Lecture 3:

Public health indicators:

Demographic indicators

1

Public health indicators

Represent complex (synthetic) numerical expression of the impact of a social factor or the simultaneous action of a group of social factors and/or health determinants on the state and dynamics of demographic, health and social status of the population.

They are applied to describe, evaluate and analyze the state and dynamics of health of the population or some groups of the population.

2

Main groups of public health indicators

Physical development indicators

Demography indicators

Morbidity indicators

3

Terminology and definitions 4

Demography as a science studies: 1. The fundamental changes of the size and structure of

populations according to the demographic processes (Formal demography); Formal demography limits its

object of study to the measurement of populations processes.

2. The changes resulting from the influence of natural and social phenomena (Social demography).

broader field of Social demography studies the

relationships between economic, social, cultural and biological processes influencing a population.

Demography AND STATISTICS 5

Demography is a quantitative study of human populations. Demographers study subjects such as the geographical distribution of people, birth and death rates, socioeconomic status, and age and sex distributions in order to identify the influences on population growth, structure, and development.

Demography is the statistical study of all populations. It can be a very general science that can be applied to any kind of dynamic population, that is, one that changes over time or space.

It encompasses the study of the size, structure and distribution of populations, and spatial and/or temporal

changes in them in response to birth, migration, agingand death.

Demography and Public Health Needs

Understanding a society's demography is an essential tool in determining current and future public health needs. Demographic structure can affect public health needs in at least three ways:

(1) age structure and sex ratio affect the types of health problems encountered;

(2) population growth rates affect future needs for health care delivery, and

(3) the existence of substantial immigrant and refugee populations can also be important to plan the volume of care.

6

Basic demographic equation

Suppose that a country (or other entity) contains

Populationt persons at time t. What is the size of the

population at time t + 1 ?

Populationt + 1 = Populationt + Natural increaset +

Netmigrationt

Natural increase from time t to t + 1:

Natural increaset = Birthst − Deathst

Net migration from time t to t + 1:

Net-migrationt = Immigrationt − Emigrationt

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IMPACTS OF BIRTH and DEATH rate

The health needs of a population differ

considerably by age and by sex.

A population's history of birth and death rates

changes the age structure in a way that is easy to

predict.

Generally, a fertility decline reduces the

proportion of children in a population,

while a decline in death rates increases life

expectancy and the proportion of elderly in the

population.

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HOW sex ratio can affect health care needs

For most age groups, the sex ratio (that is the ratio of males to

females) is close to equal.

Men have higher death rates than women. As a result, at older

ages sex ratios are generally much lower.

There are many fewer men than women.

Women are likely to have longer life spans than men, they are more

likely to become widows and to have to care for themselves at

older ages.

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APPLICATION OF DEMO-INDICATORS

Demographic indicators are the basis for:

the planning of resources,

anticipating needs,

deployment strategies and

the evaluation of results. These indicators, while occurring with

some delay in terms of social facts and events, are very sensitive

to medium-and long-term forecasts.

The demographics are interpreted in the context of quality of

life. First of all, these are the years of active life after 65 years of

age.

The general trend towards an ageing population in developed

countries implies increased demand for health care.

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Methods for the collection of demographic DATA

1. Direct:

Direct data come from vital statistics registries that track all births and deaths as well as certain changes in legal status such as marriage, divorce, and migration (registration of place of residence).

Censuses: Usually within 10 years’ period entries of households data.

2. Indirect:

Studying the trends in life expectancy and the growth of the population using research methods and mathematical models.

- Representative sample of the population is interviewed about their reproductive attitudes .

-Predictions about further state of the population are based on calculations using matrices ,,life tables,, etc.

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Indirect methods of data collections12

Required in countries where full data are not available, such as is the case in much of the developing world.

One of these techniques is the “sister method”, where survey researchers ask women how many of their sisters have died or had children and at what age.

With these surveys, researchers can then indirectly estimate birth or death rates for the entire population.

Other indirect methods include asking people about siblings, parents, and children.

