The Added Value of An Open Narrative in Verbal Autopsies – A Mixed-Methods Evaluation from Malawi

Background: The World Health Organization’s standardised verbal autopsy (VA) instrument consists of closed questions, ascertaining signs and symptoms of illness preceding death, and an optional open narrative. As VA analyses increasingly use automated algorithms, the inclusion of narratives should be justified. We evaluated the role of open narratives on VA processes, data quality and respondent emotion.Methods: A mixed-methods analysis was conducted using VA process data for deaths of children aged 0–59 months between April 2013 and November 2016 in Mchinji district, Malawi. Deaths were randomised at the point of interview to receive closed questions only or an open narrative followed by closed questions. Upon concluding the VA, interviewers self-completed questions relating to respondent emotions. Logistic regression was conducted to determine associations with visible emotions during VAs. A group discussion with the interviewers was conducted at the project end, to understand field experiences and explore future recommendations. Qualitative data were coded using deductive themes.Results: A total of 2509 VAs were included, with 49.8% (n = 1341) allocated to open narratives. Narratives lasted a median of 7 minutes (range: 1–113 minutes). Interviewers reported improved respondent rapport and felt narratives improved data quality, although there was no difference in the proportion of deaths with an indeterminate cause (5.3% vs. 6.1%). The majority of respondents did not display visible emotions during VA (81%). Those with a narrative had higher, but not statistically significant, odds of displaying emotion (aOR: 1.20; 95% CI: 0.98, 1.47). Factors associated with visible emotions were: infant deaths compared to neonates; deaths at a health centre or en-route to hospital versus home; and higher socio-economic status. Non-parental respondents and increased time between death and interview were associated with lower odds of emotion.Conclusion: Conducting an open narrative at the start of the VA to build rapport, something valued by the interviewers, may outweigh the additional time taken and slight increase in respondents becoming emotional. However, undue burdens associated with narratives may be further justified if the quality and utility of information from the narrative was promoted through standardised recommendations.