Basanta Chalise (Roll no. 1)MHP&E 1st batch

IOMNepal

Identify the determinants of mortality and discuss first ten

important factors.

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Outline

• Introduction• Sources of data• Measures of Mortality• Mortality estimates• Determinants of Mortality– Proximate / Direct– Distal / Indirect

• Number of slides= 27 • Estimated time= 20 minutes

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Introduction• 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 resuscitation.2

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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 death

Demographic

• Mortality is one of the three components of population change.•Mortality can be taken as the one of the vital factors that affects the structure, size and growth of the population.3

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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

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Measures of Mortality6

• Crude death rate• Specific death rate (Cause/

age specific)• Case fatality rate • Proportional mortality rate • Survival rate• Standardized mortality

ratio• Comparative Mortality

Index (CMI)

Infant mortality rateNeonatal Mortality ratePost-neonatal Mortality

rateAverage expectation of life

at birthUnder-five mortality rateChild Mortality rateMaternal 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

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Mortality Estimates : Global, Regional and National7

Place

Life expectancy

NMR IMR U5MR MMR

1990 2012 1990 2012 1990 2012 1990 2012 1990 2013

Global

64 70 33 21 63 35 90 48 380 210

Nepal

54 68 53 24 99 34 142 42 790 190

Low income

53 62 47 30 104 58 166 82 900 450

High income

75 79 7 4 12 5 15 6 24 17

The top ten leading causes of death in the world (2012)

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9

S.N

In World In high income countries In low income countries

1. Ischemic heart disease Ischemic heart disease Lower respiratory infection

2. Stroke Stroke HIV/AIDS

3. COPD Tracheobronchus, lung cancer

Diarrhoeal disease

4. Lower respiratory infection

Alzheimer disease and other dementia

Stroke

5. Tracheobronchus, lung cancer

COPD Ischemic heart disease

6. HIV/AIDS Lower respiratory infection

Malaria

7. Diarrhoeal disease Colon rectum cancer Preterm birth complication

8. Diabetes mellitus Diabetes mellitus Tuberculosis

9. Road injury Hypertensive heart disease

Birth asphyxia and birth trauma

10. Hypertensive heart disease

Breast cancer PEM

Determinants of the Mortality8

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• 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 proximate causes.

Proximate determinants:–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. 11

Distal (underlying) determinants:– Socio-economic factors: Household wealth, community

development, women’s education and employment, etc.

– 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

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First ten important determinants of mortality

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1. Income level/Employment status: • Positive association between income level and the life

expectancy.• 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 health improvement.10

• 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

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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 death.

• There are powerful two-way interactions between disease and nutrition.12

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3. Epidemics:• 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

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4. Injuries:

• Globally around 9% of total death are responsible for the injuries which are both

i. Un-intentional (road, poisoning, falls, fire/heat, drowning)

ii. and intentional (self harm, interpersonal violence, collective violence)14

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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.

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6. Education:• 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.

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7. Women empowerment and employment:

• 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 policies.16

• 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.

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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

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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.

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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 the mortality.

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Summary:• Without “Live Birth” no “Death” is taken into account.• Mortality influence the size, structure and growth of the

population• 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. 25

References:

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, 19995. Mishra B D: An Introduction to the study of population. 3 rd edition New Delhi: South Asian Publisher Pvt. Ltd; 20046. K Park. Park’s text book of preventive and social medicine, 19th Ed. Jabalpur: Banarsidas Bhanot, 20077. WHO, World Health Statistics, http://www.who.int/mediacentre/news/releases/2014/world-health-statistics-2014/en/ ,

assessed 2th September 20148. 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, 200610. 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,

1968.13. The Influenza Pandemic of 1918, http://virus.stanford.edu/uda/, assessed 2th September 201414. 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 York, 2013

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

Acknowledgement

Prof. Dr. Kiran Dev BhattaraiMaharajgunj Medical Campus,

Institute of Medicine

THANK YOU….Suggestions and feedback!!!

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