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Indicators are required not only to measure the health status of the community but also to compare the health status of one country with that of another, for assessment of health care needs, for allocation of scarce resources and for monitoring and evaluation of health services, activities and programs.
According to W.H.O indicators are variable which helps to measure changes. The various health indicators are classified as follows:-
There are varieties of mortality indicators. These include crude death rate (CDR), Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Child Mortality Rate, less than 5 mortality, disease specific mortality.
Increase or decrease in these rates will determine changing trends of health status and comparative health status of community. All these indicators are valid partially, reliable and sensitive. Some are very sensitive and specific to the situation.
e.g. the infant mortality rate is the most sensitive indicator of health whereas maternal mortality rate is sensitive indicator of obstetrical value.
It includes incidence and prevalence of communicable and non communicable diseases in the community. These indicators will give information about the proportion of people who are suffering from various diseases in the community and the possible cause of mortality in the community.
The following morbidity rates are used for ascertaining ill health in the community:
1. Incidence and prevalence
2. Notification rates
3. Attendance rates at outpatient department, health centres.
4. Admission, readmission and discharge rates.
5. Duration of stay in hospital
6. Spells of sickness or absence from work or school.
It includes incidence and prevalence of cases that are not able to perform full range activities because of some inherited or acquired problems .e.g.
1. Prevalence of blindness
2. Deafness and dumbness
3. Prevalence of paralytic
4. Poliomyelitis
5. Mental and socially handicapped
6. Sickness
Nutritional status is a positive health indicator. Three nutritional status indicators are considered important as indicators of health status. They are:
1. Anthropometric measurement of preschool children e.g. weight and height, mid arm circumference.
2. Height (and sometimes weight) of children at school entry.
3. Prevalence of low birth weight(less tan 2.5kg).
These indicators include incidence and prevalence of alcohol and drug abuse, child abuse and neglect, women abuse, child delinquencies, suicide and homicide and road traffic accident etc. These problems are increasing because of industrialization and urban slums.
Health care delivery system includes the health services provided to the community through PHC, CHC, and various hospitals. The frequently used indicators of health care delivery are:
1. Doctor-Population ratio
2. Doctor-nurse ratio
3. Population-bed ratio
4. Population per health/sub centre
5. Population per traditional birth attendant
It is referred to the utility of the services health.
Health policy means the health services which are specially designed for a particular age group, disease and health aspect for community welfare. The uses of these policies indicate that how much a person is aware about the health policies and the records of health policy indicator the utilization of health policies.
The quality of life is directly related to the socio-economic status of a person. If a person will be educated and having a job or proper earning sources he will have a quality life.
Traditionally and universally, most epidemiological studies begin with mortality data. Mortality data are relatively easy to obtain, and, in many countries, reasonably accurate. Many countries have routine systems for collecting mortality data. Each year, information on deaths is analyzed and the resulting tabulations are made available by each government. Mortality data provide the starting point for many epidemiological studies. In fact, they are the major resource for the epidemiologist.
The basis of mortality data is the Death Certificate. So we first look at death certification for ascertaining the frequency of disease in a population. For ensuring national and international comparability, it is very necessary to have a uniform and standardized system of recording and classifying deaths.
The international death certificate is in two parts. Part I deals with the immediate cause, and the underlying cause which started the whole trend of events leading to death. The underlying cause of death is recorded on line. In Part II is recorded any significant associated diseases that contributed to the death but did not directly lead to it.
In order to improve the quality of maternal mortality and infant mortality data and to provide alternative method of collecting data on deaths during pregnancy and infancy, a set of questions are added to the basic structure of international death certificate for use in India.
Mortality data are not without limitations. Problems are posed by
1. Incomplete reporting of deaths. This is not a problem in developed countries, but in India and other developing countries, this may be considerable,
2. Lack of accuracy: That is inaccuracies in the recording of age and cause of death. The practice of medical certification of death is not widespread. If it does exist, the cause of death is often inaccurate or incomplete due to such difficulties as lack of diagnostic evidence, inexperience on the part of the certifying doctor and absence of post mortem which may be important in deciding the cause of death,
3. Lack of uniformity: There is no uniform and standardized method of collection of data. This hampers national and international comparability
4. Choosing a single cause of death: Most countries tabulate mortality data only according to the underlying cause of death. Other diseases (or risk factors) and conditions which contribute to the patient’s death are not tabulated, and valuable information is thereby lost,
5. Changing: Changing coding systems and changing fashions in diagnosis may affect the validity. We also need uniform definitions and nomenclature,
6. Diseases with low fatality: Lastly, mortality statistics are virtually useless, if the disease is associated with low fatality (e.g., mental diseases, arthritis).
