Chapter Two
Health Determinants, Measurements,
and Trends
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
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”
Figure 2.1: Key Determinants of
Health
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
Table 2.1: Key Health Status Indicators
Source: Data from the Public
Health Agency of Canada.
What Determines Health.
Available at:
http://www.phacaspc.gc.ca/phsp/determinants/ indexeng.php#determinants.
Accessed November 19,
2010.
Figure 2.2: Life Expectancy at Birth,
by World Bank Region, 2008
Figure 2.3: Infant Mortality Rate
Figure 2.4: Neonatal Mortality Rate
Figure 2.5: Under-5 Child Mortality Rate
Figure 2.6: Maternal Mortality Rate
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
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, selfinflicted injuries, and violence, among other
things
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
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
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
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
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.
Table 2.3: The 10 Leading Causes of
Death and DALYs (cont.)
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
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.
Table 2.4: The Leading Causes of the
Burden of Disease (cont.)
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
Table 2.5: The 10 Leading Causes of Death in
Children Ages 0-14, by Broad Income Group, 2001
Table 2.6: The 10 Leading Causes of Death in
Adults 15-59, by Broad Income Group, 2001
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
Risk Factors
• Risk factor- an aspect or personal behavior or lifestyle, 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 middleincome countries are malnutrition, high blood
pressure and high cholesterol, smoking, and
unsafe sex
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
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
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
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
Demography and Health
The Demographic Divide
• Highest income countries: low fertility,
declining populations, aging populations
• Lowest income countries: relatively high
fertility, growing populations
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
Figure 2.9: The Demographic 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
Figure 2.10: The Burden of Diseae by
Group of Cause, Percent of Deaths, 2001
Progress in Health Status
• Improvements in raising life expectancy and
improving health not uniform across countries
• Life expectancy in South Asia and subSaharan 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
Table 2.11: Life Expectancy and
Percentage Gain in Life Expectancy, 19602008, by World Bank Region
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
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
Looking Forward
Climate Change
• Impact not entirely clear
• Possible migration from places that become
inhabitable
• Adverse weather
• Possible change in populations of disease
vectors
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
Looking Forward
Emerging and Re-emerging Infectious
Disease
• Occurrence and impact difficult to predict
• Pandemic flu
• Anti-microbial resistance
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
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