1. Health indicators Prof. Ashry Gad Mohamed Dr. Salwa Tayel Department of family and Community Medicine

2. At the end of the lecture students should be able to: 1.Recognize the concept of health indicators. 2.Define health indicators. 3.Understand uses of health indicators. 4.Classify types of health indicators and give examples of these indicators. OBJECTIVES OF THE LECTURE 12/12/2015

3. Health indicator is a variable that reflects the state of health of persons in a community. (Oxford Dictionary of Epidemiology) They are quantitative measures that can be used as a guide to monitor and evaluate the quality of health care. Linguistically indicator is an indication of a given situation What is health indicator? 12/12/2015

4. Valid – measures what it is supposed to measure. Reliable – provides same information under different observations, conditions Sensitive – sensitive to changes in the situation Specific – reflects changes only in that situation Relevant: relevant to the community needs & problems. Characteristics of a good indicator: 12/12/2015

5. Realistic, applicable and feasible. Measurable and observable. Known and agreed to by the staff whose performance is being assessed. Clear and targeted to date or period. Used in assessment continuously over time. Characteristics of a good indicator: 12/12/2015

6. Uses of Health Indicators 1.Compare health status of one country with other countries or worldwide. 2.Compare health status of different areas or groups of people over time. 3.Assessment of health care needs. 4.Proper allocation of human and non human resources according to the needs. 5.Monitoring and evaluation of health services, activities, and programs. 12/12/2015

7. Types of Health Indicators 1.Mortality indicators 2.Morbidity indicators 3.Disability indicators 4.Nutritional status indicators 5.Health care delivery indicators 6.Utilization rates 7.Social and mental health indicators 12/12/2015

8. 8.Environmental indicators 9.Socioeconomic indicators 10.Health policy indicators 11.Indicators of quality of life 12.Other indicators Types of Health Indicators 12/12/2015

9. What Are the Leading Health Indicators? Physical Activity Overweight and Obesity Tobacco Use Substance Abuse Responsible Sexual Behavior Mental Health Injury and Violence Environmental Quality Immunization Access to Health Care. 12/12/2015

10. A mortality rate is a measure of the frequency of occurrence of death in a defined population during a specified period of time. Mortality Rates 12/12/2015

11. Crude Death Rate (CDR) The crude mortality rate is the mortality rate from all causes of death for an entire population. We usually multiply by 1000. = … Deaths/1000 individual in the specified year and locality. 12/12/2015

12. It is important to use the population size at the midpoint of the time interval as an estimate of the average population at risk especially if: a denominator population is growing or shrinking during the period of time for which a rate is to be computed. e.g. If a death rate is to be calculated for the year 2014, then the population of July 1, 2014 is used for the denominator. Mid-year population

13. Age-specific mortality rates 12/12/2015 An age-specific mortality rate is a mortality rate limited to a particular age group. The numerator is the number of deaths in that age group The denominator is the number of persons in that age group in the population. Examples of age-specific mortality rates are neonatal, post- neonatal, infant and under 5-years mortality rates.

14. Infant mortality rate (per 1 000 live births) Infant mortality rate is the probability of a child born in a specific year or period dying before reaching the age of one. In Saudi Arabia (2011) both sexes 16.5 12/12/2015

15. Infant Mortality Rate 12/12/2015

16. Neonatal mortality rate (per 1 000 live births) The number of deaths of neonates (infants <28 days of age) in a calendar year, divided by number of live births in that year, multiplied by 1000. In Saudi Arabia (2004): Neonatal Mortality Rate =11 12/12/2015

17. Post-Neonatal mortality rate (per 1 000 live births) 12/12/2015 Post-neonatal mortality rate is the number of deaths among infants from 28 days up to 1 year of age during a given time period divided by the number of live births during the same time period multiplied by 1,000

18. 12/12/2015 Neonatal Post-Neonatal 28 day (0 day) 1year Birth Period of Infancy Infancy

19. Stillbirth rate (per 1000 total births) For international comparison purposes, stillbirths are defined as third trimester fetal deaths (> or = 1000 grams or > or = 28 weeks). Total births : Total births is defined as the sum of live births and still births. 12/12/2015

20. Still birth ratio (per 1000 total births) Number of fetal deaths of 28 weeks of gestation or more in certain year and locality per 1000 live births 12/12/2015

21. It is expressed as the sum number of still births and early neonatal deaths (less than 7 days of life) per 1000 total births (still births plus live births). It the best indicator of Maternal and Child Health services Perinatal Mortality Rate 12/12/2015

