1.
Dr. Khem R Sharma
AP, SPH & CM

2.
After the end of this session each student should be able to:
• Comprehend & recognize different sources of epidemiological data
• Appreciate the concept of Health Indicators
• Evaluate the characteristics of Health Indicators
• Identify different categories of Health Indicators and their uses

3.
Definition of Health
• State of complete physical mental and social well being, not merely
an absence of disease or infirmity that enables a person to live a
socially and economically productive life – WHO
• How healthy is any given community ?
• Indices are required to quantify the health status of a community to
compare it internally (different subgroups of population) and
externally (with other provinces or between countries)

4.
Indicators of Health
• Indicators are required not only to measure the health status of a
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

5.
Health Indicators
• Indicators help to measure the extent to which the objectives and
targets of a program are being attained.
• lf measured sequentially over time, they can indicate direction and
speed of change and serve to compare different areas or groups of
people at the same moment in time

6.
Health Indicator Vs Health Index
• Indicators are only a reflection of a given situation at a particular time
based on the available data
• They are defined as variables which help to measure changes in
WHO's guidelines for health program evaluation
• The term indicator is to be preferred in relation to health trends,
• Health index is generally considered to be an amalgamation of health
indicators

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‘DATA’ Vs ‘INFORMATION’
• DATUM (singular) or DATA (plural) refers to raw numbers or other
measures, usually discrete and gives objective facts about events.
• INFORMATION refers to what emerges when data are processed,
analyzed, interpreted and presented. Information is data
transformed (contextualized, categorized, corrected, calculated,
condensed) into a message

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FROM REALITY TO ACTION
Real world
Data
Information
Action
Source: Oxford Handbook of Public Health Practice

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Sources of epidemiologic data
• TWO TYPES OF DATA SYSTEMS:
 ROUTINE: Health information systems
NON-ROUTINE:
- Surveys
- Research programs

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ROUTINE DATA SOURCES
• HIS (Health Information System) and its subsystems
are collected as part of an ongoing system

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CHARACTERISTICS OF HIS
• A health system is not a static phenomena - It is in a
continuous process of change due to pressures from
both outside and within the system
• HIS is an integral part of the health system
• HIS generates the data to measure the change of a
health system

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HIS SUB-SYSTEMS
• Epidemiological surveillance
• Routine service reporting
• EWARS
• Special program reporting systems
• Administrative systems
• Vital registration systems
• Demographic Surveys
• Censuses
• Special studies/Program Evaluations

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NON-ROUTINE DATA SOURCES
• DHS
• Special Surveys
• Program or Project Evaluation
• Clinical trials
• Epidemiological Surveys (Descriptive/Analytical)

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Non-Routine Data Sources by Levels
 Policy or program level
 Facility/Service delivery point level
 Client level
 Population level

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LEVELS OF INFORMATION WITHIN THE IDENTIFIED DATA
SOURCES
The next quest is to identify the level of information one is interested in
within the identified Data sources
• LEVELS OF DATA:
1. Policy or Program level
2. Population level
3. Service Environment level
4. Client level
5. Spatial/Geographic level

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POLICY/PROGRAM LEVEL
• This is policy/legislation formulation level,
Sources:
- Official legislative & administrative documents
- National budgets or other related data
- Policy inquiries
- Census (periodic count/enumeration of a population)
• Tools:
- Indexing questionnaires (for country specialists
and rankings)
- Special/contract studies

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FACILITY LEVEL
 Facilities-services, infrastructure, etc.
 Audits/inventories
 Facility surveys
 Health care providers, other staff
 Performance reviews, competency measures
 Training records

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POPULATION LEVEL
Where you need to know the size/composition of a population.
Sources such as:
- Population census bureau, Sentinel surveillance systems, Vital statistics
system (birth & death certificates), Sample households or individuals, Special
population samples (demographic/occupational group, or geographic sector)
Tools:
- Birth/Death certificates
- Census questionnaires
- Household/Individual Special Surveys

