly health needs in Turkey and to make health planning death fits to country needs. Especially, the primary data sources are death statistics derived from SIS from provinces and districts. But, SIS gathers only the deaths occurred in the province and district centers. Because of this situation, there is no datas related to deaths from the settlements which are smaller than province and district centers. Instead of health needs determined from the results of analyzes of current situation, the regional distribution of health investment and expenditures are planned according to political decision process and previous years budget adjustments. In this concept, evaluation of regional needs according to public health and health planning and it s too important to develop scientific methodologies to support decision making mechanisms for resource distribution process. Although the verbal autopsy method has been used since 1937, it has lost its significance in countries where health information systems have been developed; however, it maintains its importance in countries where health information systems are not highly developed. After the studies of time based health status measures lasting thirty years, burden of diseases concept and measures of it which is disability adjusted life years (DALY) developed by Global Burden of Disease Study lasted at 1993 is giving a new approach to health planner for determining public health needs in a wide perspective. DALY concept is purposed to evaluate burden of disease of premature deaths caused by several diseases and diseases that results disability but not results in death with a single measure. For this reason, the verbal autopsy study was conducted as a necessary part of the National Burden of Disease and Cost Effectiveness Project in order to confirm the causes of death reported in the routine registration systems. Age and sex specific death rates from this study were used in deriving life tables. At the same time, the studys results were also important for the calculations of the mortality component of years of life lost (YLL) and subsequently the final DALYs.

OBJECTIVES
This survey was planned and administered according to the following long-term and shortterm objectives.

2.1 Short Term Objectives

1. Identify the national, rural and urban, age and sex specific mortality rates in Turkey, 2. Define the medical causes of death for the 0-28 days and 29 days-5 years age groups, as well as adult mortality in Turkey overall by applying the verbal autopsy method conducted by physicians, 3. Use these findings as data sources to show the demographic structure of Turkey and to design life tables, 4. Identify the Turkish national, urban, rural and regional number of deaths for each disease and condition using the verbal autopsy results; and with all other data sources concerning Turkeys demographic structure and causes of death, calculate YLL of burden of disease and DALYs in accordance with these estimations, 5. Verify the physician interviewers verbal autopsy diagnoses by checking hospital records, and identify the sensitivity and specificity of these diagnoses.

2.2 Long Term Objectives

1. Determine the number and causes of death in Turkey and provide the appropriate selection of health programs that lead towards reduction of these causes of death, 2. Be a source and pioneer for future verbal autopsy studies in our country and show the applicability of the method for our society, 3. Supplement and improve the existing system for compiling death-related data.

GENERAL INFORMATION 3.1 Literature Review on Verbal Autopsy

Studies employing verbal autopsy have been conducted for research and planning purposes since the 1930s, although its first detailed and thorough application was in 1990 at Johns Hopkins University. The method is based on getting information about deceased persons, whose families allow investigation of the diseases that caused the deaths. In this way, inadequacy of information due to the absence of a health professional before the death can be overcome (2,3,4,6). The verbal autopsy method is based on 3 assumptions, as follows (6-13): 1. Various diseases can be distinguished based on their major clinical findings and symptoms. The validity of the method is high when the patient has clear findings, when these findings exist in all other such cases resulting in death, and when findings for other fatal illnesses are not present 2. 3. Reports by the family of the deceased are vital in the identification of the prominence and severity of the signs and symptoms. The time interval after death is important to the identification and recollection of signs and symptoms. In order to obtain valid results in verbal autopsy studies, these issues must be taken into consideration. For instance, the shorter the time that has elapsed between death and the administration of the verbal autopsy, the more accurate the results can be. However, generally it is believed that it is not ethical to administer a verbal autopsy earlier than one month following the death. In addition, because the death is so recent, a high proportion of families refuse the request (3,4,7-12,39). In many VA studies it was determined that families tend to accept the request about one year after the death. On the other hand, especially when identifying causes of death in children, the shorter the interval, the more valid the data (4,5,9,11,38). This is also important in certain cultures when birth intervals are short and when mothers have more than one child needing care. In addition, respondents knowledge of signs and symptoms of the causes of death can be another major factor in the validity and reliability of the results. (4,5,7,9,11,39).

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For the verbal autopsy method, the lack of both a standard questionnaire and universally acceptable diagnostic criteria has been an important problem. In India, a research group (the Society for Education Action and Research in Community Health, SEARCH) developed a standard questionnaire as well as diagnostic and classification criteria based on symptoms/signs combinations for each disease, especially for use in studies of infant deaths. However, some of the criteria developed in a specific region might be valid only for that region, and may not be valid for another setting; also, different communities may have different traditional habits (4). In some of the verbal autopsy studies on child mortality, mothers or other family members were asked to talk about the illness and the history of the death of the children, and then a classification was determined based on the mothers report. In some other studies, caregivers were asked in closed-ended questions whether certain signs had been present in the child before death. When closed-ended questions are used, the coding method for the signs/symptoms combinations that will be inquired about should be determined beforehand. In questionnaires that include closed-ended questions, some signs that are highly sensitive to a given system or organ are asked about. Then, if the person answers these questions affirmatively, it is useful to ask more detailed questions in order to increase the specificity (4,5,7,9,11-13,39). For identifying infant and child causes of death, standard criteria were prepared in two groups based on neonatal deaths and deaths in children aged 29 days to 5 years. Decisions on the diagnosis of diseases are more widely applicable after the physicians usage of VA in determining the main causes of death. Many prior studies have been conducted using verbal autopsy, and a broad variety of clinical signs and symptoms have been identified for many diseases. Table 3.1 shows some examples of studies that have been conducted in several countries (14-20). Causes of death differ among these countries; however, the methods of these studies, their signs/symptoms classifications, and the questionnaires they used are not alike. In addition, there are also some VA studies on the validity and reliability of these methods (21-28).

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Table 3.1 Some Studies Using the Verbal Autopsy Concept

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)

Country, Year

Study Type

Age

Weeks Elapsed Between Death and Interview Criteria in Diagnosis of Death

Bangladesh, 88 Bangladesh, 78-89 Gambia , 82-89 Liberia , 88 Guinea-Bisseau 78 India, 71 73

Retrospective Retrospective Life analysis Retrospective Life analysis Life analysis

months 0 63 months 0 60 months 0 60 months 0 72 months 0 48 months 0 60

1 52 weeks 17 80 weeks 0 12 weeks 1 52 weeks 10 35 weeks 0 2 weeks

Algorithm Algorithm Clinical Decision Algorithm Clinical Decision Clinical Decision

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METHODOLOGY 4.1 Overview of the Research

The Verbal Autopsy methods are a component of the Household Survey. In the survey, data were collected on deaths occurring in the last one year in the primary sampled household and in two neighboring households on each side of the primary household (two on the left and two on the right). In addition to these deaths, data were also collected on respondents siblings who died during the last one year but who were away from the house. In addition, we contacted the hospital for all of those who died in hospitals, and conducted a validity analysis comparing the Verbal Autopsy and hospitalbased records in terms of causes of death. In this study, for the application of VA in terms of determining the number of deaths that occurred in hospitals and which reached hospital records, the sampling method below was used in order to determine the number of deaths.

Within this context besides the household sample which reducted from the National Health Survey, 2 left and 2 right of the households neighbourhood scanned and deaths occurred in the last one year determined in this population. In addition to that, respondents siblings death questioned during the household visits. 1170 deaths were identified as valid. Respondents were defined that their siblings deaths who were living outside the household in last one year were 87. But in siblings deaths, 6 deaths were excluded from analysis because their ages were not defined. 81 siblings deaths were not included in the analysis of age and sex specific death rates becouse respondents siblings were not visited. As a result, the number valid in the analysis of age and sex specific death rates was 1089.
In neighbors totally, 165.085 people were identified. In this population when the number that age and sex were not defined was excluded, this population is reached to 163.495. Total number of household members are 48.057. The total number of households interviewed by verbal autopsy was about 48.057. When the populations were combined with neighbors and the number that age and sex are not defined was excluded, total populations were 211.552. Age and sex specific death rates were calculated according to this population in verbal autopsy. In Appendx.3, deaths identified by regions and districts and distribution of applied verbal autopsy questionnaires are presented.

4.2 Determining the Validity of Verbal Autopsy The field application was completed in one phase. In order to determine VA validation, all hospital death records were used, and then the validity analyses of VA results had been done versus hospital records. 4.3 Type of the Survey
This was a cross-sectional survey, which identified the causes of death using the verbal autopsy method and based on a representative sampling according to age and sex in Turkey. In addition, there was also a methodological study, which determined the validity of the verbal autopsy method.

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4.4 Timing of the Survey A pre-test study of the VA research was done in July-August 2002, and the field survey was
performed between 21 April- 23 May 2003. Also Hospital study was completed between 1-28 May 2003.

4.5 Data Collection 4.5.1 National Health Survey Verbal Autopsy Questionnaire Form
We reviewed the verbal autopsy form used in the World Health Survey (WHS) that was developed by WHO. Since we determined that this questionnaire was not sufficient for our countrys need for causes of death, questionnaire forms of other studies were gathered from a comprehensive literature review. Based on these efforts, the questionnaire form developed by the London School of Hygiene and Tropical Medical for Tanzania, and the questionnaire used in Jordan were reviewed and adapted as a new questionnaire form for our survey (29-30). While developing the questionnaire form for this study, we adapted the case and health conditions descriptions to Turkish and to the conditions of Turkey. During the workshop meeting in July 2002, an expert group discussed the questionnaire form, and we then conducted a pretest after making adaptations based on the experts opinions. The verbal autopsy questionnaire used in this project consists of three parts. The first part includes adults over 5 years old, the second includes deaths that occurred 0-28 days after birth, and the third part investigates deaths between 29 days and 5 years of age. Among the adult deaths, there are also questions for causes of death for all women aged 15-49. The primary points considered in preparing the questionnaire form are as follows (4,6,8,11,12,16,21,28,31,39): 1. Most of the questionnaire consists of close-ended questions. Close-ended questions were common among other Verbal Autopsy studies. One or a few highly sensitive symptoms/findings were asked about for each body system inquiry, and if the responded reported that these were also seen for the deceased, physician interviewers moved onto detailed modules. In brief, the main principle in preparing the questionnaire was to develop a questionnaire form starting from the disease of the deceased before death and its symptoms and findings of the disease 2. While developing the new form, Turkish terminology was used to describe health conditions.

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3. The verbal autopsy questionnaire used in the survey consists of three parts. The first part includes adult deaths, the second neonatal deaths (0-28 days) and the third deaths in children aged 29 days - 5 years. These same age groups are defined in the methods applied world wide, and are the ones used in the questionnaires developed by the London School of Hygiene and Tropical Medicine for use in Tanzania, and which were tested for standardization in questionnaires used in other countries. 4. Among the adult deaths, there are questions for causes of death for all 15-49 age women. 5. A pre-test study was conducted in order to determine the validity and reliability of the questionnaire. 6. The Verbal Autopsy was administered in every province where the Household Survey was administered. For all cases that died in a hospital, a validity study was conducted by using hospital death records. 7. Sociodemographic information (age and sex) from neighboring households was taken from the neighboring household information form, which was an addition to the household questionnaire form. Crude mortality rates and age and sex specific death rates were calculated for use in the preparation of life tables. Questionnaires were revised based on problems observed in the pretest. Questionnaires were prepared in a format for optic reader, and the manual for interviewers was similarly revised.

4.5.2 Identification of Causes of Death

After finalizing to develop the questionnaire form process, a detailed interviewers handbook/ manual was completed. Interviewer training was conducted using the manual as a guide. Problems and solutions based on the criteria in the SEARCH base, which were expected to be especially important to evaluate mortality causes among the infants and young children also were included in this manual (4). In addition, these criteria were reinforced in the training and examples were given in order to standardize the completion of the questionnaire and causes of death.

15

We reinforced the need to consider primary and contributing causes of death. After the completion of questionnaire, the sections that include the final and main cause of death were carefully coded by interviewer by the help of informations obtained. While determining the cause of death, choosing one reason of death or classifying main underlying reason of death is not recommended, if more than one reason is ascertained, it is proposed to list all causes. Verbal autopsy may seem insufficient when it results in only one uncertain cause of death. However, epidemiologically, even though the death cause is not clearly classified, the rough delineation between infectious disease or anomaly is sufficient. While classifying the cause of death, the main cause and the final cause generally are listed separately. Sometimes there may be an intermediate cause as well. However, these three causes may not present. The main cause used in death statistics is the main death cause. In this survey, the main death cause and the final cause were coded (4,5,8,27,28, 39, 43). Main cause: first disease or incident that lead to death. Final cause: last disease or case that lead to the death of the person.

Diagnoses those are not appropriate to be coded as the main cause and final cause
Cardiac arrest, respiratory arrest, septic shock, cardiogenic shock, renal failure, bleeding, shock, cerebrovascular events, injuries (traumatic) are generally the final results of death and the reasons that lead to this cause were coded instead.(43).

Deaths that have one cause

In some cases, there may only be a main death cause. Cancer types may be an example of this. As a result of cancer, death may come after bleeding, cerebral metastasis and arrest; however, the main cause here is always cancer. In addition, for infectious diseases, only the main cause should be registered (Typhoid, diphtheria, etc.).

Cause and effect relationships

If a person with prostate cancer dies in a traffic accident, the main cause here is the traffic accident. It would not be correct to say that the cause is cancer, because the main cause and the final cause should have a cause and result relationship. The relationship should be logical. Since the cancer doesnt lead to traffic accident, the main cause here is the traffic accident.

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Deaths in the 0-28 Days and the 29 Days- 5 Years Age Groups
In this part main cause of dead is also enrolled. Causes such as prematurity and malnutrition can be main causes of death. However, one should be more careful when coding prematurity or intrauterine growth retardation as causes of death after day 29. These points are looked over when the main cause is determining. Especially after the age of one, the death of child can not be prematurity, since this child already completed one year old, so these problems should be over. All these points should be taken into consideration while determining the main cause of deaths. Moreover, causes of deaths are coded based on the ICD 10 coding system by trained group who are worked in ICD coding of household survey and the causes of deaths are presented according to the definitions in ICD 10 coding manual. In the application, the interviewer reviewed the diagnosis of the doctor and in any case of incoherency was resolved after having talked to the doctor who completed the verbal autopsy when necessary. All the above issues were described in detail during the training sessions to assist doctors in identifying the correct cause of death.

4.5.3

Lag Time of Verbal Autopsy

In earlier verbal autopsy studies, it was shown that the shorter the time interval between time of death and administering the verbal autopsy, the more valid the results were. However, in various studies it is shown that families have been interviewed after a period of 1 year. Given the important role of memory after an interval of one year that is in the literature, verbal autopsy studies are usually conducted only on deaths that occurred within the last year (4,6,8,14,24,28,39).

4.5.4 Selection and Training of Interviewers

The number of interviewers to conduct the verbal autopsy phase was calculated by considering the sample size of the household population, the estimated crude mortality rate for Turkey, and total number of deaths expected. Interviewer selection was completed after determining the required number of interviewers. The most important criteria were that the interviewer was a medical doctor. Priority was given to selecting interviewers from the region where the questionnaire was administered. While applying household questionnaire, regional health authorities were conducted. Interviewers were selected from Ankara, Izmir, Istanbul and Diyarbakir regions. Also a regional coordinator is ap-

17

pointed for each region. Physicians who analyzed hospital records were selected separately from interviewing physicians. The reason of this application is to avoid bias from having the same person involved in both phases of determining the cause of death. After selection procedure, skilled training is done for physician interviewers in Ankara for one day. During these sessions, interviewers were trained by practicing from the verbal autopsy manual. They practiced with the VA questionnaire form by doing applications on previous questionnaire forms with the help of staff of epidemiology group of Baskent University Burden of Disease and Cost Effectiveness Project. In addition, experts from Refik Saydam Hygiene Center Presidency, School of Public Health explained the monitoring and control form developed by them during this training. In Appendix 1, interviewer-training program was presented.

4.5.5

Monitoring

Verbal autopsy activities were monitored within a protocol. Job definitions and responsibilities of activities were defined. Every effort was made to complete activities within the time line by careful coordination and teamwork. Field responsibility was the purview of field coordinators and regional coordinators. The field and regional coordinators reviewed each verbal autopsy form before being sent to the central office. If necessary, editing was done by interviewers in contact with the family of the deceased still living in that region. Completion was defined in two ways. If the person did not die in the hospital, verbal autopsy questionnaire form was completed when the form was returned to the central office. If the person died in a hospital, the verbal autopsy application was partially complete when the verbal autopsy form was returned to the central office, but only fully completed once the regional hospital verification specialist returned his/her form to the central office. The central office passed the forms to the appropriate department for data entry. After evaluation of pre-test, necessary corrections are done, so any problem is faced with at the main field application.

Verbal Autopsy monitoring and control form developed by Ministry of Health (Appendix 4) were sent to the Ministry of Health Refik Saydam Hygiene Center Presidency after completion of the VA interview.

18

4.5.6. Validity Analysis

Deaths were divided into 3 region Among cases identified, hospital records were analyzed for all deaths occurred at hospitals. Because 5 of the 1089 deaths were stillbirth, 327 (%30,2) deaths among 1084 were occurred in the hospitals determined in this survey. Cause of death information of all 327 hospital deaths was coded from existing hospital records. One physician from each region who was independent of those who conducted the verbal autopsy completed these hospital record forms. A total of 255 deaths were completed of the 327 (78.0%). Reasons for not completing the remainder included missing hospital records, refusal of hospital officers to examine records, and not having records for some emergency service deaths. As mentioned above, a separate physician was assigned to examine records for deaths that occurred in hospitals. Field coordinators were responsible for sending information related to hospital deaths to the physician assigned to following hospital records. After contacting the hospital, this person determined the cause of death by examining hospital records at their source, and reported the information to the central office. This also reinforces the advantage of selecting physician interviewers from the specific regions: the person knew the hospitals better and expended less time and financial resources. Moreover, attributing this task to an independent verbal autopsy interviewer enabled the field verbal autopsy interviewer to focus on his/her own duty and avoided these interviewers having to go to the region in order to collect hospital records.

After completing the validity study using hospital records we produced the following: 1. Comparisons of the percent of deaths with hospital records and between urban and rural areas. 2. Determination of reliability and validity of cause of death information using verbal autopsy versus hospital records. 3. To obtain relevant information on the improvement of coding system as well as the administrative capacity of the hospital systems of Turkey.

19

4.6 Data Analyses

The first phase included descriptive analysis. Moreover, by acquiring a complete list of household members of the sampled and neighborhood households, we produced an independent household table. Excluding the sibling deaths out of the sampled house, we calculated the crude mortality rate, age specific mortality rates and sex specific mortality rates both in the sampled households and in the neighbor households. Validity analysis was performed to determine the agreement between the hospital registry and verbal autopsy.

4.6.1 Validity and Reliability

The validity (accuracy) and reliability (among interviewer) of the verbal autopsy were tested in the pre-test. Validity and reliability of inter-interviewers were tested by comparison to the hospital records for case-identification and for causes of death. Validity of the verbal autopsy was tested by sensitivity and specificity calculations. Sensitivity indicates how successful the verbal autopsy method was in identifying the number of patients who died. So the proportion of the people who are identified as patients according to both `the method` and `gold standard reference test`, to the people, who are showed as patients by gold standard reference test, gives the sensitivity of the test. However specificity shows how accurately the new method identifies the cases that did not die. The proportion of the healthy ones identified by both the new test and reference test, to the total number of the ones whose healthiness are shown by reference test, gives the specificity of the test. In this study, hospital records were considered as the reference test (golden standard).

4.6.2 Pre-Test Application

In order to test the mortality module and the verbal autopsy questionnaire introduced by some parts in this module for use in WHS, 63 cases were completed during the pretest. We selected a sample size of 63 deaths to obtain an adequately precise confidence interval. Since validity analyses are not hypotheses testing studies, the strength of the association and precision are the important aspects of selecting the sample size. Validity estimates based on very small samples are not accurate. The results of the organization, and the reliability and validity of the study were reviewed by the project team and the appendixes of this phase of the study have already been presented (32-37).

20

Two specialist physicians were selected to provide medical guidance and to act as field coordinators for the study. Another three physicians, each with approximately three years experience, were chosen and trained as verbal autopsy interviewers. They were provided training for half a day about the purpose and methods of the study, and in the use of the questionnaire. During and immediately following the initial field pretest of the household questionnaire, these three verbal autopsy interviewers conducted verbal autopsies on those deaths identified by the household survey team. The pretest was conducted in Ankara, Aya, and Kzlcahamam.

When the household survey team identified a death within the previous year, the decedents name and address were forwarded to the verbal autopsy team. The deaths were distributed to the three interviewers who made four attempts at completing the interview. Even if the interviewee initially refused the interview, the interview team attempted to obtain consent again. Sometimes the team judged that another interviewer would have better success and the case was reassigned. Four contact attempts were distributed across various times of the day and weekend: one attempt on a weekday morning (8 a.m.-12 p.m.), one attempt on a weekday afternoon (12 p.m.-5 p.m.), one attempt on a weekday evening (7 p.m.-7:30 p.m.), and one attempt anytime on a weekend. An informed consent form was completed before initiating the interview. The interview duration was approximately 15-20 minutes.

The pretest of the new verbal autopsy questionnaire form that was explained in detail above was completed, and then household deaths and death of siblings were have been queried. The deaths of neighbors on both sides (2 rights, 2 left) of the primary household were not identified in this pretest phase. In the pretest it couldnt be reached to 63 deaths. For this reason, to achieve the required sample size, deaths that occurred at Bakent University Hospital, Dr. Sami Ulus Childrens Hospital and SB Ankara Hospital (Ministry of Health) were used. From the three hospitals, (because of loss due to people moving, refusing to participate, not having anyone capable of answering the questions, etc.), 20 records of people who died in each hospital during the last year (July 2001 through June 2002) were randomly selected. Similarly to the deaths in the household, four attempts were made to achieve interviews. Verbal autopsy interviewers did not view the hospital records containing the cause of death.

For each death in the hospital, the retest interviewer was sent to hospitals to examine the hospital records. Hospital cause of death forms were sent to the central office, recorded, and prepared for data entry.

21

63 verbal autopsies were completed, 14 of which were from household survey (from the field) and 49 of which were based on deaths from hospitals. Verbal autopsy interviewers identified causes of death. After the interviewers completed the verbal autopsy forms in the field, field coordinators in the projects central office reviewed the forms, and the final cause of death was determined.

Of the anticipated 63 deaths identified in the household survey, 30 deaths were retested for reliability. These 30 deaths were randomly selected and given to another interviewer for retesting. This retest interviewer was different from the original interviewer. If a randomly selected case was for a neonatal or 29 day-5 year age, the case was discarded and a new case selected (these were very uncommon events and could not be separately analyzed). Verbal autopsy interviewers were especially sensitive when asking about recent deaths. The first interviewer informed the household that there might be a follow-up interview. After the interviews were completed, the verbal autopsy forms were reviewed by field coordinators and the final cause of death was determined. These forms were sent to data entry for analysis. Causes of death were identified by VA interviewers. As stated in the Terms of Reference, ICD 10 coding was used in order to make comparisons with studies carried out in other countries. For each death that occurred in a hospital, one of three interviewers was sent by field coordinators to examine the hospital records. By sending a letter to Ministry of Health to perform pre-test study at each hospital in Ankara during the pretest phase, we ensured that interviewers had access to the hospital records. The interviewer who examined the medical records was selected as independent of the initial interviewer. This process was done in order to present our methods validity. Hospital death causes forms were send to central office for recording and entering data. Revising current hospital records for the cause of death tests validity and reliability of verbal autopsy. 30 verbal autopsies were evaluated for reliability and 63 verbal autopsies were evaluated for validity and reliability was tested by calculating the coherency coefficient (with Kappa). Sensitivity and specificity tests are used in determination of validity of verbal autopsy diagnosis.

22

4.6.3 Main Field Application

Physicians were assigned to one of four main geographic groups (Ankara, Diyarbakr, Istanbul, and zmir) after their one-day training. A code number was assigned to each physician working in each group. Each area was the responsibility of a coordinator, and a code number was also assigned to these coordinators. Names and code numbers of the physicians who participated in the training program are provided in appendix 2. Questionnaire forms were adapted for optical scanning. The manual and official letters and identity cards prepared by the Ministry of Health were distributed to all physicians. The Death Determination Forms for listing household deaths were separated from the questionnaire form. Physicians visited the houses to administer the verbal autopsy based on addresses in this determination form. One of the physicians administering the verbal autopsy was assigned to determine causes of deaths in the hospitals. When deaths were identified as having been linked to a hospital, this independent physician completed the cause of death from the appropriate hospitals records. Occasionally no appropriate person could be located in the households where a death was reported even after four visits (0.5%). In some households, eligible respondents refused the interview (2.5%). Sometimes the date of death that was reported in the household survey was not in the timeframe of the verbal autopsy requirement of last one year. So these deaths were not included (1,3%). After physicians filled out the monitoring and control form provided by Ministry of Health Refik Saydam Hygiene Center Presidency, School of Public Health they sent the forms back and corrections were done in light of their feedback.

4.6.4 Statistical Methods Used In the Study

The first section of findings consists of the descriptive tables. Analysis of data was done by version 11.0 of SPSS statistical software. Causes of death obtained by interviewers and in hospital records were coded in accordance with the ICD 10 coding system as stated in Terms of Reference and they were evaluated separately for deaths of infants aged 0-28 days, infants and children aged 29 days to 5 years, and for adult age groups. Diseases coded to systems were grouped and validity and reliability analysis were done with this grouped disease.

4.6.5 Limitations of the Research

23

We used cause of death from the hospital files as our reference (gold standard) diagnosis. Ideologically, the autopsy diagnosis should be used. However, autopsy is relatively uncommon and this was not a viable option for the present study. While determining the causes of deaths from hospital records, physicians werent recorded only the causes of deaths that were diagnosed by the hospital physicians such as pneumonia or meningitis but they also used a full review of information from hospitals, including physician notes and laboratory and clinical findings in the files in order to verify the causes of deaths. In this survey, the symptoms that were existed in the deceased prior to their death were interviewed by a closed ended questionnaire form. As explained above, this questionnaire form was developed according to these diagnostic symptoms combinations that were determined and listed before. Because the results based on these predetermined classifications were more objective, we could obtain reliable and accurate results in comparisons. . The most important data sources related to cause of deaths is the records of SIS, which is collected from centre of province and districts. Causes of deaths are given as below 5 years age, 5 years and above 5 years in SIS records. In this research, this type of classification was not used. For this reason, just the comparisons of death causes for above 5 years above were done. No national data for comparison with this study were available. Therefore, this presents one kind of limitation in this study. The interviewing physicians were selected from the regions in which interviews were conducted to decrease problems with validity due to local language differences. A further support for the validity is that interviews were conducted with the closest possible relatives of the deceased. Physicians with greater field experience were also chosen preferentially. These measures were used in a combined approach to provide the greatest possible support for the validity of the study.

24

RESULTS
In the first part of the results, age and sex specific mortality rates of Turkey and life tables are provided for Turkey in national, urban and rural terms, according to the results of the VA Survey to the readers. In part two, results of the VA Survey are presented.

5.1 Age and Sex Specific Mortality Rates of Turkey

In Tables 5.1-5.3, age and sex specific death rates for Turkey Death rates for Turkey are given in national, urban and rural terms. In Tables 5.4-5.6, life tables are presented.

Table 5.1 Age and Sex Specific Death Rates for Turkey
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)

Age Groups 0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ TOTAL

Number of Male Deaths 43 13 6 4 6 14 14 7 12 20 36 37 46 65 78 76 68 41 47 633

Total Male Population 2131 7072 10649 11242 10284 8513 7777 7985 7440 7214 5794 5298 3487 3288 2435 2238 1043 483 454 104827

Age Specific Number Total Death Rate of Female Female (%o) Deaths Population 20,18 1,84 0,56 0,36 0,58 1,64 1,80 0,88 1,61 2,77 6,21 6,98 13,19 19,77 32,03 33,96 65,20 84,89 103,52 45 18 6 2 3 9 5 0 6 7 12 17 12 32 48 61 63 40 70 456 1966 6752 10042 10646 10841 10213 8707 8381 7550 7055 5615 5067 3538 3349 2670 2137 1137 532 527 106725

Age Specific Death Rate (%o) 22,89 2,67 0,60 0,19 0,28 0,88 0,57 0,00 0,79 0,99 2,14 3,36 3,39 9,56 17,98 28,54 55,41 75,19 132,83

Total Number of Deaths 88 31 12 6 9 23 19 7 18 27 48 54 58 97 126 137 131 81 117 1089

Total Population 4097 13824 20691 21888 21125 18726 16484 16366 14990 14269 11409 10365 7025 6637 5105 4375 2180 1015 981 211552

25

In the NBD-CE Verbal Autopsy study, infant mortality rates in Turkey were found to be 20,2/1000 for males and 22,9/1000 for females. When the Turkish Demographic Health Survey of 1998 is compared with the results of this survey, it shows that infant mortality rate for males is 51.0/1000 and 45.5/1000 is for females (42). By evaluating the crude death rates for Turkey according to the results of NBD-CE study, the crude death rate is found to be 5.1/1000. This rate is 6.0/1000 for males and 4.2/1000 for females .According to the censuses done by SIS and the State Planning Organization (SPO), the crude death rate was 6.7/1000 for the year 1993 (40,41).

Table 5.2 Age and Sex Specific Death Rates for Urban Areas in Turkey
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)

Age Groups 0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ TOTAL

Number of Male Deaths 21 3 3 1 4 7 6 5 8 13 24 22 30 37 43 36 37 22 24 346

Total Male Population 1219 3804 5795 6182 5767 5037 4657 4777 4319 4330 3430 3058 1951 1674 1163 1000 458 215 234 59070

Age Specific Number Total Death Rate of Female Female (%o) Deaths Population 17,23 0,79 0,52 0,16 0,69 1,39 1,29 1,05 1,85 3,00 7,00 7,19 15,38 22,10 36,97 36,00 80,79 102,33 102,56 15 7 3 1 1 7 3 0 2 1 5 11 9 19 22 28 27 25 37 223 1178 3696 5426 5753 5921 5976 5209 5003 4415 4227 3269 2846 1874 1685 1216 1016 550 240 274 59774

Age Specific Death Rate (%o) 12,73 1,89 0,55 0,17 0,17 1,17 0,58 0,00 0,45 0,24 1,53 3,87 4,80 11,28 18,09 27,56 49,09 104,17 135,04

Total Number of Deaths 36 10 6 2 5 14 9 5 10 14 29 33 39 56 65 64 64 47 61 569

Total Population 2397 7500 11221 11935 11688 11013 9866 9780 8734 8557 6699 5904 3825 3359 2379 2016 1008 455 508 118844

26

According to the verbal autopsy results, the crude death rate in urban areas in Turkey is 4,7/1000. For urban areas, according to the results of verbal autopsy, the crude death rate for males is 5,9/1000 and 3,7/1000 for females. If death rates in urban areas are evaluated by age and sex as given in Table 5.2, the number of deaths in the 0 age group in females is 15 and death rate is 12,7/1000, and the corresponding number of deaths for males is 21, with a death rate of 17.2/1000. In the Turkish Demography and Health Survey of 1998, infant mortality rate was 35.2/1000 in urban Turkey (42).

Table 5.3 Age and Sex Specific Death Rates for Rural Areas in Turkey
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)

Age Groups 0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ TOTAL

Number of Male Deaths 22 10 3 3 2 7 8 2 4 7 12 15 16 28 35 40 31 19 23 287

Total Male Population 912 3268 4854 5060 4517 3476 3120 3208 3121 2884 2364 2240 1536 1614 1272 1238 585 268 220 45757

Age Specific Number Total Death Rate of Female Female (%o) Deaths Population 24,12 3,06 0,62 0,59 0,44 2,01 2,56 0,62 1,28 2,43 5,08 6,70 10,42 17,35 27,52 32,31 52,99 70,90 104,55 30 11 3 1 2 2 2 0 4 6 7 6 3 13 26 33 36 15 33 254 788 3056 4616 4893 4920 4237 3498 3378 3135 2828 2346 2221 1664 1664 1454 1121 587 292 253 46951

Age Specific Death Rate (%o) 38,07 3,60 0,65 0,20 0,41 0,47 0,57 0,00 1,28 2,12 2,98 2,70 1,80 7,81 17,88 29,44 61,33 51,37 130,43

Total Number of Deaths 52 21 6 4 4 9 10 2 8 13 19 21 19 41 61 73 67 34 56 520

Total Population 1700 6324 9470 9953 9437 7713 6618 6586 6256 5712 4710 4461 3200 3278 2726 2359 1172 560 473 92708

27

When infant mortality rate was evaluated for rural Turkey, the number of deaths for females is 30 and death rate is 38.1/1000, whereas the number of deaths for males is 22 and death rate is 24.1/1000. In the Turkish DHS, the overall rural infant mortality rate is 55/1000. Crude overall death rate in rural areas is 4.9/1000 for females and 6.3/1000 for males. Crude overall death rate in rural areas was 5.5/1000.