22. Under-5 mortality rate (per 1 000 live births) Under-five mortality rate is the probability of a child born in a specific year or period dying before reaching the age of five. In Saudi Arabia (2006) both sexes 26 female 23 male 28 12/12/2015

23. Child Mortality Rates (deaths of children under age five per 1,000 live births) 12/12/2015

24. Adult mortality rate (per 1000 population) Probability that a 15 year old person will die before reaching his/her 60th birthday. In Saudi Arabia (2006) both sexes 178 female 136 male 205 12/12/2015

25. Adult Mortality Rates (probability of death between ages 15 and 60) 12/12/2015

26. Maternal mortality ratio (per 100 000 live births) The number of maternal deaths per 100 000 live births during a specified time period, usually 1 year. In Saudi Arabia (2005) MMR= 18 Maternal death is the death of a woman while pregnant or within 42 days after termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. 12/12/2015

27. Maternal mortality ratio (per 100 000 live births) 12/12/2015

29. Cause-specific mortality rate The number of deaths attributed to a specific cause divided by the population at the midpoint of the time period multiply by 100,000. 12/12/2015

30. Example of Cause-specific mortality rates Deaths due to tuberculosis (per 100 000 population) In Saudi Arabia (2006) =5.0 12/12/2015

31. Proportionate mortality rates Defined as the number of deaths assigned to a specific cause in a calendar year, divided by the total number of deaths in that year, the quotient multiplied by 100

32. Case fatality rate (Death to case ratio) It reflects severity and virulence of diseases

33. Morbidity Rates 12/12/2015

34. Morbidity indicators are used to supplement mortality data. The following morbidity parameters can be used as health indicators: a) Incidence rate b) Prevalence rate c) Disease Notification rates,….. Morbidity Rates 12/12/2015

35. Incidence Rate Incidence measures the number of new cases of a disease (or other health-related phenomenon) that occur during a specified period of time in a population at risk 12/12/2015

36. Prevalence Rate Prevalence measures the number of cases (new and old) of the disease (or other health- related phenomenon) at a point or period in time. It measures the status of the disease in the population. 12/12/2015

37. 3. Disability rates: Health implies full range of daily activities, thus limitations in these activities are used as indicators of health status. These indicators include: a) Bed disability days b) Work or school loss days during a certain period c) limitation of daily activities as cooking, washing, cleaning, dressing, etc. 12/12/2015

38. 4. Nutritional indicators Nutritional status is a positive health indicator. These include: a) Anthropometric measurements of infants and preschool children (Height and weight,… c) Prevalence of low birth weight 12/12/2015

39. 5. Health care delivery indicators These reflect the equity of distribution of health resources in the country. The frequently used indicators of health care delivery are: a) Doctor / population ratio b) Population / bed ratio c) Population / health center ratio 12/12/2015

40. 6. Utilization rates These show the extent of utilization of the health services or the actual coverage. These rates are affected by availability and accessibility of health services as well as attitude of the population towards these services. Examples of these indicators include: a) Vaccination coverage b) Antenatal visits c) Utilization rates of contraceptives d) Bed occupancy rates e) Average length of stay in hospitals 12/12/2015

41. 7. Social and mental health indicators These include Violence rates against women, child abuse, suicide, homicide, as well as drug abuse and smoking. 12/12/2015

42. 8. Environmental indicators These reflect the quality of physical, chemical, and biological environment. The most useful of these are: a) Percentage of houses supplied with safe water supply b) percentage of houses supplied with public sewerage system c) Air pollution indicators can also be used especially in developed countries. 12/12/2015

43. 9. Socioeconomic indicators These are indirect measures of health. They are behind the changes of other health indicators. These include: a) Percent of illiteracy in the country, especially among young women. b) Rates of unemployment c) National income per capita d) Rate of natural of increase e) Total dependency ratio 12/12/2015

44. 10. Health policy indicators The most important indicators are: a) Adequacy of the total budget assigned to the health activities. b) Proportion of total health resources devoted to basic and primary health care services in the community. 12/12/2015

45. 11. Indicators of quality of life: This indicator measures not only how long an individual will live, but also the high quality of life during this period. There are many scales that measure the health related quality of life of he individual. E.g. Looking after physical health, Eating a balanced diet, Freedom from anxiety, Understanding right and wrong, Access to community places,…. 12/12/2015

46. Last JM, editor. Dictionary of epidemiology. 4th ed. New York: Oxford University Press; 2001 Principles of EPIDEMIOLOGY in Public Health Practice Third Edition An Introduction to Applied Epidemiology and Biostatistics. Centers for Disease Control and Prevention (CDC) Reference book & page number for the lecture resource 12/12/2015