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SERVICE ENVIRONMENT LEVEL
This is a complex level requiring different types of data from
Sources such as:
- Administrative records (service stats, HMIS data, financial & transport data)
- Service delivery point information (audit information, inventories, facility survey
data)
- Staff information (performance assessments, training records, provider data,
quality of care data)
- Client visit registers
Tools:
- Health Service Information Systems, Facility Sample Surveys, Facility records,
Performance Monitoring Reports

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INDIVIDUAL LEVEL
“Individual” refers to a client, participant, patient or documents
related to a single person as can be obtained from
• Sources such as:
- Medical records, Interview data, Case Surveillance (epidemiology of disease)
- Provider-Client interactions
Tools:
- Case reports; - Survey questionnaire; - Client register analysis
- Patient flow analysis; - Direct observation

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INDIVIDUAL LEVEL
Can measure “program exposure” represented by utilization, as well
as service experience, quality of care/service delivery, disease
surveillance
• Is the service volume increasing?
• What are the services catered?
• Who are the clients?
• How does it vary by public/private sector?
• What are their consultation experiences?
• Would they return/recommend the service?

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INDIVIDUAL LEVEL
1. Client Exit Interviews
2. Case surveillance (epidemiology)
3. Provider-client observation
4. Service Delivery Point records and
registers
5. Patient-flow analysis

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MEASUREMENT TOOLS
• Facility audits, Inventories
• Facility surveys
• Provider interviews
• Provider-client observation
• Provider training records
• Situation analysis

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GEOGRAPHIC LEVEL
These are modern and specialized methods
sources include:
- Cadastral maps (land ownership)
- Land Demarcation Department with:
- Satellite Imagery and Area Photography
- Digital Line Graphs and Elevation Models
Tools:
- Global Positioning System
- Computer Software Programs (GIS)

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Rapid Appraisal / Qualitative Methods
• Key Informant Interviews
• Focus Group Discussions
• Community Interviews
• Direct Observation

26.
A. Intoxicated driver arrests.
B. Electronic health records.
C. Measurement of toxins in a river.
D. Medical board action against a physician.
Which of the following are examples of a health-related
source of data collection?
Knowledge Check
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27.
Rate Vs Ratio Vs Proportion
Rate measures the occurrence of some event (development of
disease or the occurrence of death) in a population during a given
time period
• Indicates the change in some event that takes place in a population
over a period of time
Ratio expresses a relation in size between two random quantities
where the numerator is not a component of the denominator
Proportion is a ratio which indicates the relation in magnitude of a
part of the whole and the numerator is always included in the
denominator

28.
Characteristics of an Ideal Indicator
1) Valid - they should actually measure what they are supposed to
measure
2) Reliable and objective - the answers should be the same if
measured by different people in similar circumstances
3) Sensitive - they should be sensitive to changes in the situation
concerned
4) Specific - they should reflect changes only in the situation
concerned

29.
Characteristics of an Ideal Indicator…..
5) Feasible - they should have the ability to obtain data needed, and
6) Relevant - they should contribute to the understanding of the
phenomenon of interest
• In real life there are few indicators that comply with all these criteria
• We have problems in defining health - we also have problems in measuring
health

30.
Health Indicators
• Measurements of health have been framed in terms of illness (or lack
of health), the consequences of ill-health (e.g., morbidity, disability)
and economic, occupational and domestic factors that promote ill-
health - all the antitheses of health
• Health is multidimensional, and each dimension is influenced by
numerous factors, some known and many unknown
• Our understanding of health, therefore, cannot be quantified in terms
of a single indicator; it must be conceived in terms of a profile

31.
Uses of Indicators of Health
• Measurement of the health of the community
• Description of the health status of a community
• Comparision of Health of different communities
• Identification of health needs and Priortizing them
• Evaluation of Health services
• Planning and allocation of health resources
• Measurement of success of health programs

32.
Health Indicators
1) Mortality indicators
2) Morbidity indicators
3) Disability rates
4) Nutritional status indicators
5) Health care delivery indicators
6) Utilization rates
7) Indicators of social and mental
health
8) Environmental indicators
9) Socio-economic indicators
10)Health policy indicators
11)Indicators of quality of life, and
12)Other indicators.

