Chapter Two Health Determinants, Measurements, and Trends Overview What are the determinants of health? What are the most important health indicators and key terms related to measuring health status and the burden of disease? What are the leading causes of death and the burden of disease in low-, middle-, and high-income countries? What are the demographic and epidemiological transitions? 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 in health status that have occurred historically Determinants of Health The interconnected factors that determine an individual’s health status Determinants include personal and inborn features, socioeconomic 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 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 Carrying out disease surveillance To perform these functions, it is important to use a consistent set of indicators in order to make comparisons Key Health Indicators Key Health Indicators Key Health Indicators Key Health Indicators Key Health Indicators Key Health Indicators 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 13 Key Health Indicators Terms Prevalence—number of people suffering from a certain health condition over a specified period Incidence—the rate at which new cases of a disease occur in a population 14 Key Health Indicators Communicable diseases—illnesses caused by a particular infectious agent that spreads directly or indirectly from people to people, animals to people, or people to animals; also called infectious diseases Noncommunicable diseases—illnesses not spread by an infectious agent Injuries—include road traffic injuries, falls, self-inflicted 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 Often there are cultural barriers to timely vital registration Vital Registration Measuring the Burden of Disease Health-Adjusted Life Expectancy (HALE) Summarizes expected number of years to be lived in what might be termed the equivalent of good health A health-expectancy measure To calculate HALE: the years of ill health are weighted according to severity and subtracted from overall life e.

1. Chapter Two
Health Determinants, Measurements, and Trends
Overview
What are the determinants of health?
What are the most important health indicators and key terms
related to measuring health status and the burden of disease?
What are the leading causes of death and the burden of disease
in low-, middle-, and high-income countries?
What are the demographic and epidemiological transitions?
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 in health status that have occurred historically
Determinants of Health
The interconnected factors that determine an individual’s health
status
Determinants include personal and inborn features,
socioeconomic 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

2. 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
Carrying out disease surveillance
To perform these functions, it is important to use a consistent
set of indicators in order to make comparisons
Key Health Indicators
Key Health Indicators
Key Health Indicators
Key Health Indicators
Key Health Indicators
Key Health Indicators

3. 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
13
Key Health Indicators
Terms
Prevalence—number of people suffering from a certain health
condition over a specified period
Incidence—the rate at which new cases of a disease occur in a
population
14
Key Health Indicators
Communicable diseases—illnesses caused by a particular
infectious agent that spreads directly or indirectly from people
to people, animals to people, or people to animals; also called
infectious diseases
Noncommunicable diseases—illnesses not spread by an
infectious agent
Injuries—include road traffic injuries, falls, self-inflicted
injuries, and violence, among other things
Vital Registration

4. 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
Often there are cultural barriers to timely vital registration
Vital Registration
Measuring the Burden of Disease
Health-Adjusted Life Expectancy (HALE)
Summarizes expected number of years to be lived in what might
be termed the equivalent of good health
A health-expectancy measure
To calculate HALE: the years of ill health are weighted
according to severity and subtracted from overall life
expectancy
18
Measuring the Burden of Disease
Disability-Adjusted Life Year (DALY)
The sum of years lost due to premature death (YLLs) and years
lived with disability (YLDs). DALYs are also defined as years
of healthy life lost
A health-gap measure
Indicates losses due to illness, disability and premature death in
a population

5. Burden of Disease Data
Important to gain an understanding of:
Leading causes of illness, disability, and death in the world
Variations in these causes by age, sex, ethnicity, and
socioeconomic status
Changes over time and how these causes might change in the
future
Burden of Disease Data
Overview of Patterns and Trends in the Burden of Disease
People in much of the world are living longer than before and
dying at lower rates than earlier
As people live longer, there is an increase in the years people
live with disability
The burden of disease is predominantly noncommunicable in all
World Bank regions, except sub-Saharan Africa
Burden of Disease Data
Overview of Patterns and Trends in the Burden of Disease
Over the last few decades, the burden of disease has shifted
increasingly toward noncommunicable diseases in all World
Bank regions
This shift has been fueled, among other things, by a reduction in
communicable diseases and the aging of populations
Burden of Disease Data
Burden of Disease Data

6. Burden of Disease Data
Burden of Disease Data
Burden of Disease Data
Causes of Death by Region
Higher income countries tend to have a greater burden of
noncommunicable diseases
The lowest income countries have a greater burden of
communicable diseases
Africa and South Asia are set apart by their large burdens of
communicable disease
27
Burden of Disease Data
Burden of Disease Data
Burden of Disease Data
Burden of Disease Data

7. Burden of Disease Data
Burden of Disease Data
Burden of Disease Data
Burden of Disease Data
Burden of Disease Data
The Burden of Deaths and Disease Within Low- and Middle-
Income Countries
Rural people will be less healthy
Disadvantaged ethnic minorities will be less healthy
Females will suffer from their weak social positions
Poor people will be less healthy
Uneducated people will be less healthy
Risk Factors

8. 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
Risk Factors
Risk Factors
Demography and Health
Population Growth
Current world population is 7.2 billion and growing
Majority of population growth will occur in low- and middle-
income countries
This growth will put substantial pressure on the environment
and infrastructure
Demography and Health
Demography and Health
Population Aging
Population of the world is aging
Elderly support ratio—ratio between the number of people that
are 15–64 years of age, compared with the number that are 65
years of age or older
Affects burden of disease because people will be living longer
with morbidities and disabilities