Crude death rates for urban and rural Turkey are summarized in Table 5.4. Table 5.4 Crude Death Rates in Turkey by Urban vs. Rural Location and Regions (NBDCE Study Verbal Autopsy Survey, Turkey, 2003) Males Crude Death Rate (%o) Turkey Urban Rural Regions Marmara and Aegean Mediterranean Central Anatolia Black Sea Eastern and South Eastern Anatolia 6,0 4,9 8,2 5,7 5,5 2,9 3,6 6,7 4,1 4,5 4,5 3,6 7,5 5,5 5,0 6,0 5,9 6,3 Females Crude Death Rate (%o) 4,2 3,7 4,9 Crude Death Rate (%o) 5,1 4,7 5,5

Crude death rates were also evaluated by region. As a result of these evaluations, in the Marmara and Aegean the crude death rates are 4.5/1000 overall, 2.9/1000 for females and 6.0/1000 for males. In the Mediterranean region, the corresponding crude death rates are 3.6/1000 overall, 3.6/1000 for females and 4.91000 for males. In the Central Anatolia region, crude death rates are 7,5/1000 overall, 6.7/1000 for females and 8.2/1000 for males. In the Black sea region crude death rates are 5,5 in Turkey, 4.1 in females and 5.7 in males respectively. In Eastern and Southeastern Anatolia, crude death rates are 5,0/1000, 4.5/1000 and 5.5/1000 respectively. The death rates for 0-28 days and below 5 years were not given by region due to the small values and possible misunderstandings in interpretations

28

Table 5.5 National Life Table for Turkey

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Males X 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ Females x 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ n 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 n 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 nMx 0,0201783 0,0018382 0,0005634 0,0003558 0,0005834 0,0016445 0,0018002 0,0008766 0,0016129 0,0027724 0,0062133 0,0069838 0,0131919 0,0197689 0,0320329 0,0339589 0,0651965 0,0848861 0,1035242 nMx 0,0228891 0,0026659 0,0005975 0,0001879 0,0002767 0,0008812 0,0005743 0 0,0007947 0,0009922 0,0021371 0,003355 0,0033917 0,0095551 0,0179775 0,0285447 0,055409 0,075188 0,1328273 a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 nqx 0,0198184 0,0073206 0,0028132 0,0017775 0,0029129 0,0081891 0,0089606 0,0043736 0,0080321 0,0137665 0,0305914 0,0343196 0,0638534 0,0941892 0,148289 0,1565074 0,2802968 0,3501281 1 nqx 0,0224271 0,0105957 0,002983 0,0009389 0,0013827 0,0043965 0,0028671 0 0,0039656 0,0049487 0,0106289 0,0166357 0,0168161 0,0466608 0,0860215 0,1332169 0,2433372 0,3164557 1 npx 0,9801816 0,9926794 0,9971868 0,9982225 0,9970871 0,9918109 0,9910394 0,9956264 0,9919679 0,9862335 0,9694086 0,9656804 0,9361466 0,9058108 0,851711 0,8434926 0,7197032 0,6498719 0 npx 0,9775729 0,9894043 0,997017 0,9990611 0,9986173 0,9956035 0,9971329 1 0,9960344 0,9950513 0,9893711 0,9833643 0,9831839 0,9533392 0,9139785 0,8667831 0,7566628 0,6835443 0 lx 100000 98018,159 97300,603 97026,877 96854,415 96572,288 95781,452 94923,196 94508,036 93748,936 92458,339 89629,906 86553,84 81027,082 73395,202 62511,503 52727,989 37948,503 24661,666 lx 100000 97757,289 96721,48 96432,961 96342,422 96209,211 95786,231 95511,599 95511,599 95132,835 94662,047 93655,896 92097,866 90549,135 86324,037 78898,313 68387,728 51746,45 35370,991 Ndx 1981,8408 717,55607 273,72638 172,46157 282,12763 790,8353 858,25674 415,15924 759,10069 1290,5966 2828,4332 3076,0658 5526,7582 7631,8799 10883,699 9783,5136 14779,486 13286,837 24661,666 Ndx 2242,7112 1035,8083 288,51988 90,53888 133,2107 422,98026 274,63223 0 378,76377 470,78815 1006,1511 1558,0294 1548,7309 4225,0982 7425,7236 10510,586 16641,278 16375,459 35370,991 nLx 98216,343 390350,5 485818,7 484703,23 483566,76 480884,35 476761,62 473578,08 470642,43 465518,19 455220,61 440459,36 418952,3 386055,71 339766,76 288098,73 226691,23 156525,42 238221,2 nLx 97981,56 388543,22 482886,1 481938,46 481379,08 479988,6 478244,57 477557,99 476611,08 474487,2 470794,86 464384,4 456617,5 442182,93 413055,88 368215,1 300335,44 217793,6 266293,03 Tx 7260031,5 7161815,2 6771464,7 6285646 5800942,8 5317376 4836491,7 4359730 3886152 3415509,5 2949991,3 2494770,7 2054311,4 1635359,1 1249303,3 909536,58 621437,85 394746,62 238221,2 Tx 7719290,6 7621309,1 7232765,8 6749879,7 6267941,3 5786562,2 5306573,6 4828329 4350771 3874160 3399672,8 2928877,9 2464493,5 2007876 1565693,1 1152637,2 784422,08 484086,64 266293,03 ex 72,600315 73,066208 69,593245 64,782524 59,893426 55,061096 50,495075 45,929027 41,119804 36,432515 31,906168 27,834133 23,734491 20,18287 17,021594 14,549908 11,78573 10,402166 9,6595745 ex 77,192906 77,961543 74,779313 69,995567 65,058997 60,145615 55,400171 50,55228 45,55228 40,723689 35,913789 31,272755 26,759507 22,174436 18,137394 14,609149 11,470217 9,3549729 7,5285714

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

* Definitions of symbols used in Life Tables in Table 5.5 and 5.6 are given at appendix 6.

29

Table 5.5 National Life Table for Turkey

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) (Continued)
Both sex groups x n 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
n

Mx

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

n x

n x

lx 100000 97892,821 97019,432 96738,501 96606,001 96400,432 95810,231 95259,647 95056,144 94487,135 93597,395 91648,971 89292,283 85680,741 79640,308 70383,224 60163,296 44447,66 29662,196

n x

Lx

Tx 7479048,7 7380945,2 6991470 6507075,2 6023713,9 5541197,8 5060671,2 4582996,5 4107207 3633348,8 3163137,5 2700021,6 2247668,4 1810235,9 1396933,3 1021874,4 695508,13 433980,74 248706,1

ex 74,790487 75,398227 72,062574 67,264585 62,353413 57,481048 52,819737 48,110576 43,208222 38,45337 33,795145 29,460468 25,172035 21,127687 17,540531 14,518722 11,56034 9,7638604 8,3846154

0,0214791 0,0022425 0,00058 0,0002741 0,000426 0,0012282 0,0011526 0,0004277 0,0012008 0,0018922 0,0042072 0,0052098 0,0082562 0,014615 0,0246817 0,0313143 0,0600917 0,079803 0,1192661

0,0210718 0,0089219 0,0028956 0,0013697 0,0021279 0,0061224 0,0057466 0,0021363 0,005986 0,0094165 0,0208171 0,0257143 0,0404463 0,0704993 0,1162362 0,145204 0,2612164 0,3326489 1

0,9789282 0,9910781 0,9971044 0,9986303 0,9978721 0,9938776 0,9942534 0,9978637 0,994014 0,9905835 0,9791829 0,9742857 0,9595537 0,9295007 0,8837638 0,854796 0,7387836 0,6673511 0

2107,1788 873,38901 280,93074 132,50034 205,56898 590,20149 550,58355 203,50277 569,00918 889,7404 1948,4235 2356,6878 3611,5428 6040,4331 9257,0837 10219,928 15715,637 14785,464 29662,196

98103,539 389475,15 484394,83 483361,26 482516,08 480526,66 477674,69 475789,48 473858,2 470211,32 463115,91 452353,14 437432,56 413302,62 375058,83 326366,3 261527,39 185274,64 248706,1

According to Verbal Autopsy research results, the expected number of deaths for males in Turkey is 206.080 while this number is found to be 140.520 for females and 345.800 overall. Including the verbal autopsy results, when all data sources are used this value is found to be 430,460. As is known, the number of deaths obtained from research results is often lower than real values. In Table 5.5, National Life Table for Turkey according to Verbal Autopsy results was given for male, females and both sexes. Life expectancy for males is 72.6 and 77.19 for females. When sexes are evaluated together, life expectancy is 74.80 and infant death mortality is found to be 22/1000.

30

Table 5.6 Life Table for Urban Turkey

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Males X 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ Females x 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ n 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 n 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
n

Mx

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

n x

n x

lx 100000 98303,579 97994,059 97740,735 97661,714 97323,609 96649,689 96029,079 95527,831 94647,187 93236,971 90031,116 86849,804 80419,661 71997,562 59813,795 49936,288 33154,792 19647,284 lx 100000 98741,083 97996,429 97725,895 97640,997 97558,579 96988,87 96709,979 96709,979 96491,178 96377,109 95642,863 93812,219 91586,25 86564,204 79072,416 68878,919 53820,37 31580,548

n x

Lx

Tx 7181708,2 7083235 6690763,6 6201426,6 5712920,4 5225457,1 4740523,9 4258827 3779934,7 3304497,1 2834786,8 2376616,5 1934414,2 1516240,6 1135197,5 805669,12 531293,91 323566,21 191561,02 Tx 7777752,5 7678885,5 7285708,3 6796402,5 6307985,3 5819986,4 5333617,7 4849370,6 4365820,7 3882817,8 3400647,1 2920597,2 2446959,5 1983463,3 1538087,2 1123995,6 754117,27 447369,05 233866,76

ex 71,817082 72,054702 68,277237 63,447718 58,497032 53,691568 49,048517 44,349347 39,568937 34,913844 30,404106 26,397724 22,273098 18,854103 15,767166 13,46962 10,639436 9,7592593 9,75 ex 77,777525 77,767888 74,346672 69,545564 64,60386 59,656326 54,99206 50,143436 45,143436 40,240133 35,284801 30,536488 26,08359 21,65678 17,768166 14,214762 10,948448 8,3122627 7,4054054

0,0172272 0,0007886 0,0005177 0,0001618 0,0006936 0,0013897 0,0012884 0,0010467 0,0018523 0,0030023 0,0069971 0,0071942 0,0153767 0,0221027 0,0369733 0,036 0,080786 0,1023256 0,1025641
n

0,0169642 0,0031486 0,0025851 0,0008085 0,003462 0,0069245 0,0064212 0,0052198 0,0092187 0,0148997 0,034384 0,0353357 0,0740375 0,1047269 0,1692247 0,1651376 0,3360581 0,4074074 1
n x

0,9830358 0,9968514 0,9974149 0,9991915 0,996538 0,9930755 0,9935788 0,9947802 0,9907813 0,9851003 0,965616 0,9646643 0,9259625 0,8952731 0,8307753 0,8348624 0,6639419 0,5925926 0
n x

1696,4214 309,52008 253,32372 79,020725 338,10529 673,91954 620,61016 501,24793 880,64375 1410,216 3205,8558 3181,3115 6430,1434 8422,0986 12183,767 9877,5075 16781,495 13507,508 19647,284
n x

98473,221 392471,47 489336,98 488506,12 487463,31 484933,25 481696,92 478892,28 475437,55 469710,4 458170,22 442202,3 418173,66 381043,06 329528,39 274375,21 207727,7 132005,19 191561,02
n

Mx

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

Lx

0,0127334 0,0018939 0,0005529 0,0001738 0,0001689 0,0011714 0,0005759 0 0,000453 0,0002366 0,0015295 0,0038651 0,0048026 0,011276 0,0180921 0,0275591 0,0490909 0,1041667 0,1350365

0,0125892 0,0075415 0,0027607 0,0008687 0,0008441 0,0058397 0,0028755 0 0,0022624 0,0011822 0,0076185 0,0191404 0,0237279 0,0548341 0,086546 0,1289134 0,2186235 0,4132231 1

0,9874108 0,9924585 0,9972393 0,9991313 0,9991559 0,9941603 0,9971245 1 0,9977376 0,9988178 0,9923815 0,9808596 0,9762721 0,9451659 0,913454 0,8710866 0,7813765 0,5867769 0

1258,9173 744,65372 270,53399 84,897832 82,418331 569,70889 278,89064 0 218,80086 114,06925 734,24584 1830,6447 2225,9688 5022,0454 7491,7879 10193,498 15058,549 22239,822 31580,548

98866,974 393177,16 489305,81 488417,23 487998,94 486368,62 484247,12 483549,9 483002,89 482170,72 480049,93 473637,7 463496,17 445376,14 414091,55 369878,34 306748,22 213502,29 233866,76

31

Table 5.6 Life Table for Urban Turkey (Continued)

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Both sex groups x n 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
n

Mx

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

n x

n x

lx 100000 98518,153 97994,398 97732,754 97650,901 97442,254 96824,861 96384,237 96138,17 95589,374 94810,596 92780,391 90223,176 85737,894 78876,902 68790,342 58674,115 42599,015 25112,956

n x

Lx

Tx 7459662,6 7360996,3 6968180,7 6478862,8 5990403,7 5502670,8 5017003 4533980,3 4052674,2 3573355,4 3097355,5 2628378 2170869,1 1730966,4 1319429,4 950261,3 631600,16 378417,34 209137,41

ex 74,596626 74,717157 71,107949 66,291622 61,345094 56,471095 51,815236 47,040682 42,154685 37,38235 32,668874 28,329025 24,061102 20,189047 16,727703 13,813877 10,764545 8,8832415 8,3278689

0,0150188 0,0013333 0,0005347 0,0001676 0,0004278 0,0012712 0,0009122 0,0005112 0,001145 0,0016361 0,004329 0,0055894 0,0101961 0,0166716 0,0273224 0,031746 0,0634921 0,1032967 0,1200787

0,0148185 0,0053163 0,00267 0,0008375 0,0021367 0,006336 0,0045507 0,002553 0,0057084 0,0081471 0,0214133 0,027562 0,0497132 0,0800229 0,1278772 0,1470588 0,2739726 0,4104803 1

0,9851815 0,9946837 0,99733 0,9991625 0,9978633 0,993664 0,9954493 0,997447 0,9942916 0,9918529 0,9785867 0,972438 0,9502868 0,9199771 0,8721228 0,8529412 0,7260274 0,5895197 0

1481,8474 523,75413 261,644 81,853228 208,64686 617,393 440,62484 246,06647 548,7965 778,77749 2030,2055 2557,2145 4485,2822 6860,9918 10086,56 10116,227 16075,1 17486,059 25112,956

98666,337 392815,6 489317,88 488459,14 487732,89 485667,79 483022,74 481306,02 479318,86 475999,92 468977,47 457508,92 439902,68 411536,99 369168,11 318661,14 253182,83 169279,93 209137,41

In Table 5.6, the life table for males and females calculated from the Verbal Autopsy Survey data in urban areas is presented. As seen in this life table for urban areas, life expectancy at birth for males is 71.82 and for females are 77.78. In rural areas, these values are 73.32 and 76.10 at birth respectively. The life table for urban areas was developed by combining both sexes and by using the WHO Logit Life Table System. According to this life table, overall infant mortality rates for both sexes is 15/1000 and life expectancy is 74.60.

32

Table 5.7 Life Table for Rural Turkey

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Males X 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ Females x 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ n 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 n 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
n

Mx

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

n x

n x

lx 100000 97638,978 96452,599 96154,998 95870,376 95658,367 94700,003 93493,634 93202,648 92607,294 91490,198 89197,211 86259,871 81881,197 75073,972 65410,165 55632,861 42616,871 29784,533 lx 100000 96319,018 94944,104 94636,077 94539,421 94347,463 94125,05 93856,352 93856,352 93259,491 92275,395 90908,93 89689,222 88884,353 85478,822 78163,321 67447,12 49514,355 38244,016

n x

Lx

Tx 7332320,4 7234445,3 6846736,7 6365217,7 5885154,3 5406332,4 4930436,5 4459952,4 3993211,7 3528686,8 3068443,1 2616724,6 2178081,9 1757729,2 1365341,3 1014130,9 711523,37 465899,04 284895,53 Tx 7609746,4 7513059,3 7131083 6657132,6 6184193,8 5711976,6 5240795,4 4770841,9 4301560,1 3833770,5 3369933,3 2911972,5 2460477,1 2014043,1 1578135,2 1169029,8 805003,74 512600,06 293204,13

ex 73,323204 74,093824 70,985507 66,197471 61,386578 56,517089 52,063741 47,703274 42,844402 38,103768 33,53849 29,336395 25,250233 21,466823 18,186613 15,504179 12,789624 10,932268 9,5652174 ex 76,097464 78,001826 75,108224 70,344554 65,413917 60,541921 55,679071 50,831316 45,831316 41,108636 36,520389 32,031754 27,433364 22,659142 18,462295 14,956246 11,935332 10,352554 7,6666667

0,0241228 0,00306 0,000618 0,0005929 0,0004428 0,0020138 0,0025641 0,0006234 0,0012816 0,0024272 0,0050761 0,0066964 0,0104167 0,0173482 0,0275157 0,0323102 0,0529915 0,0708955 0,1045455
n

0,0236102 0,0121507 0,0030855 0,00296 0,0022114 0,0100186 0,0127389 0,0031124 0,0063877 0,0120627 0,0250627 0,0329308 0,0507614 0,0831354 0,1287238 0,1494768 0,2339623 0,3011094 1
n x

0,9763898 0,9878493 0,9969145 0,99704 0,9977886 0,9899814 0,9872611 0,9968876 0,9936123 0,9879373 0,9749373 0,9670692 0,9492386 0,9168646 0,8712762 0,8505232 0,7660377 0,6988906 0
n x

2361,0217 1186,3788 297,60136 284,62259 212,00879 958,36349 1206,3695 290,98548 595,35387 1117,0964 2292,9874 2937,3395 4378,6737 6807,2254 9663,8066 9777,3042 13015,99 12832,338 29784,533
n x

97875,08 387708,6 481518,99 480063,43 478821,86 475895,93 470484,09 466740,71 464524,86 460243,73 451718,52 438642,7 420352,67 392387,92 351210,34 302607,57 245624,33 181003,51 284895,53
n

Mx

a 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

Lx

0,0380711 0,0035995 0,0006499 0,0002044 0,0004065 0,000472 0,0005718 0 0,0012759 0,0021216 0,0029838 0,0027015 0,0018029 0,0078125 0,0178817 0,029438 0,0613288 0,0513699 0,1304348

0,0368098 0,0142746 0,0032443 0,0010213 0,0020305 0,0023574 0,0028547 0 0,0063593 0,0105522 0,0148085 0,0134168 0,008974 0,0383142 0,0855826 0,1371001 0,2658789 0,2276176 1

0,9631902 0,9857254 0,9967557 0,9989787 0,9979695 0,9976426 0,9971453 1 0,9936407 0,9894478 0,9851915 0,9865832 0,991026 0,9616858 0,9144174 0,8628999 0,7341211 0,7723824 0

3680,9816 1374,9146 308,02672 96,656191 191,95821 222,41269 268,6984 0 596,86074 984,09593 1366,4645 1219,7084 804,86888 3405,5308 7315,5016 10716,201 17932,764 11270,339 38244,016

96687,117 381976,28 473950,45 472938,74 472217,21 471181,28 469953,5 469281,76 467789,61 463837,21 457960,81 451495,38 446433,94 435907,94 409105,36 364026,1 292403,69 219395,93 293204,13

33

Table 5.7 Life Table for Rural Turkey

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) (Continued)
Both sex groups x n 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ 1 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
n

Mx

A 0,1 0,4 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5

n x

n x

lx 100000 97023,128 95744,585 95441,756 95250,163 95048,512 94495,583 93784,341 93642,049 93045,223 91992,4 90155,453 88058,118 85482,13 80298,329 71790,082 61479,879 46104,172 33952,685

n x

Lx

Tx 7473707,9 7376387,1 6991363,1 6513397,2 6036667,4 5560920,7 5087060,5 4616360,7 4147794,7 3681076,5 3218482,5 2763112,8 2317578,9 1883728,3 1469277,1 1089056,1 755881,2 486921,07 286778,93

ex 74,737079 76,0271 73,020976 68,244734 63,376977 58,506131 53,833844 49,22315 44,294147 39,56223 34,986395 30,648316 26,318742 22,036516 18,29773 15,170008 12,294774 10,561323 8,4464286

0,0305882 0,0033207 0,0006336 0,0004019 0,0004239 0,0011669 0,001511 0,0003037 0,0012788 0,0022759 0,004034 0,0047075 0,0059375 0,0125076 0,0223771 0,0309453 0,0571672 0,0607143 0,1183932

0,0297687 0,0131777 0,0031629 0,0020074 0,0021171 0,0058173 0,0075267 0,0015172 0,0063735 0,0113152 0,0199685 0,0232635 0,0292533 0,0606419 0,105958 0,143616 0,2500933 0,2635659 1

0,9702313 0,9868223 0,9968371 0,9979926 0,9978829 0,9941827 0,9924733 0,9984828 0,9936265 0,9886848 0,9800315 0,9767365 0,9707467 0,9393581 0,894042 0,856384 0,7499067 0,7364341 0

2976,872 1278,5427 302,82947 191,5924 201,65166 552,9291 711,24178 142,29152 596,82632 1052,8226 1836,9476 2097,3352 2575,988 5183,8002 8508,2475 10310,203 15375,707 12151,487 33952,685

97320,815 385024,01 477965,85 476729,8 475746,69 473860,24 470699,81 468565,98 466718,18 462594,06 455369,63 445533,93 433850,62 414451,15 380221,03 333174,9 268960,13 200142,14 286778,93

In rural Turkey, according to life table calculated by combining the two sexes, the infant death rate is 31/1000 and life expectancy at birth is 74,74 (Table 5.7).

Table 5.8 Child and Adult Death Rates (%o)

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Overall Turkey Urban Area Males Females 20,0 20,0 0-5 age 15-60 age Rural Area Males Females 35,5 50,5

5q0 27,0(Male) 32,8 (Female) (0-5 age death rate) 163,4 (Male) 60,0 (Female) 45q15 (15-60 age Death probability)

176,5

62,0

145,9

59,8

34

For overall Turkey, the death rate for under-5 age accepted for 5q0 value for males is 27/1000 and for females is 32.8/1000. In urban areas these values are 20.0/1000 for males and 20.0/1000 for females. In rural areas, the calculated rates are 35.5/1000 for males and 50.5/1000 for females. According to results of DHS 1998 survey in Turkey, these values are 60.9/1000 for males and 58.3/1000 for females (Table 5.8). Between ages 15-60, 45q15 values which indicate the probability of death are similar across urban, rural and overall Turkey and also for females and males. 45q15 for Turkey in general is 163.4/1000 for males and 60.0/1000 for females. The corresponding values are 176,5/1000 for urban males and 62.0/100 for urban females, and 145.9/1000 for rural males and 59.8/1000 for rural females. All calculated values are similar to life tables whose accuracy and completeness are verified and calculated from all data sources (Table 5.8). Due to the lack of death data, crude regional life tables and age and sex specific death rates could not be given.

5.2 Evaluation of Verbal Autopsy Results

A total of 12. 000 households were selected from 480 blocks to provide representative data for Turkey, and those 12.000 households and their two neighboring households on each side (two on the left, two on the right) were visited for a total of 60,000 households and the deaths occurred inside the household and syblings of the respondent which is in the sample occurred within last one year outside the household was also questioned. Interviewers asked if the respondent had lost any siblings in the last year. In this manner a total of 1185 deaths were identified, but death rates by age and sex were calculated from 1170 deaths because 15 deaths either occurred more than one year ago or were not identified properly in terms of age and sex. In these 1170 deaths, 81 siblings death who were living at outside the household were subtracted because, their household was not visited. Therefore age and sex specific death rates were calculated from these 1089 deaths. For cause of death analysis, in these 1170 death, verbal autopsy were applied to 1089 deaths, because for some of the deaths, any person were found or addresses were not identified. But in the course of data checking, five deaths were found to be stillbirths. Analysis and results are provided for these stillbirths separately in the report. Therefore, the evaluation of verbal autopsy questionnaires was done for 1084 deaths. In the evaluation of causes of death, there were 28 deaths for which causes could not be identified by a physician, due to lack of information. All deaths were categorized as household deaths, sibling deaths or two right household/ two left household deaths. Household deaths in all identified deaths are 326 (27,9%), sibling deaths are 87 (7,4%), neighboring household deaths are 751 (64,2%). For 6 deaths (0,5%) there is no information. These amounted to 301 household deaths (27,6%), 87 sibling deaths (8,0%), and 701 neighboring household deaths (64,4%) for the deaths in verbal autopsy survey. In Table 5.9, interview results of the verbal autopsy survey are given.

35

Table 5.9 Distribution of Interview Results of Verbal Autopsy Survey

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Interview 1 Number Completed 941 Refused 12 Postponed 1 No person at home 89 No available person at home 16 Other 24 Total 1083 Missing Observation 1 Interview 2 Number Completed 65 Refused 9 Postponed 4 No person at home 43 No available person at home 8 Other 11 Total 140 Missing Observation 944 % 86,9 1,1 0,1 8,2 1,5 2,2 100 0,1 % 46,4 6,4 2,9 30,7 5,7 7,9 100,0 87,1 Interview 3 Number % Completed 35 48,6 Refused 7 9,7 Half-finished 2 2,8 No person at home 16 22,2 No available person at home 4 5,6 Other 8 11,1 Total 72 100,0 Missing Observation 1012 93,4 Interview 4 Number % Completed 15 45,5 Refused 2 6,1 No person at home 6 18,2 No available person at home 3 9,1 Other 7 21,2 Total 33 100,0 Missing Observation 1051 97

For the results, we first provide general demographic information on the respondents, followed by the medical history related to all deaths. Secondly, adult deaths, infant deaths, and child deaths are examined separately. During the application of VA, the questionnaires were coded as 0-28 days, 29 days- 5 years and adult. Of 1084 deaths, 35 deaths (3.2 %) were among infants aged 0-28 days, 68 deaths (6.3%) were among children aged 29 days -5 years, and 981 deaths (90.5%) were among adults and 5 stillbirths were also determined.

5.2.1 Distribution of Participants In this section, the respondents age, sex, educational status and relationship to the deceased
are examined.

36

Table 5.10 Relationships of Respondents to the Deceased

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Relation Of Respondent to Deceased Children Spouse Son / daughter in-law Mother / Father Siblings Grandchildren Other relatives Grandmother / grandfather No family relations Mother in-law / father in-law Co-wife Other Total Missing observations: 34 (3.1 %) Number 312 210 146 127 61 58 48 17 12 7 1 51 1050 % 29,7 20 13,9 12,1 5,8 5,5 4,6 1,6 1,1 0,7 0,1 4,9 100,0

As seen in Table 5.10, 29.7 % of respondents were children, followed by spouses of the deceased at 20,0 %. Respondents who were the mother in-law/father in-law of the deceased amounted to 0.7 %. Co-wives amounted to 0,1%.

Table 5.11 Distributions of Respondents by Age Groups and Sex

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex of the Respondent Total Male Female Age Groups of the Respondent Number % Number % Number % 18-29 92 18,8 122 21,7 214 20,4 30-39 112 22,9 145 25,8 257 24,5 40-49 117 23,9 104 18,5 221 21,0 50-59 78 15,9 98 17,5 176 16,7 60-69 42 8,6 59 10,5 101 9,6 70+ 49 10,0 33 5,9 82 7,8 490 100,0 561 100,0 1051 100,0 Total Missing observations: 33 (3,0%)

Ages and sexes of 1051 total respondents appear in the survey. 46.6 % of all respondents are males and 53,4 % is females. The mean age is 43,6115,6. The age group with the highest percentage respondents are the 30-39 age group (24.5 %), and then comes the 40-49 age group (21.0 %). The lowest percentage is 70+-year-old age group (7.8 %).

37

Table 5.12 Respondents Educational Status

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Education Status of Respondent Illiterate Literate, ungraduated Primary school Secondary school or equivalent High school or equivalent Faculty/University Total Missing observations: 28 (2,6%) Number 197 65 530 79 129 56 % 18,7 6,2 50,2 7,5 12,2 5,3

1056 100,0

Table 5.12 gives the educational status of respondents. According to a total of 1056 questionnaires, the educational status of respondents was found to be as follows: the highest percentage was comprised by primary school graduates (50.2 %), and 18.7 % were illiterate. Those having high school degrees or equivalents amounted to 12.2 %. The smallest percentage was comprised by elementary school graduates (5.3%).

5.2.2 General Information About the Deceased

In Table 5.13, the distribution of deaths by location is given.

Table 5.13 Urban-Rural Distribution of Place of Death

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Urban Place of Death Home Work Hospital Road Other Number 330 6 205 27 9 % 57,2 1,0 35,5 4,7 1,6 Rural Number 306 4 122 31 18 481 % 63,6 0,8 25,4 6,4 3,7 100,0 Total Number 636 10 327 58 27 1058 % 60,1 0,9 30,9 5,5 2,6 100,0

577 100,0 Total Missing observations: 26 (2.4%)

Places of death were recorded in the survey for a total of 1058 deaths. Of these, 60.1 % occurred at home, 30.9 % occurred at hospitals and 5.5 % on the road. If rural and urban classifications are studied separately, urban area deaths divided into 57.2 % at home and 35.5 % at hospitals. In rural areas, 63.6 % of deaths occurred at home and 25.4 % occurred at hospitals. Overall, 54.5 % of deaths occurred in urban areas and 45.5 % in rural areas.

38

In Table 5.14, the distribution of places of deaths by age groups is given. Among infants aged 0-28 days, 57.1% of deaths occurred at hospitals and 37.1 % at home. This rate is reversed in children aged 29 days-5 years, with 26.9 % of deaths occurring at hospitals and 56.7 % at home. For adult deaths, 61.2 % occurred at home, 30.2 % at hospitals.

Table 5.14 Distribution of Place of Death by Age Groups

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) 0-28 Place of Death Days Infant Number % Home 13 37,1 Road 1 2,9 Work Hospital 20 57,1 Other 1 2,9 35 100,0 Total Missing observations: 26 (2.4%) Age Groups 29 Days- 5 Years Children Number % 38 56,7 8 11,9 18 26,9 3 4,5 67 100,0 Total Adult Number % 585 61,2 49 5,1 10 1,0 289 30,2 23 2,4 956 100,0 Number 636 58 10 327 27 1058 % 60,1 5,5 0,9 30,9 2,6 100,0

Table 5.15 Distribution of Place of Death by Regions

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Marmara and Central AnatoAegean lia Mediterranean Black Sea Place of Death Number % Number % Number % Number % Home Work Hospital Road Other 193 3 105 5 4 62,3 1,0 33,9 1,6 1,3 55 1 40 5 3 52,9 1,0 38,5 4,8 2,9 147 1 67 17 7 61,5 0,4 28,0 7,1 2,9 80 3 34 7 1 64,0 2,4 27,2 5,6 0,8 Eastern and South Eastern Anatolia Number 161 2 81 24 12 % 57,5 0,7 28,9 8,6 4,3 Total

Number 636 10 327 58 27

% 60,1 0,9 30,9 5,5 2,6

310 100,0 104 100,0 Total Missing observations: 26 (2.4%)

239 100,0

125 100,0

280 100,0

1058 100,0

Distribution of places of death according to regions is as follows: Marmara and Aegean, 62,3 % at home, 33.9 % at hospitals; Mediterranean, 52.9% at home, 38.5% at hospitals; Central Anatolia 61.5 % at home, 28.0% at hospitals; Black Sea 64.0 % at home, 27.2 % at hospitals; Eastern and Southeastern Anatolia, 57,5 % at home, 28.9 % at hospitals (Table 5.15).

39

Table 5.16 Distribution of At-Home Deaths by Urban-Rural Location and Sex

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Urban Sex Male Female Total Number 194 136 330 % 58,8 41,2 100,0 Rural Number 149 157 306 % 48,7 51,3 100,0 Total Number 343 293 636 % 53,9 46,1 100,0

The distribution of 636 at-home deaths by urban-rural location and sex is given in Table 5.16. Of these deaths, 51.9 % occurred in urban areas and 48.1 % in rural areas. 53.9 % of deaths that occurred at home were among males and 46.1 % were among females. In urban areas, 58,8 % of at-home deaths were among males and 41.2 % among females. In rural areas, these proportions were 48,7 % for males and 51,3 % for females.

Table 5.17 Distribution of At-Home Deaths by Age Groups

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Age Groups 0-28 days 29 day-5 year Adult Total Number 13 38 585 636 % 2,0 6,0 92,0 100,0

Age distribution of the deaths that occurred at home appears in Table 5.17. Adult deaths have the highest proportion (92,0 %), then comes 29 day-5 year old children at 6,0 % and lastly 0-28 day infant deaths at 2,0 %.

Table 5.18 gives the regional distribution of deaths that occurred at home.

40

Table 5.18 Distribution of At-Home Deaths by Region

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Regions Marmara and Aegean Mediterranean Central Anatolia Black Sea Eastern and South Eastern Anatolia Total Number 193 55 147 80 161 636 % 30,3 8,6 23,1 12,6 25,3 100,0

The highest proportion of at-home deaths in the distribution is seen in the Marmara and Aegean regions (30.3%). Next is that of Eastern and Southeastern Anatolia (25.3 %). The lowest proportion is seen in the Mediterranean region (8.6%). Distribution of deaths is given in Table 5.19 by urban-rural location and sex, and in Table 5.20 by urban-rural location and age groups. As seen in Table 5.19, 63,0% of deaths in urban areas were among males and 37,0% among females; in rural areas, male deaths amounted to 54,2%, and female deaths to 45,8%. By age groups, 3,2 % of deaths occurred among 0-28 day old infants, 6,3 % occurred among 29 day - 5-year-old children, and 90,5% occurred among adults. In urban areas, 92,9 % of deaths occurred among adults, 4,5% among 29 day-5 year old children and 2,5 % among 0-28 day old infants. These proportions were 87.5 %, 8.4 % and 4.1 % in rural areas. In 0-28 day old infants, 51.4 % of deaths were among males and 48.6 % among females. In 29 day-5 year old children, 45.6 % of deaths were among males and 54.4 % among females. In adults, 60,2 % of deaths was among males and 39,8% among females. Overall, 59,0 % of deaths were among males and 41,0 % among females. (Table 5.21)

Table 5.19 Distribution of Deaths by Urban-Rural Location and Sex

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Urban Sex Male Female Total Number 375 220 595 % 63,0 37,0 100,0 Rural Number 265 224 489 Number 54,2 45,8 100,0 % 640 444 1084 Total Number 59,0 41,0 100,0

41

Table 5.20 Distribution of Deaths by Age Groups

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Urban Age Groups 0-28 days 29 day-5 year old Adult Total Number 15 27 553 595 % 2,5 4,5 92,9 100,0 Rural Number 20 41 428 489 % 4,1 8,4 87,5 100,0 Total Number 35 68 981 1084 % 3,2 6,3 90,5 100,0

Table 5.21 Distribution of Deaths by Age Groups and Sex

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) 0-28 day old infants Sex Number Male Female Total 18 17 35 % 51,4 48,6 100,0 29 day-5 year old children Number % 31 37 68 45,6 54,4 100,0 Adult Number 591 390 981 % 60,2 39,8 100,0 Total Number 640 444 1084 % 59,0 41,0 100,0

Table 5.22 Distribution of Deaths by Age Groups and Regions

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Place of Death 0-28 day 29 day5 year Adult Total Marmara and Central AnaAegean Mediterranean tolia Black Sea Number % Number 3 1 104 % 8,6 1,5 9,6 Number % Number % 5 14,3 8 11,8 310 31,6 323 29,8 7 20,0 7 10,3 234 23,9 248 22,9 4 11,4 4 5,9 Eastern and South Eastern Anatolia Number % 16 45,7 48 70,6 217 22,1 281 25,9

Total Number % 35 100,0 68 100,0 981 100,0 1084 100,0

100 10,2

120 12,2 128 11,8

Table 5.22 illustrates distribution of deaths by age groups. 45,7 % of 0-28 day infant deaths occurred in Eastern and Southeastern Anatolia region, 20.0 % in Central Anatolia and 14,3 % in Marmara, Aegean, 11,4% in Black Sea regions. The lowest proportion for infant deaths is identified in the Mediterranean Region (8.6%). Distribution of 29 day-5 year old children deaths comprises 70.6% deaths in Eastern and Southeastern Anatolia and ranked in the first line, 11.8 % deaths in Marmara and Aegean regions and 10.3 % deaths in the Central Anatolia region. One death (1,5%) was identified in the Mediterranean region concerning 29 day-5 year old children. Marmara and Aegean regions take the first place in adult deaths (31.6 %). Death proportions are 23.9 % for Central Anatolia, 22,1 % for Eastern and South Eastern Anatolia, 12.2 % for Black Sea Region and 10.2 % for Mediterranean Region. When we examine distribution of deaths by their places of burial, we identified burial places of 1051 deaths in total. It is seen that % 13,4 of the burial places are found in provinces, 32,4 % are in districts, 38,3 % are in villages, 15,7 % are in sub district and 0.1 % are in foreign countries.