33.
1) Mortality Indicators
• These are variables that help to count the deaths occurring in the
community
• Mortality indicators represent the traditional measures of health
status.
• Mortality indicators are losing their sensitivity as health indicators in
developed countries as mortality rates have declined to very low
levels
• Mortality indicators continue to be used as the starting point in
health status evaluation

34.
Crude Death Rate (CDR)
• The number of deaths per 1000 population per year in a
given community.
• indicates the rate at which people are dying
• Although health should not be measured by the number
of deaths that occur in a community, CDR is the only
available indicator of health in many countries
• Usefulness of the crude death rate is restricted because it
is influenced by the age-sex composition of the
population
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35.
Life Expectancy
• Life expectancy at birth is "the average number of years that will be
lived by those born alive into a population if the current age-specific
mortality rates persist
• highly influenced by the infant mortality rate where that is high.
• increase in life expectancy is regarded as an improvement in health
status.
• Life expectancy is a good indicator of socioeconomic development in
general
• It has been adopted as a global health indicator

36.
Infant mortality rate
• Ratio of deaths under 1 year of age in a given year to the total
number of live births in the same year; usually expressed as a rate per
1000 live births
• Universally accepted indicator of health status of infants and the
whole population and of the socio-economic conditions under which
they live.
• Sensitive indicator of the availability, utilization and effectiveness of
health care, particularly perinatal care

37.
Child mortality rate
• number of deaths at ages 1 to 4 years per year, per 1000 children of
that age group at the mid-point of the year concerned
• It excludes infant mortality
Under-5 mortality rate
• total deaths occurring in the under-5 age group.
• High rate reflects high birth rates, high child mortality rates and
shorter life expectancy
Neonatal/Perinatal mortality

38.
Maternal Mortality Ratio
• annual number of death of a woman while pregnant or within 42 days of termination of
pregnancy from any cause related to or aggravated by the pregnancy or its management
but not from accidental or incidental causes per 100,000 live births
• Uses: To know the health status of the mothers
To identify the social factors responsible for maternal deaths
To evaluate the functioning of health delivery systems
For research purposes
Indicator of MDG and SDG
Disease-specific mortality rate
Proportional mortality rate
• The proportion of all deaths currently attributed to that condition

39.
2) Morbidity Indicators
• Mortality indicators do not reveal the burden of ill-health in a
community; eg- mental illness and rheumatoid arthritis.
• Morbidity indicators are used to supplement mortality data to
describe the health status of a population.
• Morbidity indicators reveal the burden of ill health in the
community, but do not measure the subclinical or in-apparent
diseased states (submerged part of iceberg)

40.
Incidence and Prevalence

41.
Incidence
• The number of NEW cases occurring in a defined population during a
specified period of time
• Measures the rate at which new cases are occurring in a population
and is not influenced by the duration of the disease
• Use of incidence is generally restricted to acute conditions.
• Attack rate/ Secondary attack rate

42.
Prevalence
• All current cases (old and new) existing at a given point in time or
over a period of time in a given population.
• Point/Period prevalence
• Assuming that the population is stable, and incidence and duration
are unchanging
Prevalence = incidence x mean duration of disease
• Incidence is related to the occurrence of disease (causal factor) and
duration to factors that affect the course of the disease (prognostic
factors)

43.
Relation between Incidence and Prevalence
Prevalence Pot

44.
2) Other Morbidity Indicators
Disease Notification Rate
OPD Attendance Rate
Admission, Readmission and Discharge Rate
Duration of Stay in Hospital and Spells of Sickness
Absence from Work/School.

