Indicators of Health

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INDICATORS OF HEALTH 1 Guide: Dr B G Parasuramalu By: Dr Malatesh Undi

Plan Of Presentation:

Plan Of Presentation Introduction Health Indicators of Health Characteristics Uses Classification of Indicators of Health Millennium Development Goals Summary References 2


Health Health is defined as “ a state of complete physical, mental & social wellbeing, and not merely an absence of disease or infirmity” (WHO) This statement has been amplified to include the ability to lead a “socially and economically productive life” Health cannot be measured in exact measurable forms Hence measurement have been framed in terms of illness (or lack of health), consequences of ill-health (morbidity, mortality) & economic, occupation & domestic factors that promote ill health- all the antithesis of health. 3

Indicators of Health:

Indicators of Health 4 Indicator also termed as Index or Variable is only an indication of a given situation or a reflection of that situation Health Indicator is a variable, susceptible to direct measurement, that reflects the state of health of persons in a community. Indicators help to measure the extent to which the objectives and targets of a programme are being attained. Health Index is a numerical indication of the health of a given population derived from a specified composite formula.


Characteristics Valid – they should actually measure that they are supposed to measure Reliable – the results should be the same when measured by different people in similar circumstances Sensitive – they should be sensitive to changes in the situation concerned Specific – they should reflect changes only in the situation concerned Feasible – they should have the ability to obtain data when needed Relevant – they should contribute to the understanding of the phenomenon of interest 5

Uses of Indicators of Health:

Uses of Indicators of Health Measurement of the health of the community. Description of the health of the community. Comparison of the health of different communities. Identification of health needs and prioritizing them. Concurrent evaluation and terminal evaluation of health services. Planning and allocation of health resources. Measurement of health successes . 6

Classification of Indicators of Health:

Classification of Indicators of Healt h Mortality Indicators Morbidity Indicators Disability Rates Nutritional Indicators Health Care Delivery Indicators Utilization Rates Indicators of Social And Mental Health Environmental Indicators Socio-economic Indicators Health Policy Indicators Indicators of Quality of Life Other Indicators 7

Mortality Indicators :

Mortality Indicators Crude Death Rate is considered a fair indicator of the comparative health of the people. It is defined as the number of deaths per 1000 population per year in a given community, usually the mid-year population The usefulness is restricted because it is influenced by the age-sex composition of the population, socioeconomic and socio-cultural environment of the communities. Current CDR is 7.48 deaths/1,000 population (Source: ) 8

Mortality Indicators :

Mortality Indicators Expectation of life is the average number of years that will be lived by those born alive into a population if the current age specific mortality rates persist. It is a statistical abstraction based on existing age-specific death rates. Estimated for both sexes separately. Good indicator of socioeconomic development Positive health indicator of long time survival Life expectancy at birth: Total population: 66.8 years male: 65.77 years female: 67.95 years (Source: ) 9

PowerPoint Presentation:

Infant mortality rate The ratio of deaths under 1yr of age in a given year to the total number of live births in the same year, usually expressed as a rate per 1000 live births Indicator of health status of not only infants but also whole population & socioeconomic conditions Sensitive indicator of availability, utilization &effectiveness of health care, particularly perinatal care. Current IMR – 47.57/1000live birth (Source: ) Under-5 Proportionate Mortality rate Defined as proportion of total deaths occurring in the under-5 age group Reflects both infant and child mortality Current rate – 66.59/1000 (Source: ) 10

Steady decline in IMR (figures per 1000 live birth):

Steady decline in IMR (figures per 1000 live birth) 11 NFHS-3, India, 2005-06

Child Mortality Rate:

Child Mortality Rate The number of deaths at ages 1-4yrs in a given year, per 1000 children in that age group at the mid-point of the year. Correlates with inadequate MCH services, malnutrition, low immunization coverage and environmental factors Current rate – 18/1000 (Source: ) Other indicators are Perinatal mortality rate, Neonatal mortality rate, Stillbirth rate, etc. Correlates with inadequate antenatal care and perinatal care 12

NFHS-3, India (2005-2006) (figures per 1000 live birth) :

NFHS-3, India (2005-2006 ) (figures per 1000 live birth) 13 NFHS-3, India, 2005-06

Mortality Indicators :

