HEALTH INDICATORS AND

HEALTH DETERMINANTS
 Health Indicators

Health indicators are used to measure health of a

community
Health indicators can be used to compare health of
two communities
It can be used to assess the health needs of a
community
It is useful for monitoring and evaluation of health
programmes
 Qualities of an ‘indicator’

• Validity – The indicator should measure what

it is supposed to measure
• Reliability – It should give the same value
when measured by different people
• Sensitivity – It should show the changes in the
situation
 Health indicators

• Mortality indicators
• Morbidity indicators
• Disability rates
• Nutritional status indicators
• Health care delivery indicators
• Socio-economic indicators
• Indicators of quality of life
 Mortality indicators

• Crude death rate

• Specific death rate
• Case fatality rate
• Expectation of life
• Infant mortality rate
• Maternal mortality rate
 Crude death rate

• ‘is the number of deaths (from all causes) per

1000 estimated mid-year population in one
year, in a given place’

= Number of deaths during a year X 1000

Mid-year population
 Specific death rate
• Is the death rate due to a specific disease, or
in a specific age or sex group etc.
• Specific death rate due to Tuberculosis =

Number of deaths due to Tuberculosis during a year X 1000

Mid-year population
 Case fatality rate

• It is the number of people dying due to a

specific disease.
• It shows the severity of the disease
= Number of deaths due to a disease X 100
Total number of cases due to the disease
 Infant Mortality Rate (IMR)

• Number of infant deaths in a year per 1000

live births =
Number of deaths of children less than 1 year of age in a year X 1000
Number of live births in the same year
 Standardized mortality rate

• is the ratio of observed deaths in the study group to

expected deaths in the general population. This ratio
can be expressed as a percentage.
• Different countries have different population structure
• So it is possible to compare the mortality rates of the
countries
• We have standardize the mortality rate to make
effective comparisons
• We choose a standard population for comparison
 The requirements for calculating SMR for a cohort are

• First the age specific death rate of the

population of the country is calculated
• Then a ‘standard’ population is taken in which
the population of different age groups are
known
• Then the expected death of the standard
population is calculated from the death rate of
the country
 More ……..reading
• Age-specific mortality rate
• Crude death rate
• Maternal mortality rate
 Measurements of Morbidity

1) Incidence
2) Prevalence
Incidence: is the number of new cases per population at risk in a given
time period. The Incidence rate MUST contain the time period.
• Incidence rate = new cases in specific period of time X 1000
Population at that time
• Example: There are 500 new cases of Hepatitis A in a city with a
population of 30,000 in the year 2008 what is the incidence rate of
Hepatitis A.
• Incidence of hepatitis A = 500 X 1000
30,000
= 16.7 per 1000 per year
 Prevalence

• It is the proportion of cases in the population at

a given time rather than rate of occurrence of
new cases.
• Prevalence is defined as all cases (old and new)
present at a given point of time or a period of
time in a given population.
• Prevalence is of two types:
• Point prevalence
• Period prevalence
• Point Prevalence
• Point prevalence refers to the total number of
cases (old and new) present at given point of
time, usually a day.
• Prevalence of Cutaneous leishmaniasis in Zawia
on 5th May, 2009
• Normally when we say prevalence it is Point
Prevalence
 Period Prevalence

• Is the total number of cases (old and new)

existing during a defined period of time in a
defined population.
• Prevalence of Pulmonary Tuberculosis in Zawia
in year 2008
 Physical Quality of Life Index
• Quality of life is difficult to define and
measure.
• One method is to combine three indicators –
Infant Mortality rate, Life expectancy at 1 year
of age and Literacy
• The index is calculated for each country
• The maximum is 100 and minimum 0
 Human Development Index

• Human Development Index is calculated from

Longevity (life expectancy at birth), Knowledge
(adult literacy rate and mean years of
schooling) and Income (Gross Domestic
Product per capita)
• Maximum is 1 and minimum 0
 Section 2
HEALTH DETERMINANTS
 The determinants of health
• Many factors combine together to affect the
health of individuals and communities.
 The determinants of health include:

• the social and economic environment,

• the physical environment,
• the person’s individual characteristics and behaviours.
• Income and social status - higher income and social status are linked to
better health. The greater the gap between the richest and poorest
people, the greater the differences in health.
• Education – low education levels are linked with poor health, more stress
and lower self-confidence.
• Physical environment – safe water and clean air, healthy workplaces, safe
houses, communities and roads all contribute to good health.
Employment and working conditions – people in employment are
healthier, particularly those who have more control over their working
conditions
• Social support networks – greater support from families, friends and
communities is linked to better health. Culture - customs and
traditions, and the beliefs of the family and community all affect
health.
• Genetics - inheritance plays a part in determining lifespan, healthiness
and the likelihood of developing certain illnesses. Personal behaviour
and coping skills – balanced eating, keeping active, smoking, drinking,
and how we deal with life’s stresses and challenges all affect health.
• Health services - access and use of services that prevent and treat
disease influences health
• Gender - Men and women suffer from different types of diseases at
different ages.
 Natural History of Disease
• It is the course a disease takes in individual
people from its pathological onset until its
eventual resolution through complete
recovery , death and or complications in the
absence of intervention.
 Natural History of Disease