45.
3) Disability Rates
• Death rates have not changed markedly in recent years,
despite massive health expenditures
• Disability rates related to illness and injury have come into
use to supplement mortality and morbidity indicators
• disability rates are of two categories
a) Event-type indicators
i. Number of days of restricted activity
ii. Bed disability days
iii. Work-loss days
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b) Person-type indicators
i. Limitation of mobility: eg-confined to bed, confined to the
house, special aid in getting around
ii. Limitation of activity: eg-limitation to perform the basic
activities of daily living i.e. eating, washing, dressing
Sullivan's index = life expectancy of the nation - the
probable duration of bed disability and inability to perform
major activities
• It is an expectation of life free from disability

47.
HALE (Health Adjusted Life Expectancy)
• the equivalent number of years in full health that a newborn can
be expected to live based on the current rates of ill health and
mortality
DALY (Disability Adjusted Life Years)
• expresses the years of life lost to premature death and years
lived with disability adjusted for the severity of disability
• One DALY is "one lost year of healthy life“
• Simplest and the most commonly used measure to find the
burden of illness and the effectiveness of the interventions in a
defined population

48.
4) Nutritional Status Indicators
• These give information about the nutritional sate of the
children and include:
1) anthropometric measurements of preschool children
(like weight and height, mid-arm circumference)
2) heights (and sometimes weights) of children at school
entry
3) prevalence of low birth weight (less than 2.5 kg).
• Underweight, Obesity and Anaemia are generally
considered reliable nutritional indicators in adults
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49.
5) Health Care Delivery Indicators
• These indicators reflect the equity of distribution of health resources
in different parts of the country and of the provision of health care
• Doctor-population ratio
• Bed-nurse ratio
• Population-bed ratio
• Population per health facility

50.
6) Utilization Rates
• Utilization of services - or actual coverage - is expressed as the
proportion of people in need of a service who actually receive it in a
given period, usually a year
• relationship exists between utilization of health care services and
health needs and status of any population
• proportion of infants who are "fully immunized" against the EPI
diseases (Immunization coverage)
• proportion of pregnant women who receive antenatal care, or have
their deliveries supervised by a trained birth attendant
• percentage of the population using the various methods of family
planning.

51.
INDICATORS OF HEALTH
7) Indicators of social and mental health:
• These social indicators provide a guide to social action for
improving the health of the people.
• Rates of suicides, homicides, violence, crimes, RTAs, drug
abuse, smoking and alcohol consumption etc.
8) Environmental indicators:
• Environmental indicators reflect the quality of physical and
biological environment in which diseases occur and in which
the people live
• proportion of population having access to safe drinking water
and improved sanitation facility, level of air pollution, water
pollution, noise pollution etc
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INDICATORS OF HEALTH
9) Socio Economic Indicators:
• They measure health indirectly
• rate of population increase, Per capita GNP, Dependency ratio,
Level of unemployment, literacy rate, family size etc
10) Health policy Indicators
• The single most important indicator of political commitment is
"allocation of adequate resources"
• proportion of GNP spent on health services, proportion of GNP
spent on health related activities including safe water supply,
sanitation, housing, nutrition etc. and proportion of total health
resources devoted to primary health care
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53.
11) Indicators of Quality of Life
• Quality of life is difficult to define and even more difficult to measure
• Various indicators have been devised to express Quality of Life over
the years
• PQLI, HDI, IMR, Literacy rate

54.
12) Other Indicator Series
a) Social Indicators: 12 Categories (population, family formation,
learning and educational services, earning activities etc)
b) Basic Needs Indicators: calorie consumption, Illiteracy
c) Health For All Indicators
d) MDG & SDG Indicators

55.
SDG Indicators
• 232 (total 244- but 9 indicators repeat under different categories)
• Goal 1- End Poverty
• Goal 2- End Hunger
• Goal 3- Healthy Life & Well Being
• Goal 4- Quality Education……..etc

56.
To Summarize…
• Epidemiologic data is obtained from various sources in form of Indices
• There is no single comprehensive indicator of a nation's health, while
each available indicators reflect one aspect of population health
• Search for a single global index of health status continues with the use
of multiple indicators arranged in profiles or patterns that should make
comparisons between areas, regions and nations possible

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