Statistics on causes of death are important and widely used for a number of purposes. They may be employed in explaining trends and differentials in overall mortality, indicating priorities for health action and the allocation of resources, in designing intervention programmes, and in the assessment and monitoring of public health problems and programmes – moreover, they give important clues for epidemiological research.
The commonly used measures are described below:
The simplest measure of mortality is the ‘crude death rate’. It is defined as “the number of deaths (from all causes) per 1000 estimated mid-year population in one year, in a given place”. It measures the rate at which deaths are occurring from various causes in a given population, during a specified period. The crude death rate is calculated from the formula:
Number of deaths during the year
————————————————- X 1000
Mid-year population
It is important to recognize that the crude death rate summarizes the effect of two factors:
1. population composition
2. age-specific death rates (which reflect the probability of dying)
When analysis is planned to throw light on aetiology, it is essential to use specific death rates. The specific death rates may be – (a) cause or disease specific – e.g., tuberculosis, cancer, accident; (b) related to specific groups – e.g., age- specific, sex-specific, age and sex specific, etc. Rates can also be made specific for many other variables such as income, religion, race, housing, etc. Specific death rates can help us to identify particular groups or groups “at-risk”, for preventive action. They permit comparisons between different causes within the same population.
No. of deaths from tuberculosis
during a calendar year
——————————————X 1000
Mid-year population
Case fatality rate represents the killing power of a disease. It is simply the ratio of deaths to cases. The time interval is not specified. Case fatality rate is typically used in acute infectious diseases (e.g., food poisoning, cholera, measles). Proportional mortality rate (Ratio)
Total number of deaths due to a particular disease
——————————————————————-X 100
Total number of cases due to the same disease
It is sometimes useful to know what proportion of total deaths are due to a particular cause (e.g., cancer) or what proportion of deaths are occurring in a particular age group (e.g., above the age of 50 years). Proportional mortality rate expresses the “number of deaths due to a particular cause (or in a specific age group) per 100 (or 1000) total deaths”. Thus we have:
a. Proportional mortality from a specific disease
Number of deaths from the specific disease in a year
——————————————— X100
Total deaths from all causes in that year
b. Under-5 proportionate mortality rate
Number of deaths under 5 years of age in the given year
———————————————————— X 100
Total number of deaths during the same period
c. Proportional mortality rate for aged 50 years and above
Number of deaths of persons aged 50 years and above
———————————————————-X 100
Total deaths of all age groups in that year
It is the proportion of survivors in a group, (e.g., of patients) studied and followed over a period (e.g., a 5-year period). It is a method of describing prognosis in certain disease conditions. Survival experience can be used as a yardstick for the assessment of standards of therapy. The survival period is usually reckoned from the date of diagnosis or start of the treatment. Survival rates have received special attention in cancer studies.
Total number of patients alive after 5 years
————————————————————- X 100
Total number of patients diagnosed or treated
If we want to compare the death rates of two populations with different age composition, the crude death rate is not the yard- stick. This is because; rates are only comparable if the population upon which they are based are comparable. And it is cumbersome to use a series of age specific death rates. The answer is age adjustment or age standardization which removes the confounding effects of different age structures and yields a single standardized rate.
Morbidity has been defined as “any departure, subjective or objective, from a state of physiological well-being”. The term is used equivalent to such terms as sickness, illness, disability etc. The WHO Expert Committee on Health Statistics noted in its 6th Report that morbidity could be measured in terms of 3 units –
1. persons who were ill;
2. the illnesses (periods or spells of illness) that these persons experienced; and
3. the duration (days, weeks, etc) of these illnesses.
Three aspects of morbidity are commonly measured by morbidity rates or morbidity ratios, namely frequency, duration and severity.