Demographic methods for modeling population processes. They include models of mortality (including the life table, hazards models, fertility models (Hernes model, Coale-Trussell models, parity progression ratios), marriage (Singulate Mean at Marriage, Page model), disability (Sullivan's method, multistate life tables), population projections.

census 13

A census is usually conducted by a national government and attempts to enumerate every person in a country. However, in contrast to vital statistics data, which are typically collected continuously and summarized on an annual basis, censuses typically occur only every 10 years or so, and thus are not usually the best source of data on births and deaths. Analyses are conducted after a census to estimate how much over or undercounting took place. Censuses do more than just count people. They typically collect information about families or households, as well as about such individual characteristics as age, sex, marital status, literacy/education, employment status and occupation, and geographical location. They may also collect data on migration (or place of birth or of previous residence), language, religion, nationality (or ethnicity or race), and citizenship.In countries in which the vital registration system may be incomplete, the censuses are also used as a direct source of information about fertility and mortality; for example the censuses of the People's Republic of China gather information on births and deaths that occurred in the 18 months immediately preceding the census.

POPULATION CENSUS14

1. Population - number and territorial distribution2. Population structure by sex and age3. Citizenship4. Ethno-demographic characteristics of the population5. Legal and de-facto marital status6. Educational structure of the population7. Economic activity of the population8. Migration of the population9. Housing conditions – type of dwelling, average number of inhabitants,average area10. Housing characteristics and availability of durables

History of censuses in Bulgaria

1880-the Principality of Bulgarian

1887 – Circuit

1892-1900 Homes, farm animals – a special law on the Census

1905 – agricultural equipment and buildings

1910 – transport in agriculture

1920 – Treaty of Neuilly same

1926 – agricultural equipment, craft-industrial enterprises

1934 – educational institutions

1946 – housing

1956 – family representative excerpts 1965-birth rate, excerpts 1975 –lowest territorial level 1985 – register of population, Villa fund

1992 – employment, unemployment, privatization, agrarian reform

2001-Eurostat

2011- Latest census, Bulgaria in the EU

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Dynamics of the population in Bulgaria

according to censuses 1900-2011

16

Characteristics of human populations17

Characteristics: size, density, age, sex distribution,employment, incomeresidencehealthThe study of human populations:vital statistics: births, marriages, deaths, migration, growth,

DEMO-INDICATORS

1. Indicators for the current state of the population

STATICS

2. Indicators for the development of the population DYNAMICS

Indicators for the reproduction of the population

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19

Country Populationnumber

millions

Populationas

% of EU

Surface Surface as

% of EU

Density Population/km

2

ЕС 494.8 100% 4,422,773

100% 112

Австрия 8.3 1.7% 83,858 1.9% 99

Белгия 10.5 2.1% 30,510 0.7% 344

България 7.7 1.6% 110,912 2.5% 70

Кипър 0.8 0.2% 9,250 0.2% 84

Чехия 10.3 2.1% 78,866 1.8% 131

Дания 5.4 1.1% 43,094 1.0% 126

Естония 1.4 0.3% 45,226 1.0% 29

Финландия 5.3 1.1% 337,030 7.6% 16

Франция [4]

64.1 13.0% 643,548 14.6% 99

Германия 82.3 16.6% 357,021 8.1% 231

Гърция 11.1 2.2% 131,940 3.0% 84

Унгария 10.1 2.0% 93,030 2.1% 108

Indicators for the current state of the

population STATICS

Number of the population

Mean Annual number of the population

Type of the population (0-14, 15-49, 50 + till 1996.

After 1996 in Bulgaria the distribution is 0-17, 18—64, 65+.

Age and gender distribution

Mean longevity of life.

20

Annual number of the population

The annual number of the Population, for a given year =

Number of the Population of latest census +

Natural growth for the time between (t) +

Net-migration for the same time (t).