42

Table 5.23 Distribution of Deaths Among Age 12+ Adults by Marital Status
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Marital Status (N=946) Married Widowed (Spouse dead) Single Divorced Single living together Married living separate Total Missing observations: 2 (0.2%) Number 576 308 48 6 4 2 944 % 61,0 32,6 5,1 0,6 0,4 0,2 100,0

Distribution of adult deaths by marital status was examined (above 12 years and above). In all, there were 946 persons with age greater than 12. In respondents, 61.0% of these deaths are observed as still married, 32.6 % are widowed and 5.1% have never been married (Table 5.23). Distribution of deaths by ILO profession groups is illustrated in Table 5.24. The highest proportion (65.2 %) is seen in the 00 coded profession category of ILO classification (Housewives, Retired, Annuity Holder, Students, Unemployed, Prisoners). The profession group including agriculturalists, livestock-dealers, foresters, fishermen and hunters take the second place with a proportion of 13.9 %. Professions of 2.5 % deaths could not be defined.

Table 5.24 Distribution of Deaths Among Age 12+ Adults by Occupation

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Occupation (N=946) Housewives, Retired, Students, Incapable Of Working, & Prisoners Agriculturists, Livestock Dealers, Foresters, Fishermen, & Hunters Non-Agricultural Production & The Ones Who Use Means Of Transportation Commercial & Sale Personnel Administrative Personnel & Relevant Studies Service Employee Unappointed Employees Scientific & Technical Personnel (Including Businessman With Private Professions & Related Jobs) Entrepreneur, Directors, & High Level Administrators Total Missing observations: 305 (32.2%) Number 418 89 48 26 18 16 16 9 1 641 % 65,2 13,9 7,5 4,1 2,8 2,5 2,5 1,4 0,2 100,0

Distribution of cigarette, alcohol and substance or drug habits of deaths are given in Table 5.25.

43

Table 5.25 Distribution of Adult Deaths by Smoking Habits, Alcohol Use, and Substance / Drug Use
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003 Habits(N=981) Smoking (n=939) Alcohol (n=937) Substance / Drug (n=921) Number 412 117 51 % 43,9 12,5 5,5

In 939 deaths, 43.9 % were using cigarettes, in 937 deaths, 12.5 % were using alcohol and in 921 deaths, 5.5 % were substance or drug dependent.

5.2.3 Medical History Related to Death

In Table 5.26, the presence of symptoms/complaints before death is shown: for 971 deaths responses were taken. 84.3 % of the deceased were reported to have had symptoms and 1,2 % of the respondents dont have any idea about the complaints.

Table 5.26 Presence of Pre-Death Symptoms / Complaints in the Deceased

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Pre-Death Symptoms Yes No Don't Know Total Missing observations: 113, (10,4%) Number 819 140 12 % 84,3 14,4 1,2

971 100,0

In Table 5.27 is shown the distribution of pre-death complaints of 891 persons. A total of 1329 answers were presented from these 891 persons. On average, one or two complaints were defined per person. Hypertension with a percentage of 16,2 % comes first, diabetes mellitus second with 8,5 % and third is dyspnea with 8,1 %.

44

Table 5.27 Distribution of Pre-Death Complaints

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Symptoms before death Hypertension Diabetes Mellitus Dyspnea Stroke Heart Failure Chest Pain Gastric Disease Renal Insufficiency Asthma Head ache Bronchitis Myocardial Infarction Chronic Heart Failure Lung CA Abdominal Pain Vomiting Dementia Coronary Arteria Coughing Prostate CA Arthritis Cirrhosis Fever Brain Tumor Joint Pain Lung Disease Noisea Gastric CA Osteoporosis Eye Disease Guatr Diarrhea Cardiac congestion COPD Jaundice Left Hemiplegia Vessel Obstruction Leukemia Breast CA Benign Prostate Hyperplasia Right Hemiplegia Alzheimer Swollen Leg Epilepsy Loss of Appetite Hole in Heart Liver CA Liver Disease Chronic Bronchitis Parkinson Tuberculosis Intestinal Disease Dizziness Fatigue Retention of Urine Osteoarthritis Cyanosis Pneumonia Hip fracture Number Percent Symptoms before death 215 16,2 Larynx CA 113 8,5 Gastric Bleeding 107 8,1 Bedridden 51 3,8 Unable to walk 51 3,8 Anemia 46 3,5 Leg Pain 29 2,2 Hernia 24 1,8 Growth Retardation 23 1,7 Glaucoma 19 1,4 Constipation 19 1,4 Large Intestine CA 19 1,4 Cardiac Valvular Disease 18 1,4 Arm Pain 17 1,3 Coronary Heart Disease 15 1,1 Meningitis 15 1,1 Bladder CA 14 1,1 Uterus CA 13 1,0 Gallstone 12 0,9 Hoarseness 12 0,9 Mental Retardation 12 0,9 Flank Region Pain 11 0,8 Oral Sore 10 0,8 Intestinal CA 10 0,8 Fainting 10 0,8 Brain Atrophy 9 0,7 Obstruction of Brain Vessels 8 0,6 By-pass 8 0,6 Skin CA 8 0,6 Swollen under the Knee 7 0,5 Growth Retardation due to Premature Birth 7 0,5 Gastroenteritis 7 0,5 Amnesia 7 0,5 Hemorrhoids 7 0,5 Bone Marrow Cancer 7 0,5 Cancer 7 0,5 Ascites 6 0,5 Itching 6 0,5 Cataract 6 0,5 Hemiplegia 6 0,5 Cholelithiasis 6 0,5 Aphasia 5 0,4 Convulsion 5 0,4 Coronary Failure 5 0,4 Chronic Pulmonary Disease 5 0,4 Chronic Renal Failure 5 0,4 Esophagus Ca 5 0,4 Obesity 5 0,4 Psychiatric problem 5 0,4 Low back pain 5 0,4 Respiratory Failure 5 0,4 Spastic paralysis 4 0,3 Traffic Accident 4 0,3 Ulcer 4 0,3 Uremia 4 0,3 Senility 4 0,3 Dysphasia 4 0,2 Weakness 4 0,3 Lymphoma 4 0,3 Number Percent 4 0,3 4 0,3 4 0,3 4 0,3 3 0.2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 3 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2 2 0,2

45

Table 5.27 Distribution of Pre-Death Complaints (Continued)

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Symptoms before death Mouth Dryness Crying Hematemesis Familial Mediterranean Anemia Mental retardation Alcoholism Angio Gunshot Injury Fracture in the Feet Obstruction of leg arteries Mass in the head Lumbar hernia Arthritis of the Lumbar Vertebrae Mass on the Lumbar Vertebrae Lumbar Pain Intracranial Bleeding Brain Trauma Throat Pain Renal Cysts Burger Disease Wound on the nose Nasal Acne Epistaxis Quick tired Tachycardia Chin Ca Splenectomy Dandy walker Cysts Trauma Loss of Equilibrium Depressive symptoms Diabetic Foot Distoji Asphenia Efor Dyspnea Sucking Difficulties Constipation Meteorism Larynx Ca Gonoarthrosis Umbilical Wound Mass in the breast Pressure on the chest Eye Ca Mass in the Eye Blindness Influenza Gout Seizure Hepatitis B Hepatosplenomegali Hyperlipidemia Hypertensive Heart Disease Urinary incontinence Hematuria Wheezing Insulin dependent Diabetes Mellitus Swelling in the head Number 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Percent 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 Symptoms before death Obstructions of heart arterials Hemoptysis Hepatic Failure Hepatic Mass Cardiac Aritmia Bone Ca Measles Cholesterol Colitis With colostomies Coma Ear Pain Manic Depression Mental Motor Retardation Migraine MS Multiple Myeloma Nephrolithiasis Shoulder pain Peptic Ulcer Peripheral Neuropathy Pica Pleurisy Polyuria Rabdomyosarcoma Rectum CA Gallbladder Ca Gallbladder operation Pain in the right testis Pain in the right abdomen Anxiety Nervous disease Splenomegaly Sciatalgia Cold Arm Pain Edema CVE Swollen Loss of Consciousness Hypotension Asphyxia due to malpresentation Tobrasetpenos Forgetfulness Wegener Granlomatosis Vertigo Skin eruptions Wounds Anterograde Amnesia Eneral edema Esophageal burns Number 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Percent 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1

Total

1329

100,0

46

Examination of Deaths within last one year by any health personnel is given in Table 5.28. The health personnel examined 83,9 % of these deaths. Among 971 respondents, 34,8 % knew the physician who had examined them last. When we examine distribution of deaths by age groups and sex, male adults have the highest percentage among the yes answers (54,5 %). Next are the female adults (36,8%).

Table 5.28 Distribution of Deceased According to Whether They Were Seen by a Health Professional in Their Last One Year
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Yes Age and Sex Groups 0-28 Male Female Total 29 day-5 year Male Female Total Adult Male Female Total Missing observations: 34 (3,1%) Number 14 12 26 22 29 51 480 324 804 % 53,8 46,2 100,0 43,1 56,9 100,0 59,7 40,3 100,0 No Number 3 4 7 8 7 15 97 50 147 % 42,9 57,1 100,0 53,3 46,7 100,0 66,0 34,0 100,0 Total Number 17 16 33 30 36 66 577 374 951 % 51,5 48,5 100,0 45,5 54,5 100,0 60,7 39,3 100,0

Distribution of deaths within last one year as for Inpatient Treatment in hospitals by age and sex is given in Table 5.29. 93,8% of male adults gave yes response. This proportion is 87,4 % for female adults. Among 29 day-5 year old children, this distribution is 4,2 % for males and 8,8% for females and among 0-28 day infant deaths, 2,0 % for males and 3,7% for females. Total number of yes responses for both sexes is 568; the percentage of this number is 54,2 % of all respondents. In male deaths, this percentage is 56,8%, and in female deaths, it is 50,5%. Moreover, it is stated that 63,1 % of deaths are discharged from the hospital within last one year prior to their deaths and 31,8 % are operated prior to their death. 96,2 % of respondents stated that they knew the organ that was operated on. But 161 of them were indicated the organ operated on. In average 7 years before, 2 months before, and 20 days before answer were given to the question of how long ago did the deceased have the operation? Only 14 respondents could answer the question concerning which operation was done. In Table 5.30, distribution of variety of operations for these 14 deaths. 226 respondent (96,2%) were identified as knowing the organ that operated but, 161 of them gave the name of the organ. The organs that are operated are given in Table 5.31. Gall bladder with 13,7% comes first, then hearth with 11,2% and eye end appendix with 10,6%.

47

Table 5.29 Distribution of the Deceased Who Received Inpatient Treatment in a Hospital in Their Last One Year, by Age and Sex
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Male Age Groups 0-28 day infant 29 day-5 year child Adult Total Female 0-28 day infant 29 day-5 year child Adult Total Number %* Number %* Number %* Number %* Number %* Number %* Number %* Number Yes 7 2,0 15 4,2 331 93,8 353 100,0 8 3,7 19 8,8 188 87,4 215 No 9 3,4 15 5,7 240 90,9 264 100,0 8 3,8 18 8,6 183 87,6 209 100,0 Dont Know 1 20,0 4 80,0 5 100,0 2 100,0 2 100,0 Total 17 2,7 30 4,8 575 92,4 622 100,0 16 3,8 37 8,7 373 87,6 426 100,0

100,0 %* *Percentages are column percentages in each sex group Missing observations: 36 (3,3%)

Table 5.30 Distribution of Reported Operations, by Type

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Kinds of operation Gall Bladder Appendix Uterus Intestinal Obstruction Lung Gastric The large intestine Brain By pass Cardiac valve Hipbone fracture Hernia Intestinal perforation Total Number 2 1 1 1 1 1 1 1 1 1 1 1 1 14 % 14,3 7,1 7,1 7,1 7,1 7,1 7,1 7,1 7,1 7,1 7,1 7,1 7,1 100,0

48

Table 5.31 Distribution of Organs Operated On

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Organs operated Gall bladder Hearth Eye and appendix Stomach Groin Brain Big bone and joint Colon Appendix Spinal cord Extremities such as Arm and leg Prostate Head Breast Lung Umbilicus Thyroid Liver Small intestine Kidney Vagina Corpus Uteri Skin Neck Esophagus Vertebrea Mediasten Spleen Pancreas Anus Urethra Urinary bladder Testis Arteries Connective tissue Total Number 22 18 17 13 11 8 8 7 7 4 4 4 3 3 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 161 % 13,7 11,2 10,6 8,1 6,8 5,0 5,0 4,3 4,3 2,5 2,5 2,5 1,9 1,9 1,9 1,9 1,2 1,2 1,2 1,2 1,2 1,2 1,2 0,6 0,6 0,6 0,6 0,6 0,6 0,6 0,6 0,6 0,6 0,6 0,6 100,0

Table 5.32 illustrates the distribution of death diagnoses reported by respondents. Death diagnoses are the exact responses given by respondents. Among the responses, myocardial infarction takes the first place with the highest proportion of 15,0 %. Then heart failure with 8,2 % and lung cancer with 4,6 % comes.

49

Table 5.32 Distribution of Death Diagnoses Reported by Respondents

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Cause of death according to the respondents Myocardial Infarction Heart Failure Lung Cancer Intracranial Bleeding Hypertension Cardiac Disease Renal Failure Senility Diabetes Mellitus Traffic Accident Deaths caused by age Lung Disease Stroke Dyspnea CVE Stomach CA Brain Tumor COPD Dyspnea Cirrhosis Pneumonia Hepatic CA Obstruction of Brain Vessel Bronchitis Meningitis Tuberculosis Cancer Leukemia Lung failure Sudden Death Suicide Prostate CA Post Operation Alzheimer Asthma Dementia Pancreases CA Blood Poisoning Intestinal CA Brain CA Drowning Electrical Injury Diarrhea Fever Trauma of Head Premature Birth Growth Retardation Death due to Febrile Convulsion Larynx CA Anemia Malnutrition Breast CA Parkinson Elevation of urea level Number 163 89 50 45 45 34 27 28 28 26 24 23 22 20 20 17 16 13 13 13 13 10 10 9 9 9 9 9 8 8 7 7 6 6 5 5 5 5 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 % 15,0 8,2 4,6 4,1 4,1 3,1 2,5 2,6 2,6 2,4 2,2 2,1 2,0 1,8 1,8 1,6 1,5 1,2 1,2 1,2 1.2 0,9 0,9 0,8 0,8 0,8 0,8 0,8 0,7 0,7 0,6 0,6 0,6 0,6 0,5 0,5 0,5 0,5 0,4 0,4 0,4 0,4 0,4 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 Cause of death according to the respondents Osteoporosis Obstruction of Vessel Acute MI Aspiration Pneumonia Gunshot Injury Intestinal infection Knife Injury Prolonged Labor Encephalitis Eye tumor Hydrocephaly Internal Bleeding Bone Marrow Cancer Stroke Large Bowel CA Colon CA Coma Chronic Bronchitis Gunshot Bladder CA Metastasis Lung CA Gastric Bleeding Gastric Disease Gallbladder CA Gallbladder Disease Septicemia Intracranial Bleeding due to Traffic Accident Falling down a tree Ventricular Fibrillation Injury Thalasemia Sweating Emphysema Aortic Aneurism ASD After Vaccination Stroke due to obesity Gangrene of the foot Gangrene of the legs Intestinal Disease Intestinal Bleeding Intestinal Obstruction Intestinal Perforation Brain Atrophy Brain Stroke Brain Shrinkage Stupor Cervical Vertebrae Fracture Renal CA Number 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 % 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1

50

Table 5.32 Distribution of Death Diagnoses Reported by Respondents (Continued)

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Cause of death according to the respondents Renal Cyst Butchiary Skin CA Murder Chin Ca Multiple Organ Metastasis Cervical vertebral fracture due to fall from roof Dandy walker Cyst Debility Renal Insufficiency due to Diabetes Diabetic Coma Diabetic MI Dysentery Natural disaster Asphyxia at Birth due to Malpresentaton Death by Freezing Falling After Effort Test Eclampsia Electrolyte Imbalance Infection Epilepsy Deprivation of General Health Nasal Polyp CA Larynx CA GIS Bleeding Occult Cardiac Disease Breast Mass Pond drowning Eye Paralysis Guatr Sunstroke Hepatic Coma Hodgkin Lymphoma Acute MI due to Hypertension Internal Guatr Explosion Internal Organ Deprivation Disease inside of him Bacteremia Suicide (Hang) Suicide (Gunshot Injury) Unrecovered Sores Intracranial Tumor Intracranial Edema Hole in his Heart Large Intestinal Dysfunction Complications after heart transplantation Coagulation Disorder Hepatic Patient Hepatic Failure Number 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 % 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 Cause of death according to the respondents Abdominal blatancy Abdominal Aortic Aneurysm Bone Cancer Umbilical cord Compression Coronary Cardiac Failure Coal Poisoning Chronic Pulmonary Disease Lymphoma Meconium Aspiration Fall from Stairs Gastric Ulcer MS Multiple Myeloma Nidon Blood Type Incompatibility After Operation Fluid Flow from Pancreas PEM Peptic lcer Activity Thrombosis Pneumothorax Psychosis Rectum CA Assault Injury Jaundice Septic shock (Food Intoxication) Cerebral Hemorrhage Cerebral Thromboembolism Cold(Hypothermia) Respiratory Tract Infection Tension due to Diabetes Pistol Shot Brain Death due to Tension Trauma due to Traffic Accident Thromboembolism Tuberculosis Sequel Ulcer Upper Respiratory Tract Infection Stone Fall on him Edema of the Body Body Sores Burn (DIC) Found Dead in Bed Disseminated Metastasis Esophagus Cancer Fall Down and Drowning High Dose Heroin Intake Intracranial Bleeding due to falling Toxic Goiter Toxic Diarrhea TOTAL Number 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1087 % 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 100,0

Missed Observation 24 (%2,2)

51

Table 5.33 Distribution of Deaths in Terms of Whether a Physician Provided a Diagnosis, by Sex and Age Groups
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Male Age Groups 0-28 day infant 29 day-5 year old child Adult Total Female 0-28 day infant 29 day-5 year old child Adult Total Number %* Number %* Number %* Number %* Number %* Number %* Number %* Number Yes 12 2,5 23 4,8 447 92,7 482 100,0 7 2,5 26 9,3 248 88,3 281 No 3 2,7 6 5,5 101 91,8 110 100,0 7 5,6 11 8,91 106 85.5 124 100,0 Dont Know 1 4,5 1 4,5 20 90,9 22 100,0 1 7,1 13 92,9 14 100,0 Total 16 2,60 30 4,94 568 92,5 614 100,0 15 3,60 37 8,8 367 87,6 419 100,0

100,0 %* Percentages are column percentages in each sex group Missing observations: 51 (4,7%)

Distribution of state of physician diagnosis for deaths by age and sex groups is given in Table 5.33. There are 1033 responses in total. 73,9 % of responses comprises physician diagnoses (763). The proportion of male deaths is 63,2 %, and for females 36,8 % of deaths occurred with a physicians diagnosis. When we examine the distribution of deaths by age then the proportion of adult males having a physician diagnosis is 92,7 % and that of female adults is 88,3 %. The percentage of receiving a physician diagnosis among 29 day-5 year old male children is 4,8 %, female children is 9,3%. 2,5 % of 028 day male infants and 2,5 % of 0-28 day female infants are identified having received a physician diagnosis.

Table 5.34 Distribution of Whether Deaths Were Due to Injury, by Age Groups
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Yes No Dont Know Total Age Groups Number % Number % Number % Number % 1 1,3 30 3,1 31 3 0-28 day infant 9 12,0 57 5,9 1 50,0 67 6,5 29 day-5 age child 65 86,7 872 90,9 1 50,0 938 90,5 Adult 75 100,0 959 100,0 2 100,0 1036 100,0 Total Missing Observation 48(% 4,4)

52

In Table 5.34 distribution of deaths occurred due to injury by age groups were given. 1036 answer were taken for this question and it was obtained that there were 75 deaths (7,2 %) caused by injury. In the age groups the most significant result were obtained for adults (86,7 %). Types of injury, distribution of events causing the injury, distribution of places where the injury occurred and the positions at the time of the injury are given in Tables 5.35-5.40 by age and sex groups. 40% (30/75) of injuries are traffic accidents, 10,7 % (8/75) home accident, 9,3% each for suicide, occupational accidents and attack (7/75 each). 41,3% (31/75) of injuries are due to the motor vehicle. 16,0 % (12/75) were results of fall, 14,7 % (11/75) drowning, 10,7 % (8/75) firearms. Of the injuries, 42,7% at street or highway, 26,7 % at home. 10,1 % of deceased were using a motor vehicle, 8,7 % in motor vehicle. 21,8 % was walking.

Table 5.35 Distribution of Types of Injury Causing Death, by Sex and Age Groups
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Road Traffic Home Age Occupational Dont Groups Accident (N=75) Accident Accident Disaster Attack Suicide Other know Total 29 day1 2 2 5 5 year children Number %* Adult Total Number %* Number %* 29 day5 year children Number Female %* Adult Total Number %* Number 4,3 22 95,7 23 100,0 2 28,6 5 71,4 7 50,0 2 50,0 4 100,0 4 100,0 4 2 100,0 2 100,0 7 100,0 7 100,0 7 100,0 7 100,0 5 100,0 5 100,0 2 100,0 2 100,0 33,3 4 6 1 1 9,1 50 90,9 55

Sex

Male

66,7 100,0

100,0 100,0 100,0 1 50,0 1 50,0 2 100,0 3 20,0 12 80,0 15

100,0 100,0 %* *Percentages are column percentages in each sex group Missing observations: 5 (6,7%)

- 100,0

The highest proportion of male traffic accidents is among adults with 95,7 % and the lowest proportion is among 29 day-5 year children with 4,3 %. The percentage of female adult traffic accidents is 71,4 %. The distribution of male adults and 29 day-5 year age groups is the same for home accidents (50,0 %) Home accidents are four and all of them are adult female. In 0-28 days infant, one deaths caused by injuries but, the kind of injury didnt identified.

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Table 5.36 Distribution of Events Causing Injury, by Sex and Age Groups
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Age Motor Firearm, Dont Groups N = 75 Vehicle Burn Poison Fall Drowning mine know Other Total 29 day1 1 1 3 6 5 year children Number %* Adult Number %* Total Number %* 29 day5 year children Number Female %* Adult Number %* Total Number 4,2 23 24 1 1 50,0 1 50,0 2 14,3 6 85,7 7 30,0 7 70,0 10 100,0 1 100,0 1 100,0 6 6 1 1 9 9 10,0 54 90,0 60

Male

95,8 100,0 100,0 100,0 2 28,6 5 71,4 7 -

100,0 100,0 100,0

100,0 100,0 5 5

100,0 100,0 100,0 100,0 2 100,0 2 100,0 1 50,0 1 50,0 2 4 23,5 13 76,5 17

- 100,0 - 100,0

%* 100,0 *Percentages are column percentages in each sex group More than one choice signed

100,0 100,0

When examining the distribution of events causing injury by age and sex groups, motor vehicle accidents are found 24 among males and this number refers to 77,4 % (24/31) of all the motor vehicle accidents. The proportion of females is 22,6 % (7/31). The proportion of male adults in terms of motor vehicle accidents is identified as 95,8 % (23/24) in all males whereas that of female adults is 71,4 % (5/7) in all females, 4,2% for 29 day-5 year old male children in all males and 28,6 % for female children in all females. In addition, in adult males, 85,7%, in 29 days-5 year age children 14,3%, injuries due to fall occurred (Table 5.36). The time of occurrence of injuries before death were coded as year, month and day. The average time of injuries before death defined as 38 day from 43 answers.

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Table 5.37 Distribution of Injuries by Place of Occurrence

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Place of Injury (N=75) Street/Highway Home Construction Area Playground/Park Area Trade and Service Areas (shop, bank,etc.) Public buildings Sea, River, Lake, Stream Industrial Area Dont Know Other Total Number 32 20 3 2 2 2 2 1 1 10 75 % 42,7 26,7 4,0 2,7 2,7 2,7 2,7 1,3 1,3 13,3 100,0

Table 5.38 Distribution of Situations at the Time of Injury

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Position Prior to Fatal Injury (N=69) Walking (pedestrian) Leisure activities (except sports) Riding in a motor vehicle Working around the house (garden, field etc.) Driving a motor vehicle On duty at a paid job Don't know Unpaid work (except cooking) (housework, etc.) Cooking Other Number 15 9 6 8 7 7 3 3 1 10 % 21,8 13,0 8,7 11,6 10,1 10,1 4,3 4,3 1,4 14,5

*More than one choice signed

In Tables 5.39 and 5.40, the distribution of body injured and medical conditions relevant to the death are given.

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Table 5.39 Distribution of Injuries by Body-Part Injured

(NBD-CE Study, Verbal Autopsy Survey, Turkey, 2003) Part of Body Injured (N=75) Head / Neck Chest Arm / leg Abdomen Low back Waist * More than one choice signed Number 56 18 18 12 5 3 % 74,7 24,0 24,0 16,0 6,7 4,0

Table 5.40 Distribution of Medical Conditions Caused by Injury

(NBD-CE, Verbal Autopsy Survey, Turkey, 2003) Medical Conditions (N=75) Coma Hemorrhage Fainting Loss of Consciousness Headache Paralysis Vomiting Other * More than one choice signed Number 26 25 8 7 1 1 1 14 % 34,7 33,3 10.7 9.3 1,3 1,3 1.3 18,7

In injuries, more than one organ and more than one medical condition were sometimes involved. 74,7 % of body parts injured were head or neck, 24,0 % at chest and arm or leg. Due to injury, 34,7 % coma, 33.3 % hemorrhage 10,7 % fainting and 9,3 % loss consciousness occurred. Other conditions amounted to 18,7%, but these were not identified.

5.2.4 Adult Deaths

In this part, results about adult deaths will be given in terms of organ systems. There were 981 adult deaths coded in questionnaire. For 957 adults the ages were coded. 2,6% are 5-19 , 4,5% are 2034 , 10,8% 35-49 , 21,5% are 50-64 , 40,4% are 65-79 , 20,2% are +80 . Mean age is calculated as 64,9317,91. Symptoms/complaints experienced by adults who died were classified by the organ system: for example, the cardiovascular system, nervous system, respiratory system, digestive and genitourinary systems, and immune system. In addition, information related to cancer deaths are provided below. The frequency of various symptoms by system is shown in Table 5.42, the data of symptoms during pregnancy related to women who died between ages 15-49 is shown in Table 5.43. In symp-

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toms of cardiovascular system, 52,9 % had dyspnea complaints, 44,7 % had edema complaint, 42,0 % had chest pain less than 24 hours. Percentage of myocardial infarcts is 19,7 % and paralysis before death is 13 %. According to respiration system symptoms, productive cough with 67,8 % comes first then, with 56,4 % dry cough and with 39,4 % cough lasting more than one month comes. The lowest percentages were for foul breath with 12,8 %, diagnosed tuberculosis with 5 %, and medical treatment for tuberculosis with 4,9 %. Symptoms of digestive system are; the first symptom is sudden loss of weight with 32,1 %, abdominal pain with 30,7 %, heartburn with 26,7 %. The least percentage is diarrhea lasting more than one month with 7,2 % hematemesis with 7,6 %. Symptoms of genitourinary system are; 18,5 % pain in the groin, 15,7 % dysuria, 8,5 % hematuria. In symptoms of infectious diseases, 53,3 % of deceased had chills / rigors associated with fever, 23,8 % had fever before death, 23,6 % had fever recur every third / fourth day. In cancer symptoms; 13,1 % had ever complain of the presence of any mass or tumor in any part of the body and in 36,7 % mass persist until death. The distribution of the specified tumors was given in Table 5.41 for 53 deaths. The maximum percentage is lung (22,6%), secondly brain with 15,1% and thirdly gastric and hepatic with 7,5% each

Table 5.41 Distribution of Reported Tumors by Location

(NBD-CE, Verbal Autopsy Survey, Turkey, 2003) Location of the Tumor Lung Brain Gastric Hepatic Head Breast Prostate Eye and its appendices Pancreas Colon Bone Marrow Chin Pharynx Larynx Esophagus Mediastinum Rectum Appendices Skin Total Number 12 8 4 4 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1 53 % 22,6 15,1 7,5 7,5 5,7 5,7 5,7 3,8 3,8 3,8 3,8 1,9 1,9 1,9 1,9 1,9 1,9 1,9 1,9 100,0

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Table 5.42 Distribution of Symptoms and Conditions Before Death, by Organ Systems
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Within Last One Month Deceased Had (N=981) Cardiovascular System Symptoms Dyspnea complaints Edema complaints Chest pain lasting less than 24 hours Tachycardia Recurrent sore throat, joint pain, swelling Complaints of cyanotic lips, fingers and nails Myocardial infarcts Nervous System Symptoms Had paralysis the month prior to death Respiration System Symptoms Productive Cough Dry Cough Cough lasting more than one month Chest or side ache Wheezing Hemoptysis Infectious Disease Symptoms Halitosis Diagnosed with tuberculosis Medical treatment for tuberculosis Digestive System Symptoms Acute weight loss Abdominal pain complaints Heartburn complaints Recurrent vomiting complaints Oral moniliasis Jaundice complaints Complaints of blood in stools Hematemesis complaints Diarrhea lasting more than one month Chills / rigors associated with fever Fever before death Fever recurring every third / fourth day Febrile convulsions Cancer Symptoms Deceased or family member ever informed about tumor Mass persisting until death In the last 6 months time, weight loss of 6 kg or more with no apparent reason Complaints of mass or tumor anywhere in body Genitourinary System Symptoms Complaints of pain in the groin Dysuria complaints Hematuria complaints Presence of Symptoms Yes Number 502 424 399 343 238 221 187 123 253 211 374 353 310 97 121 47 43 302 288 251 129 86 83 81 71 67 120 225 53 38 163 150 309 123 175 148 80 No % Number 52,9 427 44,7 496 42,0 500 36,1 537 25,1 675 23,3 19,7 13,0 67,8 56,4 39,4 42,0 32,8 26,0 12,8 5,0 4,9 32,1 30,7 26,7 13,7 9,1 8,8 8,6 7,6 7,2 53,3 23,8 23,6 16,9 39,6 36,7 32,6 13,1 18,5 15,7 8,5 683 724 820 111 155 555 548 609 262 765 866 810 624 614 631 789 814 826 807 840 831 91 652 149 182 234 241 627 795 713 745 803 Dont Know % Number 45,0 20 52,3 29 52,7 50 56,6 69 71,1 36 72,0 76,5 86,4 29,8 41,4 58,5 58,1 64,4 70,2 81,0 91,5 91,7 66,2 65,4 67,1 83,7 86,3 87,8 85,5 89,4 88,8 40,4 68,8 66,2 80,9 56,8 58,9 66,1 84,8 75,4 79,1 85,0 45 36 6 9 8 20 43 26 14 58 33 30 16 37 59 25 43 32 56 29 38 14 70 23 5 15 18 13 20 58 49 62 Total % 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100, 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 % Number 2,1 949 3,1 949 5,3 949 7,3 949 3,8 949 4,7 3,8 0,6 2,4 2,1 2,1 4,6 2,8 3,8 6,1 3,5 3,4 1,7 3,9 6,3 2,7 4,6 3,4 5,9 3,1 4,1 6,2 7,4 10,2 2,2 3,6 4,4 1,4 2,1 6,1 5,2 6,6 949 947 949 373 374 949 944 945 373 944 946 883 942 939 941 943 943 941 944 940 936 225 947 225 225 412 409 949 938 946 942 945

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When the symptoms and conditions in the pre-death period were analyzed by organ system, it was seen that in the nervous system symptoms occurring in the month before death were paralysis during or after loss of consciousness in 70 people (56,9%), and paralysis without loss of consciousness during or afterward in 49 (39.8%). Four (3,3%) persons indicated that they did not know whether or not paralysis occurred.

Table 5.43 Distribution of Pre-Death Findings Among 15-49 Year Old Females, as Reported by Respondents
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Symptoms (N=40) Symptoms Situations Yes Number 3 2 1 No % Number 13,6 19 9,5 5,6 19 16 Dont Know % Number 86,4 90,5 88,9 1 % 5,6 Total Number 22 21 18 % 100,0 100,0 100,0

Continuous Fever Hypertension, edema in lower limbs and / or excessive loss of weight during pregnancy Persistent fever and headache after childbirth (in 6 weeks)

When the informations belong to 15-49 age female deaths examined, total 40 female deaths were found between 15-49 age. If the values of 15-49 age women are analyzed, 9,5 % had hypertension edema in lower limbs and / or over loss of weight during pregnancy. Any deaths during birth were identified. 13,6 % had continuous fever. In the NBD-CE Verbal Autopsy Study, two mother deaths occurred. One of them is pregnant when she died and the other is maternal death occurred after 6 weeks from birth.

