Essay title: The best way to understand the overall health of a population is by examining health indicators.

To what
extent do you agree with this statement?
I. Introduction
A complex web of social, environmental, economic, and genetic factors shapes an individuals health.
Population health adds another layer of complexity, as a population is composed of those complex individuals. A
health indicator is a measurement that quantifies these different factors and the health outcomes that result. I define
a health indicator as a statistic that measures population health outcomes (i.e. disease burden) or health-related
phenomena (e.g. risk factors, social determinants of health, health service usage). I define a population as a
community of humans ranging from the size of a small living community to the global community.
It is necessary to examine health indicators in order to understand the overall health of a population, as their
examination reveals patterns and disparities. But is examining health indicators enough to fully understand health?
This discussion must be preceded by asking a fundamental question: what is the purpose for understanding the health
of a population in the first place? Different purposes will require different information, and thus a different evaluation
of whether or not examining health indicators is the best method by itself, or if it should be supplemented with
additional information for utmost understanding.
In this paper, I will first describe the importance of examining health indicators to understand the overall
health of a population, along with issues that make them more or less useful. Then, I will separate the discussion into
three purpose categories: (1) research, (2) health systems planning, and (3) intervention. For each purpose, I will
discuss how examining health indicators contributes to understand of the overall health of the population, and
explore if that understanding is sufficiently informed by the indicators, or if it could be augmented by other types of
information.

II. Health Indicator Types and Issues

The World Health Organization defines health as a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity (WHO 2003). Statistics included under the umbrella of health
indicator reflect this broad definition of health and its influences. Larson and Mercer (2004) make the distinction
between direct and indirect health indicators: direct indicators being measures of morbidity and mortality, whereas
indirect health indicators include social determinants of health. The World Health Organization (WHO) (2012b)
includes statistics from health service coverage to health expenditure to demographics in its list of Global Health
Indicators.
Health indicators for specific diseases include epidemiological measures such as incidence, prevalence, and
case fatality rate. Incidence is the rate of new cases in the susceptible population, and prevalence is the existing
proportion of cases in the susceptible population. Case fatality rate is the likelihood that someone is to die from the
disease, given that they have the disease. It may seem intuitive that case fatality rate for a specific disease should be
somewhat constant across populations. However, that is not the case, as is well demonstrated by the differences in
reported case fatality rates for Ebola Virus Disease, in which past outbreaks have shown case fatality rates ranging
from 25% - 90%: a huge difference in the likelihood one will die from the disease (WHO 2014a). Incidence, prevalence

and case fatality rate describe elements of a specific disease in a specific population at a particular point in time.
Examining these indicators for multiple diseases over different time points in a population contributes to the
understanding of the overall health of a population.
There are also indicators that measure population dynamics such as life expectancy, fertility rate, death rate,
and age structure. Life expectancy tells us how long someone is expected to live. Fertility rates and death rates
describe the trajectory of the population size in the future. Age structure shows the proportion of people in each age
category of the population. Examining these indicators can contribute to understanding of the overall health of a
population since population size and structure has a dynamic relationship with health. One of these relationships is
described by the epidemiologic transition theory, where a switch from infectious diseases to more chronic diseases
results in lower mortality rates and subsequently fertility rates (Omran 1971). Increasingly however, epidemiology and
demographics have a more complex relationship due to the increase in urbanization and globalization, where it is
common that populations have a double burden of disease, communicable and non-communicable, such as in Accra,
Ghana (Agyei-Mensah and de-Graft Atkins 2010) and some Asian megacities (Khan et al 2013).
Two well-known indicators combine both epidemiology and demographics: the disability-adjusted live year
(DALY) and the healthy life years (HeaLY). DALYs take into account both years of life lost (YLLs) and years lived with
disability (YLDs) (Murray et al 2013). Calculation of DALYs requires knowledge of both the prevalence of disease, and
life expectancy (Murray et al 2013). HeaLYs are similar to DALYS, with some distinctions: they do not assign value to
younger or older years of life, and they incorporate incidence rates (Hyder and Morrow 2002). DALYs and HeaLYs
contribute to understanding of the overall health of a population because they standardize measures, making it
possible to aggregate the burden of multiple diseases in a population, compare populations, and look across time
(Cohen et al 2012). Additionally, DALYs can be disaggregated based on other measurements to reveal inequalities
between subpopulations.
Risk factors are also health indicators: they are factors that increase the risk that an individual will develop a
specific disease. The Institute for Health Metrics and Evaluation (IHME) includes risk factors in their GBD Compare
tool, to see how much a certain risk factor attributes to total DALYs for a certain disease, such as domestic violence,
various nutritional status measures, sanitation, and tobacco and alcohol consumption (IHME 2013). Risk factors can
include individual characteristics and health behaviours. If one subscribes to the belief that health outcomes are the
result of individual behaviour, then these would be the risk factors to use. However, if one has a social determinants
view, then another set of risk factors is the social determinants of health (SDoH) (Kawachi et al 2002). SDoH are
factors such as socioeconomic status, race, occupation, educational level, etc. that influence health directly or
indirectly (WHO 2014b). From a social determinants perspective, statistics that quantify these determinants are health
indicators because their examination leads to an understanding of health inequalities in a population (Kawachi et al
2002). Additionally, these categories of risk factors are related, such that a social determinant like income level
influences the likelihood that an individual engages in an unhealthy behaviour like smoking (Kawachi et al 2002).
A last group of health indicators relates to health system characteristics and performance. The WHO (2010)
provides a list of recommended core indicators for examining health systems that fall under the categories of: Health
Service Delivery (i.e. number of health facilities and inpatient beds per 10,000 population), Health Workforce (i.e.
density of health workers per population, graduates of health professionals), Health Information (i.e. information