Mortality Indicators Maternal Mortality Rate Ratio of number of deaths arising during pregnancy or puerperal period per 1000 live births Accounts for the greatest number of deaths among women of reproductive age in developing countries Current MMR – 254/100000 live births (Source: ) Disease Specific Death Rate is mortality rate which is computed for specific diseases. E.g. TB mortality is 23 per 100000 population per year . (Source: TB INDIA 2011 RNTCP Annual Report 2011) Proportional Mortality Rate is the proportion of all deaths attributed to the specific disease E.g. Coronary heart disease causes 25 to 30 % of all deaths in developed world. 14

Morbidity Indicators:

Morbidity Indicators Morbidity Indicators reveal the burden of ill health in a community, but do not measure the subclinical or inapparent disease states. 1. Incidence and Prevalence Incidence The number of new events or new cases of a disease in a defined population, within a specified period of time. E.g. Incidence of TB (new sputum+ve cases) is 168 per 100000 population per year . (Source: TB INDIA 2011 RNTCP Annual Report 2011) Prevalence The total number of all individuals who have an attribute or disease at a particular time divided by population at risk of having attribute or disease at this point of time Reflects the chronicity of the disease E.g. Prevalence of TB (sputum+ve in population) is 249 per 100000 population .(Source: TB INDIA 2011 RNTCP Annual Report 2011) 15

Morbidity Indicators:

Morbidity Indicators Notification rates is calculated from the reporting to public authorities of certain diseases e.g. yellow fever , poliomyelitis - They provide information regarding geographic clustering of infections, quality of reporting system etc. Attendance rates at OPDs and at health centers. Admission, Readmission and discharge rates. Duration of stay in hospital – reflects the virulence and resistance developed by the etiological factor Spells of sickness or absence from work or school. - reflects economical loss to the community Hospital data constitute a basic and primary source of information about diseases prevalent in the community. 16

Disability Rates:

Disability Rates Disability Rates are of two categories Event type Indicators - number of days of restricted activity - bed disability days - work-loss days within a specified period Person type Indicators - limitation of mobility e.g. confined to bed, confined to house, special aid in getting around. - limitation of activity e.g. limitation to perform the basic activities of daily living (ADL) e.g. eating, washing, dressing, etc. 17

Disability Rates:

Disability Rates Sullivan’s Index refers to “expectation of life free of disability”. Sullivan’s Index = life expectancy of the country -probable duration of bed disability and inability to perform major activities from. It is considered as one of the most advanced indicators currently available. HALE is Health Adjusted Life Expectancy. It is based on the framework of WHO’s ICIDH. It is based on life expectancy at birth but includes an adjustment for time spent in poor health. It is the equivalent number of years in full health that a newborn can expect to live based on current rates of ill-health and mortality. 18

Disability Rates:

Disability Rates DALY s : Disability Adjusted Life Years . It is defined as the number of years of healthy life lost due to all causes whether from premature mortality or disability. It is the simplest and the most commonly used measure to find the burden of illness in a defined population and the effectiveness of the interventions Two things needed to measure DALYs are - Life table of that country, to measure the losses from premature deaths - Loss of healthy life years resulting from disability; the disability may be permanent (polio) or temporary (TB, leprosy), physical or mental. 19

Disability Rates:

Disability Rates Uses of DALYs To assist in selecting health service priorities To identify the disadvantaged groups Targeting health interventions Measuring the results of health interventions Providing comparable measures for planning & evaluating programmes To compare the health status of different countries DALY express years of life lost to premature death and years lived with disability for the severity of the disability One DALY is one lost year of healthy life 20

Disability Rates:

Disability Rates Premature death – defined as one that occurs before the age to which a dying person could have expected to survive if he or she was a member of a standardized mode population with a life expectancy at birth equal to that of world longest surviving population e.g. Japan QALY is Quality Adjusted Life Year. It is the most commonly used to measure the cost effectiveness of health interventions . It estimates the number of years of life added by a successful treatment or adjustment for quality of life. 21

Nutritional Status Indicators:

Nutritional Status Indicators Nutritional Status is a positive health indicator. Newborns are measured for their i. Birth–weight ii. Length iii. Head circumference They reflect the maternal nutrition status Anthropometric measurements of pre-school children Weight – measures acute malnutrition Height – measures chronic malnutrition Mid-arm circumference - measures chronic malnutrition Growth Monitoring of children is done by measuring weight-for-age, height-for-age, weight-for- height , head & chest circumference and mid-arm circumference. In adults Underweight, Obesity and Anemia are generally considered reliable nutritional indicators. 22

Trends in Child Nutritional Status (figures in %):

