1. Health Determinants, Measurements, and Trends
Chapter Two
Health Determinants, Measurements, and Trends

2. The Importance of Measuring Health Status
In order to address global health issues, we must understand:
The factors that influence health status most
The indicators used to measure health status
The key trends that have occurred historically

3. Determinants of Health
The interconnected factors that determine an individual’s health status
Determinants include personal features, social status, culture, environment, educational attainment, health behaviors, childhood development, access to care, and government policy
Increasing attention is being paid to the “social determinants of health”

4. Figure 2.1: Key Determinants of Health

5. Key Health Indicators Health status indicators are useful for:
Finding which diseases people suffer from
Determining the extent to which the disease causes death or disability
Practicing disease surveillance
To perform these functions, it is important to use a consistent set of indicators

6. Table 2.1: Key Health Status Indicators
Source: Data from the Public Health Agency of Canada. What Determines Health. Available at: index-eng.php#determinants. Accessed November 19, 2010.

7. Figure 2.2: Life Expectancy at Birth, by World Bank Region, 2008

8. Figure 2.3: Infant Mortality Rate

9. Figure 2.4: Neonatal Mortality Rate

10. Figure 2.5: Under-5 Child Mortality Rate

11. Figure 2.6: Maternal Mortality Rate

12. Key Health Indicators Terms
Morbidity- sickness or any departure, subjective or objective, from a psychological or physiological state of well-being
Mortality- death
Disability- temporary or long-term reduction in a person’s capacity to function
Prevalence- number of people suffering from a certain health condition over a specified time period
Incidence- the rate at which new cases of a disease occur in a population

13. Classifications of Disease
Key Health Indicators
Classifications of Disease
Communicable disease- illnesses caused by a particular infectious agent that spread directly or indirectly from people to people, animals to people, or people to animals
Noncommunicable disease- illnesses not spread by an infectious agent
Injury- include road traffic injuries, falls, self-inflicted injuries, and violence, among other things

14. Vital Registration
Vital registration systems record births, deaths, and causes of death
An accurate system is key to having quality data on a population
Many low- and middle-income countries lack a vital registration system
Developing a system is progress towards understanding and addressing health problems

15. Measuring the Burden of Disease
Twp indicators used to compare how far countries are from a state of good health
Health-Adjusted Life Expectancy (HALE)- summarizes expected number of years to be lived in what might be termed the equivalent of good health
Disability-Adjusted Life Year (DALY)- a unit for measuring the amount of health lost because of a particular disease or injury

16. Measuring the Burden of Disease
DALY
“Health gap measure,” indicating losses due to illness, disability and premature death in a population
Gives a better estimate of the health of a population than death rate
Accounts for health conditions like mental illness that rarely cause death

17. The Global Burden of Disease
Important to understand:
Leading causes of illness, disability, and death in the world
Variations by age, sex, ethnicity, and socioeconomic status
Changes over time

18. Table 2.3: The 10 Leading Causes of Death and DALYs
Source: Adapted with permission from Lopez AD, Mathers CD, Murray CJL. The burden of disease and mortality by condition: data, methods, and results for In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World Bank and Oxford University Press; 2006.

19. Table 2.3: The 10 Leading Causes of Death and DALYs (cont.)

20. The Global Burden of Disease
Causes of Death by Region
Higher income countries tend to have a greater burden of noncommunicable disease
Lower income countries to have a greater burden of communicable disease
Africa and South Asia are set apart by their large burdens of communicable disease

21. Table 2.4: The Leading Causes of the Burden of Disease
Source: Reprinted with permission from Lopez AD, Mathers CD, Murray CJL. The burden of disease and mortality by condition: data, methods, and results for In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World Bank and Oxford University Press; 2006:91.