Disease frequency is measured by incidence and prevalence rates. The average duration per case or the disability rate, which is the average number of days of disability per person, may serve as a measure of the duration of illnesses. The case fatality rate may be used as an index of severity. This section focuses on incidence and prevalence rates, which are widely used to describe disease occurrence in a community.
The value of morbidity data may be summarized as follows:
1. They describe the extent and nature of the disease load in the community, and thus assist in the establishment of priorities.
2. They usually provide more comprehensive and more accurate and clinically relevant information on patient characteristics, than can be obtained from mortality data, and are therefore essential for basic research.
3. They serve as starting point for aetiological studies, and thus play a crucial role in disease prevention.
4. They are needed for monitoring and evaluation of disease control activities.
Incidence rate is defined as “the number of NEW cases occurring in a defined population during a specified period of time”.
It is given by the formula:
Number of new cases of specific disease during a given time period
———————————————————– —————————X 1000
Population at risk during that period
For example, if there had been 500 new cases of an illness in a population of 30,000 in a year, the incidence rate would be: 500/30,000 x1000 =16.7 per 1000 per year
Note: Incidence rate must include the unit of time used in the final expression. If you write 16.7 per 1000, this would be inadequate. The correct expression is 16.7 per 1000 per year.
It will be seen from the above definition that incidence rate refers –
1. Only to new cases
2. During a given period (usually one year)
3. In a specified population or “population at risk”, unless other denominators are chosen.
4. It can also refer to new spells or episodes of disease arising in a given period of time, per 1000 population. For example, a person may suffer from common cold more than once a year. If he had suffered twice, he would contribute 2 spells of sickness in that year. The formula in this case would be:
Number of spells of sickness starting in a
defined period
————————————————————– X 1000
Mean number of persons
exposed to risk in that period
Incidence measures the rate at which new cases are occurring in a population. It is not influenced by the duration of the disease. The use of incidence is generally restricted to acute conditions.
The incidence rate, as a health status indicator, is useful for taking action:
(a) to control disease, and
(b) for research into aetiology and pathogenesis, distribution of diseases, and efficacy of preventive and therapeutic measures.
For instance, if the incidence rate is increasing, it might indicate failure or ineffectiveness of the current control programmes. Rising incidence rates might suggest the need for a new disease control or preventive programme, or that reporting practices had improved. A change or fluctuation in the incidence of disease may also mean a change in the aetiology of disease, e.g., change in the Host, agent and environmental characteristics. Analysis of differences in incidence rates reported from various socio-economic groups and geographical areas may provide useful insights into the effectiveness of the health services provided.
The term “disease prevalence” refers specifically to all current cases (old and new) existing at a given point in time, or over a period of time in a given population. A broader definition of prevalence is as follows: “the total number of all individuals who have an attribute or disease at a particular time (or during a particular period) divided by the population at risk of having the attribute or disease at this point in time or midway through the period”. Although referred to as a rate, prevalence rate is really a ratio.
Prevalence is of two types :
1. Point prevalence
2. Period prevalence
Point prevalence of a disease is defined as the number of all current cases (old and new) of a disease at one point of time, in relation to a defined population. The “point” in point prevalence, may for all practical purposes consist of a day, several days, or even a few weeks, depending upon the time it takes to examine the population sample.
Point prevalence is given by the formula:
Number of all current cases (old and new) of a specified disease existing at a given point in time
——————————————————————————————————————-X 100
Estimated population at the same point in time
When the term “prevalence rate” is used, without any further qualification, it is taken to mean “point prevalence”.
Point prevalence can be made specific for age, sex and other relevant factors or attributes.
A less commonly used measure of prevalence is period prevalence. It measures the frequency of all current cases (old and new) existing during a defined period of time (e.g., annual prevalence) expressed in relation to a defined population. It includes cases arising before but extending into or through to the year as well as those cases arising during the year. Period prevalence is given by the formula:
Number of existing cases (old and new) of a specified disease during a given period of time interval
——————————————————————————————————————————–X 100
Estimated mid-interval population at-risk
1. Prevalence helps to estimate the magnitude of health/ disease problems in the community, and identify potential high-risk populations
2. Prevalence rates are especially useful for administrative and planning purposes, e.g., hospital beds, manpower needs, rehabilitation facilities, etc.
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