Trends in Child Nutritional Status (figures in %) 23 NFHS-3, India, 2005-06

Health Care Delivery Indicators:

Health Care Delivery Indicators These indicators reflect the equity of distribution of health resources in different parts of the country and of the provision of health care Doctor-population Ratio – 1/1700 (sug. norm 1/3500) Nurse-population ratio – 0.8/1000 (sug. norm 1/500) Population-bed Ratio – 8.9/10000 Population per PHC/sub center- is 20000-30000 in Karnataka while in some states, it is more than 50000. Population per traditional birth attendant – 0.47/1000 (Source: 24

Utilisation Rates:

Utilisation Rates Utilisation Rates or actual rates is expressed as the proportion of people in need of a service who actually receive it in a given period, usually a year It depends on availability & accessibility of health services and the attitude of an individual towards health care system They direct attention towards discharge of social responsibility for the organization in delivery of services E.g. Proportion of infants who are fully immunized – 43% Proportion of pregnant women who receive ANC care or have institutional deliveries Percentage of population who adopt family planning Bed occupancy ratio, bed-turn over ratio, etc. 25

Trends in Immunizations by Vaccine:

Trends in Immunizations by Vaccin e 26 NFHS-3, India, 2005-06

Knowledge of Modern Spacing Methods (figures in %):

Knowledge of Modern Spacing Methods (figures in %) 27 NFHS-3, India, 2005-06

Indicators of Social and Mental Health:

Indicators of Social and Mental Health These Include rates of suicide, homicide, other crime, road traffic accident, juvenile delinquency, alcohol and substance abuse, domestic violence, battered-baby syndrome, etc. These indicators provide a guide to social action for improving the health of people. Social and mental health of the children depend on their parents. E.g. Substance abuse in orphan children 28

Environmental Indicators:

Environmental Indicators These reflect the quality of physical and biological environment in which diseases occur and people live. The most important are those measuring the proportion of population having access to safe drinking water and sanitation facilities. These indicators explains the prevalence of communicable diseases in a community The other indicators are those measuring the pollution of air and water, radiation, noise pollution, exposure to toxic substances in food and water 29

Percentage of Household by Improved Source of Drinking Water:

Percentage of Household by Improved Source of Drinking Water 30 According to WHO/UNICEF an improved source of drinking water includes water piped into dwelling/yard/plot, water available from public tap or stand pipe or a tube well or borehole, or a protected well or spring NFHS-3, India, 2005-06

Selected Household Characteristics:

Selected Household Characteristics 31 NFHS-3, India, 2005-06

Socioeconomic Indicators:

Socioeconomic Indicators These do not directly measure health but are important in interpreting health indicators. These are Rate of growth of population: India-decadal(2001-2011)-17.64%,annual(2011)-1.344% Karnataka -17.51% (2001-2011) (source:, ) Per capita GNP - Rs. 54,835 per person (2011) (source: ) Dependency ratio – 57.59 (2008) (source: Literacy rates: India - 74.04% (2011) Karnataka - 75.6% (2011 ) (source: Family size India-4.8 Karnataka - 4.6 (Source:NFHS 3) Housing – the number of persons per room Per capita “calorie” available Countries with favourable socioeconomic indicators have reported less health related problems 32

Literacy among women has doubled in 30 years; however, even among the youngest one-fourth of women and one-tenth of men are illiterate (figures in %):

Literacy among women has doubled in 30 years; however, even among the youngest one-fourth of women and one-tenth of men are illiterate (figures in %) 33 NFHS-3 shows that even among those in the age group 15-19, only 89% of men and 74% of women are literate NFHS-3, India, 2005-06

Total Fertility Rate:

Total Fertility Rate 34 NFHS-3, India, 2005-06

Health Policy Indicators:

Health Policy Indicators The single most important indicator of political commitment is allocation of adequate resources The relevant indicators are Proportion of GNP spent on health services- 8.7% (Source: ) Proportion of GNP spent on health related activities like water supply and sanitation & housing and nutrition-8.5% (Source: ) Proportion of total health resources devoted primary health care 35

Indicators of Quality of Life:

Indicators of Quality of Life Life expectancy is no longer important The Quality Of Life has gained its importance Physical Quality of Life Index It consolidates infant mortality, life expectancy at age of 1yr and literacy. For each component the performance of individual country is placed on a scale of 1 to 100. The composite index is calculated by averaging the three indicators giving equal weight to each of them. The resulting is placed on the 0 to 100 scale. The PQLI does not consider the GNP. 36