22. Table 2.4: The Leading Causes of the Burden of Disease (cont.)

23. The Global Burden of Disease
Causes of Death by Age
Children in low- and middle-income countries often die of communicable disease
HIV/AIDS and TB are among the leading causes of death among adults in low- and middle-income countries

24. Table 2.5: The 10 Leading Causes of Death in Children Ages 0-14, by Broad Income Group, 2001

25. Table 2.6: The 10 Leading Causes of Death in Adults 15-59, by Broad Income Group, 2001

26. The Global Burden of Disease
The Burden of Deaths and Disease Within Countries
In most low- and middle-income countries:
Rural people will be less healthy
Disadvantaged ethnic minorities will be less healthy
Women will suffer from their weak social positions
Poor people will be less healthy
Uneducated people will be less healthy

27. Risk Factors
Risk factor- an aspect or personal behavior or life-style, an environmental exposure, or an inborn or inherited characteristic, that, on the basis of epidemiological evidence, is known to be associated with health-related conditions considered important to prevent
Most important risk factors in low- and middle-income countries are malnutrition, high blood pressure and high cholesterol, smoking, and unsafe sex

28. Table 2.8: The Leading Risk Factors for the Burden of Disease, 2001, Low- and Middle-Income and High-Income Countries, Ranked in Order of Percent of Total DALY

29. Demography and Health Population Growth
Majority of population growth will occur in low- and middle-income countries
Put pressure on the environment
Create need for more infrastructure and services

30. Demography and Health Population Aging
Population of the world is aging
Implications for burden of disease because people will be living longer with morbidities and disabilities
Healthcare financing will be affected by change in ratio of working people to those over 65 years

31. Demography and Health Urbanization
Majority of the world’s population lives in urban areas for the first time
Enormous pressure on urban infrastructure like water and sanitation

32. The Demographic Divide
Demography and Health
The Demographic Divide
Highest income countries: low fertility, declining populations, aging populations
Lowest income countries: relatively high fertility, growing populations

33. The Demographic Transition
Demography and Health
The Demographic Transition
Shift from pattern of high fertility and high mortality to low fertility and low mortality
Mortality declines due to better hygiene and nutrition
Population grows with younger share of population increasing
Fertility declines
Population growth slows and older share of population increases

34. Figure 2.9: The Demographic Transition

35. The Epidemiologic Transition
Demography and Health
The Epidemiologic Transition
Shift from burden of disease dominated by communicable disease to burden of disease dominated by noncommunicable disease
Most low-income countries are in ongoing transition so they face large burdens of communicable and noncommunicable disease

36. Figure 2.10: The Burden of Diseae by Group of Cause, Percent of Deaths, 2001

37. Progress in Health Status
Improvements in raising life expectancy and improving health not uniform across countries
Life expectancy in South Asia and sub-Saharan Africa lag that in other regions
Life expectancy in Europe and Central Asia changed little due to break-up of Soviet Union
Life expectancy in East Asia has increased dramatically due to rapid economic growth

38. Table 2.11: Life Expectancy and Percentage Gain in Life Expectancy, 1960-2008, by World Bank Region

39. Looking Forward Economic Development
Economies of low-income countries need to grow in order to invest in health
Impact of economic development will depend on countries investing in areas that improve health such as water, sanitation, and education

40. Scientific and Technological Change
Looking Forward
Scientific and Technological Change
Development of vaccines, drugs, and diagnostics
Country’s ability to adopt these changes will determine their effect on health

41. Looking Forward Climate Change Impact not entirely clear
Possible migration from places that become inhabitable
Adverse weather
Possible change in populations of disease vectors

42. Looking Forward Political Stability
Necessary for long-term gains in health
Instability causes illness, disability and death as well as breakdown of infrastructure and services

43. Emerging and Re-emerging Infectious Disease
Looking Forward
Emerging and Re-emerging Infectious Disease
Occurrence and impact difficult to predict
Pandemic flu
Anti-microbial resistance

44. Projecting the Burden of Disease
Looking Forward
Projecting the Burden of Disease
Substantial changes from 2004 to 2030
Low- and lower-middle-income countries will shift away from communicable disease
Causes associated with aging will increase in importance
Mental health issues will increase in importance

45. The Development Challenge of Improving Health
Health usually increases as national income increases
Some countries have achieved higher life expectancies than their incomes would predict
This is possible with investments in nutrition, education, good hygiene, and low-cost services that have a high impact such as vaccination programs