5.2.5 Deaths Among Infants Aged 0-28 Days

In this section of the report, results concerning infant deaths, including maternal conditions, the birth, etc. are described. Then complications during delivery and the problems of infants are given. In this part, conditions related to newborn status such as type of birth, time of delivery is also given. Total number of 0-28 days infant death is 35 (3,2% of total). Of the 35 infant deaths, 25 (71,4 %) were 0-7 days infant deaths, 9 (25,7 %) were 8-28 infant deaths. The day of death for one infant could not be identified. 76,5 % of respondents indicated that they had been near the baby while she/he had been ill. In Table 5.44, prenatal, childbirth, and post partum conditions of the mother are provided in detail. 88,2 % of mothers reported their health was good after the birth. During pregnancy, 18,2 % had high blood pressure and 55,9% of them were immunized for tetanus. There were 13 cases where mothers reported complications of pregnancy. Among these 15,4% were hypertension, 7,7 % had epilepsy and the same reported diabetes. 53,9% gave the dont know answer. 2,9 % of women had problems with spasm / eclampsia. 70,6 % of the births was normal: that is, there were no major complications. During birth, 9,1% of women reported they had a fever. 21,2 % of deliveries was multiple deliveries and 61,8% of was normal deliveries. 26,5 % of deliveries was compulsory cesarean. 70,6 % of deliveries was on time but 17,6 % was early. Assessing premature births reported in 5 responses, the the mean

59

time of premature birth was found to be 1 month 25 days early. Mean weights of infants are obtained by 3077,78gr 1040,54gr. Average weight for normal deliveries is (3472,73gr 773,10gr), whereas average weight for premature births is estimated as (1600,00605,53). The question was the baby born dead was answered, Yes by 5 respondents. In other deaths, for 30 answers given, the deaths occurred on average at 5 days, 8 hours after delivery.

Table 5.44 Distribution of Mothers Health Conditions before Giving Birth, During the Birth and After the Birth, as Reported by Respondents
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) (N=35) Maternal Status Healthy Patient Total Maternal Blood Pressure Status During Pregnancy Not High High Dont Know Total Maternal Tetanus Immunization Status During Pregnancy Yes No Dont Know Total Maternal Complications Hypertension Diabetes Mellitus Epilepsy Other Dont Know Total Maternal Spasm / Seizure Before Delivery No Yes Dont Know Total Number 30 4 34 Number 24 6 3 33 Number 19 13 2 34 Number 2 1 1 2 7 13 Number 31 1 2 34 % 88,2 11,8 100,0 % 72,7 18,2 9,1 100,0 % 55,9 38,2 5,9 100,0 % 15,4 7,7 7,7 15,4 53,9 100,0 % 91,2 2,9 5,9 100,0

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Table 5.44 Distribution of Mothers Health Conditions before Giving Birth, During the Birth and After the Birth, as Reported by Respondents
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) (Continued) Status of Delivery Process without major difficulties Yes No Total Maternal Fever During Delivery No Yes Dont Know Total Multiple Pregnancy No Yes Total Type Of Birth Normal birth Obligatory caesarian Interventional (forceps, vacuum) Elective caesarian Total Gestation Period Normal gestation period Early birth Late birth Total Number 24 10 34 Number 26 3 4 33 Number 26 7 33 Number 21 9 2 2 34 Number 24 6 4 34 % 70,6 29,4 100,0 % 78,8 9,1 12,1 100,0 % 78,8 21,2 100,0 % 61,8 26,5 5,9 5,9 100,0 % 70,6 17,6 11,8 100,0

Table 5.45 shows complications and infant indicators following birth.

Table 5.45 Distribution of Situations Encountered During and After Delivery Prior to Deaths Among 0-28 Day Old Infants
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Complications, Conditions (N=35) Yes Baby cried immediately after birth Baby was weighed right after birth Small Gestational Age Baby was unable to breast-feed Delayed breathing after birth Baby stopped moving before birth Baby breast-fed after birth, then stopped Number 24 18 11 12 7 6 8 Complication Status No Dont Know Total Number 34 34 34 34 28 34 19 % 100,0 100,0 100,0 100,0 100,0 100,0 100,0 % Number % Number % 70,6 7 20,6 3 8,8 52,9 10 29,4 6 17,6 32,4 22 64,7 1 2,9 35,3 20 58,8 2 5,9 25,0 15 53,6 6 21,4 17,6 42,1 25 10 73,5 52,6 3 1 8,8 2,9

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42,1 % of infants stopped breast feeding after birth and 35,3 % of infants were unable to breast feed. Of the complications after delivery, the most significant complaint was small birth size, with 32,4 %. 70,6 % of infants cried immediately after birth, and 52,9 % were weighed after birth. Umbilical cord prolapse was not seen. The distribution of some complications seen after live deliveries is given in Table 5.46.

Table 5.46 Distribution of Deaths Among 0-28 Day Old Infants by Post-Delivery Complications
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Complications (N=35) Yes Cyanosis Had respiratory distress Tachypnea Had intercostal retraction Had vomiting Had fever Had convulsions Was coughing Had green bloody, watery / loose, unusual & frequent defecation Icteric sclera Any malformation / disability at birth Inflammatory Drainage of Umbilical cord Bulging fontanelle Number 21 20 19 15 12 10 7 7 5 4 3 3 3 Complication Status No % Number 61,8 10 58,8 10 57,6 9 45,5 9 36,4 18 29,4 19 20,6 22 20,6 24 14,7 11,8 9.1 8.8 9,4 25 28 28 25 21 Don know % Number 29,4 3 29,4 4 27,3 5 27,3 9 54,5 3 55,9 5 64,7 5 70,6 3 73,5 82,4 84.8 73.5 65.6 4 2 2 6 8 Total % 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 % Number 8,8 34 11,8 34 15,2 33 27,3 33 9,1 33 14,7 34 14,7 34 8,8 34 11,8 5,9 6.1 17.6 25.0 34 34 33 34 32

The most significant post delivery complication is cyanosis with 61,8 % and then respiratory distress with 58,8 %, tachypnea with 57,6 %, intercostals retraction with 45,5 %. Fever occurred in 10 infants (29.4%) and on average continued for 5 days. Icteric sclera occurred on average at 2 days after delivery (4 infants). In 5 infants, green, bloody, watery / loose, or unusual defecation continued on average for 7 days.

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5.2.6 Deaths Among Children Aged 29 Days - 5 Years

In this section, information on causes of death, child prematurity, breast-feeding and other aspects of the childs health and history are provided. These results are based on 68 (6,3 %) children deaths aged 29 days to 5 years. Ages were defined for 67 children, 29,9% are smaller than 6 month, 28,4% are 6 month- 12 month, 41,8% are above 1 year. In 68 deaths (84,8 %), respondents had been near to deceased in the period up to the time of death. For 59 respondents who reported how long the child had been sick before death, the mean time was 6 month, 5 days. Table 5.47 gives the distribution of some complications seen in deaths of children aged 29 days-5 years. 87,7 % of children was breast-feeding but 38,1 % had stopped breast-feeding before death. 37,9% were small for gestational age (SGA), 12,1 % were premature. Premature births occurred on average at 1 month, 22 days before time for the 7 reported cases. Before death, 72,2 % had fever and in 58,3%, fever was intermittent, in 33,3% fever was continuous. In response to a question about how long fever continued in terms of months and days, the average reported time was 2 months, 12 days in 48 children. 69,7 % had respiratory distress, 62,1 % had tachypnea, and at the same percentage intercostal retraction complications were seen. In 51,5% of deaths there was vomiting, and in 10,9 % of deaths there was hematemesis. Vomiting continued on average for 2 months 22 days in 34 children. 48,5 % of the children had diarrhea, 7,7 % had diarrhea with blood. In 32 reported cases, mean duration of diarrhea was calculated as 2 months and 1 day. Of the children who died, 77,3% had no edema, 10,3% had edema on the back and front of their body. 47,0% of children were coughing before they died and on the basis of 31 reported cases, 61,3% had dry coughing, 35,5% had productive coughing. Coughing continued on average for 2 months, 11 days. 45,5% had severe weight loss and in the 29 reported cases, this continued on average for 3 months, 16 days. 39,4% had distension and this continued on average for 4 months, 20 days in 23 reported children.

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Table 5.47 Distribution of Deaths Among 29 Day-5 Year Old Children, by Complications and Breastfeeding Status
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Complication Status Conditions, Complications (N=68) Was breast feeding Had fever Respiratory distress Tachypnea Intercostal retraction Vomiting Had diarrhea Coughing Weight loss Severe weight loss during illness Had convulsions Had abdominal distention Stopped breast feeding before death Small for gestational age Cyanotic finger tips Abdominal pain Had whitish rash on the tongue Icteric sclera Had pale palms or nails Hair turned reddish or yellow Was born premature Puffiness on back and front of body * Hematemesis Bloody diarrhea Puffiness on face * Puffiness on arm, leg and joint * * More than one choice signed Yes Number 57 48 46 41 41 34 32 31 30 30 27 26 24 25 26 25 16 16 14 9 8 7 7 5 2 2 No Dont know Total % Number % Number % Number % 87,7 8 12,3 65 100,0 72,7 16 24,2 2 3,0 66 100,0 69,7 20 30,3 66 100,0 62,1 25 37,9 66 100,0 62,1 24 36,4 1 1,5 66 100,0 51,5 31 47,0 1 1,5 66 100,0 48,5 32 48,5 2 3,0 66 100,0 47,0 35 53,0 66 100,0 45,5 32 48,5 4 6,1 66 100,0 45,5 34 51,5 2 3,0 66 100,0 40,9 37 56,1 2 3,0 66 100,0 39,4 38 57,6 2 3,0 66 100,0 38,1 38 60,3 1 1,6 63 100,0 37,9 41 62,1 66 100,0 39,4 39 59,1 1 1,5 66 100,0 38,5 28 43,1 12 18,5 65 100,0 24,2 46 69,7 4 6,1 66 100,0 24,2 48 72,7 2 3,0 66 100,0 21,2 48 72,7 4 6,1 66 100,0 13,8 55 84,6 1 1,5 65 100,0 12,1 57 86,4 1 1,5 66 100,0 10,3 68 100,0 10,9 57 89,1 66 100,0 7,7 57 87,7 3 4,6 65 100,0 3,0 68 100,0 2,9 68 100,0

Immunization status and past disease status of children are shown in Table 5.48.

Table 5.48 Distribution of Deaths Among 29 Day-5 Year Old Children, by Immunization Status and Presence of Rash or Skin Diseases
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Immunization (N=68) and Rash or Skin Diseases He / She immunized Immunized against polio Immunized with BCG (scar on left shoulder) Had measles Had skin disease or rash

Yes Number 45 42 38 5 5

No % Number 68,2 17 63,6 19 57,6 18 7,6 53 7,6 59

Dont know % Number 25,8 4 28,8 5 27,3 10 80,3 8 89,4 2

Total % 100,0 100,0 100,0 100,0 100,0

% Number 6,1 66 7,6 66 15,2 66 12,1 66 3,0 66

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68,2 % was immunized: 63,6 % were immunized against polio, 57,6 % were immunized against tuberculosis. In 39 deaths the time of the last immunization was determined, and on average it had occurred at 6 months, 17 days before death. 7,6 % had measles, and 7,6 % had skin diseases or rash. In Table 5.49, some results related to deaths of 29 day-5 year age children were given.

Table 5.49 Distribution of Deaths Among 29 Day-5 Year Old Children, by Selected Symptoms
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Symptoms (N=68) Symptom status Yes Number 30 20 19 11 7 5 No % Number 45,5 33 30,3 42 28,8 44 16,7 51 10,6 47 7,6 59 Dont know % Number 50,0 3 63,6 4 66,7 3 77,3 4 71,2 12 89,4 2 Total % 100,0 100,0 100,0 100,0 100,0 100,0 % Number 4,5 66 6,1 66 4,5 66 6,1 66 18,2 66 3,0 66

Loss of verbal response Stupor Convulsions Any stiffness of the whole body Stiff neck Both of his / her legs/arms paralyzed

As seen in table, 45,5% had loss in responding voices 30,3 % had stupor, 28,8 % had convulsions and 16,7 % stiffness of the whole body. In 20 children that had loss of consciousness, the time of loss of consciousness was defined in 16 deaths and it was found on average to have occurred 10 days before death.

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5.2.7 Findings Related to Stillbirths

In this part, findings of 5 stillbirths were given. In Table 5.50, findings of respondents, in Table 5.51, findings of stillbirths, in Table 5.52, distribution of conditions before birth, at birth and after birth, among respondent in stillbirths are given. 2 of the stillbirths (40,0%) are household deaths, 3 of the deaths (60,0%) are neighbouring household deaths. For all the deaths, interview was completed at first interview.

Table 5.50 General Information About Respondents Who Reported Stillbirths

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Number Sex of Respondent Male Female Relation Of Respondent to Deceased Mother/Father Grandmother/Grandfather Education of Respondent Primary school Age of Respondent 28 33 43 53 Total 4 1 3 2 5 1 2 1 1 5 % 80,0 20,0 60,0 40,0 100,0 20,0 40,0 20,0 20,0 100,0

4 of the respondent (80,0%) are male, 1of them (20,0%) are female. 3 of the respondents (60,0%) are mother or father of the deceased, 2of them (40,0%) is grandfather or grandmother. All of the respondents are primary school graduated. Mean age of respondents is 3810.

Table 5.51 Distribution of General Characteristics of Stillbirths

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Number Sex Male Female Urban/Rural Urban Rural Regions Central Anatolia Eastern and South Eastern Anatolia 2 3 1 4 1 4 40,0 60,0 20,0 80,0 20,0 80,0 %

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Table 5.51 Distribution of General Characteristics of Stillbirths (Continued)

(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Place of Death At Home At Hospital Total Number 2 3 5 % 40,0 60,0 100,0

3 of the stillbirths (60,0%) is female infant, and 4 (80,0%) of the stillbirths occurred at rural. In region distribution, 4 of the stillbirths (80,0%) are at Eastern and South Eastern Anatolia, 1 of them is at Central Anatolia. 2 of the stillbirths (40,0%) are at home, 3 of them (60,0%) are at hospitals.

Table 5.52 Distribution of Findings Associated With Stillbirths, Before, During and After Delivery
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Maternal Health Status Healthy Patient Total Maternal Blood Pressure Status During Pregnancy Not high High Dont know Total Maternal Tetanus Immunization Status During Pregnancy Yes No Dont know Total Maternal Complications Hypertension Dont know Total Maternal Spasm / Seizure Before Delivery No Yes Total Status of Delivery Process without major difficulties Yes No Total Maternal Fever During Birth Yes No Total Number 4 1 5 Number 2 1 2 5 Number 4 1 5 Number 1 2 3 Number 4 1 5 Number 4 1 5 Number 2 3 5 % 80,0 20,0 100,0 % 40,0 20,0 40,0 100,0 % 80,0 20,0 100,0 % 33,3 66,7 100,0 % 80,0 20,0 100,0 % 80,0 20,0 100,0 % 40,0 60,0 100,0

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Table 5.52 Distribution of Findings Associated With Stillbirths, Before, During and After Delivery (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Type of Birth Normal spontaneous birth Interventional (forceps, vacuum) Voluntary cesarean Total Gestation Period Normal Early Total Stopping moving before delivery Yes No Total Delaying of breathing after birth Yes Dont know Total Number 3 1 1 5 Number 4 1 5 Number 3 2 5 Number 1 1 2 % 60,0 20,0 20,0 100,0 % 80,0 20,0 100,0 % 60,0 40,0 100,0 % 50,0 50,0 100,0

4 of the respondent answered the question, did the diagnosis were the physician diagnosis and 3 (75,0%) of them gave yes to this question. In 4 deaths (80,0), after delivery, the health condition of mother was found as healthy, in 1 death (20,0%), high blood pressure while pregnant is identified. In 4 deaths (80,0%), mother did not immunized to tetanus during pregnancy, in 1 deaths (20,0%), respondent dont know whether or not mother immunized to tetanus during pregnancy. In distribution of complaints of mother, in 1 death (33,3%), just hypertension is identified. In 2 deaths (66,7%) respondent dont know. Before delivery, one of the mothers (20,0%) had spasm / eclampsia. In 4 deaths (80,0%), the birth was normal and no major difficulties were encountered. Maternal fever during birth was identified in 3 mothers (60,0%). 3 of the delivery (60,0%) are normal, 1 of them (20,0%) is interventional (forceps, vacuum), 1 of the delivery (20,0%) is obligatory cesarean. 4 of the birth (80,0%) was at time, 1 of them (20,0%) was early birth and occurred 2 months early. At 3 of the births (60,0%), infant was stopped the moving before death and at one of the births (50,0%), after birth, delaying of breathing after birth was occurred.

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5.2.8 Causes of Death

In this section, main cause of death of 0-28 days infant, 29 days-5 years aged children and for above 5 years age are introduced for Turkey and urban, rural area.

5.2.8.1 Main Causes of Death Among Male and Female Infants Aged 0-28 Days
Main cause of deaths of male and female 0-28 days infant deaths are given in Tables 5.53-5.55 for Turkey, urban and rural.

Table 5.53 Distribution of Main Causes of Death Among 0-28 Day Old Infants, by Sex and Physician Diagnosis
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Turkey Total Males Females Main Cause of Death Number % Number % Number % Respiratory distress syndrome (RDS) of newborn 5 27,8 4 25,0 9 26,5 Preterm infants 3 16,7 1 6,3 4 11,8 Neonatal Bacterial Sepsis, unspecified 2 11,1 2 12,5 4 11,8 Birth Anoxia 2 11,1 1 6,3 3 8,8 Meningitis, unspecified 1 5,6 1 6,3 2 5,9 Hydrocephalus, unspecified 1 5,6 1 6,3 2 5,9 Pneumonia, unspecified 2 12,5 2 5,9 Septicemia, unspecified 1 6,3 1 2,9 Disseminated intravascular coagulation [defibrination syndrome] 1 5,6 1 2,9 Neonatal aspiration of meconium 1 5,6 1 2,9 Pneumothorax 1 6,3 1 2,9 Atrioventricular septal defect 1 5,6 1 2,9 Congenital Heart Anomaly, unspecified 1 5,6 1 2,9 Asphyxia 1 6,3 1 2,9 Growth Retardation, unspecified 1 6,3 1 2,9 Total 18 100,0 16 100,0 34 100,0 Missing Value 1 (% 2,9)

Infant Respiratory Distress Syndrome (RDS) takes the first place in evaluation of causes of death among male and female infants in 0-28 day age group with a proportion of 26,5 %. Neonatal sepsis and preterm other babies with 11,8% are second causes. Birth anoxia with 8,8% is third cause. Infant RDS comes in the first place for male infants overall in Turkey with a proportion of 27.8 %, then preterm infants with 16,7% neonatal sepsis and birth anoxia with a percentage of 11.1 %. Female infants comprise infant RDS 25.0 % and neonatal sepsis 12.5%.

69

Table 5.54 Distribution of Main Causes of Death Among 0-28 Day Old Infants, by Sex and Physician Diagnosis: Turkey, Urban Region
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Total Male Female Main Cause of Death Number % Number % Number % Preterm infants 2 22,2 2 14,3 Birth Anoxia 2 22,2 2 14,3 Neonatal Bacterial Sepsis, unspecified 2 22,2 2 14,3 Septicemia, unspecified 1 20,0 1 7,1 Disseminated intravascular coagulation [defibrillation syndrome] 1 11,1 1 7,1 Meningitis, unspecified 1 20,0 1 7,1 Hydrocephalus, unspecified 1 20,0 1 7,1 Pneumonia, unspecified 1 20,0 1 7,1 Respiratory distress syndrome (RDS) of newborn 1 11,1 1 7,1 Neonatal aspiration of meconium 1 11,1 1 7,1 Pneumothorax 1 20,0 1 7,1 Total 9 100,0 5 100,0 14 100,0 Missing Value 1(% 6,3) Urban

The most common cause of infant death for urban Turkey is prematurity, Birth Anoxia, neonatal sepsis with 14,3% and septicemia, Disseminated intravascular coagulation (defibrillation syndrome), meningitis, pneumonia, hydrocephalus, pneumonia, respiratory distress syndrome (RDS), neonatal aspiration of meconium, pneumothorax with 7,1 %. In the 1999 SIS cause of death analysis for the birth to 4 years age group, perinatal causes were (28,3 % and 26,1 % respectively). In the year 2000, SIS reported these rates as 37,3 % for males and 38,6 % for females for newborns. Also according to SIS 2000 data, meningitis were the second cause, however in the present verbal autopsy study, only one male child was classified with meningitis (20,0 %). In this study, prenatal conditions were evaluated separately and we concluded that prematurity was the most important cause of death.

70

Table 5.55 Distribution of Main Causes of Death Among 0-28 Day Old Infants, by Sex and Physician Diagnosis: Turkey, Rural Region
(NBD-CE Study Verbal Autopsy, Turkey, 2003) Rural Main Cause of Death Respiratory distress syndrome (RDS) of newborn Preterm infants Neonatal Bacterial Sepsis, unspecified Meningitis, unspecified Hydrocephalus, unspecified Pneumonia, unspecified Birth Anoxia Atrioventricular septal defect Congenital Heart Anomaly, unspecified Asphyxia Growth retardation, unspecified Total Sex Total Male Female Number % Number % Number % 4 44,4 4 36,4 8 40,0 1 11,1 1 9,1 2 10,0 0,0 2 18,2 2 10,0 1 11,1 0,0 1 5,0 1 11,1 0,0 1 5,0 0,0 1 9,1 1 5,0 0,0 1 9,1 1 5,0 1 11,1 0,0 1 5,0 1 11,1 0,0 1 5,0 0,0 1 9,1 1 5,0 0,0 1 9,1 1 5,0 9 100,0 11 100,0 20 100,0

In rural Turkey, the largest cause of death was infant Respiratory Distress Syndrome (40,0 %). In urban communities, premature and neonatal sepsis was reported (10,0 %). In developing countries the premature babies are born at the expected date, but they are small for gestational age. In developed countries the premature babies are premature and immature. Prematurity is important itself and also important due to increasing the mortality and morbidity of other diseases. In this study, prematurity and diseases occurred due to prematurity, in rural areas played an important role for this age group.

5.2.8.2 Main Causes of Death Among Male and Female Children Aged 29 Days - Years
Main cause of deaths of male and female 29 days 5 years aged children are given for Turkey and urban, rural area in Tables 5.56-5.58.

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Table 5.56 Distribution of Main Causes of Death Among Male and Female Children Aged 29 Days 5 Years, by Sex and Physician Diagnosis: Turkey (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Turkey Main Cause of Death Pneumonia, unspecified Meningitis, unspecified Bronchopneumonia, unspecified Septicemia, unspecified Diarrhea and gastroenteritis of presumed infectious origin Car occupant [any] injured in unspecified traffic accident Measles without complication Unspecified protein-energy malnutrition Encephalitis, myelitis and encephalomyelitis, unspecified Asthma, unspecified Ventricular septal defect Congenital malformation of heart, unspecified Asphyxiation Malignant neoplasm of brain, unspecified Anemia, unspecified Bacterial meningitis, unspecified Hydrocephalus, unspecified Intracerebral hemorage,unspecified Unspecified acute lower respiratory infection Pulmonary edema Respiratory failure, unspecified Other disorders of lung Non-infectious gastroenteritis and colitis, unspecified Hepatic failure, unspecified Other and unspecified cirrhosis of liver Acute nephritic syndrome Chronic renal failure Artesia of foramina of Magnesia and Luschka Atrioventricular septal defect Congenital malformation of great arteries, unspecified Hirschsprung's disease Polycystic kidney, unspecified Unspecified injury of thorax Squeal of unspecified burn, corrosion and frostbite Drowning Other complications following immunization, not elsewhere classified Fall involving bed, unspecified Heart failure, unspecified Total Missing Value 1 (% 1,5) Male Number % 5 4 2 1 2 1 16,7 13,3 6,7 3,3 6,7 3,3 Female Number % 4 1 2 3 1 2 2 2 1 2 1 10,8 2,7 5,4 8,1 2,7 5,4 5,4 5,4 2,7 5,4 2,7 Total Number % 9 5 4 4 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 67 13,4 7,5 6,0 6,0 4,5 4,5 3,0 3,0 3,0 3,0 3,0 3,0 3,0 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 1,5 100,0

1 1 2 2

3,3 3,3 6,7 6,7

1 1 1 1 1 3,3 1 3,3 1 1 1 3,3 1 1 1 1 1 1 3,3 3,3 1 1 1 1 1 1 1 1 1 30 3,3 1 3,3 3,3 3,3 100,0

2,7 2,7 2,7 2,7 2,7 2,7 2,7 2,7 2,7 2,7

2,7 2,7 2,7 2,7 2,7 2,7

37

100,0

Pneumonia has a proportion of 13,4 % and meningitis has a proportion of 7,5 %, 6,0% bronchopneumonia and septicemia, in distribution of causes of death among 29 day-5 year old male and female children in Turkey. Infectious diarrhea and gastreonteritis, traffic accidents were seen at the fourth place with 4.5%. It is found that pneumonia with 16,7 %, and meningitis with 13,3 % come in the first place among male children; whereas the same distribution for female children is defined as

72

10,8 % pneumonia, 8,1% septicemia and 5,4 % bronchopneumonia, road traffic accidents, measles and protein- energy malnutrition.

Table 5.57 Distribution of Main Causes of Death Among Male and Female Children Aged 29 Days 5 Years, by Sex and Physician Diagnosis: Turkey, Urban Region
(NBD-CE Study Verbal Autopsy, Turkey, 2003) Sex Urban Total Male Female Main Cause of Death Number % Number % Number % Pneumonia, unspecified 1 9,1 2 13,3 3 11,5 Diarrhea and gastroenteritis of presumed infectious origin 1 9,1 1 6,7 2 7,7 Asthma, unspecified 2 13,3 2 7,7 Measles without complication 1 6,7 1 3,8 Malignant neoplasm of brain, unspecified 1 6,7 1 3,8 Meningitis, unspecified 1 9,1 1 3,8 Bronchopneumonia, unspecified 1 6,7 1 3,8 Unspecified acute lower respiratory infection 1 9,1 1 3,8 Pulmonary edema 1 6,7 1 3,8 Other disorders of lung 1 9,1 1 3,8 Hepatic failure, unspecified 1 6,7 1 3,8 Acute nephritic syndrome 1 6,7 1 3,8 Chronic renal failure 1 9,1 1 3,8 Atresia of foramina of Magendie and Luschka 1 9,1 1 3,8 Ventricular septal defect 1 9,1 1 3,8 Congenital malformation of great arteries, unspecified 1 6,7 1 3,8 Hirschsprung's disease 1 6,7 1 3,8 Polycystic kidney, unspecified 1 6,7 1 3,8 Asphyxiation 1 9,1 1 3,8 Other complications following immunization, not elsewhere classified 1 9,1 1 3,8 Car occupant [any] injured in unspecified traffic accident 1 6,7 1 3,8 Fall involving bed, unspecified 1 9,1 1 3,8 Total 11 100,0 15 100,0 26 100,0 Missing value 1(%3,7)

In urban Turkey in the age group of children 29 days to 5 years, pneumonia (11,5%), gastroenteritis of presumed infectious origin, and asthma (7,7 %) were the most common causes of death (7,7 %). In the SIS 1999 lower respiratory infectious were reported to be 6,1% of deaths in males and 7,2 % in females. In SIS 2000 mortality statistics, this proportion was 11,1% and 10,8 % respectively. In the age group of 1 to 4 years in the 2000 SIS, other respiratory diseases were combined with bronchitis and asthma, and the prevalence was 15,8 % in males and 16,1 % in females. In 0-4 year old age group, congenital heart diseases are 13,5 % in males and 12,6 % in females. In this study, in urban children, the percentage of ventricular septal defect in males is 9,1% and congenital malformation of great arteries in females is 6,7%.

73

Table 5.58 Distribution of Main Causes of Death Among Male and Female Children Aged 29 Days 5 Years, by Sex and Physician Diagnosis: Turkey, Rural Region
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Total Male Female Main Cause of Death Number % Number % Number % Pneumonia, unspecified 4 21,1 2 9,1 6 14,6 Meningitis, unspecified 3 15,8 1 4,5 4 9,8 Septicemia, unspecified 1 5,3 3 13,6 4 9,8 Bronchopneumonia, unspecified 2 10,5 1 4,5 3 7,3 PEM, unspecified 2 9,1 2 4,9 Encephalitis, myelitis and encephalomyelitis, unspecified 1 5,3 1 4,5 2 4,9 Congenital cardiac malformation, unspecified 2 10,5 2 4,9 Car occupant (any) injured in unspecified traffic accident 1 5,3 1 4,5 2 4,9 Diarrhea and gastroenteritis of presumed infectious origin 1 5,3 1 2,4 Measles without complication 1 4,5 1 2,4 Anemia, unspecified 1 4,5 1 2,4 Bacterial meningitis, unspecified 1 4,5 1 2,4 Hydrocephalic, unspecified 1 5,3 1 2,4 Heart failure, unspecified 1 5,3 1 2,4 Intracerebral hemorrhage, unspecified 1 4,5 1 2,4 Respiratory failure, unspecified 1 4,5 1 2,4 Non-infectious gastroenteritis and colitis, unspecified 1 4,5 1 2,4 Other and unspecified cirrhosis of liver 1 4,5 1 2,4 Ventricular septal defect 1 4,5 1 2,4 Atrioventricular septal defect 1 4,5 1 2,4 Unspecified injury of thorax 1 4,5 1 2,4 1 5,3 4,5 1 2,4 Asphyxiation Drowning 1 4,5 1 2,4 Unspecified burn, corrosion, frostbite sequel 1 5,3 1 2,4 Total 19 100,0 22 100,0 41 100,0 Rural

In rural children aged 29 days to 5 years, when the distribution of causes of death among males and females is examined, pneumonia occurred a rate of 14,6 %, meningitis and septicemia at 9,8 % each, and bronchopneumonia at 7,3%. Particularly in developing countries, pneumonia is still one of the most frequent causes of morbidity and mortality. In this study, pneumonia deaths were dependent on symptoms like cough and tachypnea; respiratory distress symptoms and fever began 6 hours before death, and cyanosis began 1 hour before death.

74

5.2.8.3 Causes of Death Among Males and Females Above 5 Years of Age
Main causes of death among over-5 year old male and female will be given for Turkey, urban and rural.

