global health promotion
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W1Chapt2Slides.pptxHealth Determinants, Measurements, and Trends
Chapter 2
Chapter 2: Health determinants, measurements, and trends
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Key Concepts in Relation to Global Health
The determinants of health
Key health indicators
Measuring the burden of disease
The global burden of disease
The key risk factors for various health problems
The demographic and epidemiological transitions
In this chapter we are going to discuss what the issues that influence global health are, how health status is measured, what are the global burden and what are some key risk factors for global health problems. Many factors act in combination that affect the health of individuals, communities, and in the bigger picture global health.
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The factors that influence health status most
The indicators used to measure health status
The key trends that have occurred historically
The Importance of Measuring Health Status
As we try to define health, we also try to quantify the amount of health an individual or a community possesses. Two basic things are taken in consideration –what are the indicators taken into account to measure the health status and what are the factors that influence health status. Finally, the key trends in health status that have been going on historically gives us clear idea about the health in a certain country.
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Figure 2.1: Key Determinants of Health
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.
Source: Dahlgren G. and Whitehead M. 1991
The notion of good health became synonymous with access to health care while health depends on number of factors. As we will move with this course, we will see that there are interconnected factors that determine an individual’s health status. Determinants include personal features, like genetic makeup, sex and age; have significant contribution on what diseases we get and how healthy we live. For instance, if one inherits genetic component for breast cancer then to have the disease, it is also important to have appropriate exposures which might actually cause the disease in that person. Social status and culture very intricately relate with disease occurrence. Higher social status paired with higher income often leads to higher education and better health. Environment, both indoor and outdoor, plays a role in determining health. Safe and pollution free outdoor environment could enhance health while indoor air pollution and poor ventilation could lead to respiratory diseases and asthma. Education is another strong determinant of health. Education has shown to have extremely strong and positive correlation between level of education and all key health indicators. Recent attention has been given to individual health practices and behaviors in relation to being healthy. One’s health depends on personal behaviors like eating, drinking, driving or smoking. Recent research has brought our attention to physical activity and its link to a number of diseases for example obesity, and breast cancer. Access to health care does have its role in good health as even after being born healthy, practicing healthy behavior, one might get sick. The more quickly one has access to quality health care , the more likely he/she is to stay healthy. Finally, government policy and intervention also fit in the puzzle of the status of health as countries where government promote and ensure higher education, safe water, or universal health insurance are more likely to have healthy nations.
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Determinants of Health
Determinants of Health : A Framework for Reaching Healthy People 2020 Goals.
This video demonstrates determinants of health with examples for further clarification on the topic.
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Evidence and data are vital to address key global health issues. Health data like infant mortality concern the health status of people and communities. Such data are useful for finding which diseases people suffer from, determining the extent to which the disease causes death or disability, and practicing disease surveillance. To perform these functions, it is important to use a consistent set of indicators so that comparisons could be made across people in the same country or across different countries. The table here listed some commonly used health indicators which are more elaborately discussed in your textbook.
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Life Expectancy at Birth, by World Bank Region, 2008
Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed Jan. 1, 2016.
As you can see from this slide, the life expectancy for high income countries that belong to the organization for economic cooperation and development is around 80 years, to be more precise, high income country like in the United States the life expectancy is about 77 years. However, in Sub-Saharan Africa the life expectancy is pretty low around 52 years.
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Infant Mortality Rate, by World Bank Region, 2008
Data from The World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed Jan 11, 2016
In high life expectancy countries infant mortality is low. We see very low infant mortality rates for high income countries whereas countries from Sub-Saharan Africa experience high infant mortality rates. Sub-Saharan African countries have as high as 100 infant deaths for every 1000 live birth. Which region is next to Sub-Saharan Africa for high infant mortality rate? Can you think of some reasons for such high infant mortality rates for these regions?
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Neonatal Mortality Rate
Data from http://www.who.int/gho/child_health/mortality/neonatal/en/Accessed Jan 11, 2016.
The health status indicator neonatal mortality rate reflects how many infants die younger than 28 days of age in a given year for 1000 live births. From this chart we can see that poor countries in Sun-Saharan region or in South Asian region experience high neonatal mortality rates.
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What are neonates dying of?
Preterm births
Severe infection
Asphyxia
Congenital anomalies
Tetanus
Let’s quickly take a view what are the reasons for neonatal death. We’ll be discussing in detail all of these reasons when we talk about child’s health.
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Under-5 Child Mortality Rate
Data from http://www.who.int/gho/child_health/mortality/neonatal/en/Accessed Jan 11, 2016.
The probability that a newborn will die before reaching age five, expressed as a number per 1000 live births. The graph here shows similar to infant mortality the under-five mortality is also higher in Sub-Saharan Africa and South East Asia.
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Worldwide, under- five mortality rate has gone down and it has gone down significantly for high income countries. For countries like Sub-Saharan Africa and South East Asia –the rate has dropped since 1980 to 2010, however around 1990-1995 Sub – Saharan Africa experienced high rates of under-five mortality which started to show downward trend after 2000.