system performance), Essential Medicines (i.e. availability of selected medicines), Health Financing (i.e. general
government expenditure on health), and Leadership and Governance (i.e. policy index). It is important to consider
these health indicators when trying to understand overall health because can reveal the state of the health system,
what individuals are able to access, and how much services cost. Groups like the IHMEs Access, Bottlenecks, Cost, and
Equity (ABCE) Project publish in-depth reports of the efficiency and cost-effectiveness of health systems that take into
account many of these health system indicators (IHME 2014).
Although health indicators are widely used to measure and understand health, they do raise some concerns.
For example, in developing countries it can be difficult to determine the burden of disease because death registries
are often inadequate. In some cases, verbal autopsies (VA) are used to determine cause of death (entailing an
interview with family of the deceased), but there are concerns about their validity as well (Murray et al 2011, Murray
et al 2014). The Population Health Metrics Research Consortium developed a gold standard of verbal autopsy
(Murray et al 2011). Based on much of the existing research, the WHO (2012a) recommends a tool for VA assessment.
Furthermore, Murray et al (2014) found that physicians evaluating VAs resulted in less accurate data of cause of death
than VA evaluations done by software.
Self-reported data, which can be used to obtain prevalence and incidence, or just general measures of an
individuals overall health, is also cause for concern. Thomas and Frankenberg (2002) find that often times, selfreports of health reflect what the individual believes about health, rather than their literal health status. Beliefs are
important to consider, but may introduce difficulty in population comparisons. Additionally, Baker et al (2004)
discusses how self-reports can be misleading for analyses: someone may be more likely to report that they have a
condition if that condition is more severe, because they are more likely to have had contact with medical personnel
who inform them more clearly of their health condition. Gunasekara et al (2012) identifies self-reports for change in
health over time as potentially problematic, because by rating health highly at the start, individuals place a limit on
how much their health can improve given the scale at hand.
Health indicators are also subject to bias if they systematically miss sections of the population. For instance,
demographic indicators, which are useful for understanding SDoH, may leave out homeless populations and
undocumented migrants (London by the Trust for London and New Policy Institute 2011). Additionally, health
behaviours can also be difficult to measure, such as illegal drug use (Ledberg and Wennbeg 2014). It is important to
consider what populations and activities are not accounted for using traditional census or health care data because
they could reveal trends in population health that would be otherwise missed.
Finally, measuring health is limited to how one defines or values certain health conditions. Specifically, social
health is often overlooked in health indicators. Social health is not included on the list of WHO (2012b) indicators, or
in the IHME GBD Compare Tool (IHME 2013). However, Carlson et al (2011) sees social health as important because
when social functioning, such as interactions with other people and societal institutions, is poor, it can be a risk factor
for mental conditions and a lesser quality of life.
Taken together, these health indicators contribute a great deal to the understanding of the overall health of a
population. Incidence, prevalence and case fatality rates inform understanding of specific diseases in a population.
DALYs show the burden of disease overall, and can be disaggregated by population demographics and diseases. SDoH
and other risk factors shed light on possible reasons why the population is healthy or unhealthy. And health system