Table 5.59 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Turkey Main Cause of Death Male Number % Female Number % Total Number %

Essential (primary) hypertension Acute myocardial infarction, unspecified Bronchus and lung malignant neoplasm, unspecified Cardiovascular disease, unspecified Chronic Obstructive Pulmonary Disease, unspecified Diabetes mellitus, unspecified Heart failure, unspecified Car occupant (any) injured in unspecified traffic accident Atherosclerotic heart disease Alzheimers Disease, unspecified Chronic Ischemic Heart Disease, unspecified Gastric malignant neoplasm, unspecified Senility Brain neoplasm, uncertain or unknown behavior Chronic renal failure, unspecified Stroke, not specified as hemorrhage or infarction Cerebrovascular disease, unspecified General and unspecified atherosclerosis Hepatic malignant neoplasm, unspecified Other and unspecified cirrhosis of liver Unspecified chronic bronchitis Colon malignant neoplasm, unspecified Pneumonia, unspecified Leukemia, unspecified Congestive heart failure Occlusion and stenosis of unspecified cerebral artery Asthma, unspecified Septicaemia, unspecified Breast malignant neoplasm, unspecified Malignant neoplasm of prostate Pancreas malignant neoplasm, unspecified Non-insulin-dependent diabetes mellitus Parkinsons disease Discharge from other and unspecified area Tuberculosis of lung, confirmed by unspecified means

55 62 49 36 36 19 12 21 18 7 17 8 6 10 10 5 8 6 7 6 4 7 5 4 6 3 1 1 6 3 1 4 5 2

9,5 10,7 8,5 6,2 6,2 3,3 2,1 3,6 3,3 1,2 2,9 1,4 1,0 1,7 1,7 0,9 1,4 1,0 1,2 1,0 0,7 1,2 0,9 0,7 1,0 0,5 0,2 0,2 1,0 0,5 0,2 0,7 0,9 0,3

64 30 7 18 9 19 15 6 4 15 4 10 11 6 5 9 6 8 4 5 6 2 4 4 2 5 7 5 6 2 4 1 2

17,0 8,0 1,9 4,8 2,4 5,1 4,0 1,6 1,1 4,0 1,1 2,7 2,9 1,6 1,3 2,4 1,6 2,1 1,1 1,3 1,6 0,5 1,1 1,1 0,5 1,3 1,9 1,3 1,6 0,5 1,1 0,3 0,5

119 92 56 54 45 38 27 27 22 22 21 18 17 16 15 14 14 14 11 11 10 9 9 8 8 8 8 6 6 6 5 5 5 5 4

12,5 9,6 5,9 5,7 4,7 4,0 2,8 2,8 2,3 2,3 2,2 1,9 1,8 1,7 1,6 1,5 1,5 1,5 1,2 1,2 1,0 0,9 0,9 0,8 0,8 0,8 0,8 0,6 0,6 0,6 0,5 0,5 0,5 0,5 0,4

75

Table 5.59 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Turkey Main Cause of Death Malignant neoplasm of gallbladder and bile duct Larynx malignant neoplasm, unspecified Gastrointestinal hemorrhage, unspecified Asphyxiation Effects of electric current Tuberculosis of lung, without mention of bacteriological or histological confirmation Injuries, unspecified Intentional self harm by other and unspecified means Malignant neoplasm of Gastro Intestinal Tract Other specified sites, neoplasm uncertain or unknown behavior Diabetes mellitus with ketoacidosis Unspecified dementia Epilepsy, unspecified Acute renal failure, unspecified Unspecified injury of head Fracture of neck of femur Intentional self harm by drowning and submersion Intentional self harm, discharge from other and unspecified firearms Esophagus malign neoplasm, unspecified Malignant neoplasm of rectum Malignant neoplasm of skin, unspecified Endometrial malignant neoplasm Malignant neoplasm of uterus, unspecified Bladder malignant neoplasm, unspecified Brain Malignant Neoplasm, unspecified Malignant neoplasm without specification of site Non-Hodgkins lymphoma, unspecified type Bone and joint particular cartilage, neoplasm uncertain or unknown behavior Anemia, unspecified Diabetes mellitus with renal complications Unspecified mental retardation Meningitis, unspecified Cardiac valvular disease, unspecified Cardiomegaly Cerebral atherosclerosis Abdominal aortic aneurysm, without rupture Tromboanjitis obliterans [Buerger] Emphysema, unspecified Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation Alcoholic cirrhosis of liver Burn of unspecified body region, unspecified degree Other fall from one level to another, unspecified Unspecified fall, unspecified area Exposure to unspecified factor 2 1 1 2 2 2 3 1 1 1 2 0,3 0,2 0,2 0,3 0,3 0,3 0,5 0,2 0,2 0,2 0,3 1 1 1 0,3 0,3 0,3 1 1 0,3 0,3 1 1 0,2 0,2 2 1 1 1 1 0,3 0,2 0,2 0,2 0,2 1 1 1 1 2 1 1 2 2 0,3 0,3 0,3 0,3 0,5 0,3 0,3 0,5 0,5 3 3 1 1 1 1 0,5 0,5 0,2 0,2 0,2 0,2 1 1 1 1 2 2 0,3 0,3 0,3 0,3 0,5 0,5 3 3 2 3 3 3 2 2 1 2 2 3 3 0,5 0,5 0,3 0,5 0,5 0,5 0,3 0,3 0,2 0,3 0,3 0,5 0,5 3 0,8 1 1 2 1 1 0,3 0,3 0,5 0,3 0,3 1 0,3 Male Number % Total Female Number % Number % 4 1 1 1,1 0,3 0,3 4 4 4 2 4 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 0,4 0,4 0,4 0,2 0,4 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,3 0,2 0,2 0,2 0,2

76

Table 5.59 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Turkey Main Cause of Death Male Number % Female Number % Total Number %

Bacterial food borne intoxication, unspecified Acute poliomyelitis, unspecified Acute hepatitis B without delta-agent and without hepatic coma Other and unspecified infectious diseases Gum malignant neoplasm, unspecified Nasopharynx malignant neoplasm, unspecified Sigmoid colon malignant neoplasm, unspecified Malignant neoplasm of recto sigmoid junction Vertebral column malign neoplasm Connective and soft tissue malignant neoplasm, unspecified Cervix uteri malignant neoplasm, unspecified Female genital organ malignant neoplasm, unspecified Malignant neoplasm of testis, unspecified Malignant neoplasm of kidney, except renal pelvis Thorax malignant neoplasm Hodgkins Disease, unspecified Multiple myeloma Chronic lymphocytes leukemia Acute leukemia of unspecified cell type Vertebral column, benign neoplasm Liver, gall bladder and bile ducts neoplasm of uncertain or unknown behavior Thalassaemia, unspecified Aplastic anemia, unspecified Agranulocytosis Thyrotoxicosis, unspecified Insulin-dependent diabetes mellitus Diabetes mellitus with periphery complication Unspecified protein-energy malnutrition Obesity Pure hypercholesterolemia Dependence syndrome, alcohol Unspecified nonorganic psychosis Reaction to severe stress, unspecified Encephalitis, myelitis and encephalomyelitis, unspecified Other specified degenerative diseases of nervous system Multiple sclerosis Cerebral palsy of infant, unspecified Hemiplegia, unspecified Tetraplegia, unspecified Paralytic syndrome, unspecified Rheumatic heart disease, unspecified

1 1 1 1 1 1 1 1 1 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 0,2 0,2 1 0,2 1 0,2 0,2 0,3 0,2 0,2 1 0,2 1 0,2 1 0,2 0,2 0,2 0,2 1 0,2 0,2 1 0,2 1 1 1 1 1 0,2 0,2

0,3

0,3 0,3 0,3

0,3 0,3

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,2 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1

0,3 0,3 0,3

0,3

0,3 0,3 0,3 0,3

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Table 5.59 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Turkey Main Cause of Death Male Number % Female Number % Total Number %

Hypertension secondary to endocrine disorders Pulmonary embolism with mention of acute cor pulmonale Disease of pericardium, unspecified Aortic valve stenosis Cardiac arrhythmia, unspecified Heart disease, unspecified Intracerebral hemorrhage, unspecified Hypertensive encephalopathy Embolism and thrombosis of unspecified artery Budd-Chiari syndrome Unspecified pneumoconiosis Pulmonary edema Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation Peptic ulcer, unspecified as acute or chronic, with perforation Acute vascular disorders of intestine Other and unspecified intestinal obstruction Hepatic failure, unspecified Chronic hepatitis, unspecified Calculus of gallbladder without cholecystitis Cholangitis Disease of digestive system, unspecified Rheumatoid arthritis, unspecified Gout, unspecified Wegener's granulomatosis Disorder of muscle, unspecified Osteoporosis, unspecified Acute tubulo-interstitial nephritis Other chronic renal failure Disorder of kidney and urethra, unspecified Hyperplasia of prostate Unspecified lump in breast Eclampsia, unspecified as to time period Congenital malformation of aortic and mitral valves, unspecified Congenital malformation of peripheral vascular system, unspecified Respiratory arrest Lack of expected normal physiological development, unspecified Fracture of neck, part unspecified Fracture of foot, unspecified

1 1 1 1 1 1 1 1 1 0,2 0,2 0,2 0,2 0,2 0,2 1 0,2 1 0,2 1 1 1 1 0,2 0,2 0,2 1 1 1 1 1 1 1 1 0,2 0,2 1 0,2 1 0,2 0,2 0,2 1 1 1 1 1 1 0,2 1 0,2 0,2 1 0,2 1 1 1 1 0,2 0,2 1

0,3

0,3 0,3 0,3

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1

0,3 0,3

0,3 0,3

0,3 0,3 0,3

0,3 0,3 0,3

0,3

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Table 5.59 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Turkey Main Cause of Death Male Number % Female Number % Total Number %

Unspecified frostbite of unspecified site Heroin poisoning Heatstroke and sunstroke Drowning Other complications of cardiac and vascular prosthetic devices, implants, graft Unspecified adverse effect of drug or medicament Fall from, out of through building or structure Contact with knife, sword or dagger Accidental poisoning, unspecified area Assault by unspecified means Reduced mobility Total Missing value 26 (%2,7)

1 1 1 1 1 1 1 1 1 1 579

0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 100,0 1 376 0,3 100,0

1 1 1 1 1 1 1 1 1 1 1 955

0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 0,1 100,0

Table 5.60 Distribution of the Top 10 Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Turkey Main Cause of Death Essential (primary) hypertension Acute myocardial infarction, unspecified Bronchus and lung malignant neoplasm, unspecified Cardiovascular disease, unspecified Chronic Obstructive Pulmonary Disease, unspecified Diabetes mellitus, unspecified Heart failure, unspecified Car occupant (any) injured in unspecified traffic accident Atherosclerotic heart disease Alzheimers Disease, unspecified Chronic Ischemic Heart Disease, unspecified Gastric malignant neoplasm, unspecified Male Number 55 62 49 36 36 19 12 21 18 7 17 8 Total Female % Number % Number % 9,5 64 17,0 119 12,5 10,7 30 8,0 92 9,6 8,5 7 1,9 56 5,9 6,2 18 4,8 54 5,7 6,2 9 2,4 45 4,7 3,3 19 5,1 38 4,0 2,1 15 4,0 27 2,8 3,6 6 1,6 27 2,8 3,3 4 1,1 22 2,3 1,2 15 4,0 22 2,3 2,9 4 1,1 21 2,2 1,4 10 2,7 18 1,9

According to verbal autopsy results, overall in Turkey, hypertension comes in the first place in causes of death among adults, at 12,5 %. Acute myocardial infarction comes second (9.6%), and lung CA takes third place (5,9%). In females, hypertension is first among causes of death, at 17,0%. This is followed by acute myocardial infarction at 8,0% and diabetes mellitus at 5,1%. In males, MI is the most important cause, at 10,7%. Next come hypertension (9,5%), lung CA (8,5%), and cardiovascular disease (6,2%) (Table 5.60).

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Table 5.61 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Urban Region
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Urban Main Cause of Death Essential (primary) hypertension Acute myocardial infarction, unspecified Bronchus and lung malignant neoplasm, unspecified Cardiovascular disease, unspecified Chronic Obstructive Pulmonary Disease, unspecified Diabetes mellitus, unspecified Car occupant (any) injured in unspecified traffic accident Gastric malignant neoplasm, unspecified Heart failure, unspecified Chronic Ischemic Heart Disease, unspecified General and unspecified atherosclerosis Senility Atherosclerotic heart disease Alzheimers Disease, unspecified Congestive heart failure Cerebrovascular disease, unspecified Brain neoplasm, uncertain or unknown behavior Asthma, unspecified Other and unspecified cirrhosis of liver Liver malignant neoplasm, unspecified Stroke, not specified as hemorrhage or infarction Pneumonia, unspecified Chronic renal failure, unspecified Colon malignant neoplasm, unspecified Pancreas malignant neoplasm, unspecified Unspecified chronic bronchitis Septicemia, unspecified Occlusion and stenosis of unspecified cerebral artery Malignant neoplasm of gallbladder Breast malignant neoplasm, unspecified Leukemia, unspecified Non-insulin-dependent diabetes mellitus Parkinsons disease Fracture of neck of femur Pulmonary Tuberculosis, confirmed by unspecified means Injuries, unspecified Intentional self harm by unspecified means Intentional self harm by other and unspecified firearm discharge Pulmonary Tuberculosis, without mention of bacteriological or histological confirmation Malignant neoplasm of rectum Colon, malignant neoplasm Larynx malignant neoplasm, unspecified Malignant neoplasm of prostate Bladder malignant neoplasm, unspecified 2 1 2 3 1 2 2 1 2 1 2 2 2 2 0,6 0,3 0,6 0,9 0,3 0,6 0,6 0,3 0,6 0,3 0,6 0,6 0,6 0,6 1 0,5 1 0,5 Male Number % 36 35 32 22 18 11 14 5 8 13 5 3 7 5 6 5 5 1 4 4 1 4 4 4 3 2 10,4 10,1 9,3 6,4 5,2 3,2 4,1 1,4 2,3 3,8 1,4 0,9 2,0 1,4 1,7 1,4 1,4 0,3 1,2 1,2 0,3 1,2 1,2 1,2 0,9 0,6 6 7 2 4 2 3 2 6 3 2 5 2 2 1 2 3 4 4 3 3 1 2 1 3,1 3,7 1,0 2,1 1,0 1,6 1,0 3,1 1,6 1,0 2,6 1,0 1,0 0,5 1,0 1,6 2,1 2,1 1,6 1,6 0,5 1,0 0,5 Female Number % 30 14 5 10 6 11 3 8 5 15,7 7,3 2,6 5,2 3,1 5,8 1,6 4,2 2,6 Total Number % 66 49 37 32 24 22 17 13 13 13 11 10 9 9 8 8 7 7 7 6 6 6 6 5 5 5 4 4 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 12,3 9,1 6,9 6,0 4,5 4,1 3,2 2,4 2,4 2,4 2,1 1,9 1,7 1,7 1,5 1,5 1,3 1,3 1,3 1,1 1,1 1,1 1,1 0,9 0,9 0,9 0,7 0,7 0,6 0,6 0,6 0,6 0,6 0,6 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4

0,5

80

Table 5.61 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Urban Region (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Urban Main Cause of Death Total % Male Female Number % Number % Number

Other specified sites, neoplasm uncertain or unknown behavior Diabetes mellitus with renal complications Epilepsy, unspecified Abdominal aortic aneurysm, without mension of rupture Emphysema, unspecified Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation Discharge from other and unspecified firearms Intentional self harm by hanging, strangulation and suffocation Alcoholic cirrhosis of liver Bacterial food borne intoxication, unspecified Acute poliomyelitis, unspecified Acute hepatitis B without delta-agent and without hepatic coma Nasopharynx malignant neoplasm, unspecified Esophagus malign neoplasm, unspecified Sigmoid colon malignant neoplasm, unspecified Malignant neoplasm of recto sigmoid junction Malignant neoplasm of skin, unspecified Connective and soft tissue malignant neoplasm, unspecified Cervix uteri malignant neoplasm, unspecified Malignant neoplasm of uterus Malignant neoplasm of testis, unspecified Malignant neoplasm of kidney, except renal pelvis Non-Hodgkins lymphoma, unspecified type Multiple myeloma Vertebral column, benign neoplasm Liver, gall bladder and bile ducts neoplasm of uncertain or unknown behavior Bone and particular cartilage, neoplasm uncertain or unknown behavior Thalassaemia, unspecified Aplastic anemia, unspecified Agranulocytosis Diabetes mellitus with ketoacidosis Unspecified protein-energy malnutrition Unspecified dementia Reaction to severe stress, unspecified Unspecified mental retardation Meningitis, unspecified Encephalitis, mellitus and encephalomyelitis, unspecified Multiple sclerosis Hemiplegia, unspecified Paralytic syndrome, unspecified

1 2 1 2 2 2 2 2 1 1 1 1 1 1 1

0,3 0,6 0,3 0,6 0,6 0,6 0,6 0,6

2 1 1

1,0 0,5 0,5

2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2

1 0,3 0,3 0,3 0,3 0,3 0,3 0,3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0,3 0,3 0,3 1 0,3 0,3 0,3 0,3 1 0,3 0,3 0,3 0,3 0,3 0,3 0,0 0,3 0,3 0,3

0,5

0,5 0,5 0,5

0,5

0,5

0,5

0,5

81

Table 5.61 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Urban Region (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Total Male Female Main Cause of Death Number % Number % Number % Rheumatic heart disease, unspecified 1 0,3 1 0,2 Aortic valve stenosis 1 0,3 1 0,2 Cardiac valvular disease, unspecified 1 0,5 1 0,2 Cardiomegaly 1 0,3 1 0,2 Heart disease, unspecified 1 0,3 1 0,2 Cerebral atherosclerosis 1 0,3 1 0,2 Hypertensive encephalopathy 1 0,5 1 0,2 Tromboanjitis obliterans [Buerger] 1 0,3 1 0,2 Embolism and thrombosis of unspecified artery 1 0,3 1 0,2 Budd-Chiari syndrome 1 0,5 1 0,2 Acute vascular disorders of intestine 1 0,3 1 0,2 Other and unspecified intestinal obstruction 1 0,5 1 0,2 Hepatic failure, unspecified 1 0,5 1 0,2 Chronic hepatitis, unspecified 1 0,3 1 0,2 Calculus of gallbladder without cholecystitis 1 0,3 1 0,2 Cholangitis 1 0,5 1 0,2 Gastrointestinal haemorrage, unspecified 1 0,3 1 0,2 Disease of digestive system, unspecified 1 0,3 1 0,2 Rheumatoid arthritis, unspecified 1 0,5 1 0,2 Gout, unspecified 1 0,3 1 0,2 Wegener's granulomatosis 1 0,3 1 0,2 Disorder of muscle, unspecified 1 0,3 1 0,2 Osteoporosis, unspecified 1 0,5 1 0,2 Acute tubulo-interstitial nephritis 1 0,5 1 0,2 Acute renal failure, unspecified 1 0,3 1 0,2 Other chronic renal failure 1 0,3 1 0,2 Hyperplasia of prostate 1 0,3 1 0,2 Congenital malformation of peripheralvaskular system, unspec. 1 0,5 1 0,2 Respiratory arrest 1 0,5 1 0,2 Unspecified injury of head 1 0,5 1 0,2 Fracture of neck, part unspecified 1 0,3 1 0,2 Fracture of foot, unspecified 1 0,5 1 0,2 Heroin poisoning 1 0,3 1 0,2 Fall from, out of through building or structure 1 0,3 1 0,2 Other fall from one level to another, unspecified 1 0,3 1 0,2 Unspecified fall 1 0,3 1 0,2 Contact with knife, sword or dagger 1 0,3 1 0,2 Accidental poisoning by and exposure to other gases and vapours 1 0,3 1 0,2 Assault by unspecified means 1 0,3 1 0,2 Reduced mobility 1 0,5 1 0,2 Total 345 100,0 191 100,0 536 100,0 Missing value 17 (%3,1) Urban

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Table 5.62 Distribution of the Top 10 Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Urban Region
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Urban Main Cause of Death Essential (primary) hypertension Acute myocardial infarction, unspecified Trachea, bronchus and lung CA Cardiovascular disease, unspecified Chronic Obstructive Pulmonary Disease, unspecified Diabetes mellitus, unspecified Car occupant (any) injured in unspecified traffic accident Stomach,malign neoplasm, unspecified Heart failure, unspecified Chronic ischemic heart disease, unspecified Generalized and unspecified atherosclerosis Senility Total Male Female Number % Number % Number % 36 10,4 30 15,7 66 12,3 35 10,1 14 7,3 49 9,1 32 9,3 5 2,6 37 6,9 22 6,4 10 5,2 32 6,0 18 5,2 6 3,1 24 4,5 11 3,2 11 5,8 22 4,1 14 4,1 3 1,6 17 3,2 5 1,4 8 4,2 13 2,4 8 2,3 5 2,6 13 2,4 13 3,8 13 2,4 5 1,4 6 3,1 11 2,1 3 0,9 7 3,7 10 1,9

Based on the verbal autopsy, the most common cause of death among over 5 year old male and females in urban area is hypertension with 12,3% and then MI with 9,1% and lung CA with 6,9%. The most common cause of death among females in urban areas was hypertension (15,7 %). The others major causes are MI (7,3 %) and diabetes mellitus (5,8 %). Other deaths in females are cardiovascular diseases with 5,2%, stomach CA with 4,2% and chronic obstructive pulmonary disease and unspecified atherosclerosis, with 3,1% each. The most common cause of death among urban males was hypertension (10,4 %). Then, MI with 10,1% and malignant tumor of lung, bronchus trachea with 9,3% (Table 5.62). According to Turkish SIS mortality statistics for 1999 (39), the most common cause of death among males is other hearth diseases with 28,2% and ischemic heart disease with 7,0% and other respiratory diseases with 6,9%. Also based on SIS data 1999 (39), the two most common causes of death among females in the over-5 age group of were other heart diseases (25,3 %) and cerebrovascular disease (7,0 %). In Table 5.63, causes of adult male and female deaths in rural areas are provided based on verbal autopsy methods and in Table 5.64, the first 10 cause of death were given.

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Table 5.63 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Rural Region
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Rural Main Cause of Death Male Number % Female Number % Total Number %

Essential (primary) hypertension Acute myocardial infarction, unspecified Cardiovascular disease, unspecified Chronic Obstructive Pulmonary Disease, unspecified Bronchus and lung malignant neoplasm, unspecified Diabetes mellitus, unspecified Heart failure, unspecified Alzheimers Disease, unspecified Atherosclerotic heart disease Car occupant (any) injured in unspecified traffic accident Brain neoplasm, uncertain or unknown behavior Chronic renal failure, unspecified Chronic Ischemic Heart Disease, unspecified Stroke, not specified as hemorrhage or infarction Senility Cerebrovascular disease, unspecified Liver malign neoplasm, unspecified Unspecified chronic bronchitis Leukemia, unspecified Gastric malignant neoplasm, unspecified Effects of electric current Other and unspecified cirrhosis of liver Colon malignant neoplasm, unspecified Prostate malignant neoplasm Occlusion and stenosis of unspecified cerebral artery Discharge from other and unspecified firearms Gastrointestinal hemorrhage, unspecified General and unspecified atherosclerosis Breast malignant neoplasm, unspecified Pneumonia, unspecified Pulmonary Tuberculosis, confirmed by unspecified means Acute renal failure, unspecified Anemia, unspecified Brain Malignant Neoplasm, unspecified Asphyxia Unspecified dementia Diabetes mellitus with ketoacidosis

19 27 14 18 17 8 4 2 11 7 5 6 4 4 3 3 3 2 2 3 3 2 3 4 3 3 2 1 1 1 2 1 2 1 1

8,1 11,5 6,0 7,7 7,3 3,4 1,7 0,9 4,7 3,0 2,1 2,6 1,7 1,7 1,3 1,3 1,3 0,9 0,9 1,3 1,3 0,9 1,3 1,7 1,3 1,3 0,9 0,4 0,4 0,4 0,9 0,4 0,9 0,4 0,4

34 16 8 3 2 8 10 11 2 3 4 3 4 4 4 3 2 3 3 2 1 2 1

18,4 8,6 4,3

53 43 22 21

12,6 10,3 5,3 5,0 4,5 3,8 3,3 3,1 3,1 2,4 2,1 2,1 1,9 1,9 1,7 1,4 1,2 1,2 1,2 1,2 1,0 1,0 1,0 1,0 1,0 0,7 0,7 0,7 0,7 0,7 0,5 0,5 0,5 0,5 0,5 0,5 0,5

1,1 4,3 0,0 5,9 1,1 1,6 2,2 1,6 2,2 2,2 2,2 1,3 1,1 0,5 1,6 1,1 0,5 1,1 0,5

19 16 14 13 13 10 9 9 8 8 7 6 5 5 5 5 4 4 4 4 4 3 3 3 3 3 2 2 2 2 2 2 2

1 1 2 3 2 1 2 1 1 1

1,1 0,0 0,5 0,0 1,6 1,6 0,5 1,1 0,5 0,5 0,5

84

Table 5.63 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Rural Region (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Rural Main Cause of Death Male Number % Female Number % Total Number %

Endometrial malignant neoplasm Malignant neoplasm without specification of site Unspecified injury of head Larynx malignant neoplasm, unspecified Parkinsons disease Septicemia, unspecified Exposure to unspecified factor Burn of unspecified body region, unspecified degree Non-insulin-dependent diabetes mellitus Pulmonary embolism with acute pulmonalea Pulmonary Tuberculosis, without mention of bacteriological or histological confirmation Pulmonary Edema Acute leukemia of unspecified cell type Congenital malformation of aortic and mitral valves, unspecified Intentional self harm by hanging strangulation and suffocation Asthma, unspecified Colon, malignant neoplasm Dependence syndrome, alcohol Lack of expected normal physiological development, unspecified Cerebral atherosclerosis Other fall from one level to another, unspecified Disorder of kidney and urethra, unspecified Malignant neoplasm of skin, unspecified Diabetes mellitus with periphery complication Gum malignant neoplasm, unspecified Corpus uteri, unspecified Unspecified fall Eclampsia, unspecified as to time period Other and unspecified infectious diseases Epilepsy, unspecified Thorax malignant neoplasm Non-Hodgkins lymphoma, unspecified type Hodgkins Disease, unspecified Female genital organ malignant neoplasm, unspecified Cardiac arrhythmia, unspecified Endocarditic, valve unspecified Other complications of cardiac and vascular prosthetic devices, implants, graft

2 1 1 2 1 2 1 1 1 1 1 1 0,4 0,4 0,9 0,4 0,9 0,4 0,4 0,4 1 0,4 0,4 0,4 1 1 1 1 0,4 0,4 1 1 1 1 1 1 0,4 1 1 1 1 1 0,4 0,4 1 1 1 0,4 1 1 0,4 1 1 0,4 1 2 1 1

1,1 0,5 1,1 0,5 0,5 0,0 0,5 1,1

2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,5 0,2 0,2 0,2 0,2 0,2 0,2 0,0 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2

1 2

0,5

0,0 0,5

1,1 0,5 0,5 0,5 0,5 0,5 0,5 0,5

0,5 0,5

0,5 0,5

85

Table 5.63 Distribution of Main Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Rural Region (Continued)
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Sex Rural Main Cause of Death Male Number % Female Number % Total Number %

Alcoholic cirrhosis of liver Cardiomegaly Bone and articular cartilage, neoplasm uncertain or unknown behavior Chronic lymphocytes leukemia Unspecified lump in breast Meningitis, unspecified Gastric ulcer, unspecified as acute or chronic, without hemorrhage or Unspecified or undefined vertebral column neoplasm Vertebral column malign neoplasm Peptic ulcer, unspecified as acute or chronic, without hemorrhage or perforation Disease of pericardium, unspecified Unspecified pneumoconiosis Pure hypercholesterolemia Malignant neoplasm of gallbladder Other specified degenerative diseases of nervous system Drowning in Water Cerebral palsy Heatstroke and sunstroke Unspecified frostbite of unspecified site Unspecified no organic psychosis Intentional self harm by unspecified means Unspecified mental retardation Other specified sites, neoplasm uncertain or unknown behavior Tetraplegia, unspecified Thyrotoxicosis, unspecified Trombonists obliterans [Buerger] Injury, unspecified Esophagus malign neoplasm, unspecified Hypertension secondary to endocrine disorders Unspecified adverse effect of drug or medicament Insulin-dependent diabetes mellitus Intracerebral hemorrhage, unspecified Obesity Total

1 1

0,4 0,4 1 0,5

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 419

0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 100,0

1 1

0,4 0,4 1 0,5

1 1 1 1 1 1 1

0,4 0,4 0,4 0,4 0,4 0,4 0,4 1 1 0,5 0,5 0,5

1 1 1

0,4 1 0,4 0,4 1 1 1 0,5 0,5 0,5

0,4 1 1 0,5 0,5

1 1

0,4 0,4 1 1 0,5 0,5

1 1 1 1 234

0,4 0,4 0,4 0,4 100,0

185

100,0

86

Table 5.64 Distribution of the Top 10 Causes of Death in the Over-5 Age Group, by Sex and Physician Diagnosis: Turkey, Rural Region
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) Sex Male Main Cause of Death Number % Essential (primary) hypertension 19 8,1 Acute myocardial infarction, unspecified 27 11,5 Cardiovascular disease, unspecified 14 6,0 Chronic Obstructive Pulmonary Disease, unspecified 18 7,7 Bronchus and lung malignant neoplasm, unspecified 17 7,3 Diabetes mellitus, unspecified 8 3,4 Heart failure, unspecified 4 1,7 Alzheimers Disease, unspecified 2 0,9 Atherosclerotic heart disease 11 4,7 Car occupant (any) injured in unspecified traffic accident 7 3,0 Brain neoplasm, uncertain or unknown behavior 5 2,1 Chronic renal failure, unspecified 6 2,6 Rural Female Number % 34 18,4 16 8,6 8 4,3 3 2 1,1 8 4,3 10 0,0 11 5,9 2 1,1 3 1,6 4 2,2 3 1,6 Total Number % 53 12,6 43 10,3 22 5,3 21 5,0 19 4,5 16 3,8 14 3,3 13 3,1 13 3,1 10 2,4 9 2,1 9 2,1

According to the verbal autopsy results, in rural areas of Turkey, hypertension takes first rank in the 5+ age group with 12,6%. Then comes MI with 10,3% and cardiovascular diseases with 5,3%. The most common cause of death in adult females was hypertension (18,4 %). The second most common cause of death was MI with 8,6 % followed by Alzheimer with 5,9 %. For adult males in rural areas, the most common cause of death was MI (11,5 %). The second cause was hypertension (8,1%), followed by chronic obstructive pulmonary disease with 7,7% and bronchus, trachea and lung malignant neoplasm (7,3%). Diabetes Mellitus with 3,4% and traffic accidents with 3,0% are other cause of deaths in male adults (Table 5.64). Based on 2000 SIS mortality statistics (40) for females aged 5 and older, other heart diseases were ranked first (27,5 %) and among males this was 23,6 %. For those 5 and older cerebrovascular diseases were 8.9 % of deaths for females and 6.9 % among male deaths.

5.3 Validity of the Verbal Autopsys Application

A total of 327 deaths in hospitals were obtained. The validity test of verbal autopsy for the full household survey sample compared to hospital records as done for the pretest. Of the 327 hospital deaths, a total of 255 hospital records were obtained. Of these, 15 were 0-28 day infants, 15 were 29 day- 5 year old children, and 225 were adults.

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5.3.1 Deaths Among Infants Aged 0-28 Days

35 infant deaths (0-28 days) were assessed in urban and rural area. 57,1 % (20) of these infant deaths occurred in hospitals. We were able to review 15 of these 20 deaths. (5 hospital records could not be reviewed. The comparison of physicians diagnoses based on verbal autopsy to hospital records is shown below in Table 5.65.

Table 5.65 Comparison of Causes of Death Diagnosed by Physicians in Verbal Autopsy Survey and Hospital Records, for Deaths Among Infants Aged 0-28 Days
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Main Cause of Death According to Hospital Records Physician Diagnosis ARDS Asphyxia Birth trauma DIC Fetal Distosi Congenital Hearth ease Neonatal Sepsis Pneumonia Pneumothorax Prematurity TOTAL 1 3 2 1 1 1 1 1 1 1 1 1 2 2 1 1 2 15 1 1 2 Dis3 1 1 1 1 1 1 Meningitis ARDS Asphyxia Brain Hem. DIC Fetal Distosi Congenital Hearth Disease 3 1 2 1 1 1 Neonatal sepsis Pneumonia Pneumothorax Prematurity TOTAL

As seen in Table 5.65, for 12 out of 15 deaths, the diagnosis of physicians made based on verbal autopsy matches the diagnosis based on hospital records. One of the non-matching deaths was with a verbal autopsy diagnosis of neonatal sepsis compared to a diagnosis of meningitis in the hospital record. The other mismatching deaths are brain hemorrhage by hospital record and birth trauma with a verbal autopsy and asphyxia by hospital record and birth trauma with a verbal autopsy. We considered a sample size of ten cases would be sufficient in order to test the validity of verbal autopsy study.

Sensitivity and specificity analysis was not possible for every disease because of the small numbers. The reason for the high validity may be due, in part, to imposing strict criteria developed by SEARCH during preparation phase of the field study, and provided to physicians as detailed lists in the interviewers manual as we described in the methods section of this report. In addition, one of the

88

basic assumptions of the verbal autopsy methods is diseases can be distinguished from each other when they have definitive symptoms and findings. In other studies, the reliability of verbal autopsy was very high for causes like measles, pneumonia, prematurity, and diarrhea. However, sensitivity and specificity values of diseases like malaria, meningitis, and tuberculosis have been found to be lower. In our study, similar to the literature, meningitis, brain hemorrhage and one of the asphyxia diagnoses were the only disease that was not accurately diagnosed with verbal autopsy. For diseases with similar symptoms and findings, future research needs to concentrate on specific studies with sufficient sample sizes.

5.3.2 Deaths Among Children Aged 29 Days - 5 Years

There were 68 children deaths. Among these, 18 (26,5 %) occurred in hospitals. We completed records on 15 of these 18 cases (83,3%). The comparison of verbal autopsy diagnosis and hospital records is provided in Table 5.66 below.

Table 5.66 Comparison of Causes of Death Diagnosed by Physicians in Verbal Autopsy Survey and Hospital Records for Deaths Among Children Aged 29 Days- 5 Years
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Main Cause of Death According to Hospital Records Physician Diagnosis Measles Congenital Hearth Disease Lower Respiratory Tract Infection Congenital Anomaly Meningitis Pneumonia Sepsis Intracranial Hemorrhage TOTAL Intracranial Hem Sepsis Immune. Hem Measles Congenital Hearth Disease Meningitis Pneumonia Congenital Anomaly TOTAL

1 2

1 2

1 1 4 4 1 1 4 1 1 2 1 4 1

1 1 4 4 1 15

89

In this age group, only one verbal autopsy did not match with the hospital-based assessment. In this case, the verbal autopsy identified lower respiratory infection and the hospital record showed this as immune system related diseases. For the reason that the other death causes are different than each other with unlike symptoms and findings and also match with hospital records , it can be said that the validity of VA is high.

5.3.3 Deaths Among the Above 5 Years Age Group

There were 981 deaths among adults and 289 occurred in the hospital (29.4 %). We completed 225 (77.9 %) of these cases during the validity comparison with hospital records. Since the ICD-10 system does not lend itself to validity analyses, we conducted the comparison using the same groupings as used in pretest analysis. Distribution of Grouped Main Causes of Deaths According to Physician Diagnosis and Hospital Records from Verbal Autopsy was presented in Table 5.67. Among above 5 years age deaths occurred at hospital, validity analysis for the first 10 main causes of deaths and the deaths which the numbers of cases are suitable for validity analysis were given in Tables 5.685.76.

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Table 5.67 Distribution of Grouped Main Causes of Death in the Over-5 Age Group According to Physician Diagnoses in Verbal Autopsy Survey and Hospital Records
(NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
Main Death Cause According to Physician ISCHEMIC HEART DISEASE HYPERTENSION ALL CANCERS MYOCARDIAL INFARCTION LUNG CANCER CHRONIC OBSTRUCTIVE PULMONARY DISEASE DIABETES MELLITUS CEREBROVASCULAR EVENTS CHRONIC RENAL FAILURE CIRRHOSIS TRAFFIC ACCIDENTS TRAUMA GIS BLEEDING SEPSIS PNEUMONIA HOMICIDE SUICIDE TUBERCULOSIS PULMONARY EMBOLISM ALCOHOLIC CIRRHOSIS ALZHEIMER ANEMIA FOOD BORNE INTOXICATION BUDCHIARI ECLAMPSIA EPILEPSY HEROIN HEARTH FAILURE CHOLECYSTIT LYMPHOMA LEUKEMIA MENINGITIS WEGENER DEBILITY SPASTIC PARALYSIS Main Death Cause According to Hospital Records

Number % 33 31 27 23 17 17 14 13 6 6 4 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Number % 34 30 25 21 20 17 12 9 7 6 4 4 3 3 3 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 225 15,1 13,3 11,1 9,3 8,9 7,6 5,3 4,0 3,1 2,7 1,8 1,8 1,3 1,3 1,3 0,9 0,9 0,9 0,9 0,9 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 100,0

14,7 ISCHEMIC HEART DISEASE 13,8 HYPERTENSION 12,0 ALL CANCERS 10,2 MYOCARDIAL INFARCTION 7,6 LUNG CANCER 7,6 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 6,2 CEREBROVASCULAR EVENTS 5,8 DIABETES MELLITUS 2,7 CHRONIC RENAL FAILURE 2,7 CRRHOSIS 1,8 TRAFFIC ACCIDENTS 1,3 SEPSIS 1,3 GIS BLEEDING 1,3 PNEUMONIA 0,9 HEART FAILURE 0,9 TRAUMA 0,9 SUICIDE 0,9 CHOLECYSTIT 0,4 MENINGITIS 0,4 CARDIAC VALVULAR DISEASE 0,4 PULMONARY EMBOLISM 0,4 HOMICIDE 0,4 TUBERCULOSIS 0,4 LUNG EDEMA 0,4 LOWER RESPIRATORY TRACT INF 0,4 ANEMIA 0,4 FOOD BORNE INTOXICATION 0,4 BUDCHIARI 0,4 ECLAMPSIA 0,4 EPILEPSY 0,4 HEROIN 0,4 LYMPHOMA 0,4 LEUKEMIA 0,4 WEGENER 0,4 SCHIZOPHRENIA CHRONIC HEARTH DISEASE SPASTIC PARALYSIS

Total

225

100,0 Total

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Table 5.68 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (All Cancers) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
In terms of Physician Diagnosis Cancer Other Diagnosis TOTAL In terms of Hospital Records Cancer Other Diagnosis 23 4 2 196 25 200 TOTAL 27 198 225

Sensitivity is determined as 92,0 % and the specificity is determined as 98,0 % for verbal autopsy method for cancer.

Table 5.69 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Lung CA) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
In terms of Physician Diagno- In terms of Hospital Records sis Lung Cancer Other Diagnosis 15 2 Lung Cancer 5 203 Other Diagnosis TOTAL 20 205 TOTAL 17 208 225

When the physician diagnosis for lung cancer by reference test hospital records were examined, it is identified that the sensitivity is 75,0 % and that of specificity is 99,0 % (Table 5.69).