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What are Under –Fives dying of? (excluding neonatal causes of death)
Pneumonia
Diarrhoea
Malaria
Measles
HIV/AIDS
}
~ 50%
Malnutrition contributes to more than half of all under-five deaths
50% of death among under-five in developing countries occurred because of pneumonia, diarrhea, malaria, measles and HIV/AIDS.
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Maternal Mortality Rate
Data from Trends in Maternal Mortality 1990 to 2015. http://apps.who.int/iris/bitstream/10665/193994/1/WHO_RHR_15.23_eng.pdf?ua=1 Accessed Jan 11, 2016.
Maternal mortality indicator shows the number of deaths among pregnant women per 100,000 live births due to child birth related complications. Can you find out why Sub-Saharan Africa region has highest number of maternal mortality rates than any other region? How do you think maternal mortality rates, infant mortality rates, neonatal rates and under five child mortality rates are connected?
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Concepts and Definition
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
These are some key concepts and definitions we need to know to study the health status of a country.
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Incidence or Prevalence?
Source: Interactive Textbook on Clinical Symptom Research. Available at http://painconsortium.nih.gov/symptomresearch/chapter_19/sec4/cihs4pg1.htm
(no audio)
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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
Non-communicable disease- illnesses not spread by an infectious agent
Injury- include road traffic injuries, falls, self-inflicted injuries, and violence, among other things
(no audio)
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Measuring the Burden of Disease
Life expectancy minus the period of less than a full healthy life
Highest HALE is Canada 70.1 years for male and 74.0 for female
“Health gap measure,” indicating losses due to illness, disability and premature death in a population
Better estimation of the health of a population than death rate
Accounts for health conditions like mental illness that rarely cause death
Health Adjusted Life Expectancy (HALE)
Disability Adjusted Life Year (DALY)
Two indicators used to compare how far countries are from a state of good health are as follows Health-Adjusted Life Expectancy (HALE)- summarizes expected number of years to be lived in what might be termed the equivalent of good health and Disability-Adjusted Life Year (DALY)- a unit for measuring the amount of health lost because of a particular disease or injury
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The Global Burden of Disease
Causes of Death by Region
Causes of Death by Age
Causes of Death by gender
To understand global burden of disease, it is important to understand the leading causes of illness, disability, and death in the world and their variations by region, age and gender. It is also essential to understand the changes that occur over time.
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The 10 Leading Causes of Death, 2001
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.
As the table illustrate, major share of the leading causes of death belongs to non-communicable diseases and this is true for low and middle income countries and high income countries. The rest goes to communicable diseases for low and middle income countries, but for high income countries only a very minimum percentage of death attributed to communicable diseases.
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The 10 Leading Causes of DALYs, 2001
Low and middle income countries
High –income countries
When we look at DALYs for low and middle income countries, we see that communicable diseases and injuries are little more important than non-communicable diseases. Unipolar depressive disorders which were not among the ten leading causes of death are in the ten leading causes of DALYs.
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Leading cause of death by income
The global burden of disease hasn’t changed much since 2001, but this chart is interesting because it displays the differences in income group. What do you think the primary reasons are that the differences occur (e.g. why lower respiratory infections are number one in low income countries?)
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Causes of Death by Region
Diseases vary by region as one might expect. In general, the higher the income status of one region, the more likely it is that the leading causes of death will be non-communicable diseases.
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Causes of Death by Age
Children in low-and middle-income countries often die of communicable diseases that are no longer problems in the more developed countries. In high income countries more than 2/3 of all people live beyond the age of 70 and die of chronic disease otherwise known as non-communicable disease. In middle income countries almost 50% of all people live to the age of 70 and die of chronic diseases however, conditions like TB, HIV and road traffic accidents are also leading causes of death. In low income countries only 20% of all people reach to the age of 70 and more than 1/3 of all deaths occur among children under 15. People predominantly die of infectious diseases like diarrheal disease, complication of pregnancy, and TB.
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Causes of Death by Gender
In low and middle income countries the causes of death are alike for men and women. However, men tend to die more from road traffic accidents and women from diabetes. Some social and environmental factors play critical role in women mortality and morbidity. 99% of maternal mortality occurs in the developing countries. On the other hand, men are more diagnosed with TB and die from it than women. So is true for cardiovascular disease.
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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.
In addition to consider the influence of region, gender, and sex, it is vital to examine the mortality rates and DALYs within countries by same factors. As it can be imagined in low and middle income countries, rural people are less likely to be healthy because of lack of access to care and/or malnutrition. Disadvantaged, poor, and uneducated people are less likely to be healthy and women are more likely to suffer from morbidity because of their weak social positions.
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Risk Factors
Probability of an adverse outcome, or a factor that raises the probability
Risk is defined as “a probability of an adverse outcome, or a factor that raises this probability.” when we answer a questions in health history, we are helping the provider to find out the risk factors that we face ourselves.