The natural growth = births (t) − deaths (t)

Net-migration (t) = Immigration (t)−Emigration (t)

21

AGE GROUPS ACCORDING WHO

According to WHO the following groups are detected:

Young age – up to 44

Middle age – 45- 59

Advanced (aged) – 60 –74

Elderly– 75 – 89

Over 90 .

22

Types of age groups of the

population predicting structure

Type Age groups

0-14 15-49 over 50

progressing 30% 50% 20%

Stationary 25% 50% 25%

Regressing 20% 50% 30%

(till 1996)

23

Structure by age and sex 24

The process of demographic aging continues. It is expressed by reducing the absolute number and relative share of the population younger than 15 years and increasing the share of population aged 65 years and older. The share of population over 65 increased from 16.8% in 2001 to 18.5% in 2011. At the same time in 2001 persons under 15 years are15.3% of the population in the country. In 2011 their share decreases to 13.2%.

The population aged 65 years and more has the biggest relative share in the followingdistricts: Vidin - 25.5%, Montana and Gabrovo - 24%, Lovech - 23.3%, andKyustendil - 22.8%. The share of adult population is lowest in districts Blagoevgrad,Varna and Sofia - capital – 16%.

62.2% of the population in the country is at working age, i.e. 4 576 904 persons.52.5% of them are men and 47.5% - women. The bigger share of the population atworking age lives in the urban areas - 75.8%, and 24.2% - in rural.

Population pyramide STRUCTURE 25

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27

28

29

30

Life longevity for the period 1935-2009

for the population in Bulgaria

Periods Total Men Women

1935–1939 51.75 50.98 52.56

1956–1957 65.89 64.17 67.65

1960–1963 69.59 67.82 71.35

1969–1971 71.11 68.58 73.86

1974–1976 71.31 68.68 73.91

1978–1980 71.14 68.35 73.55

1984–1986 71.19 68.17 74.44

1989–1991 71.22 68.02 74.66

1993–1995 70.60 67.10 74.90

1995–1998 70.50 67.10 74.30

Periods Total Men Women

1997–1999 71.00 67.60 74.60

1998–2000 71.70 68.15 75.34

1999–2001 71.80 68.50 75.20

2000–2002 71.87 68.54 75.37

2001–2003 72.07 68.68 75.59

2003–2005 72.60 69.00 76.30

2004–2006 72.60 69.10 76.30

2005–2007 72.70 69.20 76.30

2006–2008 73.00 69.50 76.60

2007-2009 73.43 69.90 77.08

Source: National Health Institute

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RURAL/ URBAN POPULATION

DIstribution

The tendency of increase the relative share of

urban population and decrease of the rural

population is kept: 5 339 001 persons, or 72.5% live

in urban areas

and 2 025 569 persons, or 27.5 % - in rural areas.

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Urban/Rural population distribution 33

1946 1956 1960 1970 1980 1990 2000 2005 2006 2007 2008 2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

фиг 2: Разпределение по градове и села

селско

градско

години

пр

оц

ен

т

Distribution by number and sex in Bg34

years total men women

1990 8 669 269 4 269 998 4 399 271 – 50,70%

1995 8 384 715 4 103 368 4 281 347 – 51,06%

2001 7 891 095 3 841 163 4 049 932 – 51,32%

2005 7 718 750 3 743 327 3 975 423 – 51,50%

2006 7 679 290 3 720 932 3 958 358 – 51,56%

2007 7 640 238 3 699 689 3 940 549 - 51.60%.

As on 31.12. 2007 women are more than men (51.6%).

Compared to 1990 there are 570 309 men and 458 722 women

left the country or died.

WORKING AGE TRENDS

The ageing of population leads to change in its main age structure –distribution of

population under, at and over working age. Influence on the share of population at and over

working age has the ageing of population, as well as the legislative changes in determining the

retirement age.

62.2% of the country population is at working age or 4 576 904 persons. 52.5%

are male and 47.5% - female. 65% of the urban population is at working age, compared to

54.7% - of rural population.

