. 2024 Dec 30;22:177. doi: 10.1186/s12961-024-01275-8

Table 2.

Overview of the quantitative and qualitative findings from the study, The potential of an electronic death registration system in South Africa: a feasibility and acceptability study (July—November 2022)

Emerging themes	Questionnaire answers	Interview perceptions and quotes
Importance of cause of death data	80.8% (168/208) indicated mortality statistics were very important, giving a rating of 5/5, 16.8% (35/208) gave a 4/5 rating for the importance of mortality statistics and < 3.0% gave a rating of 3/5 or less 82.1% (69/84) of doctors and 75.7% (28/37) of nurses gave a rating of 5/5 for importance of mortality statistics, 16.7% (14/84) of doctors and 18.9% (7/37) of nurses gave a rating of 4/5, 1.2% (1/84) of doctors and 5.4% (2/37) of nurses gave a rating of 3/5 or less	When asked “How could these data (mortality data) help with public health planning and monitoring?” (N = 171) Respondents reported: - 38.6% (66/171) stated for health planning, prevention, and interventions - 24.0% (41/171) stated to determine resource allocation - 14.6% (25/171) stated to identify disease priorities - 8.2% (14/171) stated for health policy development -8.2% (14/171) stated for public health surveillance 6.4% (11/171) stated to identify areas of training	“Death statistics are one of the only pure sources of data in terms of understanding what is happening in the community… to identify (health) needs.” ID6, female, health facility manager “Critically important … if we had better and more complete recording on cause of death data, I think it would be really useful to really understand the burden of disease in South Africa and mortality and to do more nuanced analysis around population groups.” ID2, female, public health specialist “Important, especially when it comes to funeral insurance. Most funeral directors have funeral insurance packages, so the mortality statistics are used there….it also helps control and manage your business better.” ID12, male, funeral director
Perceived quality of cause of death data	46.2% (96/208) rated the quality 3/5 29.3% (61/208) rated it 2/5 or less 12.5% (26/208) rated it 5/5 (good quality) Among providers, 52.4% (44/84) of doctors and 48.6% (18/37) of nurses gave a rating of 3/5 for the quality of current COD data A much higher percentage of nurses rated the quality 5/5 compared with doctors [32.4% (12/37) of nurses versus 2.4% (2/84) of doctors]	When asked “Why would you be concerned with the high proportion of ill-defined causes in a mortality data set?” (N = 85) Respondents reported: - 72.8% (62/85) stated “it would bias the data and affect its usefulness for planning.” -15.3% (13/85) stated “it shows the lack of training of medical certifiers and a lack of understanding of the importance of the data.” - 11.8% (10/85) had other concerns	“Probably quite bad, particularly for people that die at home, you do not necessarily know what they die of. For people who die in-hospital … that is fairly reliable information, so it depends on where you are.” ID9, female, medical doctor “High percentage of unknown causes, which leads to poor quality data” ID10, female, medical officer “Not accurate, take an example, during COVID, there were a lot of COVID deaths, … we had families that insisted that (COVID) should not go on the death notification. It distorted the figures.” ID12, male, funeral director
Drivers behind the quality of death data	Not applicable	When asked “How could cause of death data be made fit for purpose (N = 115) Respondents reported: - 43.5% (50/115) stated “improve training in MCCD and ICD-10 coding” - 20.9% (24/115) stated “introducing an online, centralized system” - 12.3%(14/115) stated “improve data capture accuracy” - 7.0% (8/115) stated “timely release of the data” - 7.0% (8/115 stated “improve access to the data” - 4.3% (5/115) stated “integrate mortality with other systems for example, Dept of Justice.” - 2.6% (3/115) stated “Implement audit of MCCD/M&M meetings” - 1.7% (2/115) stated “Review/update MCCD form” - 0.9% (1/115) stated that system design should be simple	“Junior doctors don’t understand that the form is for statistical purposes, they think the form is just for legal purposes….when they fill in the form….they want to tell the whole story…so they do not get sued.” ID6, female, medical director “There are a lot of deaths at home … so there are a lot of deaths notified where it is mostly guesswork and I do not think there is a lot we can do about that” ID10, female, medical officer “Resources, obviously, most of our people do not have a regular physician that they attend … stigma as well. Certain diseases people do not want to be associated with.” ID12, male, funeral director “The focus must be on the quality of the data that is submitted and that really does require having the right system, the right tool, and the right training of healthcare providers to submit their data.” ID2, female, public health specialist
Acceptability of an EDRS	“Would you use an electronic system?” - 144/208 (69.2%) responded “yes” - 45/208 (21.6%) responded “maybe” - 19/208 (9.1%) responded “no”	When asked to identify the barriers to implementing an online system (N = 158) Respondents reported: - 43.0% (68/158) said “poor internet access.” - 19.6% (31/158) said “poor connectivity owing to power outages.” - 9.5% (15/158) said that poor computer literacy would be an issue - 8.9% (14/158) felt that poor funding and limited staff would be a problem -6.3% (10/158) said Corruption and theft of cables, electronic devices, and funding -5.1% (8/158) said “Integration of data from different sources/organizations” - 7.6% (12/158) identified other barriers	“It will stop papers from getting lost” ID10, female, medical officer “It will get the data to Stats SA⁵ quicker than the paper copy and maybe that will decrease the time lag of the publication of data “ ID10, female, medical officer “It would make our lives so much easier…removing the person (at Home affairs) behind the computer…” ID11, male, funeral director “I think it is possible to have an online system … that will give you immediate analytics and summaries which would be very powerful data, for action” ID2, female, public health specialist

Emerging themes

Questionnaire answers

Interview perceptions and quotes

Survey (N = 208)

