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Background: Death rarely results from a single cause; it can be caused by a variety of factors. Multiple causes of death (MCD) can provide information about the associations between causes of death revealing common combinations of conditions. Moreover, they can rectify inconsistencies in the death certificates (DC). Objective: This paper is meant to highlight the importance of multiple causes of death and point out the contributing and associated disease conditions to the underlying cause of death (UCD). Methods: The study was based on analysis of multiple causes of death for the Kuwaiti population 40 years or over in the period 1993-2001. All multiple causes up to 5 in the death certificate notification (DCN) were coded and analyzed. The data were coded according to ICD9 following the WHO rules. The ratios for the MCD/UCD were computed for the groups of diseases and for individual causes exceeding 50 entries. The relative ratios (Observed/Expected) were computed to show the associations between the groups of causes. Results: A total of 13960 DCNs were analyzed, the ratios were low for neoplasms (1.51), followed by respiratory (2.50), nervous (2.97), and digestive conditions (3.01), Ill-defined conditions had the highest ratio (13.40). Infections and genitourinary diseases had ratios of 4.19 and 4.56. Ranking changed when using MCD; circulatory, endocrinal, nervous and digestive conditions kept their position, with circulatory diseases on the top and nervous conditions occupying position 10. Relative risk (RR) was computed for the different groups; positive RR was found between infections and respiratory, digestive, genitourinary and ill-defined disease conditions. Neoplasms showed positive association was other neoplasms, and endocrine conditions were positively associated with circulatory, respiratory, and genitourinary conditions. A positive association was found between illdefined conditions with circulatory and other Ill-defined conditions. Conclusions: UCD is still essential to analyze historical trends, compare countries, and guide prevention of death; MCD offer a new sight into the study of mortality. The combination of the 2 methodologies is more useful than the isolated use of either approach. Conclusion and Recommendations: The Collection of MCD is essential, there has been major development in the area and soft ware was developed to analyze MCD data. MOH should start the development of data bases for MCD, make them available, and include the highlights in the MOH annual reports. Special reports discussing individual disease conditions particularly neoplasms and circulatory and respiratory conditions should be organized.

Analysis of the Underlying and Multiple Causes of Death for the Kuwaiti Population 40 years or over; Part II: Causes