Sofia is the district with the highest relative

35

Distribution of the population upon

working demo-status

36

Years Total

Age groups

Younger

groups - %

Working

age - %Retired - %

1990 100 21.6 55.5 22.9

1995 100 19.1 56.6 24.3

2001 100 16.3 59.2 24.5

2005 100 14.8 62.4 22.8

2006 100 14.6 62.8 22.6

2007 100 14.5 63.0 22.5

Working age

Trends:

37

demographic replacement rate

38

The reproduction of population at working age is best characterized by the demographic replacement rate.

It represents the ratio between the number of personsentering working age (15 - 19 years) and persons exiting the working age (60 – 64 years).

Totally, for the country, the ratio is 70. For comparison, in 2001 every 100 persons exiting the working age are replaced by 124 young people.

Population development

Nativity

Mortality

Natural growth

Number of life born during the year

Nativity=-------------------------------------- 1000.

average annual number of the population

Mortality is defined similarly.

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Indicators for development of the

population DYNAMICS

(1) Mortality rate because of…

War victims total number: 337 000

92 years later: vehicle accidents 30-40 000

(2)Mobility/ migrationFor a total of 100 year 410 000 emigrants

For 89-92 year 470 000 emigrants

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NATIVITY, MORTALITY and NATURAL GROWTH (total)

41

Number per1 000 people

Year Live born Dead. Nat. gr. Live born Dead Nat. gr.

.

1970 138745 77095 61650 16.3 9.1 7.2

1980 128190 97950 30240 14.5 11.1 3.4

1990 105180 108608 -3428 12.1 12.5 -0.4

1995 71967 114670 -42703 8.6 13.6 -5.0

2000 73679 115087 -41408 9.0 14.1 -5.1

2005 71075 113374 -42299 9.2 14.6 -5.4

2007 75349 113004 -37655 9.8 14.8 -5.0

2008 77712 110523 -32811 10.2 14.5 -4.3

2009 80956 108068 -27112 10.7 14.2 -3.5

Source: National Statistical Institute

Nativity, mortality and natural growth per 1000 people in Bulgaria for the period 1945 - 2007

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Раждаемост, смъртност и естествен прираст на 1000 души

от населението за периода 1945 - 2007 година

Total child mortality and child mortality rate

years number

total urban rural

1970 3788 1811 1977

1980 2594 1560 1034

1990 1554 1020 534

1995 1065 705 360

1997 1123 719 404

2000 981 657 324

2005 739 464 275

2006 720 472 248

2007 690 447 243

2008 668 444 224

2009 729 468 261

Years 1 000 live born

total urban rural

1970 27.3 22.7 33.5

1980 20.2 18.0 24.9

1990 14.8 13.8 17.1

1995 14.8 14.0 16.7

1997 17.5 15.7 22.0

2000 13.3 12.4 15.5

2005 10.4 8.9 14.6

2006 9.7 8.6 13.1

2007 9.2 7.9 12.7

2008 8.6 7.6 11.6

2009 9.0 7.7 12.9

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Total and child mortality rate trend 44

200745

Total mortality rate: 14.8

Child mortality rate: 9. 2

Premature deaths rate: 24.1

46Structure of internal migration 2007 (%)

Directions:

village to city-22%

Village to village -11%

City to city 38%

City tо village – 29%

LEADING GLOBAL DEMO-TRENDS

1. Demo-transition

2. Earth population growth

3. ЕС population demography

4. Bulgarian population demography

47

Demo-transition In the most highly developed

countries, the trend to increase

the number of the population

tends to zero. And this is not

caused by starvation or lack of

resources. The cause was

birth control in these countries.

Despite the extension of the life

longevity in these countries the

number of population stagnates

or dicreases. The model follows

periods of: 1. low or zero growth

in the pre- industrial societies, 2.

rapid population growth during

industrialization 3. reduction of

growth when it raised the

standard of living – this is the

demographic transition.

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Academicians estimates, actual, high, medium, low rate

Earth population growth

From the beginning of the censuses to 1650 population growth is

extremely slow – barely 0.06%.