Table 5.70 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Ischemic Heart Disease) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
In terms of Physician DiagnoIn terms of Hospital Records sis Ischemic Heart Disease Other Diagnosis 28 5 Ischemic Heart Disease 6 186 Other Diagnosis TOTAL 34 191 TOTAL 33 192 225

According to the verbal autopsy survey administered as the screening test for ischemic heart disease, sensitivity of physician diagnosis is identified as 82,4 % and specificity is given as 97,4 %. While evaluating cerebrovascular event which is another main disease group;

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Table 5.71 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Cerebrovascular Events-CVE) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003) In terms of Physician Diagnosis CVE Other Diagnosis TOTAL In terms of Hospital Records CVE Other Diagnosis 11 2 1 211 12 213 TOTAL 13 212 225

For CVE, sensitivity of physician diagnosis is 91.7 % whereas specificity is 99,1 %.

According to hypertension diagnosis evaluations:

Table 5.72 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Hypertension) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
In terms of Physician DiagnoIn terms of Hospital Records sis Hypertension Other Diagnosis 29 2 Hypertension 1 193 Other Diagnosis TOTAL 30 195 TOTAL 31 194 225

Sensitivity of physician diagnosis for hypertension is assessed as 96,7% and the specificity of hypertension diagnosis is identified as 99,0 %.

Table 5.73 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Diabetes Mellitus) (NBD-CE Study Verbal Autopsy Survey, Turkey, 2003)
In terms of Physician DiagnoIn terms of Hospital Records sis Diabetes Other Diagnosis Mellitus 9 5 Diabetes Mellitus 211 Other Diagnosis TOTAL 9 216 TOTAL 14 211 225

Diabetes mellitus diagnoses based on verbal autopsy resulted in 100,0 % sensitivity and a specificity of 97,7 %. Among cause of death of over 5 years age adults, sensitivity and specificity values of chronic renal failure are presented in Table 5.74.

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Table 5.74 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Chronic Renal Failure-CRF) (NBD-CE Study Verbal Autopsy Survey, Turkey,
2003) In terms of Physician Diagnosis CRF Other Diagnosis TOTAL In terms of Hospital Records CRF Other Diagnosis 5 1 2 217 7 218 TOTAL 6 219 225

For CRF, sensitivity is 71.4 % and specificity is 99.5 %. Finally, for the comparison of chronic obstructive pulmonary disease (COPD) below, sensitivity is 100 %, and specificity is 100,0 %.

Table 5.75 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Chronic Obstructive Pulmonary Disease-COPD) (NBD-CE Study Verbal
Autopsy Survey, Turkey, 2003) In terms of Physician DiagnoIn terms of Hospital Records sis COPD Other Diagnosis COPD Other Diagnosis TOTAL 17 17 208 208 TOTAL 17 208 225

Table 5.76 Assessment of Physician Diagnosis Pursuant to Verbal Autopsy Survey by Hospital Records (Myocardial Infarction-MI) (NBD-CE Study Verbal Autopsy Survey, Turkey,
2003) In terms of Physician DiagnoIn terms of Hospital Records sis MI Other Diagnosis MI Other Diagnosis TOTAL 20 1 21 3 201 204 TOTAL 23 202 225

For MI sensitivity is defined as % 95,2 and specificity is obtained as % 98,5 (Table 5.76). As shown above among adult deaths, sensitivity and specificity is quite high for diseases that are the cause of death and the numbers are available for reliability analysis by the comparison of hospital records and verbal autopsy results. These particular conditions are important contributors to overall adult mortality. These results also are similar to pretest results at August 2002.

94

CONCLUSION AND SUGGESTIONS

Knowing the mortality rates and causes of death in a community plays a major role in planning and providing both preventive and treatment services. Mortality plays a major role in the total burden of disease of a community as well. Decision-makers usually use information concerning mortality in order to plan the further activities. However, these records are usually insufficient in terms of informing decision-makers about details and providing reliable data. Therefore, decisions can be based on insufficient data. We need to gather complete, accurate and uniform data to calculate mortality rates and identify causes of death at the country level. Therefore, it is extremely important that deaths in each region are completely registered by the health facility personnel, and that record keeping is systematically supervised. In countries where mortality statistics are incomplete or unsuccessfully, one should collect information through other research means. Mortality data are extremely important in determining what costs are expended for improving the average lifetime or/and in preventing deaths for many developing countries. In cases where mortality data cannot be provided, verbal autopsy methods can be considered as an alternative to overcome these difficulties. As demonstrated in the National Burden of Disease calculations report, the usual death statistics in our country are far from representing accurate numbers. The State Institute of Statistics data are limited to provinces and districts: moreover, these data cannot sufficiently classify deaths by major causes, and 50 selected causes. For example, these data tend to collect most of the heart-related deaths under a category such as other forms of heart diseases. As a result of this, while actual heart diseases cannot be identified, causes of death unrelated to heart diseases are also considered under heart diseases. In this study, province and district centers death data are obtained. Correctness and reliability of collected data were not examined. The current regulations and procedures that determine the type, quality, and frequency of compiling the necessary required data, which are needed to achieve standardization and to increase quality, are not adequate. The 10th Chapter, Section I of article 1593 of the Social Health Code describes the rules of licenses for death burials as part of the 88th article of the directive concerning the Execution of Health Services. However, those do not contain any aspects to increase the quality and standardization of data synthesis, and only mention who should complete the licenses and one should take care of mortality statistics. What is needed is additional detail about providing details used in compiling mortality statistics. The care and sensitivity needed for mortality sta-

95

tistics are not clear. In these articles, there are clear details about the following: names of those who give the death license; the name, surname, age, identification, and address of the dead person; the place of death; the date of death; and the cause for death. However, it is stated that the last cause should be used instead of the major or intermediary causes. The current Death Statistics Form used in the evaluation of causes of death was developed and is being carried out in a manner that obscures compilation of accurate and useful cause of death data. Attention to death statistics is insufficient, and necessary actions for sensitive monitoring of these are not taken. In these items, the following should be clearly recorded: who issued the burial license, first and last name of the deceased, identification details, address of the deceased, place of death, date of death, and cause of death. However, instead of intermediate or general causes of death, final causes should be recorded. The standard form used for the evaluation of deaths, which is given in Appendix 5, shows these deficiencies. 1. In Turkey, the cause of death data collection system should be strengthened for comprehen-

siveness and standardization. More importance should be given to death statistics in health information system at ministry of health. 2. The sequence of rules for data collection should be clearly reported and a detailed regulation or procedure should be proposed involving relevant people. If possible, this should include strategic planning and system development based on devising computer assisted information systems. 3. ICD 10 coding system also is proposed, requiring revision of the death statistics form consistent with the one that is used in developed countries and we recommend that causes of death are rearranged in condition of comprising least, main and decided causes of death (International Death Causes Medical Certificate Form).

Another important aspect of improving the current data collection system is the human factor. All the personnel in the death and birth process, including physicians and also personals of The Ministry of Internal Affairs who fill out the form, should be exposed to in-service training for the importance of the records. Autonomous who have responsibility from the death and birth records and also from the import of records should be trained and stimulated. The educational programs for the importance of death and birth records should be given to health personals at undergraduate. Not only the Ministry of Internal Affairs but also the Ministry of Healths provincial and county level organizations should check the recorded deaths before submission to the central level and set up regulations for monitoring and investigation. Finally, the lack of feedback structure in current information systems results in a lack of motivation among personnel at various levels and prevents not only good communication but also full provision of services.

96

INTERNATIONAL DEATH CAUSES MEDICAL CERTIFICATE FORM

DEATH CAUSE Approximate interval Between onset and death ........................................ Disease or condition Directly cause death* (a)........................................... (Due to, or as a consequence of) ........................................ Antecedent causes (b)............................................ Morbid conditions, if any (Due to or as a consequence of) Giving rise to the above cause Stating the underlying condition last (c)............................................... (Due to, or as a consequence of) ........................................ (d).............................................. ........................................ Other significant conditions contributing to the death, but not, Related to the disease or condition causing it. ..................................... *These are not respiratory insufficiency nor heart failure; they refer To the complications that lead to disability, disease, or death. ........................................

.......................................

97

REFERENCES
123456Gray, R.; Smith, G. The use of verbal autopsy methods to determine selected Causes of death in children. Institute for International Programs Baltimore; Johns Hopkins University, Occasional paper No 10, 1990. Abu-Rashid N, Al-Jirf S, Bashour H. Causes of death among Syrian children using verbal autopsy. WHO International Publications 2 (3):440-8, 1996. http://www.ncl.ac.uk/ammp/techrep7.pdf Anonymous. Measurement of overall and cause-specific mortality in infants and children: memorandum from a WHO/UNICEF meeting. Bulletin of the World Health Organization. 72(5):707-13, 1994. Bang AT. Bang RA. Diagnosis of causes of childhood deaths in developing countries by verbal autopsy: suggested criteria. The SEARCH Team. Bulletin of the World Health Organization. 70(4):499-507, 1992. Benara SK. Singh P. Validity of causes of infant death by verbal autopsy. Indian Journal of Pediatrics. 66(5):647-50, 1999 Sep-Oct. Chandramohan D. Maude GH. Rodrigues LC. Hayes RJ. Verbal autopsies for adult deaths: their development and validation in a multicentre study. Tropical Medicine & International Health. 3(6):436-46, 1998 Jun. Chandramohan D. Maude GH. Rodrigues LC. Hayes RJ. Verbal autopsies for adult deaths: issues in their development and validation. [Review] International Journal of Epidemiology. 23(2):213-22, 1994 Apr. World Health Organization. Measurement of overall and cause-specific mortality in infants and children: memorandum from a WHO/UNICEF meeting. Chandramohan D, Maude GH, Rodrigues LC, Hayes R. (1994). Verbal autopsies for adult deaths: Issues in their development and validation. Snow RW, et al. (1992). Childhood deaths in Africa: Uses and limitations of verbal autopsies. Snow RW, et al. (1993). Maternal recall of symptoms associated with childhood deaths in rural East Africa Snow, B.; Marsh, K. How useful are verbal autopsies to estimate childhood causes of death? Health Policy Planning 1992; 7:22-29. Snow RW. Armstrong JR. Forster D. Winstanley MT. Marsh VM. Newton CR. Waruiru C. Mwangi I. Winstanley PA. Marsh K. Childhood deaths in Africa: uses and limitations of verbal autopsies. Lancet. 340(8815):351-5, 1992 Aug 8. Datta N. Mand M. Kumar V. Validation of causes of infant death in the community by verbal autopsy. Indian Journal of Pediatrics. 55(4):599-604, 1988 Jul-Aug. Ronsmans C. Vanneste AM. Chakraborty J. Van Ginneken J. A comparison of three verbal autopsy methods to ascertain levels and causes of maternal deaths in Matlab, Bangladesh. International Journal of Epidemiology. 27(4):660-6, 1998. Hoj L. Stensballe J. Aaby P. Maternal mortality in Guinea-Bissau: the use of verbal autopsy in a multi-ethnic population. International Journal of Epidemiology. 28(1):70-6, 1999 Feb. Kahn K. Tollman SM. Garenne M. Gear JS. Validation and application of verbal autopsies in a rural area of South Africa. Tropical Medicine & International Health. 5(11):824-31, 2000 Nov. Kalter, H.; Gray, R. Validation of postmortem interviewes to ascertain selected causes of death in children. Int. J. Epidemiol. 1990; 19:3806. Kumar V. Datta N. Lay reporting and verbal autopsy in assessment of infant mortality. Indian Journal of Pediatrics. 53(6):672-4, 1986 Nov-Dec. Mobley CC. Boerma JT. Titus S. Lohrke B. Shangula K. Black RE. Validation study of a verbal autopsy method for causes of childhood mortality in Namibia. Journal of Tropical Pediatrics. 42(6):365-9, 1996 Dec. Nykanen M. Tamaona W. Cullinan T. Van Oosterzee V. Ashorn P. Verbal autopsy as a technique to establish causes of infant and child mortality. East African Medical Journal. 72(11):731-4, 1995 Nov.

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89101112131415161718192021-

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Harari, M. et al. Clinical signs of pneumonia in children. Lancet 1991; 338:928-30. Mirza NM. Macharia WM. Wafula EM. Agwanda RO. Onyango FE. Verbal a utopsy: a tool for determining cause of death in a community. East African Medical Journal. 67(10):693-8, 1990 Oct. Quigley MA. Chandramohan D. Rodrigues LC. Diagnostic accuracy of physician review, expert algorithms and data-derived algorithms in adult verbal autopsies. International Journal of Epidemiology. 28(6):1081-7, 1999 Quigley MA. Armstrong Schellenberg JR. Snow RW. Algorithms for verbal autopsies: a validation study in Kenyan children. Bulletin of the World Health Organization. 74(2):147-54, 1996. Quigley MA. Chandramohan D. Setel P. Binka F. Rodrigues LC. Validity of data-derived algorithms for ascertaining causes of adult death in two African sites using verbal autopsy. Tropical Medicine & International Health. 5(1):33-9, 2000. Anker M. The effect of misclassification error on reported cause-specific mortality fractions from verbal autopsy. International Journal of Epidemiology. 26(5):1090-6, 1997 Reeves BC. Quigley M. A review of data-derived methods for assigning causes of death from verbal autopsy data. International Journal of Epidemiology. 26(5):1080-9, 1997 Oct. Tanzanian Ministry of Health. Comprehension of Swahili verbal autopsy forms. http://www.ncl.ac.uk/ammp/techrep7.pdf S.a. Khoury, D. Massad, T. Fadous. Morbidity and causes of death in Jordan 1995-1996 assessment by verbal autopsy. Bulletin of the World Health Organization, 1999, 77(8). Lopez AD. Assessing the burden of mortality from cardiovascular diseases. World Health Statistics Quarterly - Rapport Trimestriel de Statistiques Sanitaires Mondiales. 46(2):91-6, 1993. Donner, A. and M. Eliasziw (1987). Sample size requirements for reliability studies. Statistics in Medicine 6(4): 441-8. Dunn G. Design and analysis of reliability studies. New York: Oxford University Press, 1989. Eliasziw, M., S. L. Young, et al. (1994). Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example. Physical Therapy 74(8): 777-88. Fleiss JL. Statistical methods for rates and proportions (2nd edition). Wiley and Sons 1981 Fleiss JL The design and analysis of clinical experiments. New York Wiley and Sons 1986 Dunn G. Design and analysis of reliability studies. The statistical evaluation of measurement error. New York: Oxford University Press, 1989. Rodriguez L. Reyes H. Tome P. Ridaura C. Flores S. Guiscafre H. Validation of the verbal autopsy method to ascertain acute respiratory infection as cause of death. Indian Journal of Pediatrics. 65(4):579-84, 1998 Jul-Aug. Din G. Analyzing Infant Mortality Rates and the Validity of Verbal Autopsy Method in Determinning the Cause of Deaths in Antalya, PhD Thesis. Akdeniz University, Faculty of Medicine, Department of Public Health, 1995. SIS, Death Statistics, Province and Districts, 1999. SIS, Death Statistics, Province and Districts, 2000.. Turkey Demaographic Health Survey, 1998, Hacettepe Univercity, Faculty of Medicine, Department of Public Health, UNFPA. Smblolu, K. Statistical Methods for Health Science, 2000, Ankara.

99

Appendix 1: Ministry of Health Bakent University

National Burden of Disease and Cost-Effectiveness Study National Verbal Autopsy Interviewer Training April, 14 2003 Bakent University, Institute of Health Sciences 11. Street No: 26 Bahelievler

NATIONAL VERBAL AUTOPSY SURVEY INTERVIEWER TRAINING PROGRAM

09:00-09:10 : Opening (Prof.Dr.Korkut Ersoy) 09:15-10:00 : National Burden of Disease and Cost-Effectiveness Study and the Role of Verbal Autopsy in This Project (Assist.Prof.Dr.Cihangir zcan) 10:00-10:45 : General Introduction of Verbal Autopsy (Assist.Prof.Dr.Cihangir zcan) 10:45-11:00 : Coffee Break 11:00-11:30 : General Information about Diseased (Prof.Dr.Recep Akdur) 11:30-12:00 : Adult Mortality (Prof.Dr.Seval Akgn) 12:00-12:15 : Adult Mortality Related To Cancers and Female Mortality between 15-49 Years Old (Prof.Dr.Rengin Erdal) 12:15-12:30 : 0-28 Day Infant Mortality (Assist.Prof.Dr.Cihangir zcan) 12:30-13:30 : Lunch 13:30-14:00 : 29 Day- 5 Age Child Mortality (Prof.Dr.Seval Akgn) 14:00-14:30 : Defining Main and Last Causes of Death Sensitivity and Specificity of Surveys (Prof.Dr.Seval Akgn) 14:30-15:00 : Control Form (Dr. Nazan Yardm, Dr. Berrak Bora Baara) 15:00-17:30 : Field Study, Discussion and Closure

100

APPENDIX :2 MINISTRY OF HEALTH- BAKENT UNIVERSITY NATIONAL HEALTH SURVEY VERBAL AUTOPSY SURVEY Doctors in Ankara Group Head of Field: Assc.Prof.Dr. Cihangir ZCAN (01) 0312 213 70 16 Line No 1 2 3 4 5 Name Surname Dr. Erol Gkkurt Dr. Cihan Kutlu Dr. Yunus Karada Dr. Mehmet Karyad* Dr. Doan Mavi Code 7 1 2 3 4 Tel No:

Doctors in stanbul Group Head of Field : Assit. Prof. Dr Haydar Sur (02) (0532 665 39 82) Line No 1 2 3 4 5 Name Surname Dr. Abdulhamit Bulut Tekin Dr. Taner Kalc Dr. Hseyin Ko Dr. Merdan elik Dr. Glay cal* Code 11 12 13 14 15 Tel No:

Doctors in zmir Group Head of Field :Assist. Prof.Dr. Gl Ergr (03) (0532 357 47 46) Line No 1 2 3 4 Name Surname Dr. Sema Akaln Dr. Glden Gktay Aykanat Dr. Saniye zalan Dr. lhan Gktay* Code 21 22 23 24 Tel No:

Doctors in Diyarbakr Group Head of Field :Dr. Ali Tekin elebiolu (04) (0542 592 01 12) Line No Name Surname 1 Dr. Lokman Soyoral 2 Dr. Fara Baak 3 Dr. Hamit Acemolu 4 Dr. Erdem Karadeniz 5 Dr. brahim aa* * Doctors will investigate hospital records Code 31 32 33 34 35 Tel No:

101

APPENDIX 3: Distribution of Number of Deaths and Verbal Autopsy Results By Regions and Provinces
Determined death number Determined death number Applied verbal autopsy form Determined number of hospital deaths Determined number of hospital deaths 1 3 2 2 4 1 2 5 1 1 1 8 10 41 5 15 6 6 8 3 6 2 10 1 8 70 330 Number of Completed hospital survey Number of Completed hospital survey 2 1 2 3 1 3 1 4 9 26 4 17 5 9 7 2 1 7 11 63 256

Region number

Region number

Line number

Provinces

Line number

Provinces

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

20 21 22 23 2 24 25 26 27

Afyon Aydn Balkesir Bilecik Bursa anakkale Denizli Edirne stanbul zmir Krklareli Kocaeli Ktahya Manisa Mula Sakarya Tekirda Uak Yalova REGION TOTAL Adana Antalya Burdur Hatay el Isparta K.Mara Osmaniye REGION TOTAL Aksaray Ankara ankr Eskiehir Karaman Kayseri Krkkale Krehir Konya Nevehir Nide Sivas Yozgat REGION TOTAL

24 10 24 10 29 2 19 7 124 61 13 6 21 16 6 8 4

Applied verbal autopsy form 22 10 24 10 28 2 18 5 120 60 12 5 20 16 4 6 4

4 1 5 4 8 4 1 44 26 5 1 4 6 1

3 1 5 3 7 2 1 43 17 3 1 2 5 1

384 25 24 4 14 23 6 26 4 126 6 43 12 11 6 26 4 2 65 6 12 9 19 221

366 22 18 4 14 20 6 23 4 111 5 38 12 10 3 22 4 2 60 5 12 9 18 200

114 11 8 2 4 6 3 8

94 6 7 1 2 4 3 5

41 Amasya 42 Artvin 43 Bartn 44 Bayburt 45 Bolu 46 orum 47 Dzce 48 Giresun 49 Gmhane 50 Karabk 51 Kastamonu 52 Ordu 53 Rize 54 Samsun 55 Sinop 56 Tokat 57 Trabzon 58 Zonguldak REGION TOTAL Adya59 man 60 Ar 61 Ardahan 62 Batman 63 Bitlis Diyar64 bakr 65 Elaz 66 Erzincan 67 Erzurum 68 69 70 71 72 73 74 75 76 77 78 G. Antep Hakkari Idr Kars Malatya Mardin Mu Siirt .Urfa rnak Van

5 7 3 6 4 11 1 11 4 1 4 25 8 14 7 11 24 44 190 7 13 1 1 3 40 15 2 11 21 1 5 5 27 12 19 14 34 7 15 253 1170

5 7 3 5 4 11 1 11 3 1 4 24 8 14 7 11 19 30 168 7 13 1 3 40 14 2 11 20 1 4 5 26 12 19 14 33 7 13 245 1089

42 1 18 4 3 2 6

28 1 12 2 3 5

28 29 30 31 32 33 34 35 36 37 38 39 40

14 3 4 8 63

11 2 4 5 45

REGION TOTAL GENERAL TOTAL

102

APPENDIX 4: National Burden of Diseases and Cost Effectiveness Study Verbal Autopsy Control Form
4 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16

Hospital Death

Place of Burnt

Place of Birth

Main Cause of Death

Questionnaire code

Date of Name and Name and birth Household surname of surname of (Day/Month Tel No respondent deceased / Year)

A. HouseB. C. 0-28 day 29 day-5 age Adult hold Sibling Neighboor infant children

Code Code Code Code Yes No for prov- for For for ince district province district

103 0

Final Cause of Death

Code for Interview

Number of Deaths Identified Anketr Kodu

Questionnaire Type

Age of Deceased During Death

Household Tel Field Code

APPENDIX 5: DEATH STATISTICS FORM

104 1

105 2

APPENDIX 6: Definitions of Symbols Used in Life Tables

X n nMx A nqx npx lx ndx nLx Tx ex age number of years in that age age specific death rates each person who died lived on average half a year during that year mortality rate between age x and (x+1) probability of surviving between exact age x and x+n number of people alive at exact age x number of deaths in the life table population between exact ages x and x+n total number of person -years lived between exact ages and x and x+n total number of person -years lived after age x expected (average) number of years of life left for a person aged x

106 3

APPENDIX 7: VERBAL AUTOPSY QUESTIONNAIRE FORM

MINISTRY OF HEALTH / BAKENT UNIVERSITY

NATIONAL HEALTH SURVEY VERBAL AUTOPSY QUESTIONNAIRE FORM

TURKEY 2003 Term:
Name of City: Application Date: Survey Code Block Number: Line Number: Household Death: Sibling Death: Neighbor Death: ..................... ..../...../ 2003 1 2 City Traffic Code:

First Neighbor Before Second Neighbor Before

First Neighbor After Second Neighbor After

Name, Surname of Deceased, Date of Death: Survey Type:

................................................... ....../......./.......

0 - 28 Days Infant 29 Days - 5 Years Children Adult

4 107

Hello, My name is ___________________. In one of our interviewers previous visit, deaths that occurred in your household within the last one year were determined and the fact that you would be visited once more by our physicians in order to collect detailed data regarding this death was stated. Today I am visiting you for this purpose and I would like to do a survey. This survey is being carried out with the cooperation of Ministry of Health and Bakent University. I will ask you some questions about the below given issues: The following information about deaths that occurred in your household within the last one year : identity information, place of death, place of burial, physician who determined the death, etc. In order to reveal the deceaseds cause of death: some findings witnessed, existing complaints and if there was one, the physicians diagnosis before death. The information you provide will be kept in total confidence and will not be transmitted to someone else. It will only be used for the purpose of the survey. Your name, address and other personal information will be excluded from the survey and in order to reach your name and responses only a single code will be used for your identification. The answers you gave to our questions will be separated from all identification information that may be related to you and your household; thus it may not be possible to build a connection between you and your responses. However, in case of a subsequent necessity to complete the survey information, you will be contacted again. This survey will last approximately 20 minutes. Your participation in the survey is not obligatory and you may leave the survey even after you have decided to participate. During the survey, you are free not to answer the questions that you do not want to. Besides the fact that participating or renouncing after participating in this survey will not result in any penal sanctions on you or your family, it will not harm any of your benefits. If you have any questions regarding the survey, you may ask me or contact our responsible/supervisor. After I leave your household, if you would like to see someone concerning the survey, you may contact Assoc. Prof. Adnan Ksa and Assoc. Prof ahin Kavuncuba at Bakent University at the following phone number: 0312 234 1010/ 1548. Furthermore, you can contact with your City Health Director concerning your respondent rights. Read by the respondent [ ] Read by the interviewer[ ] Approved [ ] Rejected[ ]

Interviewers Name and Surname:___________________ Signature: _______________ Date: ___ / ___ / ___

MINISTRY OF HEALTH - BAKENT UNIVERSITY

VERBAL AUTOPSY QUESTIONNAIRE FORM TURKEY 2003
SURVEY CODE Block Number: Line Number:

Address

Code

Region no Name of city City traffic code Name of district Name of subdistrict Name of village Name of neighborhood Name of Boulevard/Avenue/Street/Square/Block Outdoor no/Building no Indoor no /Flat no Telephone no INTERVIEWER Name-Surname Code Checked Date Signature Sequence of Interview First Date of Interview Result of Interview (1)Completed 1 (2)Rejected 2 (3)Postponed 3 (4)Left incomplete 4 (5)Nobody in the house 5 (6)No available person to interview 6 (7)Other 7 Respondent Relation of respondent to deceased* Respondents age Respondents sex Educational status of respondent**

Code of Survey (No) Urban Rural

FIELD RESPONSIBLE Name-Surname Code Checked Date Signature Second 1 2 3 4 5 6 7

Third 1 2 3 4 5 6 7

Fourth 1 2 3 4 5 6 7

Male

Female

*Codes concerning the relation with deceased 01=Wife/husband 02=Children 03= Son/daughter in law ** Codes for educational status: 01=illiterate 02=Literate, not graduate

04= Grandchildren 05=Mother/Father 06=Mother-in-law/father-in-law 07=Brother/sister 08=Cu-Wife

09=Grandmother/grandfather 10=Other Relatives 11=No Family Relations 12=Other (specify)...

03=Primary School graduate 04=Secondary school or equivalent graduate

05=Elementary School Graduate 06= High School (or equivalent) graduate 07= Pre-University/university-undergraduate 08= Post university/masters or doctoral degree

GENERAL INFORMATION TO DECEASED 1 2 3 4 5 6 7 9

Name-Surname..................

Date of Death ___/___/___

Place of Death 1 At home 2 On the road 3 At Work 4 At Hospital .............. 5 Other .................. Place of Death 1 City.............. 2 District .............. 3 Subdistrict 4 Village............ 5 Abroad ................ Place of Burial 1 City.............. 2 District ............. 3 Subdistrict 4 Village............ 5 Abroad .................. Gender 1 Male 2 Female Age (for adults in years, for infants X/12 month, Refer to question 11 if the deceased is an inFor neonatal x/28 days) .......years/ .......months/ .....days fant between 0-28 days and 29 days-5 years. Marital Status (will be asked if 12 years or older) 1 Never married 3 Separated 5 Widowed(Spouse dead) 2 Currently Married 4 Divorced 6 Cohabiting Occupation( will be asked to aged over 12 Smoking Habits 1 Yes 2 No 9 Do not know years) (ILO Codes will be 8 Duration ................year(s) used)....................................... Substance/ drug addiction? History of drinking alcohol 10 1 Yes (specify). 2 No 9 Do not know 1 Yes 2 No 9 Do not know

MEDICAL HISTORY RELATED TO DEATH 11 12 13 14

Did [NAME] have any complaints related with health? (if yes, specify) 1 Yes .......................................................... 5 No 9 Do not know Had [NAME] been seen by a health provider before his/her death (within the last one year)? 1 Yes 5 No Do you know the physician who examined? (Name, Institution, Phone) 1 Yes 5 No 9 Do not know (if YES, specify name and institution).................................................... Had [NAME] been hospitalized in a hospital before his/her death within the last If NO, or DO NOT KNOW one year? refer to q. 16. 1 Yes 5 No 9 Do not know Did [NAME] leave hospital before his/ her death within the last one 1 Yes year? Left ___ days before Left ___ months before (If yes fill in the blanks and check the box!) 5 No 9 Do not know

15

16 18 19 20 21 22

How long before his/her death was s/ he operated on. Did [NAME] undergo any surgical opera(specify the operation) tion before his/her death? 17 Duration :..............day/...........month/..............year 1 Yes 5 No 9 Do not know Operation :............................................. If NO or DK, refer to q. 19. Do you know which organ was concerned in the operation ? If yes, specify 1 Yes ..................................... 5 No 9 Do not know As per your knowledge, what was the cause of death?.................................... Was this a diagnosis given by a physician ? 1 Yes 5 No 9 Do not know Did the death occur as a consequence of any injury ? If NO or DK, refer to q. 29 1 Yes 5 No 9 Do not know What was the cause of injury? 1 Traffic accident 4 War 7 Attack 2 Work accident 5 Disaster 8 Do not Know 3 House Accident 6 Suicide 9 Other (please specify:) What was the cause of injury? (May be more than one) 1 Motor vehicle 4 Poisoning 7 Drowning/submersion 10 Gunshot/Landmine 2 Unmotorized vehicle 5 Fall 8 Animal Bite 11 Do not know 3 Fire/Burn 6 Stab/Cut/pierce 9 Snake or insect bite 12 Other (specify............. (Specify) How long before death did the injury occur (specify) ?.............years/.............months/.............days Where did the injury occur? 1 Home 6 Sea, River, Lake, Stream 11 Do not know 2 School 7 Industrial Area 3 Street/Highway 8 Construction Area 4 Playground/ Park area 9 Public buildings 5 Trade and service areas (shop, bank, etc) 10 Other (specify) .......... What type of activity was [NAME] doing at the time of injury ? (May be more than one) 1 Driving or riding a motor vehicle 7 On duty at a paid job 2 Being in a motor vehicle 8 At school 3 Working around house (Garden, farm, etc.) 9 Sports 4 Unpaid work (housework, etc..) (except cooking) 10 Cooking 5 Leisure activities (except sports) (playing, walking, ext) 11 Other (specify) 6 Transportation from one place to another (as a pedestrian) 12 Do not know 1 Head / Neck 4 Chest Parts of body injured during injury? 2 Abdomen 5 Limbs May be more than one. 3 Back 6 Lower back 1 Loss of consciousness 5 Fainting 2 Coma 6 Vomiting Which of the medical conditions occurred during in3 Headache 7 Hemorrhage jury? ((May be more than one) 4 Paralysis

23

24

25

26

27

28

If [NAME] is 0-28 days old, refer to q.75 if 29 days- 5 years old refer to q.113. ADULT MORTALITY CARDIOVASCULAR SYSTEM
29 30 31 32 33 34 35
Did [NAME] report/ experience chest pain lasting less that 24 hrs in the month preceding the death? 1 Yes 5 No 9 Do not know Had [NAME] ever complained of dyspnea? 1 Yes 5 No 9 Do not know Had [NAME] ever complained of cyanosis on the lips, fingers, or nails? 1 Yes 5 No 9 Do not know Had [NAME] ever complain of edema especially when lie down? (the lower limbs, foot and leg, eyelids, abdomen, back, sacrum) 1 Yes 5 No 9 Do not know Had [NAME] ever complained of paroxysmal tachycardia (sudden rapid heart beats for one hour or more) before death? 1 Yes 5 No 9 Do not know Had [NAME] ever complained of recurrent sore throat, joint pain or inflammation? 1 Yes 5 No 9 Do not know Had [NAME] ever had a heart attack? 1 Yes 5 No 9 Do not know If NO, or DO NOT KNOW, refer to q.38 9 Do not know

NERVOUS SYSTEM 36 37
Did [NAME] experience paralysis in the month preceding death? 1 Yes 5 No 9 Do not know

If yes, was the paralysis accompanied or followed by sudden loss of consciousness? 1 Yes 5 No

RESPIRATORY SYSTEM 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55
Did [NAME] have a cough that lasted more than a month? 1 Yes Did [NAME] have dry cough? Did [NAME] have productive cough? Did (NAME) have blood in the sputum? Did [NAME] have offensive breath smelling? Did [NAME] have complaints of chest pain or side pain? Did [NAME] have any complaints of wheezing? Did [NAME] have a diagnosis of tuberculosis? Did [NAME] receive any medical treatment for tuberculosis? If NO, or DO NOT KNOW, refer to q. 5 No 9 Do not know 42 1 Yes 5 No 9 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 5 No 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know 9 Do not know

DIGESTIVE SYSTEM
Did [NAME] ever complain of any white patches in the mouth? 1 Yes Did [NAME] ever complain of persistent heartburn behind the chest? 1 Yes Did [NAME] ever complain of hematemesis? 1 Yes Did [NAME] ever complain of persistent vomiting? 1 Yes Did [NAME] ever complain of abdominal pain? 1 Yes Did [NAME] have diarrhea that lasted more than a month? 1 Yes Did [NAME] ever complain of blood in stools? Did [NAME] ever complain of jaundice? Did [NAME] any rapid loss of weight? 1 Yes 1 Yes 1 Yes

GENITOURINARY SYSTEM 56 57 58
Did [NAME] ever complain of pain in the lower back radiating to inguinal area? 1 Yes 5 No Did [NAME] ever mention having blood in the urine? Did [NAME] ever complain of anuria? 1 Yes 5 No 1 Yes 5 No 9 Do not know If NO, or DO NOT KNOW, refer to q.63 9 Do not know 9 Do not know 9 Do not know 9 Do not know

INFECTIOUS DISEASES 59 60 61 62
Did [NAME] have fever before death? 1 Yes 5 No 9 Do not know

Were there chills / rigors with fever? 1 Yes 5 No Did the fever recur every third / fourth day? Was the fever with convulsions / loss of consciousness?