9. Affects healthcare financing because of costs of caring for older
people
Demography and Health
Demography and Health
Urbanization
In the last decade, most of the world’s population has lived
their entire life in urban areas
People are continuing to move from rural to urban areas,
especially in low- and middle-income countries
There is enormous population pressure on urban infrastructure,
such as water and sanitation
46
Demography and Health
The Demographic Divide
Highest income countries: low fertility, often declining
populations, aging populations
Lowest income countries: relatively high fertility, growing
populations
47
Demography and Health
The Demographic Transition
Shift from pattern of high fertility and high mortality to low
fertility and low mortality

10. Mortality declines with better hygiene and nutrition
Population grows with gap between births and deaths
Fertility declines
Population growth slows and older share of population increases
as births and deaths equalize
48
Demography and Health
Demography and Health
The Epidemiologic Transition
Shift from burden of disease dominated by communicable
disease to burden of disease dominated by noncommunicable
disease
Low-income countries are going through it now
First, and historically: high and fluctuating mortality, related to
very poor health conditions, epidemics, and famine
Demography and Health
The Epidemiologic Transition
Then, progressive declines in mortality as epidemics become
less frequent
Finally, further declines in mortality, increases in life
expectancy, and the predominance of noncommunicable diseases
The pace of this transition depends on factors related to the
determinants of health
Demography and Health

11. 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 lags
behind other regions
Life expectancy in Europe and Central Asia changed little from
1990-2011, related to break-up of Soviet Union
Life expectancy in East Asia increased dramatically, partly due
to rapid economic growth
Progress in Health Status
The Burden of Disease: 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 how equitable
growth is across population groups and investments in areas that
improve health such as water, sanitation, and education
The Burden of Disease: 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
The Burden of Disease: Looking Forward
Climate Change

12. Impact not entirely clear
Possible migration from places that become uninhabitable
Adverse weather
Possible change in populations of disease vectors
The Burden of Disease: 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 that leads to further
health issues
Instability has impeded achieving the Millennium Development
Goals
The Burden of Disease: Looking Forward
Emerging and Reemerging Infectious Disease
Occurrence and impact difficult to predict
Pandemic flu could have a major impact in the future
Drug resistance outpacing our ability to produce safe and
effective drugs could also have a substantial impact on the
burden of disease
The Burden of Disease: Looking Forward
Projecting the Burden of Disease
Difficult to predict but can use models to project
Substantial changes projected 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 for all income
groups

13. 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 the “best buys” such as
nutrition, education, good hygiene, and low-cost services that
have a high impact such as vaccination programs and TB control
Further Exploration
Further Exploration
IHME GBD 2010 Compare
http://vizhub.healthdata.org/gbd-compare/
Allows you to look at causes of deaths and DALYs across
regions as a proportion of total deaths and DALYs
Further Exploration
Further Exploration
IHME. GBD 2010 Heatmap
http://vizhub.healthdata.org/irank/heat.php
Allows you to look at the ranking of leading causes of deaths
and DALYs across regions and also the absolute number of
deaths and DALYs associated with these causes
Topic Research Proposal

14. This write up for your topic is part of your writing assignments.
Do each of these three sections for the topic you want to
consider using the skills you are learning about in these
chapters. Section 1
In this section, you will begin to do the research for your topic
using your Specific Purpose Statement by creating a
bibliography with three recent sources for your topic and for
each source answer these three questions about your topic and
the source. The source must be correctly cited as per the APA
source citation stylesheet. Locate this information on our Public
Speaking Online Resource site in the library.
Using your specific purpose statement key words, research and
locate at least three sources to support your central idea.
Prepare an annotated bibliography (in bulleted format) by using
the MAP critical thinking approach (from your reading this
week) and answering the following questions about each of your
sources. Your response can be concise but should be thorough
enough to show that you have read and carefully considered the
usefulness of each citation for your topic or you will not get
credit (don’t include sources that won’t be useful)
· Message: Biased? Language? Up-to-date? Accurate?etc.
· Author and Source: Primary Source? Secondary? Tertiary?
· Purpose: What is the purpose of the source? And- How will
this information be useful in your speech?
Be sure to include bibliographic information (a full citation
using APA format) for each source.
1. In Section 2, using the research you have completed in
section 1 create a draft of your Central Idea as part of your
Speech Foundation Information. Write up your Speech
Foundation information as part of this assignment.
2. Write up the Speech Foundation Information including
creating a central idea for your topic.

15. 3. Topic:
4. General Purpose: To Inform
5. Specific Purpose (Create and include this first then do
research to create your Central Idea)
6. Central Idea:
Section 3
Talk with your audience in the classroom about your topic and
read our textbook on evidence and audience; what
considerations will you need to make regarding your topic and
evidence to connect with your audience? What kind of support
material will your audience be most interested in and why
would this be a good fit for your topic and audience? What is
the problem as you see it at this moment (without deep
research)? What is likely to be your call to action?
Include four sentences minimum indicating your audience
analysis of the value of this topic for your audience.