The population in Europe and North America and in other parts of the

world grew the fastest between 1920 and 1960.

From 1650 to the end of the 20th century the growth of the

population of the Earth is nearly 12 times.

49

NUMBER OF THE WORLD POPULATION

AND REPRODUCTION RATE (1650-2050)

50

GLOBAL TRENDS IN WORLD DEMO51

52

immigration and emigration

Factors for: Improvements in transportation and changing political

and economic circumstances;

Immigrants groups:

refugees, who are those fleeing their home countries because of

political persecution or war;

and labor or economic migrants, who go to other countries seeking

employment and a better life.

Refugees and economic migrants can move between two

countries or within a single country.

53

POPULATION GROWTH IN 20th Century

World population grew at a more rapid and sustained pace

than at any time in human history.

The global population grew from approximately 1.7 billion

people in 1900 to 6 billion in 1999.

The annual population growth rate averaged 1.3 percent for

the entire twentieth century, and was as high as 2.3 percent

between 1965 and 1970.

(A sustained 2.3 percent annual growth rate would have

meant a doubling of the world's population in thirty years.)

54

mortality decline in Europe and North

America FACTORS

Improvements in public health (including sanitation, waste disposal,

clean water supply, and quarantine); changes in personal hygiene

(including bathing, handwashing, and household cleanliness);

Improved standards of living (including better nutrition and housing);

Improved political, economic, and transportation systems, which led

to better responses to food shortages and drought.

55

PROCESSES OF CHANGING THE POPULATION

fertility,

mortality,

and migration.

Fertility involves the number of children that women

have and is to be contrasted with fecundity (a

woman's childbearing potential

56

Reproduction coefficients AND

REPRODUCTIVE ATTITUDES OF WOMEN

An indicator of the total fertility rate (total fertility rate)-demonstrates how many children a woman gives birth during her fertility period (15 – 49).

Gross reproduction rate-demonstrates how much is the average number of girls whom gave birth a woman throughout the fertile period (it is estimated that the number of births of girls is essential).

Net reproduction rate-demonstrates the average number of live born girls by a woman throughout the fertile period of woman; It is calculated, taking into account and mortality of women during the same period .

The decline in birthrates is due to dramatic changes in economic and social conditions, ideas about the family and the role of children and women, the availability of family planning programs, and the acceptance and use of contraception.

57

birth rate

The crude birth rate, the annual number of live

births per 1000 people.

The general fertility rate, the annual number of live

births per 1000 women of childbearing age (often

taken to be from 15 to 49 years old, but

sometimes from 15 to 44).

age-specific fertility rates, the annual number of

live births per 1000 women in particular age

groups (usually age 15-19, 20-24 etc.)

58

mortality rate

The crude death rate, the annual number of

deaths per 1000 people.

The infant mortality rate, the annual number of

deaths of children less than 1 year old per 1000

live births.

The expectation of life (or life expectancy), the

number of years which an individual at a given

age could expect to live at present mortality

levels.

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60

Income inequality and mortality rate 60

FERTILITY INDICATORS

The total fertility rate: the number of live births per

woman completing her reproductive life (15-49), if

her childbearing at each age reflected current

age-specific fertility rates.

The gross reproduction rate: the number of

daughters who would be born to a woman

completing her reproductive life at current age-

specific fertility rates.

The net reproduction ratio is the expected number

of daughters, per newborn prospective mother,

who may or may not survive to and through the

ages of childbearing.

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Reproduction of World

population for the year 2000

Nativity Mortality Fertility Longevity

Total: 22.1 8.9 2.7 65.4

Africa: 38.0 13.9 1.0 51.4

Asia: 21.9 7.7 2.6 66.3

Europe: 10.3 11.3 1.4 83.3

S Americ: 23.1 6.5 2.7 69.2

N Americ: 13.8 8.3 1.9 76.9

Oceania: 17.9 7.7 2.4 73.8

USA: 14.0 8.5 2.0 76.7

Bulgaria 9.0 14.1 1,3 65.4

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FOR

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ATTENTION