9 Do not know 1 Yes 5 No 1 Yes 5 No

MALIGNITY (CANCER) 63 64 65 66 67
In the last 6 months time, was there a loss of weight of more than 6 kg without a specific reason? 1 Yes 5 No 9 Do not know Did [NAME] ever complain of the presence of any mass or tumor in any part of the body? 1 Yes 5 No 9 Do not know Define the place of mass or tumor in the body 5 No 9 Do not know Did this mass persist until death? 1 Yes 5 No 9 Do not know Was the [NAME] or any member of the family ever informed of the possible existence of a malignant tumor or growth? 1 Yes 5 No 9 Do not know

If [NAME] is a male, then the interview is over. Thank you. 15-49 YEAR OLD FEMALES THAT DIED
Did [NAME] die because of one of the reasons indicated below: 1 Abortion Yes 2 Curetting Yes 3 Vaginal bleeding Yes 4 Continuous Fever Yes Other (specify :.) [Was NAME] pregnant when she died? No No No No Do not Know Do not Know Do not Know Do not Know

68

69 70

1 Yes 5 No 9 Do not know Was there hypertension, edema in lower limbs and/ or excessive loss of weight during pregnancy?

1 Yes Do not know

Did [NAME] die while giving birth? 1 Yes 5 No Was there a lasting fever and headache after childbirth (within 6 weeks after)? 1 Yes 5 No Did [NAME] die within 6 weeks after the infant was born? 1 At the end of pregnancy 3 None of these 2 6 weeks after the infant was born 9 Do not know

5 No

71 72 73

9 Do not know 9 Do not know

Our questionnaire is finished. Thank You.

10

INFANT DEATHS WITHIN 0-28 DAYS

Were you with [NAME] at the time of illness? Did the mother have high blood pressure? 1 Yes 5 No 1 Yes 5 No 9 Do not know 1 Healthy 2 Ill 75 3 Dead 9 Do not know 1 Yes Did the mother receive 77 tetanus during preg5 No nancy? 9 Do not know 1 Diabetes 5 Epilepsy 2 Tuberculosis 9 Do not know 3 Hypertension 10 Other (Specify)............ 4 Heart Disease How was [NAME]s mother after birth? 80 Was the birth normal; that is, it had no major difficulties? 5 No 1 Yes 5 No 9 Do not know

74

76

78

Which of the following did the mother have?(You may check more than one !) Did the mother have spasm/ eclampsia before birth? 1 Yes 5 No 9 Do not know

79 81

Did the mother have fever while giving birth?

1 Yes

9 Do not know

Questions concerning birth process 1 Normal Birth 2 Interventional What was the type (Forceps, Vacuum) 83 of birth? 3 Voluntary Caesarian 4 Obligatory Caesarian 9 Do not know 1 Early birth refer to q. 85 2 Birth on time refer to q. 86 3 Late birth refer to q. 86 9 Do not know refer to q. 86 Did the infant stop moving 1 Yes (local term) in the womb 86 5 No before labor? 9 Do not know If YES, refer to q. 88 Were the infant dead when 1 Yes she/he was born? 88 5 No If YES, END THE 9 Do not know INTERVIEW

82

Was the birth multiple? (twins, triplets)

1 Yes 5 No 9 Do not know

84

Was the infant born before the predicted time?

85

If early birth, how early? Did the infant have tardiness in breathing after birth? If NO, refer to q. 89

_______ Month / _______ Weeks / _______ Days 1 Yes 5 No 9 Do not know

87

89

If NO, how soon did the infant die after the birth? Did umbilical cord prolapse occur during birth? Did the infant cry immediately after birth?

_______ Hours / _______ Days / _______ Weeks 91 Do you think that the infant was smaller than usual at birth? Was the infant unable to breast-feed? If YES, refer to q. 95 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

90

1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

92

93

11

94 96

Was the infant able to breastfeed right after birth but then stopped?

1 Yes 5 No 9 Do not know

95

Was the infant weighted right after birth? If NO or DK, refer to q. 97.

1 Yes 5 No 9 Do not know

How much did the infant weight?__________ _____________gr 1Yes(Specify)_________________________ Did the infant have any malformation/ disability at birth? (lip, mouth, head, neck, chest, hips, limbs, other) Did the infant eye colour turn yellow (jaundice)? f NO or DK, refer to q. 100 Was the umbilical cord of the infant red in colour, having foul drainage or an abscess? For how long? 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know _________ Days 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

97

5 No 9 Do not know How many days after birth the eye colour turned yel- _________ Days low (joundice)? Did the infant have fever? If NO or DK, refer to q. 103. Did the infant have convulsions? Did the infant have difficulty in breathing? Did she/he have intercostal retraction 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

98

99

100

101

102

103

104

Was the infant coughing?

105

106

Did she/he have tachypnea?

107

108

Did the infant have cyanosis? Did the infant have green, bloody, watery/loose, unusual and frequent (more than 6 a day) diarrhea? If NO or DK, refer to q. 112. Did you notice a bulge in infants fontanel?

109 Was the infant vomiting?

110

111 For how long?

________ Days

112

Our questionnaire is finished. Thank You

12

CHILD DEATHS BETWEEN THE AGES OF 29 DAYS 5 YEARS Were you with the de113 ceased during his / her illness? Was the child very small 115 or smaller than usual when at birth? 117 _______Years How long was the child sick ______ Months before death? _______Days 1 Yes Was the child born premature? (use local term) If NO 5 No or DK, refer to q. 118. 9 Do not know Was the child breastfeeding? If NO or DK, refer to q. 120. Did the child have fever? If NO or DK, refer to q. 123. Was the fever continuous or on and off? 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Continuous 2 On and off 3 None of them 9 Do not know 1 Yes 5 No 9 Do not know 1 Dry 2 Productive 3 With Blood 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

1 Yes 5 No 1 Yes 5 No 9 Do not know

114

116

________ Months How may months/ ________ Weeks weeks/days ago? ________ Days Did s/he stop breastfeeding before death? 1 Yes 5 No 9 Do not know ________Months _________Days 1 Yes 5 No 9 Do not know ________Months _________Days 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

118

119

120

121

For how long? Did s/he have contractions, eye deviations, convulsions? (use the local term) For how long?

122

123

124

Was s/he coughing? If NO or DK, refer to q. 127.

125

126

Was the cough dry, productive or with blood?

127

Did s/he have breathing difficulties? Did s/he have intercostal retraction? Was s/he vomiting? If NO or DK refer to q 133 Did s/he ever vomit blood or have bloody vomit?

128

Did s/he have tachypnea? Did she/he have acrocyanosis?

129

130

131

132

For how long did the vomit- ______Months ing continue? ______Days Did s/he have hardness/swollen/tightness (distension) in abdominal part? If NO or DK refer to q. 136 Did the child have diarrhea (frequent liquid/ watery or loose or soft stools)? If NO or DK, refer to q. 138. Did s/he have bloody diarrhea? 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

133

134

135

137

How long did it occur ________ Years hard________ Months ness/swollen/tightness ________ Days (distension) in his/her 9 Do not know abdominal part? _______Months _______Days For how long?

136

138

13

139

Did s/he have abdominal pain? Was there excessive loss of weight during illness? If NO or DK refer to 143 Did the childs hair turn to reddish or yellow?

1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

140

Did s/he have rapid loss of weight? For how long? Did s/he have pale palms or nails?

1 Yes 5 No 9 Do not know _______Months _______Days 1 Yes 5 No 9 Do not know

141

142

143

144

145

Did s/he have any white patches in the mouth (oral moniliasis)?

1 Yes 5 No 9 Do not know

147

Did s/he eye colour turn yellow (jaundice)?

1 Yes 5 No 9 Do not know

1 On Face 2 front and back Did s/he have swelling or part of the body 146 puffiness anywhere? 3 Arms, Legs (May be more than one) and joints 4 No swelling 9 Do not know 1 Yes Was s/he immunized? If 5 No 148 NO or DK, refer to q. 150. 9 Do not know Was s/he against polio? immunized 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

149

_______Years How long ago was the _______Months last injection? _______Days Did s/he have TB immunization (BCG)? Did s/he have a scar on his/her left shoulder? Did s/he have any other skin disease or rash? If NO or DK, refer to q. 155. Did s/he have loss of response to voices (hearing)? How long before death? Was there any stiffness of the whole body? 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know _______Years _______Months _______Days 1 Yes 5 No 9 Do not know 1 Yes 5 No 9 Do not know

150

151

152 Did s/he have measles?

153

154

Was there any pus or discharge?

155

Did s/he have loss of con156 sciousness? If NO or DK, refer to q. 158. Were any of his/her legs or 158 arms paralyzed? Did s/he have stiffness of 160 the neck?

157

159

Did s/he have slipping in the eye and saliva com161 ing from mouth associated with convulsions?

Our questionnaire has finished. Thank you.

14

After finishing the questionnaire, fill in the 1. and 2. questions in accordance with the information you obtained and your own opinion. 1. According to the interviewer, what is the MAIN cause leading to death? 2. According to the interviewer, what is the FINAL cause leading to death? If this death had occurred in hospital and if it is within the control sample, the cause of death will be registered here after it is found in hospital records. 1. What is the MAIN cause of death in hospital records? 2. What is the FINAL cause of death in hospital records?

15

LIST OF ORGANS

1. Head 37. Spleen 2. Brain 38. Umbilicus 3. Mouth 39. Groin 4. Nose 40. Liver 5. Chin 41. Pancreas 6. Palate 42. Small intestine 7. Lip/Oral space 43. Large intestine 8. Tongue 44. Rectum 9. Gums 45. Anus 10. Pharynx 46. Appendix 11. Oropharynx 47. Gallbladder 12. Nasopharynx 48. Bile ducts 13. Larynx 49. Kidney 14. Vocal chords 50. Ureter 15. Tonsil 51. Urethra 16. Parotid 52. Bladder 17. Other unspecified large salivary glands 53. Vulva 18. Trachea 54. Vagina 19. Ear 55. Cervix 20. Eye and related structures 56. Corpus Uteri 21. Neck 57. Endometrium 22. Lymph nodes 58. Ovaries 23. Thyroid 59. Placenta 24. Esophagus 60. Fallopian Tubes 25. Diaphragm 61. Testis 26. Vertebrae 62. Scrotum 27. Spinal cord 63. Epididymis and Vas deferens 28. Extremities (arm, leg) 64. Prostate 29. Large bones and joints 65. Penis 30. Breast 66. Arteries 31. Heart 67. Veins 32. Lung 68. Bone marrow 33. Mediastinum 69. Skin 70. Connective tissue 34. Pericardium 35. Stomach 71. Other endocrine glands 36. Duodenum 72. Other

16

MINISTRY OF HEALTH / BAKENT UNIVERSITY

DEATH DETERMINATION FORM IN HOSPITAL This form will be filled for deaths that occurred in hospitals. Verbal autopsy interviewer will completely fill the information concerning the identification of deceased in this form. Information related to other causes of death will be filled at the hospital by another interviewer.
Name of City: Application Date: Survey Code Block Number: Line Number: Household Death: Sibling Death: Neighbor Death: ..................... ..../...../ 2003 City Traffic Code: Term:

First Neighbor Before Second Neighbor Before

First Neighbor After Second Neighbor After

Survey Type:

0 - 28 Days Infant 29 Days - 5 Age Children Adult

Name - Surname Fathers name Date of Birth/Age Place of Birth Address of the Household that Death is Determined Date of Death Name of the Hospital s/he deceased
1. MAIN cause of death in hospital records? 2. FINAL cause of death in hospital records?

Interviewers Name-Surname and Signature .//2003

Supervisors Name-Surname and Signature .//2003

17

JOB / PROFESSION CLASSIFICATION (ILO)

01 SCIENTIFIC AND TECNICAL PERSONNEL (INCLUDING BUSINESSMAN WITH PRIVATE PROFESSIONS AND RELATED JOBS)

Physicist, Chemists and Similar Professions. Architects, Engineers and Similar Technical Personnel Pilots, Deck Officers, Machine Officers (Marine and Air) Biologists, Scientific Agronomists and Similar Technicians Medicine and Similar Professions Statisticians, Mathematicians, System Analysts and Similar Technicians Statisticians, Mathematicians, System Analysis and Similar Technicians Economists Financial Consultants and Accountants Professions related to Law Professions related to Education Religion Men and Equivalents Authors and Other Work of Arts Related to Literature Sculptor, Artist (painter), Photographer and Relevant Members of Creative Arts Artists of Music and Stage and Other Artists Related to Entertainment Sportsmen and other Professions related to Sports Differently Classified Scientific and Technical Professions and Etc

02 ENTREPRENEUR, DIRECTORS AND HIGH LEVEL ADMINISTRATORS

High Level Administrators of Legislation Organs and Public Sector. Entrepreneurs and Administrators ( except commerce)

03 ADMINISTRATIVE PERSONNEL AND RELEVANT STUDIES

Group Chief of Office Officials. Public Administrative Officials Stenos, Typists, Operators of Card and Magazine Operators Accountant Officials Cashiers and the Staff Working for Similar Jobs Staff That Works on Machines that Make Addition Operations Chiefs of Transportation and Communication Services People that Collect Tickets (Conductors) Post Deliverer Telephone and Telegraph Operators Administrative Personnel who is not Classified Else Where and Similar Employees

04 COMMERCIAL AND SALE PERSONNEL

Directors (Wholesale and Retail Price) Entrepreneurs and Administrators in Wholesale and Retail Commerce (Property Owner of Business) Chief of Purchasing and Sales Official and Technician of Business, Traveling Tradesmen Insurance Agency and Real-Estate Commissioners, Income Bond Brokers, Sales Officials of Enterprises, Salesmen, People that Make Sales by Auction (Auction clerks) Sales Commissioners, Commercial Clerks and People that Work for Similar Professions Commercial and Sales Personnel who are not Classified Else Where

18

05 PEOPLE WORKING IN SERVICE BUSINESS

Directors of Hotels, Coffeehouses, Saloons, Restaurants, Casinos, Pastry-shops, Movies, Theatres and Similar Places Entrepreneur Property Owners that administrate Directors of Hotels, Coffeehouses, Saloons, Restaurants, Casinos, Pastry-shops, Movies, Theatres and Similar Places Cook, Waiter/Witress, Barmen and Etc Maids and Similar Employees Property Guards, Cleaning Staff Drycleaners, Laundrymen and Ironers Hairdressers, Experts in Beauty Saloons and Similar Personnel of Security and Protection Services

06 AGRICULTERISTS, LIVESTOCK DEALERS, FORESTERS, FISHERMEN AND HUNTERS

Agriculture Management Chiefs and Directors (including stewards) Agriculture Managers (Producers) Agriculture Employees Employee of Forestry Fishermen, Hunters and people working in similar professions

07 EMPLOYEES WORKING IN NON-AGRICULTURAL PRODUCTION AND THE ONES WHO USE MEANS OF TRANSPORTATION

Directors and Similar Authorities of Profession Miner, Borer, etc Employee of Production and Operation of Metal Employee that do the Primary Preparation Procedures of Wood and Paper Production Users of Oven and Chemical Tools Textile employees Leather, Fur, Tanning Works Employees of Nutrition and Drink Industry Tobacco employees Tailors, Upholsters, etc Shoe and Leather works Carpentry Employees and Etc Workers of Stone Sculpturing and Carving (including marble) Workers that operate metal by labour work Machine Mounters, Delicate, Punctual Instrument Repairers and Machine Operators (Except Electrics) Employees of Electrics and Electronics Operators of Radio, Television and Similar Media Stations Operators of Sound and Cinema Projection Instruments Lead Pipe and Hygenienic Operators, Monitors of Can, Copper and Metal Pipe Workers Jewelries Workers of Glass and glass based goods Production, products of Ceramics and Soil Plastic Material and Rubber Production Workers Paper, Cartoon and Plating Goods Printer, Bookbinder and Employees of Similar Professions Painters Employees that work in Production and Similar Affairs Qualified Workmen of Construction, Carpenter and similar Construction Employee Users of Stationary Establishment Machines Employee of Loading Unloading and Users of Construction Machines Users of Transportations Machine

08 UNAPPOINTED EMPLOYEES
People that look for a job for the first time, Unemployed and People that do not perform anything. People that Work in a Job but can not Officially Identify Military Members (Ones who give private answer as the main profession will be considered as unknown.) Except Civil Servants and Artisans) Employee Classified Else Where Unknown (Ones whose profession question is not answered)

00 NONE (Housewives, Retired, Students, Incapable of Working and Prisoners)

19

APPENDIX 8: Verbal Autopsy Survey Manual

20

APPENDIX 8: Verbal Autopsy Survey Manual

MINISTRY OF HEALTH / BAKENT UNIVERSITY

NATIONAL BURDEN OF DISEASE AND COST EFFECTIVENESS PROJECT

NATIONAL VERBAL AUTOPSY SURVEY MANUAL

1108

INTRODUCTION AND OBJECTIVE

A data collection tool has been developed to be used in Verbal Autopsy survey which is a part of National Burden of Disease and Cost Effectiveness project. Importance has been given to the preparation of a manual ,which may provide leading and technical information to interviewers so that they use the questionnaire form in the most efficient way. Information provided on births and deaths are important in estimating the health needs of a society and planning of required health care services. In this survey, all relative information concerning deaths that occurred within the last year in the household will be obtained.

Description of Survey Form and its Application

POINTS THAT MUST BE TAKEN ACCOUNT OF WHEN FILLING IN THE FORMS A dark black pencil and soft eraser will be used Shading must be done within the circle; care should be given not to go outside of the circle Pages of form must not be damaged, torn or wrinkled Nothing should be written on the black band in page margin False True

Survey Form Outline

Survey forms and contents can be prepared in different ways. One way is filling an optic form that can be read by optic scanner. This questionnaire is a form that can be read by optic scanner. A pencil and an eraser will be given to the interviwer to fill this form. It is important that coding should be done carefully in a way that shading is kept within the check boxes. In interviewer training program, this will be explained in detail. Survey Form Cover: There is some information that must be filled/coded in the space provided at bottom of the cover page of the questionnaire. City name and city traffic code where the questionnaire is applied will be written and coded. In addition, date of questionnaire will be written and coded. Survey code and Line Number: In survey form there are six boxes for this part. Block number will be written in the first four box and then household line number will be written in the last two box. These numbers will be written and coded.

Whether or not death occured in the main household which was previously visited by the interviewer during the household survey, or whether death refers to sibling deaths of the respondent or to neighbour households that reside on the two left and right hand side of the main household will be determined by marking the relevant part with an (x) sign. Deaths in the household Sibling deaths Neighbour deaths 1.right 2.right 1.left 2.left

Name and surname of the deceased and date of the death will be written in given space. Survey Type: This survey was prepeared for determinning the causes of adult deaths, 15-49 age female deaths, 0-28 day infant deaths and 29 day-5- year- old children deaths. For this reason, interviewer/doctor will be mark the proper survey type for the group
Survey Type

0-28 days infant 29 day-5 years children Adult

T.C.MINISTRY OF HEALTH BAKENT UNIVERSITY VERBAL AUTOPSY SURVEY MANUAL

Survey code and Line Number: In survey form there are six boxes for this part. Block number will be written in the first four box and then household line number will be written in the last two box. These numbers will be written and coded. Address:: Interviewer/doctor must obtain information on deaths identified by household survey interviewer which occured within the last year. With respect to this information, under the address heading, region no, city trafic code, name of district, name of subdistrict and village, name of Boulevard/Avenue/Street/Square/Block Outdoor no/Building no, Indoor no /Flat no must be written down and related places (region no, traffic code) must be filled out.

1. INFORMATION ON THE INTERVIEWER, FIELD COORDINATOR AND RESPONDENT

Interviewer and field coordinator should fill in the necessary information in relative sections. Interviewer:: Interviewer/doctor will write the personal information to questionnaire form and code in the personal interviwer code number and then sign the proper place. Field Coordinator: Questionnaire forms filled out by doctors will be delivered to field coordinator. Field coordinator will evaluate and examine the related parts of the questionnaire then, will write the personal field coordinator code number to the place in questionnaire form and will write the controlling date of the form and sign the proper place. Result of Interview: Four attempts will be performed in each interview. Interviewer should write the exact number of this interview attempt, its date and result. Interviewer/doctor must rearrange a meeting date if respondent is not available or when they could not reach the address of the household where deaths have been identified by survey interviwers. In such circumstances, this should be indicatedin the result of interview part of the form. If respondent rejects to be interviewed in all four attempts done at different dates and times, interview will be stopped. Result of interview will be stated by giving attention to the codes provided at the top of the related parts. Respondent Information: In other parts of the form, identification of respondent will be written in detail. In addition, respondents relation to the deceased is important for reliable data collection For this reason, respondents relation to the deceased part will be filled by coding in the section concerning the options of respondents relation to the deceased and age, sex, educational status are written in small boxes placed in the bottom part of that section. Interviewer will answer these questions in accordance with the below given options.
*Codes concerning the relation to the deceased 01=Wife/husband 02=Children 03= Son/daughter in law 04= Grandchildren 05=Mother/Father 06=Mother-inlaw/father-in-law 07=Brother/sister 08=Cu-Wife 09=Grandmother/grandfat her 10=Other Relatives 11=No Family Relations 12=Other (specify)...

** Codes for educational status: 01=illiterate 02=Literate, not graduate

03=Primary School graduate 04=Secondary school or equivalent graduate

05=Elementary School Graduate 06= High School (or equivalent) graduate 07= Pre-University/universityundergraduate 08= Post university/masters or doctoral degree

This questionnaire is prepared towards adult mortality, 15-49 year old females that died during pregnancy, childbirth and in labour period, infant deaths within 0-28 days and infant deaths between the ages of 29 days-5 years.

2. GENERAL INFORMATION ON THE DECEASED

In the first section of verbal autopsy there exist general information concerning causes of deaths determined among household members within last one year (question 1-10), deaths occured among siblings of the respondent within last one year and deaths among two left and right hand side of the main household. Date of death, place of death, place of burial and sex of the deceased will be written down. In question 5, age of the deceased will be recorded in days for the new-born, months for infants and years for adults.

If the death determined within last one year is an infant between the ages of 0-28 days and 29 days-5 years, then refer to question 11.

Detailed information concerning the marital status of the deceased will be explicitly specified by marking the options under the question. Similarly, his/her occupation, smoking habits, alcohol history and substance/drug addiction will be asked and recorded as yes, no, and do not know. If the deceased was smoking, the duration of smoking will be written in years, if the deceased had addiction to drugs then the drug to which s/he was addicted to will be recorded in detail.

3. MEDICAL HISTORY RELATED TO DEATH

Information towards the medical history related to death are asked in questions between 11-18. These questions will be seperately asked for each death among household members, siblings and neighbours. Yes, no or do not know options will be marked. If the responses are yes, for instance if the respondent knows the complaint of the decased before death or knows the physician who did the examination, then relative information will be made definite.. Similarly, in response to the question 15 that asks Did [NAME] leave hospital before his/ her death within last one year? the answer died in hospital will be given if the deceased died in the hospital or else the number of days, months or years of discharge before death will be stated. If the deceased had any operations, type of operation will be recorded in 16th and 17th questions. In question 19, cause of death will be recorded as stated by respondent. If the respondent uses a local terminology and you do not know the meaning of this term, the term will be directly recorded and its meaning will be asked to a local health professional or another authority. In question 20, whether or not the cause of death is a physician diagnosis will be determined. In question 21, the relation of death between injury will be questioned. If the death occured as a result of injury, questions between 22-28 will be asked. With the help of these questions cause of injury, the event or instrument that originated injury, the place of injury, what the deceased was doing at the time of injury and particularly whether or not this was a work accident will be questioned in detail and relavent options will be marked.

4. ADULT MORTALITY 4.1.DISEASE DETAILS

Deaths related to the disease are better kept in mind after long periods of time and therefore it is more possible to obtain accurate and detailed information concerning this type of causes of death. Read carefully all options in quesitons and be sure that all informaiton are completely recorded.

4.1.1.Cardiovascular System
Ischaemic heart disease is often the cause of death among middle aged and elder people who are extremely fat or have smoking, diabetes or hypertension history. A severe seizure is often experienced with the sudden inception of chest pain/tightness together with severe and frequent sweating, dyspnoea, fainting and/or falling. The case may sometimes originates from exercise/ anxiety. Death usually occured suddenly (within few hours) or sometimes within a month after another similar case. Questions between 29-35 concern the questions related to cardiovascular system.

4.1.2.Nerve System
Another important and easily identified cause of death among adults is cerebrovascular attack. Attack shows itself with a sudden stroke in half of the body and face, at the same time or after-

wards unconsciousness is experienced. While regaining consciousness, the person who experienced the stroke may have a post attack permanent weakness/ paralysis or s/he may recover. Among patients who may not have recovered, death sometimes occurs together with a recurrent case for almost 1/3 of patients within one year and three years maximum. Questions between 36-37 are composed of questions related to nerve system. If the deceased hadnt experienced a stroke within one month before death, refer to question 38.

4.1.3.Respiratory System
In this section, it is tended to collect information concerning respiratory system diseases and tuberculosis. The following issues are questioned: existance of symptoms like chronical cough, productive cough, wheezing respiration, offensive bad breath and side pain, whether or not the deceased had a complaint concerning respiratory system before death, whether or not s/he was diagnosed with tuberculosis, whether or not s/he received a medical treatment regarding this disease. Questions between 38-46 are composed of questions related ro respiratory system.

4.1.4.Digestive System
With the help of these questions, it is intended to collect information concerning whether or not the deceased had a diarrhoea that lasted more than one month, whether or not s/he had digestive system complaints like vomiting blood, stomachache, blood in stools or jaundice. Questions between 47-55 are composed of questions related to digestive system.

4.1.5. Genitourinary System

Questions between 56-58 should be asked to the respondent in detail so as to find out deaths related to genitourinary systems.

4.1.6.Infectious Diseases
In these questions, it is intended to find out whether or not an infectious disease is a cause of death. Particularly, existence of fever before death constitutes the most fundamental symptom. Between questions 59-62, it is tried to gather information concerning malaria and menengitis which are still important public health problems in our country. Questions between 59-62 are composed of questions related to infectious diseases.

4.1.7.Malignities/ Cancers
Whether or not cause of death is related to malginity will be revealed with loss of weight more than 6-10 kilos within last 6 months without any specific reason or with the presence of any mass or tumeur in any part of the body. Questions between 63-67 are composed of questions related to malignities/ cancers. Eer len kii yetikin erkek ise anket burada bitmitir. len kii 15-49 ya arasnda kadn ise ankete devam edilecektir.

5. 15-49 YEAR OLD FEMALES THAT DIED DURING PREGNANCY, CHILDBIRTH OR LABOUR PERIOD
If the determined death is a female between the ages of 15-49, then in addition to other questions, questions from 68 to 74 73 will be asked in order to find out whether or not cause of death is related to pregnancy, childbirth or labour period. With the help of these questions, whether or not the deceased encountered an event at pregnancy period, during childbirth or after childbirth. Questions between 68-74 73 are composed of questions related to 15-49 year old females that died during pregnancy, childbirth or labour period.

6. INFANT DEATHS WITHIN 0-28 DAYS

If the determined cause of death is an infant between 0-28 days, then after having filled the sex and age part in the General Information part which is placed in the first section of the verbal autopsy form, refer to the 75. QUESTION . If the determined infant death is between the ages of 29 days- 5 years, then similarly after having filled the sex and age part in the General Information part which is placed in the first section of the verbal autopsy form, refer to the 113. QUESTION. Questions between 75-82 are questions that interrogate pregnancy period of the mother. There are questions like immunization state of mother during pregnancy period, whether or not some systematical diseases like diabetes, hypertension, heart disease are present at mother during this period. Questions between 83-112 are composed of symptoms that are concerned with the pregnancy period and are found at the infant. Questions like type of birth, time of birth and questions concerning symptoms found in APGAR scoring determine the state of infant. If the answer is YES to the 89. question whether infant was born dead or not, then the questionnaire is finished by here. If the infant was born alive, all questions between 90-112 will be asked.

7. INFANT DEATHS BETWEEN THE AGES OF 29 DAYS- 5 YEARS

With the help of the following questions, it is tried to determine the cause of death during this period : whether or not child was born premature, whether there was a state of child breastfeeding, presence of fever, whether or not s/he experienced excessive fever, she had respiratory difficulties, presence of cough, vomitting, symptoms related to menengitis or any other infectious disease, immunization state, presence and type of accident. Together with the questions between 113-161 it is tried to determine causes of death of infants between the ages of 29 days and 5 years in this period. In determination of deaths within 0-28 days and 29 days 5 years STANDARD CRITERIA PROPOSED IN DETERMINATION OF CHILDHOOD CAUSE OF DEATH IN DEVELOPING COUNTRIES BY VERBAL AUTOPSY METHOD may be used. (Appendix 1).

8. CAUSES OF DEATH
After the filling process of questionnaire, in accordance with the information s/he obtained and his/her own opinion interviewer will carefully fill the parts related to main and decided cause of death that originate death. While recording casues of death, main and decided causes are usually recorded separately. Sometimes the interval cause is also stated. However, there may not be these three causes in each death case. The cause which is used in death statistics is the main cause of death. Main cause: First disease or event that leads to death. Decided cause: Last disease or event that leads the patient to death. For instance: 1. Main cause: Hypertension Decided cause: Cerebrovascular event 2. Main cause: Traffic accident Decided cause: Cerebrovascular event 3. Main cause: Acute rheumatic fever Decided cause: Cardiac arrest Some examples are given above. However, there may be a case different from the one in the 1. example. For instance, although s/he didnt have a predicted hypertension, cerebrovascular event may have occcured as a result of sudden emboly and anevrizma. In such a case, cerebrovascular event is the main casue of death. If traffic accident is not stated as main cause of death in the 2. example, this death would be wrongly classified. If accidents and empoisenments happen before a given duration relevant to death, then they should be recorded as the main casue of death. 8.1. Diagnosis that are not possible to be written as main cause of death

Cardiac arrest, respiratory arrest, senilite , hypovolemic shock, cardiogenic shock These diagnosis are usually the decided causes of death that originate death, main cause that leads to this should be recorded. 8.2. Deaths with single cause of death There may only be the main cause of death in some cases. Cancer usually fits this situation. Death may arise because of causes like hemorragie, brain metastase as a consequence of cancer, however in such a case the main cause is always cancer. Moreover, only the main casue should be recorded in many infectious disease such as typhoid, diphteria, etc. 8.3. Cause-Consequence relation

If a person has prostate cancer and died of a traffic accident then main cause of death would be traffic accident. In this case, it wouldnt be accurate to give cancer as main cause and traffic accident as decided cause of death. Because there should be a cause-consequence relation between the main and decided causes of death. There should be a rational relation. As cancer can not lead to a traffic accident, then the main cause is traffic accident. 8.4. Deaths within 0-28 days and 29 days- 5 years

Here, the main cause of death should also be recorded. Causes like premature and malnutrition are main causes of death. Nevertheless, more attention should be paid when stating prematurity or backwardness in intrauterin development in deaths after 29 days. Particularly the main cause of death of a child after the age of 1 should not be prematurity, as s/he completed the first year, it is expected that the child overcame problems that may be originated from prematurity. ( See Appendix 1)

In the last section, after the questionnaire is filled by the interviewer-physician who made the verbal autopsy concerning type of household, in other words whether or not there are household, sibling or neighbour deaths, information related to the respondent and interviewer, the information whether or not death had occurred at a hospital will be given to the physician who will be responsible, for the assessment of hospital records and then main and decided causes of death will be recorded while the relevant person visits the hospitals in which death occurred.

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T.C MINISTRY OF HEALTH AND BAKENT UNIVERSITY HOSPITAL DEATHS IDENTIFICATION FORM
This form will be filled for hospital deaths which are in controlling sample.Verbal autopsy interviewer/doctor will fill the deceased identity information completely. In this part, After survey type, ie; whether or not household, siblings or neighborhood deaths, respondent informations and interviewer informations filled out by verbal autopsy interviewer, if death occurred at hospital, this form will be given to interviewer responsible for evaluating the hospital records and this doctor will go to the hospital that death occurred and other causes of death will be filled and primary cause of death, final cause of death will be recorded.

After the filling process is completed, name and surname information of interviewer, field coordinator will be written and codes will be filled and signed.

