Mortality and morbidity aspects of self-care and barriers to accessing healthcare among Type 2 Diabetes Mellitus: novel applications in the Saudi and Swedish context

The case of verbal autopsy method to strengthen medical certifications in industerialised settings

Chronic non-communicable diseases such as cardiovascular (CVD) and type 2 diabetes mellitus (T2DM) diseases are increasingly posing major concerns globally, including Saudi Arabia due to their significant burden. While only about half of the world deaths report information on corresponding causes of death (the formal medical documentation process of the actual cause of death at the time of death), Saudi reports reveal gaps of 25-30% of reliable and complete medical certification of causes of death, including cardiovascular and type 2 diabetes deaths.

Furthermore, biomedical causes of death (like organ failure, loss of blood due to accident...etc) are often the prime focus of public health interventions, whereas other social, logistical and health system circumstances leading to death, which are equally important to the understanding the of the pathway to death, are unmeasured.

For instance, if we hypothetically had the case that a person experiencing stroke symptoms had no choice but to remain at home and take some basic or traditional medications due to difficulties with the logistic or available resources to reach to the nearest hospital, or possibly due to personal or household decision undermining the necessity to seek medical assistance, and consequently dies of stroke. Whereas, another person experiencing the same stroke symptoms but managed to attend a healthcare facility for treatment but also dies of stroke due to delay or inadequacy of care received, then both persons would typically be registered with the same biomedical cause of death data point (stroke), however both had different circumstances of death - i.e. how likely the first person would have died if s/he attended medical care on time and how likely the other person would have died if s/he received adequate care!

Towards global and national agenda, measuring the medical and non-medical causes of death in systematic way would facilitate a harmonized approach to measuring access to and adequacy of medical services.

In the context of chronic diseases such as CVD and T2DM, which are among the leading causes of death in Saudi Arabia, this research project aims to explore the mortality aspects, plausibility, acceptability, and adequacy of the proposed methods of Verbal Autopsy (VA) to be integrated into the Saudi medical certification process to improve the reliability of causes of death reported, which should more adequately guide policy-making and funding allocations for public health priorities. In settings where causes of death information are incomplete or reliable, which can be associated with industrialized or non-industrialized countries, verbal autopsy emerges as a pragmatic solution, supplementing medical certification and offering valuable insights into specific locations or probable causes.

VA is a WHO-standardized interview conducted by a trained person with the family or other caregivers of the deceased who have detailed knowledge of the circumstances, signs, and symptoms leading to the death, and the interview data are then processed into likely medical causes of death. VA is a widely spread as a validated pragmatic approach to filing gaps of causes of death. More recently, the VA has been innovated and validated to include the possibility of exploring non-medical causes of death, such as economic, social, logistical and health system factors that have prevented or delayed patients from accessing healthcare and ultimately contributed to their death.