Indicators of Quality of Life:

Indicators of Quality of Life Human Development Index It is defined as a composite index combining indicators representing 3 dimensions – longevity( life expectancy at birth) knowledge (2/3 adult literacy rate and 1/3 mean years of schooling) income (real GDP per capita in purchasing power parity in US dollars). Index = ( Actual value) –(minimum value) (Maximum value )– (minimum value) The resulting is placed on the 0 to 1 scale HDI for India was 0.519 HDI ranking of India is 119 37

Other Indicators Series:

Other Indicators Series Social Indicators as defined by the UN Statistical Office has been divided into 12 categories: population; family formation; families & households; learning & educational services; earning activities; distribution of income, consumption & accumulation; social security & welfare services; health services & nutrition; housing & its environment; public order & safety; time use; leisure & culture; social stratification & mobility. Basic Needs Indicators are used by ILO and include calorie consumption, access to water, life expectancy, deaths due to disease, illiteracy, doctors and nurses per population, rooms per person, GNP per capita. 38

Other Indicators Series:

Other Indicators Series Health For All Indicators For monitoring the progress towards the goal of Health For All by 2000 , the WHO has listed the following four categories of indicators. Health policy indicators Political commitment to HFA Resource allocation Degree of equity of distribution of health services Community involvement Organisational framework and managerial process 39

Other Indicators Series:

Other Indicators Series 40 Social and economic indicators related to health Rate of population growth GNP or GDP Income distribution Work conditions Adult literacy rate Housing Food availability Indicators for the provision of health care Availability Accessibility Utilisation Quality of care

Other Indicators Series:

Other Indicators Series Health status indicators Low birth weight Nutritional status and psychosocial development of children Infant mortality Child mortality rate (1-4yrs) Life expectancy at birth Maternal mortality rate Disease specific mortality Morbidity – incidence and prevalence Disability prevalence 41

Millennium Development Goals:

Millennium Development Goals Indicators related to health : G1 – T2; halve between 1990 and 2015 the proportion of people who suffer from hunger T2.I4; prevalence of underweight children (below 5yrs) from 53.4 ( 90 ) to 47 in 2001 T2.I5; proportion of population below minimum level of dietary of energy consumption from 25 in 1991 to 21 by 2002. G4 – T5.I13;under-5 mortality to be reduced from 112 in 1990 to 90.9 in 2002. T5.I14; infant mortality rate from 80 in1990 to 68 in 2002. T5.I15; proportion of 1yr old children immunized for measles of 56 in 2001. 42

Millennium Development Goals:

Millennium Development Goals G5 – T6; reduce maternal mortality by ¾ by 2005. T6.116; reduce MMR from 420 to 407 by 2001. T6.117; proportion of births attended by skilled health professional of 42.3 by 2001. G6 – Combat HIV/AIDS, malaria and other diseases. - reduce HIV prevalence by 0.8 by 2001 - malaria death rate to be reduced to 2.9 per lakh by 2000 - reduce TB death rate to 40.4 per lakh by 2002 - reduce TB prevalence to 426 per lakh G7 – Ensure environmental sustainability - reduce proportion of pop using biomass fuel to 81 by 2000 - to improve % of population with access to improved water source in rural to 79 & urban to 95 by 2000 - to improve % of population with improved sanitation to 61 by 2000 43


Summary Health not measured directly but using indicators Indicator should be valid, sensitive, specific, reliable, relevant and feasible Used in measuring, describing, comparing, identifying health needs and planning and evaluation of health services 44

References :

References Park K. Textbook of preventive and social medicine. 21 st ed. Jabalpur, India: Bhanot; 2011. p.24-27. John M. Last. A dictionary of epidemiology. 4 th ed. Newyork: Oxford university press; 2001. p. 93,95,96,129. Census 2011[online].2011[cited 2011 Sep 19] Available from URL: http:// Ministry of Health and Family Welfare. National Family Health Welfare [online].2011[cited 2011 Sep 16] Available from URL: TB INDIA 2011 RNTCP Annual Report [online].2011[cited 2011 Sep 16] Available from URL: Mortality Rates[online].2011[cited 2011 Sep 16] Available from URL: Human Development Index [online].2011[cited 2011 Sep 16] Available from URL: http:// /en/media/HDR_2010_EN_Table1_reprint.pdf Eleventh Five Year Plan2007-12[online].2011[cited 2011 Sep 19] Available from : URL : 45

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