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APPENDIX 1: SIS Codes for Provinces and Districts

01.ADANA 01.Seyhan 02.Yreir 03.Alada 04.Ceyhan 05.Feke 06.mamolu 07.Karaisali 08.Karata 09.Kozan 10.Pozant 11.Saimbeyli 12.Tufanbeyli 13.Yumurtalk 02.ADIYAMAN 00.Merkez 01.Besni 02.elikhan 03.Gerger 04.Glba 05.Kahta 06.Samsat 07.Sincik 08.Tut 03.AFYON 00.Merkez 01.Bamak 02.Bayat 03.Bolvadin 04.ay 05.obanlar 06.Dazkr 07.Dinar 08.Emirda 09.Evciler 10.Hocalar 11.hsaniye 12.scehisar 13.Kzlren 14.Sandkl 15.Sincanl 16.Sultanda 17.uhut 04.ARI 00.Merkez 01.Diyadin 02.Doubeyazt 03.Elekirt 04.Hamur 05.Patnos 06.Talay 07.Tutak 05.AMASYA 00.Merkez 01.Gyncek 02.Gmhacky 03.Hamamz 04.Merzifon 05.Suluova 06.Taova 06.ANKARA 01.Altnda 02.ankaya 03.Etimesgut 04.Glba 05.Keiren 06.Mamak 07.Sincan 08.Yenimahalle 09.Akyurt 10.Aya 11.Bala 12.Beypazar 13.amldere 14.ubuk 15.Elmada 16.Evren 17.Gdl 18.Haymana 19.Kalecik 20.Kazan 21.Kzlcahamam 22.Nallhan 23.Polatl 24.Kohisar

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07.ANTALYA 00.Merkez 01.Akseki 02.Alanya 03.Elmal 04.Finike 05.Gazipaa 06.Gndomu 07.bradi 08.Kale 09.Ka 10.Kemer 11.Korkuteli 12.Kumluca 13.Manavgat 14.Serik 08.ARTVN 00.Merkez 01.Ardanu 02.Arhavi 03.Borka 04.Hopa 05.Murgul 06.avat 07.Yusufeli 09.AYDIN 00.Merkez 01.Bozdoan 02.Buharkent 03.ine 04.Didim 05.Germencik 06.ncirliova 07.Karacasu 08.Karpuzlu 09.Koarl 10.Kk 11.Kuadas 12.Kuyucak 13.Nazilli 14.Ske 15.Sultanhisar 16.Yenipazar

10.BALIKESR 00.Merkez 01.Ayvalk 02.Balya 03.Bandrma 04.Bigadi 05.Burhaniye 06.Dursunbey 07.Edremit 08.Erdek 09.Gme 10.Gnen 11.Havran 12.vrindi 13.Kepsut 14.Manyas 15.Marmara 16.Savatepe 17.Sndrg 18.Susurluk 11.BLECK 00.Merkez 01.Bozyk 02.Glpazar 03.nhisar 04.Osmaneli 05.Pazaryeri 06.St 07.Yenipazar 12.BNGL 00.Merkez 01.Adakl 02.Gen 03.Karlova 04.Ki 05.Solhan 06.Yayladere 07.Yedisu 13.BTLS 00.Merkez 01.Adilcevaz 02.Ahlat 03.Groymak 04.Hizan 05.Mutki 06.Tatvan

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14.BOLU 00.Merkez 01.Drtdivan 02.Gerede 03.Gynk 04.Kbrsck 05.Mengen 06.Mudurnu 07.Seben 08.Yeniaa 15.BURDUR 00.Merkez 01.Alasun 02.Altnyayla 03.Bucak 04.avdr 05.eltiki 06.Glhisar 07.Karamanl 08.Kemer 09.Tefenni 10.Yeilova 16.BURSA 01.Nilfer 02.Osmangazi 03.Yldrm 04.Bykorhan 05.Gemlik 06.Grsu 07.Harmanck 08.negl 09.znik 10.Karacabey 11.Keles 12.Kestel 13.Mudanya 14.MKemalpaa 15.Orhaneli 16.Orhangazi 17.Yeniehir

17.ANAKKALE 00.Merkez 01.Ayvack 02.Bayrami 03.Biga 04.Bozcaada 05.an 06.Eceabat 07.Ezine 08.Gelibolu 09.Gkeada 10.Lapseki 11.Yenice 18.ANKIRI 00.Merkez 01.Atkaracalar 02.Bayramren 03.erke 04.Eldivan 05.Ilgaz 06.Kzlrmak 07.Korgun 08.Kurunlu 09.Orta 10.abanz 11.Yaprakl 19.ORUM 00.Merkez 01.Alaca 02.Bayat 03.Boazkale 04.Dodurga 05.skilip 06.Karg 07.Lain 08.Mecitz 09.Ouzlar 10.Ortaky 11.Osmanck 12.Sungurlu 13.Uurluda

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20.DENZL 00.Merkez 01.Acpayam 02.Akky 03.Babada 04.Baklan 05.Bekilli 06.Beyaa 07.Bozkurt 08.Buldan 09.al 10.ameli 11.ardak 12.ivril 13.Gney 14.Honaz 15.Kale 16.Sarayky 17.Serinhisar 18.Tavas 21.DYARBAKIR 00.Merkez 01.Bismil 02.ermik 03.nar 04.ng 05.Dicle 06.Eil 07.Ergani 08.Hani 09.Hazro 10.Kocaky 11.Kulp 12.Lice 13.Silvan 22.EDRNE 00.Merkez 01.Enez 02.Havsa 03.psala 04.Kean 05.Lalapaa 06.Meri 07.Sleolu 08.Uzunkpr

23.ELAZI 00.Merkez 01.An 02.Alacakaya 03.Arcak 04.Baskil 05.Karakoan 06.Keban 07.Kovanclar 08.Maden 09.Palu 10.Sivrice 24.ERZNCAN 00.Merkez 01.ayrl 02.li 03.Kemah 04.Kemaliye 05.Otlukbeli 06.Refahiye 07.Tercan 08.zml 25.ERZURUM 00.Merkez 01.Akale 02.at 03.Hns 04.Horasan 05.Ilca 06.spir 07.Karaoban 08.Karayaz 09.Kprky 10.Narman 11.Oltu 12.Olur 13.Pasinler 14.Pazaryolu 15.enkaya 16.Tekman 17.Tortum 18.Uzundere

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26.ESKEHR 00.Merkez 01.Alpu 02.Beylikova 03.ifteler 04.Gnyz 05.Han 06.nn 07.Mahmudiye 08.Mihalgazi 09.Mihalck 10.Sarcakaya 11.Seyitgazi 12.Sivrihisar 27.GAZANTEP 01.ahinbey 02.ehitkamil 03.Araban 04.slahiye 05.Karkam 06.Nizip 07.Nurda 08.Ouzeli 09.Yavuzeli 28.GRESUN 00.Merkez 01.Alucra 02.Bulancak 03.amoluk 04.anak 05.Dereli 06.Doankent 07.Espiye 08.Eynesil 09.Grele 10.Gce 11.Keap 12.Piraziz 13.Karahisar 14.Tirebolu 15.Yaldere 29.GMHANE 00.Merkez 01.Kelkit 02.Kse 03.Krtn 04.iran 05.Torul

30.HAKKAR 00.Merkez 01.ukurca 02.emdinli 03.Yksekova 31.HATAY 00.Merkez 01.Altnz 02.Belen 03.Drtyol 04.Erzin 05.Hassa 06.skenderun 07.Krkhan 08.Kumlu 09.Reyhanl 10.Samanda 11.Yaylada 32.ISPARTA 00.Merkez 01.Aksu 02.Atabey 03.Eirdir 04.Gelendost 05.Gnen 06.Keiborlu 07.Senirkent 08.Stler 09.arkikaraaa 10.Uluborlu 11.Yalva 12.Yeniarbademli 33.EL 00.Merkez 01.Anamur 02.Aydnck 03.Bozyaz 04.amlyayla 05.Erdemli 06.Glnar 07.Mut 08.Silifke 09.Tarsus

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34.STANBUL 01.Adalar 02.Avclar 03.Baclar 04.Bahelievler 05.Bakrky 06.Bayrampaa 07.Beikta 08.Beykoz 09.Beyolu 10.Eminn 11.Esenler 12.Eyp 13.Fatih 14.Gaziosmanpaa 15.Gngren 16.Kadky 17.Kathane 18.Kartal 19.Kkekmece 20.Maltepe 21.Pendik 22.Saryer 23.ili 24.Tuzla 25.mraniye 26.skdar 27.Zeytinburnu 28.Bykekmece 29.atalca 30.Silivri 31.Sultanbeyli 32.ile

35.ZMR 01.Balova 02.Bornova 03.Buca 04.ili 05.Gaziemir 06.Gzelbahe 07.Karyaka 08.Konak 09.Narldere 10.Aliaa 11.Bayndr 12.Bergama 13.Beyda 14.eme 15.Dikili 16.Foa 17.Karaburun 18.Kemalpaa 19.Knk 20.Kiraz 21.Menderes 22.Menemen 23.demi 24.Seferihisar 25.Seluk 26.Tire 27.Torbal 28.Urla

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36.KARS 00.Merkez 01.Akyaka 02.Arpaay 03.Digor 04.Kazman 05.Sarkam 06.Selim 07.Susuz 37.KASTAMONU 00.Merkez 01.Abana 02.Al 03.Ara 04.Azdavay 05.Bozkurt 06.Cide 07.atalzeytin 08.Daday 09.Devrekani 10.Doanyurt 11.Hann 12.hsangazi 13.nebolu 14.Kre 15.Pnarba 16.Seydiler 17.enpazar 18.Takpr 19.Tosya 38.KAYSER 01.Kocasinan 02.Melikgazi 03.Akkla 04.Bnyan 05.Develi 06.Felahiye 07.Haclar 08.ncesu 09.zvatan 10.Pnarba 11.Sarolan 12.Sarz 13.Talas 14.Tomarza 15.Yahyal 16.Yeilhisar

39.KIRKLAREL 00.Merkez 01.Babaeski 02.Demirky 03.Kofaz 04.Lleburgaz 05.Pehlivanky 06.Pnarhisar 07.Vize 40.KIREHR 00.Merkez 01.Akakent 02.Akpnar 03.Boztepe 04.iekda 05.Kaman 06.Mucur 41.KOCAEL 00.Merkez 01.Gebze 02.Glck 03.Kandra 04.Karamrsel 05.Krfez 06.Derince

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42.KONYA 01.Karatay 02.Meram 03.Seluklu 04.Ahrl 05.Akren 06.Akehir 07.Altnekin 08.Beyehir 09.Bozkr 10.Cihanbeyli 11.eltik 12.umra 13.Derbent 14.Derebucak 15.Doanhisar 16.Emirgazi 17.Ereli 18.Gneysnr 19.Hadm 20.Halkapnar 21.Hyk 22.Ilgn 23.Kadnhan 24.Karapnar 25.Kulu 26.Sarayn 27.Seydiehir 28.Takent 29.Tuzluku 30.Yalhyk 31.Yunak 43.KTAHYA 00.Merkez 01.Altnta 02.Aslanapa 03.avdarhisar 04.Domani 05.Dumlupnar 06.Emet 07.Gediz 08.Hisarck 09.Pazarlar 10.Simav 11.aphane 12.Tavanl

44.MALATYA 00.Merkez 01.Akada 02.Arapkir 03.Arguvan 04.Battalgazi 05.Darende 06.Doanehir 07.Doanyol 08.Hekimhan 09.Kale 10.Kuluncak 11.Ptrge 12.Yazhan 13.Yeilyurt 45.MANSA 00.Merkez 01.Ahmetli 02.Akhisar 03.Alaehir 04.Demirci 05.Glmarmara 06.Grdes 07.Krkaa 08.Kprba 09.Kula 10.Salihli 11.Sargl 12.Saruhanl 13.Selendi 14.Soma 15.Turgutlu 46.KMARA 00.Merkez 01.Afin 02.Andrn 03.alayancerit 04.Ekinz 05.Elbistan 06.Gksun 07.Nurhak 08.Pazarck 09.Trkolu

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47.MARDN 00.Merkez 01.Dargeit 02.Derik 03.Kzltepe 04.Mazda 05.Midyat 06.Nusaybin 07.merli 08.Savur 09.Yeilli 48.MULA 00.Merkez 01.Bodrum 02.Dalaman 03.Data 04.Fethiye 05.Kavakldere 06.Kyceiz 07.Marmaris 08.Milas 09.Ortaca 10.Ula 11.Yataan 49.MU 00.Merkez 01.Bulank 02.Hasky 03.Korkut 04.Malazgirt 05.Varto 50.NEVEHR 00.Merkez 01.Acgl 02.Avanos 03.Derinkuyu 04.Glehir 05.Hacbekta 06.Kozakl 07.rgp 51.NDE 00.Merkez 01.Altunhisar 02.Bor 03.amard 04.iftlik 05.Ulukla

52.ORDU 00.Merkez 01.Akku 02.Aybast 03.ama 04.atalpnar 05.ayba 06.Fatsa 07.Glky 08.Glyal 09.Grgentepe 10.kizce 11.Kabadz 12.Kabata 13.Korgan 14.Kumru 15.Mesudiye 16.Perembe 17.Ulubey 18.nye 53.RZE 00.Merkez 01.Ardeen 02.amlhemin 03.ayeli 04.Derepazar 05.Fndkl 06.Gneysu 07.Hemin 08.kizdere 09.yidere 10.Kalkandere 11.Pazar 54.SAKARYA 00.Merkez 01.Ferizli 02.Stl 03.Akyaz 04.Geyve 05.Hendek 06.Karaprek 07.Karasu 08.Kaynarca 09.Kocaali 10.Pamukova 11.Sapanca 12.Tarakl

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55.SAMSUN 00.Merkez 01.Alaam 02.Asarck 03.Ayvack 04.Bafra 05.aramba 06.Havza 07.Kavak 08.Ladik 09.19 Mays 10.Salpazar 11.Tekkeky 12.Terme 13.Vezirkpr 14.Yakakent 56.SRT 00.Merkez 01.Aydnlar 02.Baykan 03.Eruh 04.Kurtalan 05.Pervari 06.irvan 57.SNOP 00.Merkez 01.Ayanck 02.Boyabat 03.Dikmen 04.Duraan 05.Erfelek 06.Gerze 07.Saraydz 08.Trkeli

58.SVAS 00.Merkez 01.Aknclar 02.Altnyayla 03.Divrii 04.Doanar 05.Gemerek 06.Glova 07.Grn 08.Hafik 09.mranl 10.Kangal 11.Koyulhisar 12.Suehri 13.arkla 14.Ula 15.Yldzeli 16.Zara 59.TEKRDA 00.Merkez 01.erkezky 02.orlu 03.Hayrabolu 04.Malkara 05.Marmaraerelisi 06.Muratl 07.Saray 08.arky 60.TOKAT 00.Merkez 01.Almus 02.Artova 03.Baiftlik 04.Erbaa 05.Niksar 06.Pazar 07.Readiye 08.Sulusaray 09.Turhal 10.Yeilyurt 11.Zile

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61.TRABZON 00.Merkez 01.Akaabat 02.Arakl 03.Arsin 04.Beikdz 05.arba 06.aykara 07.Dernekpazar 08.Dzky 09.Hayrat 10.Kprba 11.Maka 12.Of 13.Srmene 14.alpazar 15.Tonya 16.Vakfkebir 17.Yomra 62.TUNCEL 00.Merkez 01.emigezek 02.Hozat 03.Mazgirt 04.Nazmiye 05.Ovack 06.Pertek 07.Plmr 63.ANLIURFA 00.Merkez 01.Akakale 02.Birecik 03.Bozova 04.Ceylanpnar 05.Halfeti 06.Harran 07.Hilvan 08.Siverek 09.Suru 10.Viranehir 64.UAK 00.Merkez 01.Banaz 02.Eme 03.Karahall 04.Sivasl 05.Ulubey

65.VAN 00.Merkez 01.Bahesaray 02.Bakale 03.aldran 04.atak 05.Edremit 06.Erci 07.Geva 08.Grpnar 09.Muradiye 10.zalp 11.Saray 66.YOZGAT 00.Merkez 01.Akdamadeni 02.Aydnck 03.Boazlyan 04.andr 05.ayralan 06.ekerek 07.Kadehri 08.Saraykent 09.Sarkaya 10.Sorgun 11.efaatli 12.Yenifakl 13.Yerky 67.ZONGULDAK 00.Merkez 01.Alapl 02.aycuma 03.Devrek 04.Ereli 05.Gkebey 68.AKSARAY 00.Merkez 01.Aaren 02.Eskil 03.Glaa 04.Gzelyurt 05.Ortaky 06.Saryahi 69.BAYBURT 00.Merkez 01.Aydntepe 02.Demirz

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70.KARAMAN 00.Merkez 01.Ayranc 02.Bayayla 03.Ermenek 04.Kazmkarabekir 05.Sarveliler 71.KIRIKKALE 00.Merkez 01.Bahl 02.Baleyh 03.elebi 04.Delice 05.Karakeili 06.Keskin 07.Sulakyurt 08.Yahihan 72.BATMAN 00.Merkez 01.Beiri 02.Gerc 03.Hasankeyf 04.Kozluk 05.Sason 73.IRNAK 00.Merkez 01.Beytebap 02.Cizre 03.Glkonak 04.dil 05.Silopi 06.Uludere 74.BARTIN 00.Merkez 01.Amasra 02.Kurucaile 03.Ulus 75.ARDAHAN 00.Merkez 01.ldr 02.Damal 03.Gle 04.Hanak 05.Posof

76.IDIR 00.Merkez 01.Aralk 02.Karakoyunlu 03.Tuzluca 77.YALOVA 00.Merkez 01.Altnova 02.Armutlu 03.narck 04.iftlikky 05.Termal 78.KARABK 00.Merkez 01.Eflani 02.Eskipazar 03.Ovack 04.Safranbolu 05.Yenice 79.KLS 00.Merkez 01.Elbeyli 02.Musabeyli 03.Polateli 80.OSMANYE 00.Merkez 01.Bahe 02.Dzii 03.Hasanbeyli 04.Kadirli 05.Sumbas 06.Toprakkale 81.DZCE 00.Merkez 01.Akakoca 02.Cumayeri 03.ilimli 04.Glyaka 05.Gmova 06.Kaynal 07.Ylca

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APPENDIX 2. LIST OF ORGANS

37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. Head Brain Mouth Nose Chin Palate Lip/Oral space Tongue Gums Pharynx Oropharynx Nasopharynx Larynx Vocal chords Tonsil Parotid Other unspecified large salivary glands Trachea Ear Eye and related structures Neck Lymph nodes Thyroid Esophagus Diaphragm Vertebrae Spinal cord Extremities (arm, leg) Large bones and joints Breast Heart Lung Mediastinum Pericardium Stomach Duodenum 37. Spleen 38. Umbilicus 39. Groin 40. Liver 41. Pancreas 42. Small intestine 43. Large intestine 44. Rectum 45. Anus 46. Appendix 47. Gallbladder 48. Bile ducts 49. Kidney 50. Ureter 51. Urethra 52. Bladder 53. Vulva 54. Vagina 55. Cervix 56. Corpus Uteri 57. Endometrium 58. Ovaries 59. Placenta 60. Fallopian Tubes 61. Testis 62. Scrotum 63. Epididymis and Vas deferens 64. Prostate 65. Penis 66. Arteries 67. Veins 68. Bone marrow 69. Skin 70. Connective tissue 71. Other endocrine glands 72. Other

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APPENDIX 3: JOB / PROFESSION CLASSIFICATION (ILO)

01 SCIENTIFIC AND TECHNICAL PERSONNEL (INCLUDING BUSINESSMAN WITH PRIVATE PROFESSIONS AND RELATED JOBS) - Physicist, Chemists and Similar Professions. - Architects, Engineers and Similar Technical Personnel - Pilots, Deck Officers, Machine Officers (Marine and Air) - Biologists, Scientific Agronomists and Similar Technicians - Medicine and Similar Professions - Statisticians, Mathematicians, System Analysts and Similar Technicians - Statisticians, Mathematicians, System Analysis and Similar Technicians - Economists - Financial Consultants and Accountants - Professions related to Law - Professions related to Education - Religion Men and Equivalents - Authors and Other Work of Arts Related to Literature - Sculptor, Artist (painter), Photographer and Relevant Members of Creative Arts - Artists of Music and Stage and Other Artists Related to Entertainment - Sportsmen and other Professions related to Sports - Differently Classified Scientific and Technical Professions and Etc 02 ENTREPRENEUR, DIRECTORS AND HIGH LEVEL ADMINISTRATORS - High Level Administrators of Legislation Organs and Public Sector. - Entrepreneurs and Administrators ( except commerce) 03 ADMINISTRATIVE PERSONNEL AND RELEVANT STUDIES - Group Chief of Office Officials. - Public Administrative Officials - Stenos, Typists, Operators of Card and Magazine Operators - Accountant Officials - Cashiers and the Staff Working for Similar Jobs - Staff That Works on Machines that Make Addition Operations - Chiefs of Transportation and Communication Services - People that Collect Tickets (Conductors) - Post Deliverer - Telephone and Telegraph Operators - Administrative Personnel who is not Classified Else Where and Similar Employees 04 COMMERCIAL AND SALE PERSONNEL Directors (Wholesale and Retail Price) Entrepreneurs and Administrators in Wholesale and Retail Commerce (Property Owner of Business) - Chief of Purchasing and Sales - Official and Technician of Business, Traveling Tradesmen - Insurance Agency and Real-Estate Commissioners, Income Bond Brokers, Sales Officials of Enterprises, Salesmen, People that Make Sales by Auction (Auction clerks) - Sales Commissioners, Commercial Clerks and People that Work for Similar Professions - Commercial and Sales Personnel who are not Classified Else Where
-

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05 PEOPLE WORKING IN SERVICE BUSINESS - Directors of Hotels, Coffeehouses, Saloons, Restaurants, Casinos, Pastry-shops, Movies, Theatres and Similar Places - Entrepreneur Property Owners that administrate Directors of Hotels, Coffeehouses, Saloons, Restaurants, Casinos, Pastry-shops, Movies, Theatres and Similar Places - Cook, Waiter/Witress, Barmen and Etc - Maids and Similar Employees - Property Guards, Cleaning Staff - Drycleaners, Laundrymen and Ironers - Hairdressers, Experts in Beauty Saloons and Similar - Personnel of Security and Protection Services 06 AGRICULTERISTS, LIVESTOCK DEALERS, FORESTERS, FISHERMEN AND HUNTERS - Agriculture Management Chiefs and Directors (including stewards) - Agriculture Managers (Producers) - Agriculture Employees - Employee of Forestry - Fishermen, Hunters and people working in similar professions 07 EMPLOYEES WORKING IN NON-AGRICULTURAL PRODUCTION AND THE ONES WHO USE MEANS OF TRANSPORTATION - Directors and Similar Authorities of Profession - Miner, Borer, etc - Employee of Production and Operation of Metal - Employee that do the Primary Preparation Procedures of Wood and Paper Production - Users of Oven and Chemical Tools - Textile employees - Leather, Fur, Tanning Works - Employees of Nutrition and Drink Industry - Tobacco employees - Tailors, Upholsters, etc - Shoe and Leather works - Carpentry Employees and Etc - Workers of Stone Sculpturing and Carving (including marble) - Workers that operate metal by labour work - Machine Mounters, Delicate, Punctual Instrument Repairers and Machine Operators (Except Electrics) - Employees of Electrics and Electronics - Operators of Radio, Television and Similar Media Stations Operators of Sound and Cinema Projection Instruments - Lead Pipe and Hygenienic Operators, Monitors of Can, Copper and Metal Pipe Workers - Jewelries - Workers of Glass and glass based goods Production, products of Ceramics and Soil - Plastic Material and Rubber Production Workers - Paper, Cartoon and Plating Goods - Printer, Bookbinder and Employees of Similar Professions - Painters - Employees that work in Production and Similar Affairs - Qualified Workmen of Construction, Carpenter and similar Construction Employee - Users of Stationary Establishment Machines - Employee of Loading Unloading and Users of Construction Machines

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Users of Transportations Machine

08 UNAPPOINTED EMPLOYEES People that look for a job for the first time, Unemployed and People that do not perform anything. - People that Work in a Job but can not Officially Identify - Military Members (Ones who give private answer as the main profession will be considered as unknown.) Except Civil Servants and Artisans) - Employee Classified Else Where - Unknown (Ones whose profession question is not answered)
-

00 NONE (Housewives, Retired, Students, Incapable of Working and Prisoners)

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APPENDIX 4: STANDARD CRITERIA PROPOSED IN DETERMINATION OF CAUSES OF DEATH WHICH OCCURRED DURING CHILDHOOD ERA WITH THE HELP OF VERBAL AUTOPSY METHOD.
1. CRITERIA CATEGORIES

Obligatory criteria(Z):This ciriteria should be found so as to diagnose. However it is necessary for the diagnosis . Accuracy criteria(D): If the obligatory criteria is performed it suppports diagnosis Auxiallary criteria(Y): It distinguishes possible cause of death from disease with similar symptoms and findings, it provides secondary data proofs for support of diagnosis. Diagnosis identifying criteria suggested for each cause of death are the required minimum criteria. Providing more criteria supports the diagnosis. 2. DEATHS WITHIN 0-28 DAYS 2.1. PREMATURITY D: pregnancy history shorter than 37 weeks

Highly probable diagnosis: 1D

2.2. LOW BIRTH WEIGHT Z: Pregnancy history longer than 37 weeks D: Born very small (As birth weight is often low in developing countries, the fact that the family states lowness of birth weight show that the infant was born very small.) D:Twins (Twins born in rural region are often born with a low birth weight )

Highly probable diagnosis: 1Z+1D

2.3. CONGENITAL MALFORMATION D: Infant with a given malformation

Highly probable diagnosis: 1D

2.4 BIRTH TRAUMA D: Crying right after birth (late crying > 3 minutes), non presence of respiration or respiration being slow during childbirth D: State of sleepiness or unconsiousness or non-presence of convulsion during or within 72 hours after birth D: Generalized flask state of an on-time-born baby during or within 72 hours after birth Y: Non presence of breast-feed or chewing of on-time-born baby during or within 24 hours after birth Y: Extended birth history (Primipar > within 24 hrs, for others >12 hrs) Y: Hip fractures and paralysis Y: Bulge in font anel Y: Syanosis or paleness at birth Y: Presentations except vertex Y: Instrumation history or manual manupulation at birth Y: Being the secondly born in twin birth Y: Low weighted infant Y: Very big infant Y: Meconium staint amnium fluide

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Probable diagnosis: 1D veya 2Y Highly probable diagnosis: 2D veya 1D+ 1Y

2.5. NEONATAL TETANUS Z: Birth of baby more than 4 days-old at death (despite the fact that possible minimum incubation duration is 48 hours, 90% of deaths related to neonatal tetanus are postpartum between 5th and 14th days. ). Z: Infant stopping breast feeding on the 4the days or afterwards D: Stiffness of body or backward twist on the 4th day or afterwards D: Infant unable to open mouth for nutrition (trismus) Y: Mother inoculated minimum 1 dose of tetanus toxoid vaccination during pregnancy Y: The fact that family acknowledges the disease as tetanus Y: Using dirty tools in cutting infants unbilical cord Y: The fact that person helping delivery did not wash his/her hands before birth Y: Omphalitis Probable diagnosis: 2Z+1D+1Y Highly probable diagnosis: 2Z+2D 2.6. NEONATAL PNEUMONI Z.Respiration symptoms starting 6 hours after delivery D: Rapid respiration that last more than 2 hours before death D: Respiratory distress (severe contraction suprasternal, intercostal and subcostal regions) D: Expratory sounds Y: Cough (Although new-borns have pneumoni they do not cough often, therefore cough is marked as Y). Y: Fever Y: Rejection to nutrition Y: Syanosis Probable diagnosis: 1 Z+ 1D Highly probable diagnosis: 1Z+ 2 D veya 1 Z+ 1D+1Y 2.7. POSTNATAL ASPIRATION Z. Severe coughing seizure following to feeding or vomitting Z: Respiratory symptoms initiating 6 hours after delivery D: Rapid respiration that last more than 2 hours before death D: Respiratory distress (severe contraction suprasternal, intercostal and subcostal regions) D: Expratory sounds Y: Cough (Although new-borns have pneumoni they do not cough often, therefore cough is marked as Y). Y: Fever Y: Rejecting nutrition Y: Syanosis Probable diagnosis: 2 Z+ 1D Highly probable diagnosis: 2Z+ 2 D veya 2 Z+ 1D+1Y 2.8. RESPIRATORY DISTRESS SYNDROME (consists of hyalen membran disease, congenital pneumi and meconium aspiration) Z:Initiation of respiratory symptoms within 6 hours after delivery D: Takipne Respiratory distress (severe contraction suprasternal, intercostal and subcostal regions) D: Expratory sounds Y: Syanosis

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Y: Thin sounded crying at birth ( show intra uterin infection n.) Y: In case of presence of the following predisposans - Prematurity - Extended birth (Primipar mothers > 24 hours, others > 12 hours) Probable diagnosis: 1 Z+ 1D Highly probable diagnosis: 1Z+ 2 D veya 1 Z+ 1D+2Y 2.9. DIAHHROEA Z: Loose or watery diahhroea more than 3 times a day Y: Vomitting Y: Reduction of breast feeding and liquid consumption by family D: Dehydratation (finding any of the symptoms as eye sphere or bulge in fontanel, oligury or darkening in colour of urine) Probable diagnosis: 1 Z Highly probabale diagnosis: 1Z+ 2 Y veya 1 Z+ 1D 2.10. DYSENTERY Z: Loose or watery diahhroea more than 3 times a day Y: Presence of blood or mucus in excrements Highly probable diagnosis: 1 Z+ 1D 2.11. HYPOTHERMY D: State of coldness at head, chest or stomach of the infant during 2 hours or more before death Highly probable diagnosis: 1D 2.12. NEONATAL SEPSISIS (consist of septisemy and menengitis) D: State of being sleepy, letargic or unconsiousness 72 hours after delivery (Compare with birth trauma) Y: Thin sounded crying at infant who was born on time Y: Sepsisis at skin or stomach Y: Fever Y. Hypothermy at infant not exposed to cold (Covered parts of body are also cold) Y: Presence of at least one of the following: vomitting, diarrhoea and abdominal distention Y: Spasm and convusions after the first 72 hours. Y: Jaundice Y: Syanosis in extremities Y: Apneic spells. Respiration of infant being regular at birth, and stopped with periods that last more than 20 seconds after Y. Existance of 1 or more of the following maternal factors - Extended membran rupture (> 24 hrs) - Extended delivery (primipar > 24 hrs, others > 12 hrs) - Amnion fluide with inflammate smell - During delivery or within last one week after delivery mothers suffering from fever that last more than 24 hours Probabale diagnosis: 1D+1Y veya 2Y Highly probable diagnosis: 1Z+ 2 Y veya 1 Z+ 1D 2.13. SUDDEN DEATH D: Sudden death of a healthy mother Highly probable diagnosis: 1D

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2.14. NUTRITION PROBLEM (rejecting nutrition, insufficiency in breast feeding and feeding with bottle ) D: Infants not being breast fed or fed by milk during a period that last 2 days or more preceding to infants death D: infants being fed with a bottle Highly probable diagnosis: 1D 2.15.OTHER Specify 2.16. UNKNOWN 3. DEATHS BETWEEN 29 DAYS- 5 YEARS

3.1. PREMATURITY D: PREGNANCY HISTORY SHORTER THAN 37 WEEKS (Findings of prematurity may not have been identified by the mother or midwives who helped in the delivery ) Highly probable diagnosis: 1 D 3.2. LOW BIRTH WEIGHT D:Born Very small (As birth weight is often low in developping countries, the fact that the family states lowness of birth weight show that the infant was born very small.) D:Twins (Twins born in rural region are often born with a low birth weight ) Highly probable diagnosis: 1 D 3.3. SEPTISEMI D: State of being sleepy, letargic or unconsiousness 72 hours after delivery (Compare with birth trauma) Y: Thin sounded crying at infant who was born on time Y: Sepsisis at skin or stomach Y:Fever Y: Hypothermy at infant not exposed to cold (covered parts of the body are also cold) Y: Presence of at least one of the following: vomitting, diarrhoea and abdominal distention Y: Spasm and convusions after the first 72 hours. Y: Jaundice Y: Syanosis in extremities Y: Apneic spells. Respiration of infant being regular at birth, and stopped with periods that last more than 20 seconds after. Y: Existance of 1 or more of the following maternal factors - Extended membran rupture (> 24 hrs) - Extended delivery (primipar > 24 hrs, others > 12 hrs) - Amnion fluide with inflammate smell - During delivery or within last one week after delivery mothers suffering from fever that last more than 24 hours Probable diagnosis:1 D+ 1 Y veya 2 Y Highly probable diagnosis: 1 D+2 Y veya 2 D +veya 3 Y 3.4. NUTRITION PROBLEM (Rejecting nutrition, insufficiency in breast feeding and feeding with bottle) D: Infants not being breast fed or fed by milk during a period that last 2 days or more preceding to infants death

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D: infants being fed with a bottle Highly probable diagnosis: 1 D 3.5. ACCIDENT, DROWNING,BURN, POISINING AND SNAKE BITE D: Existance of such an event before death Highly probable diagnosis: 1 D 3.6. MEASLES Z: RASH (skin erruption) THAT INITIATED MORE THAN 4 MONTHS OLD D:Fever and rash that last more than 3 days within 90 days preceding death D:Rash that was initially red, becoming pale following the blackening within 90 days before death D: Presence of red eyes+having cold or cough or Rash within 90 days before death Probable diagnosis:1 Z+ 1 D Highly probable diagnosis:1 Z + 1 D 3.7. MALNUTRITION (It doesnt contain protein energy malnutrition, middle level malnutrition) D: Incapacity to grow during a period of 4 months or more before death D: Excessive loss of weight and becoming thin during a period of 1 month or more before death D:.Back foot oedema D:Cheratomalazy Y: Breast feeding for a period less than 6 months or giving already prepared formules or cowmilk (usually by adding some water) during the first 3 months Y:Late inception of additional nutritions (After 9 months) Y:Not eating well during the period of 1 month or more before death (This results in acute or chronic malnutrition) Y:Recurrent diarrhoea (Existance of more than 3 episodes within 3 months before death) Y:History of measles or whooping cough within last 3 months Y:Mothers considering the infant as permenantly ill for the last 3 months Y:Infants being immobile and apathic during last month Y:Existance of night blindness Y:Familys stating illness as malnutirition (as a local terminology) Probable diagnosis: 1D veya 2 Y Highly probable diagnosis: 1 D + 1 Y veya 3 Y 3.8. PNEUMONI Z: Cough that last more than 24 hours D: Takipne initiating 6 hours before death (so as to distinguish from terminal catch) D:Respiratory distress findings initiated 6 hours before death (suprasternal, intercostal and subcostal contractions) Y:Fever Y:Santral syanosis intiated 1 hour before death Y:Wheezing Probable diagnosis: 1 Z + 1 Y Highly probable diagnosis: 1 Z + 1 D veya 2 D 3.9. WHOOPING COUGH Z: Cough that last more than 15 days with severe seizures D:Facial redness during coughing seizures Y: Infants not being inoculated against whooping cough Y: Existance of a whooping cough epidemic, contact history with a whooping cough patient.

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Y: Difficulty in nutrition related to coughing and vomitting Y: Disease being considered as whooping cough by the family (A a local terminology) Probable diagnosis: 1 Z + 2 Y Highly probable diagnosis: 1 Z + 1 D 3.10. DYSENTERY Z: Having excrements more than 3 times a day D: Existance of blood or mucus in excrements Highly probable diagnosis: 1 Z +1 D 3.11. PERMENANT DIARRHOEA Z: Having excrements more than 3 times a day D: Continuity of diarrhoea for more than 15 days Highly probable diagnosis: 1 Z + 1 D 3.12. ACUTE DIARRHOEA Z: Having watery excrements more than 3 times a day Y: Vomitting Y: Reducing water consumption D: Dehydratation (at least one of the following symptoms: thirstiness, oligury, darkening in colour of urine, eye holes, bulge in fontanel) Probable diagnosis: 1 Z Highly probable diagnosis: 1 Z + 2 Y veya 1 Z + 1 D 3.13. CENTRAL SYSTEM INFECTION (Menegitis Ansephalit, Cerebral Malaria) Z: Fever D: Loss of consciousness, changing sen sorium D: Convulsions, spasms Y:Otitis media Y:Fontanel pulsation Y: Family history for pulmoner tuberculosis Y: Stiffness in back part of the neck Y: Permenant headache and vomitting Y: Rejection of nutrition due to clenched jaw (Only for infants) Probable diagnosis: 1 Z + 2 Y veya 2 D Highly probable diagnosis: 1 Z +1 D veya 2 D 3.14. INIDENTIFIED FEVER Consists of causes except for the given causes: (pneumoni, measles ve central nerve system infections). Z: Fever D: Non-presence of rash, takipne, diarrhoea, convulsions or loss of consciousness Highly probable diagnosis: 1 Z+ 1 D 3.15. OTHER Specify

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