Online workshop questionnaire (N varies by question)

Importance of cause of death data

80.8% (168/208) indicated mortality statistics were very important, giving a rating of 5/5, 16.8% (35/208) gave a 4/5 rating for the importance of mortality statistics and < 3.0% gave a rating of 3/5 or less

82.1% (69/84) of doctors and 75.7% (28/37) of

nurses gave a rating of 5/5 for

importance of mortality statistics, 16.7% (14/84) of doctors and 18.9% (7/37) of nurses gave a rating of 4/5, 1.2% (1/84) of doctors and 5.4% (2/37) of nurses gave a rating of 3/5 or less

When asked “How could these data (mortality data) help with public health planning and monitoring?” (N = 171)

Respondents reported:

- 38.6% (66/171) stated for health planning, prevention, and interventions

- 24.0% (41/171) stated to determine resource allocation

- 14.6% (25/171) stated to identify disease priorities

- 8.2% (14/171) stated for health policy development

-8.2% (14/171) stated for public health surveillance

6.4% (11/171) stated to identify areas of training

“Death statistics are one of the only pure sources of data in terms of understanding what is happening in the community… to identify (health) needs.” ID6, female, health facility manager

“Critically important … if we had better and more complete recording on cause of death data, I think it would be really useful to really understand the burden of disease in South Africa and mortality and to do more nuanced analysis around population groups.” ID2, female, public health specialist

“Important, especially when it comes to funeral insurance. Most funeral directors have funeral insurance packages, so the mortality statistics are used there….it also helps control and manage your business better.” ID12, male, funeral director

Perceived quality of cause of death data

46.2% (96/208) rated the quality 3/5 29.3% (61/208) rated it 2/5 or less

12.5% (26/208) rated it 5/5 (good quality)

Among providers, 52.4% (44/84) of doctors and

48.6% (18/37) of nurses gave a rating

of 3/5 for the quality of current COD data

A much higher percentage of nurses rated the quality 5/5 compared with doctors

[32.4% (12/37) of nurses versus 2.4% (2/84) of doctors]

When asked “Why would you be concerned with the high proportion of ill-defined causes in a mortality data set?” (N = 85)

Respondents reported:

- 72.8% (62/85) stated “it would bias the data and affect its usefulness for planning.”

-15.3% (13/85) stated “it shows the lack of training of medical certifiers and a lack of understanding of the importance of the data.”

- 11.8% (10/85) had other concerns

“Probably quite bad, particularly for people that die at home, you do not necessarily know what they die of. For people who die in-hospital … that is fairly reliable information, so it depends on where you are.” ID9, female, medical doctor

“High percentage of unknown causes, which leads to poor

quality data” ID10, female, medical officer

“Not accurate, take an example, during COVID, there were a lot of COVID deaths, … we had families that insisted that (COVID) should not go on the death notification. It distorted the figures.” ID12, male, funeral director

Drivers behind the quality of death data

Not applicable

When asked “How could cause of death data be made fit for purpose (N = 115)

Respondents reported:

- 43.5% (50/115) stated “improve training in MCCD and ICD-10 coding”

- 20.9% (24/115) stated “introducing an online, centralized system”

- 12.3%(14/115) stated “improve data capture accuracy”

- 7.0% (8/115) stated “timely release of the data”

- 7.0% (8/115 stated “improve access to the data”

- 4.3% (5/115) stated “integrate mortality with other systems for example, Dept of Justice.”

- 2.6% (3/115) stated “Implement audit of MCCD/M&M meetings”

- 1.7% (2/115) stated “Review/update MCCD form”

- 0.9% (1/115) stated that system design should be simple

“Junior doctors don’t understand that the form is for statistical purposes, they think the form is just for legal purposes….when they fill in the form….they want to tell the whole story…so they do not get sued.” ID6, female, medical director

“There are a lot of deaths at home … so there are a lot of deaths notified where it is mostly guesswork and I do not think there is a lot we can do about that” ID10, female, medical officer

“Resources, obviously, most of our people do not have a regular physician that they attend … stigma as well. Certain diseases people do not want to be associated with.” ID12, male, funeral director

“The focus must be on the quality of the data that is submitted and that really does require having the right system, the right tool, and the right training of healthcare providers to submit their data.” ID2, female, public health specialist

Acceptability of an EDRS

“Would you use an electronic system?”

- 144/208 (69.2%) responded “yes”

- 45/208 (21.6%) responded “maybe”

- 19/208 (9.1%) responded “no”

When asked to identify the barriers to implementing an online system (N = 158)

Respondents reported:

- 43.0% (68/158) said “poor internet access.”

- 19.6% (31/158) said “poor connectivity owing to power outages.”

- 9.5% (15/158) said that poor computer literacy would be an issue

- 8.9% (14/158) felt that poor funding and limited staff would be a problem

-6.3% (10/158) said Corruption and theft of cables, electronic devices, and funding

-5.1% (8/158) said “Integration of data from different sources/organizations”

- 7.6% (12/158) identified other barriers

“It will stop papers from getting lost” ID10, female, medical officer

“It will get the data to Stats SA⁵ quicker than the paper copy and maybe that will decrease the time lag of the publication of data “ ID10, female, medical officer

“It would make our lives so much easier…removing the person (at Home affairs) behind the computer…” ID11, male, funeral director

“I think it is possible to have an online system … that will give you immediate analytics and summaries which would be very powerful data, for action” ID2, female, public health specialist

COD Cause of Death, MCCD medical certificate of cause of death, ICD-10 International Classification of Diseases 10th revision, EDRS electronic death registration system, Stats SA Statistics South Africa