• The natural history of disease can be seen as having three stages:

1- Predisease stage, the latent (a symptomatic) disease stage.
- During the predisease stage —the individual can be seen as
possessing various factors that promote or resist disease. These
factors include genetic makeup, demographic characteristics
(especially age), environmental exposures, nutritional history, social
environment, immunologic capability, and behavioral patterns.
- If the underlying disease is detectable by a reasonably safe and cost-
effective means during this stage, screening may be feasible. In this
sense, the latent stage may represent a window of opportunity during
which detection followed by treatment provides a better chance of
cure or at least effective treatment, to prevent or symptomatic
disease.
• For some diseases, such as pancreatic cancer,
there is no window of opportunity because
safe and effective screening methods are
unavailable. For other diseases, such as rapidly
progressive conditions, the window of
opportunity may be too short to be useful for
screening programs.
2- Symptomatic disease stage.
• When the disease is advanced enough to
produce clinical manifestations, it is in the
symptomatic stage. Even in this stage, the
earlier the condition is diagnosed and treated,
the more likely the treatment will delay death
or serious complications, or at least provide
the opportunity for effective rehabilitation.
 Levels of Prevention

• A useful concept of prevention that was

developed or at least popularized in the classic
account by Leavell and Clark has come to be
known as Leavell's levels. Based on this concept,
all the activities of clinicians and other health
professionals have the goal of prevention. There
are three levels of prevention .The factor to be
prevented depends on the stage of health or
disease in the individual receiving preventive care.
 Modified Version of Leavell's Levels of
Prevention
Stage of
Disease and Level of Prevention Appropriate Response
Care
Predisease Stage
Health promotion (e.g., encourage healthy
No known risk
factors Primary prevention changes in lifestyle, nutrition, and
environment)
Specific protection (e.g., recommend
Disease nutritional supplements, immunizations,
Primary prevention
susceptibility and occupational and automobile safety
measures)
Latent Disease
“Hidden” Screening (for populations) or case finding
stage;
Secondary prevention (for individuals in medical care) and
asymptomatic treatment if disease is found
disease
Symptomatic Disease
Disability limitation (i.e.,
institute medical or
Initial care Tertiary prevention surgical treatment to limit
damage from the disease
and institute primary
prevention measures)
Rehabilitation (i.e.,
identify and teach
Subsequent care Tertiary prevention methods to reduce
physical and social
disability)
Although Leavell originally categorized disability limitation under secondary
prevention, it has become customary in Europe and the United States to classify
disability limitation as tertiary prevention because it involves the management of
symptomatic disease.
• Primary prevention keeps the disease process
from becoming established by eliminating
causes of disease or by increasing resistance
to disease .
• Secondary prevention interrupts the disease
process before it becomes symptomatic .
• Tertiary prevention limits the physical and
social consequences of symptomatic disease .
 1- Health Promotion

• Health-promoting activities usually contribute to the primary

(and often secondary and tertiary) prevention of a variety of
diseases and enhance a positive feeling of health and vigor. These
activities consist of nonmedical efforts, such as changes in
lifestyle, nutrition, and the environment. Such activities may
require structural improvements in society to enable more
people to participate in them. These improvements require
societal changes that make healthy choices easier. Dietary
modification may be difficult unless a variety of healthy foods are
available in local stores at a reasonable cost. Exercise is more
difficult if bicycling or jogging is a risky activity because of
automobile traffic or social violence. Even more basic to health
promotion is the assurance of the basic necessities of life,
including freedom from poverty, environmental pollution, and
violence.
• Health promotion applies to noninfectious diseases and to
infectious diseases. Infectious diseases are reduced in
frequency and seriousness where the water is clean, where
liquid and solid wastes are disposed of in a sanitary manner,
and where animal vectors of disease are controlled.
Crowding promotes the spread of infectious diseases,
whereas adequate housing and working environments tend
to minimize the spread of disease. In the barracks of soldiers,
for example, even a technique as simple as requiring soldiers
in adjacent cots to sleep with their pillows alternating
between the head and the foot of the bed can reduce the
spread of respiratory diseases, because it doubles the
distance between the soldiers' upper respiratory tracts
during sleeping time.
 2- Specific Protection

• Usually, general health-promoting changes in environment,

nutrition, and behavior are not fully effective. Therefore, it
becomes necessary to employ specific protection .This form of
primary prevention is targeted at a specific disease or type of
injury. Examples include immunization against poliomyelitis;
pharmacologic treatment of hypertension to prevent
subsequent end-organ damage; use of ear-protecting devices
in loud working environments, such as around jet airplanes;
and use of seat belts, air bags, and helmets to prevent bodily
injuries in automobile and motorcycle crashes. Some measures
provide specific protection while contributing to the more
general goal of health promotion. Fluoridation of water
supplies not only helps to prevent dental caries but also is a
nutritional intervention that promotes stronger bones.