Basanta Chalise (Roll no. 1)
MHP&E 1st batch
Identify the determinants of
mortality and discuss first ten
• Sources of data
• Measures of Mortality
• Mortality estimates
• Determinants of Mortality
– Proximate / Direct
– Distal / Indirect
• Number of slides= 27
• Estimated time= 20 minutes 2
• Mortality refers to deaths that occur within a
population. The incidence of death can reveal
much about a population’s standard of living
and health care.1
• The United Nations and the WHO have defined
death as “Death is the permanent
disappearance of all evidence of life at any time
after birth has taken place (post-natal cessation
of vital functions without capacity of
Mortality in different point of view
• The end of the body or physiological
capacity who have had a live birth.Biological
• Indicates the decreasing in the size of
population on account of deathDemographic
• Mortality is one of the three components of
•Mortality can be taken as the one of the vital factors
that affects the structure, size and growth of the
Sources of data
• The occurrence of death is a vital event so it
need to be registered.
• In the absence of adequate registration data,
the national census and demographic sample
surveys provide alternative sources of
information on mortality.
• In Nepal according to local self government
act (1999) stated that occurrence of death is a
vital event which needs to be registered in the
office of VDC or municipality.4
Measures of Mortality6
• Crude death rate
• Specific death rate
(Cause/ age specific)
• Case fatality rate
• Proportional mortality
• Survival rate
• Standardized mortality
• Comparative Mortality
Infant mortality rate
Neonatal Mortality rate
Average expectation of life
Under-five mortality rate
Child Mortality rate
Maternal mortality Ratio 6
The measures of mortality are the quantitative and statistical
devices to label the risk of mortality to which a population is
exposed over a period of time.5
Mortality Estimates : Global, Regional
NMR IMR U5MR MMR
1990 2012 1990 2012 1990 2012 1990 2012 1990 2013
64 70 33 21 63 35 90 48 380 210
54 68 53 24 99 34 142 42 790 190
53 62 47 30 104 58 166 82 900 450
75 79 7 4 12 5 15 6 24 17
The top ten leading causes of death in
the world (2012)
In World In high income countries In low income
Ischemic heart disease Ischemic heart disease Lower respiratory
Stroke Stroke HIV/AIDS
COPD Tracheobronchus, lung
Alzheimer disease and
COPD Ischemic heart
HIV/AIDS Lower respiratory
Diarrhoeal disease Colon rectum cancer Preterm birth
Diabetes mellitus Diabetes mellitus Tuberculosis
Road injury Hypertensive heart
Birth asphyxia and
Hypertensive heart Breast cancer PEM
Determinants of the Mortality8
• Proximate determinants: Factors that directly
influence the risk of disease and the outcomes of
disease processes in individuals resulting death.
• Distal (underlying) determinants: Social, economic,
and cultural factors that influence the health status of
a population by operating through one or more of the
–Personal behaviors: Diet, hygiene, alcohol
and tobacco use, sexual behavior, etc.
–Environmental exposures: Exposure to
infectious or chemical or physical agents,
occupational hazards, etc.
–Nutrition: Under nutrition, micronutrient
deficiency, over nutrition/obesity etc.
–Injuries: Intentional or accidental injuries.
–Personal illness control: Specific preventive
and sickness care actions.
Distal (underlying) determinants:
– Socio-economic factors: Household wealth, community
development, women’s education and employment,
– Institutional factors: Health systems, health
regulations, technological developments, information
programs, environmental interventions, etc.
– Cultural factors: Traditional beliefs about health and
disease, religious values, role and status of women etc.
– Broader context: Ecological setting, political economy,
transportation and communication systems,
agricultural development, markets, urbanization, etc
First ten important determinants
1. Income level/Employment status:
• Positive association between income level and the
• Low-income people live shorter lives than high-
income people in a given country.9
• Pritchett and Summers argued from cross-country
regressions that income is more important than any
other factor, and have endorsed policies that
downplay the role of any deliberate public action in
• In 1990 alone, more than half a million child
deaths in the developing world could be attributed
to poor economic performance in the 1980s.
Wealthier nations are healthier nations.10
2. Nutritional status:
• Malnutrition has been recognized as the
one of the killer of the children.11
• Vicious circle of poverty and malnutrition
are more prone to infections resulting
• There are powerful two-way interactions
between disease and nutrition.12
• The emergence and reemergence of epidemics of
several communicable and non communicable
diseases like diarrhea, malaria, influenza,
tuberculosis, HIV/AIDS etc are responsible for the
death of children, women or any individual.
• The influenza pandemic of 1918-1919 killed more
people than the Great War, known today as World
War I (WWI), at somewhere between 20 and 40
million people. It has been cited as the most
devastating epidemic in recorded world history.13
• Globally around 9% of total death are
responsible for the injuries which are both
i. Un-intentional (road, poisoning, falls,
ii. and intentional (self harm, interpersonal
violence, collective violence)14
5. Personal behavior:
• There are several modifiable behaviors that
are responsible for the morbidity and
mortality of an individual.
