Chapter Two

1. 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: http://www.phac-aspc.gc.ca/ph-sp/determinants/ 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. 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 2001. 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 2001. 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. Demography and Health The Demographic Divide • Highest income countries: low fertility, declining populations, aging populations • Lowest income countries: relatively high fertility, growing populations

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

44. 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