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

Lucia D'Ambruoso, Jessica Price, Eilidh Cowan, Gerhard Goosen, Edward Fottrell, Kobus Herbst, Maria Van Der Merwe, Jerry Sigudla, Justine Davies, Kathleen Kahn

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Recognising that the causes of over half the world’s deaths pass unrecorded, the World Health Organization (WHO) leads development of Verbal Autopsy (VA): a method to understand causes of death in otherwise unregistered populations. Recently, VA has been developed for use outside research environments, supporting countries and communities to recognise and act on their own health priorities. We developed the Circumstances of Mortality Categories (COMCATs) system within VA to provide complementary circumstantial categorisations of deaths.
Refine the COMCAT system to (a) support large-scale population assessment and (b) inform public health decision-making.
We analysed VA data for 7,980 deaths from two South African Health and Socio-Demographic Surveillance Systems (HDSS) from 2012 to 2019: the Agincourt HDSS in Mpumalanga and the Africa Health Research Institute HDSS in KwaZulu-Natal. We assessed the COMCAT system’s reliability (consistency over time and similar conditions), validity (the extent to which COMCATs capture a sufficient range of key circumstances and events at and around time of death) and relevance (for public health decision-making).
Plausible results were reliably produced, with ‘emergencies’, ‘recognition, ‘accessing care’ and ‘perceived quality’ characterising the majority of avoidable deaths. We identified gaps and developed an additional COMCAT ‘referral’, which accounted for a significant proportion of deaths in sub-group analysis. To support decision-making, data that establish an impetus for action, that can be operationalised into interventions and that capture deaths outside facilities are important.
COMCAT is a pragmatic, scalable approach enhancing functionality of VA providing basic information, not available from other sources, on care seeking and utilisation at and around time of death. Continued development with stakeholders in health systems, civil registration, community and research environments will further strengthen the tool to capture social and health systems drivers of avoidable deaths and promote use in practice settings.
Original languageEnglish
Article number2000091
Number of pages16
JournalGlobal Health Action
Publication statusPublished - 4 Apr 2022

Bibliographical note

The authors acknowledge the South African Population Research Infrastructure Network (SAPRIN), the African Health Research Institute (AHRI) and the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) for their support. The authors gratefully acknowledge Chodwizadziwa Kabudula, Daniel Mahlangu, Dickman Gareta and Siyabonga Nxumalofrom from the Agincourt and AHRI HDSSs who supported with data, and individuals who supported the development and main- tenance of the OpenVA software, particularly Dr Jason Thomas from Ohio State University who assisted in the development of the ‘referral’ COMCAT. The authors would also like to thank Professor Sam Clark for support and advice.

Funding information
Conceptualisation of COMCAT was supported through a parent study funded by the Joint Health Systems Research Initiative from Department for International Development (DFID)/Medical Research Council (MRC)/ Wellcome Trust/Economic and Social Research Council (ESRC) (Medical Research Charities Group MR/ P014844/1). Support was also provided through the UKRI Covid-19 Extension Allocation Fund (RG15639-15) and by the University of Aberdeen and the Scottish Funding Council (SFC) (SF10206-45).

Data Availability Statement

Data are available from the respective HDSS repositories.


  • Causes of death
  • circumstances of mortality
  • South Africa
  • verbal autopsy
  • Autopsy/methods
  • Reproducibility of Results
  • Rural Population
  • South Africa/epidemiology
  • Humans
  • Cause of Death
  • CARE


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