• Sedentary life style, consumption of high fat,
harmful consumption of alcohol and tobacco,
personal hygiene, hand washing practice,
unsafe sex are now strong established
determinants of the mortality.
• The importance of women’s education is likely
a result of the fact that as primary care takers,
they are most likely to implement the health
of the fact that as primary care takers, they
are most likely to implement the healthy
behaviours that can improve their children’s
health for example they will smoke less.15
• Education makes healthy life style, utilization
of available health services, proper decision
making, health seeking behavior etc.
7. Women empowerment and
• Women and girls are at increased risk of
violence related death due to lack of
empowerment and marginalization resulting
from exclusion from social and economic
• In 2012, the UN adopted a resolution on
“eliminating maternal mortality and morbidity
through the empowerment of women”.17
• If the mother’s job allows her to generate
financial resources and to obtain the services
that may help improve survival.
8. Availability, access and utilization
of health service:
• Easy access to the health care delivery system and
proper utilization of the health services has
increased the life expectancy.
• Unavailability of health services, delay at the health
facility, lack of essential drugs, inadequate
equipment, lack of trained human resources, lack of
appropriate technology, lack of transportation has
been underlined with the cause of death.18
• Health delivery is often of low quality in both public
and private sectors. Absenteeism among medical
staff is often a problem particularly in rural areas.19
9. Environment and sanitation:
• Environmental pollution is harming both
human and plant life.
• Air pollution is positively associated with
total mortality e.g. lung cancer.
• In developing countries like Nepal open
defecation, consumption of polluted
water is taking the life of the individuals.
10. Cultural factors:
• Socio-cultural practices, health seeking
behavior, traditional beliefs, self-medication,
status and role of the women, cord cutting
practices, female genital mutilation, cultural
acceptance of alcohol, home delivery practices,
superstitious belief, religious thought etc plays
tremendous role as the distal determinants for
• Without “Live Birth” no “Death” is taken into account.
• Mortality influence the size, structure and growth of
• Sources of data
• NMR, IMR, U5MR, MMR, , CDR, ASDR are major
measures of Mortality
• Proximate/ direct and Distal/Indirect
• Personal behaviors Socio-economic factors
• Environmental exposures Institutional factors
• Nutrition Cultural factors
• Injuries Broader context
• Personal illness control
are the determinants of the mortality.
1. Arthur Haupt , Thomas T.kane and Carl Haub, PRB's Population Hand Book, 6th Edition, PRB Washington , 2011.
2. Bhende A A, Kanitkar T. Mortality. In: Principles of population studies, 21st Ed. Mumbai: Himalayan Publishing House, 2011.
3. MOHP, Nepal Population Report, Ministry of Health and Population, Population Division Ramshah path , Kathmandu, 2011.
4. Government of Nepal, Nepal Law commission , Local Self Government Act, 1999
5. Mishra B D: An Introduction to the study of population. 3rd edition New Delhi: South Asian Publisher Pvt. Ltd; 2004
6. K Park. Park’s text book of preventive and social medicine, 19th Ed. Jabalpur: Banarsidas Bhanot, 2007
7. WHO, World Health Statistics, http://www.who.int/mediacentre/news/releases/2014/world-health-statistics-2014/en/ ,
assessed 2th September 2014
8. John Hopkins Bloomberg School of Public Health and Henry Mosley, Mortality and Morbidity Trends and Differentials,
Determinants and Implications for the FutureJHU, 2006.
9. Cutler, David, Angus Deaton and Adriana Lleras-Muney.. The determinants of mortality. Journal of Economic Perspectives .
bridge University Press, reprint , 20(3): 97-120, 2006
10. Pritchett L and Lawrence H. S, “Wealthier is Healthier,” Journal of Human Resources. 1996; 31(4): 841-868.
11. DOHS, Annual Health Report 2068/69(2011/12), DOHS, MOHP, 2013.
12. Scrimshaw, Neville S., Taylor C. E., and Gordon J. E., Interactions of nutrition and infection, Geneva. World Health Organization,
13. The Influenza Pandemic of 1918, http://virus.stanford.edu/uda/, assessed 2th September 2014
14. http://www.who.int/healthinfo/global_burden_disease/en/ June 2013, assessed 2nd sep. 2014.
15. Meara, Ellen, "Why is Health Related to Socioeconomic Status? The Case of Pregnancy and Low Birth Rate" (April 2001). NBER
Working Paper No. W8231.
16. UNICEF, Breaking the silence on Violence against Indigenous Girls, Adolescents and Young Women;A call to action based on an
overview of existing evidence from Africa, Asia Pacific and Latin America;Human Rights Unit Programme Division, UNICEF, New
17. UNFPA, Maternal Health Thematic Fund, Annual Report 2011, UNFPA, New York , June 2012.
18. Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health
Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland
19. Chaudhury, Nazmul, Hammer. J, Kremer. M, Muralidharan K and Halsey. F. R, “Missing in action: teacher and health worker
absence in developing countries,” Journal of Economic Perspective, 2005. 26
Prof. Dr. Kiran Dev Bhattarai
Maharajgunj Medical Campus,
Institute of Medicine
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