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Risk Factors by countries
Lack of safe drinking water
Lack of proper sanitation
Indoor cooking with coal and wood
Malnutrition
War and injury
Smoking
Overweight and obesity
High blood pressure
High cholesterol
Smoking
Unsafe sex
Low-and Middle Income Countries
High-Income countries
Risk factors vary by geographical variation, educational status, socioeconomic status, genetic and so on. Risk factors for low and Middle income countries and high income countries vary significantly. Some of the questions we consider to assess the risk for low and middle income countries are as follows
Does the family have safe water to drink?
Do their house and community have appropriate sanitation?
Does the family cook indoors in a way that makes the house smoky?
Do the mother and father work in places that are safe environmentally?
Think of some questions that are applicable for high income countries to assess risk.
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Demography and Health
Population growth
Population again
Urbanization
The “Demographic divide”
The demographic transition
Population dynamics like growth rates, aging, urbanization, the trends of disease all influence health. In the next couple of slides we’ll discussing each of the five factors in more elaborate fashion.
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Population Growth
http://www.youtube.com/watch?v=sc4HxPxNrZ0
After growing very slowly, the world’s population more than doubled in the last half century to reach 6.9 billion. The overwhelming majority of population growth in future is projected to happen in low and middle income countries which reflect the fact that fertility is falling slowly in countries where there is high fertility rates. Lower mortality rates, longer life expectancy and large youth population have contributed to the high rise of human population.
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Population Aging
Population of the world is aging. While it can be seen as success story for public health policies, it is also an implication 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 which will result in raising the healthcare cost.
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Aging population percentage
Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed Jan. 1, 2016.
Population ages 65 and above as a percentage of the total population. Population is based on the de facto definition of population, which counts all residents regardless of legal status or citizenship--except for refugees not permanently settled in the country of asylum, who are generally considered part of the population of the country of origin.
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Urbanization
The world is becoming increasing urbanized.
Tremendous change has happened in developing countries.
Emerging health problems
Environment- water, sanitation, air pollution
Housing – crowding, respiratory disease, infectious disease
Social – lack of education, health service, crime, violence, drug use
Lifestyle- physical inactivity, smoking, alcohol, stress
The majority of world’s population live in urban areas than ever before. Between 1990 and 2025 the urban population worldwide is expected to double with 22% increase happened in developing countries. This phenomenon has emerged health problems in several areas. For example, water and sanitation systems are under increased pressure, unclean water supply can cause the transmission of infectious diseases, physical and mental condition gets affected by unhealthy housing, overcrowding can leads to the transmission of respiratory and infectious diseases, the social infrastructure systems gets overloaded .As a result there will be lack of education, health services, and increased crime, violence and drug use. The lifestyle factors like stress, physical inactivity, smoking and alcohol consumption ultimately leads to increase in chronic diseases.
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The Demographic Divide
| High- Income Countries | Middle-and Low –Income countries |
| Low fertility | Higher fertility |
| Declining populations | Growing populations |
| Aging populations | Less aging populations |
| Higher life expectancy | Lower life expectancy |
The demographic indicators in low and middle income countries and in high income countries vary tremendously. High income countries are facing the issues of having aging population, very low fertility and declining population. In contrast low and middle income countries have higher fertility, growing populations and less aging populations.
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Demographic Transition
What is demographic transition?
The shift from a pattern of high fertility and high mortality to low fertility and low mortality, with population growth occurring in between.
The first population pyramid reflects a country with high mortality and high fertility. The second pyramid reflects a country in which mortality has begun to decline but fertility remains high. The third pyramid which looks like a cylinder than pyramid , reflects a country in which fertility has been reduced and share a greater number of aged population.
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Epidemiologic Transition
A transition from infectious/communicable disease to chronic/non-communicable disease
Closely related to demographic transition
High income countries went through the transition
Low income countries are in ongoing transition, thus share the burden of both communicable and non-communicable diseases.
Discuss this slide.
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The Burden of Disease: Looking Forward
Economic development
Scientific and technical change
Climate change
Political stability
Emerging and re-emerging infectious diseases.
Economic development of a country is critically linked with the health of all people of that country. As low income countries continue to grow economically and have more equitable access to such growth across all strata of population, the chance to invest in health will raise more. Scientific and technical changes are also imperative for improved health status. For example, development of new diagnostic for TB or vaccine for HIV will have enormous impact on the global health. The direct effect of climate change on health is not simple to understand. A direct effect of climate change is extreme weather conditions such as droughts, storms or flood that in turn harm people’s health It could also lead to favorable condition for some disease vectors which allow a disease to reemerge. In low income countries political stability appears to be necessary for good health. Countries like Liberia, Afghanistan , Sierra Leone, Democratic republic of Congo are lacking well-structured health system for many years. The conflicts in these countries lead to disability, illness, death.
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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.
Health care cost remains the challenge for low and middle income countries. As low income countries moves through the demographic and epidemiological transitions, it becomes much more challenging to face such transition in lowest possible cost. Despite the economic burden, low income countries should concentrate on achieving higher life expectancy by following the example of countries like Sri Lanka, Cuba and Costa Rica. Selecting the segment of the health service that would yield higher impact on health status at low cost should get the priority such as TB control or vaccination program.
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