indicators show the availability and usage of health care. But are health indicators enough? I will now examine the
extent to which health indicators sufficiently inform understanding of health for three separate purposes: research,
health systems planning, and intervention.
III. Whats missing?
One reason to understand the overall health of a population is to conduct research on that population relative
to other populations, or on the health disparities within the population: the key questions being what disparities exist,
why they exist, and what perpetuates them? In order to have a sufficient understanding to conduct research to
answer those questions, it is necessary to examine the disease burden in the population, demographic factors and
SDoH. If the goal is to understand why there are health disparities between populations, one would also need health
indicators from comparison populations. Rose (1985) stresses this as a key to understanding the cause of overall
incidence rates in a population: to understand why whole populations differ from other populations, one must look at
population characteristics.
Looking at disparities within a population also requires examining that populations health indicators,
disaggregated by demographic factors and SDoH, but it is not sufficient for a full understanding of the populations
health. Geographic information system (GIS) mapping of disease adds to that understanding because it allows the
researcher to visualize the distribution of disease and identify causes that wouldnt necessarily be picked up with
indicators, such as was done in Austin, Texas with obesity among middle school aged children (Sage et al 2010). Tatem
et al 2012 calls for GIS mapping of demographics to visualize interactions with disease. Disease dynamics differ with
population densities, and vulnerable populations may be clustered together, aspects that wouldnt necessarily be seen
only looking at health indicators (Tatem et al 2012).
A second reason to understand health is to plan or improve existing health systems to manage and treat
health. Health indicators are needed in this case, including the overall burden of disease, DALYs related to specific
diseases, incidence rates for common diseases, demographics of the population, current governmental health
expenditure, and density of health professionals. However, GIS mapping of disease is also crucial in this case in order
to understand physically where health services are needed. Along that same line of thinking, it is important to
consider travel time to health clinics, especially in rural communities: Masters et al (2013) and Gabrysch et al (2011)
find that mothers are less likely to have an in-facility delivery with increased travel time in rural Ghana and rural
Zambia, respectively. Interviews with patients that discuss overall travel time, rather than only examining the physical
distance needed to travel, takes into account transportation infrastructure issues (Masters et al 2013).
Lastly, when planning health services, one must have a sense of not only the population demographic
makeup, but a cultural awareness. Benyamini et al (2008) find that Arab women in Israel rarely see gynaecologists,
and when they do, they are female, Arab gynaecologists. Benyamini et al (2008) adds to their analysis the cultural
understanding that Arab women in Israel generally follow strict religious tradition, and would feel uncomfortable
seeing male or non-Arab gynaecologists. Similarly, Sohn (2005) finds that religion plays a key factor in determining the
likelihood that Korean American women will use preventive services, such as having a pap smear, because they value
modesty. Health indicators can reveal who is using services, but it takes a cultural understanding to find out why, from
which a culturally competent health system can be constructed (Sohn 2005).

A final reason to understand health would be to improve it, either through disease-specific interventions, or
through public health initiatives. Knowing the burden of disease in the population disaggregated by demographics and
the SDoH is critical for improving health, because it reveals the most prominent diseases and the most vulnerable
populations. For disease-specific interventions, it is also necessary to know what existing interventions are in place,
particularly for global health NGOs. For example, Boesten (2011) discusses how the plethora of fragmented HIV/AIDS
organizations in Tanzania made it difficult for HIV-positive individuals to actually obtain the care that they needed, and
hindered community activism. If another HIV/AIDS organization were to enter into this intervention climate, what, if
any, effect would that have on the population?
Interventions to promote overall health at the population level will require different information. Rather than
being targeted, Rose (1985) describes the ideal population level intervention as having an effect on everyone, even if
they are not high risk. A population level intervention such as fluoridation of water would not require any additional
effort on the part of the individual. However, with interventions that are not as passive on the part of individuals, but
still focused on the community as a whole such as encouraging physical activity, one must consider the culture of
health in a population. Davies et al (2014) describes this in relation to London: how much do people value health and
how easy is it for them to make healthy choices? Ma et al (2010) finds that Taiwanese cultural beliefs around physical
activity both positively and negatively influence an individuals likelihood of engaging in physical activity. A
consideration of the culture surrounding health would inform planning of population level, overall health
interventions.
IV. Conclusion
Health indicators, and related statistics, contribute an incredible amount to our understanding of the health of
populations. They can be disease-specific, or reveal the overall burden of disease; they allow us to look critically about
the relationships between health and the social determinants; they allow us to analyse the performance of health
systems. However, there are some issues with health indicators such as problems with verbal autopsies,
inconsistencies with self-reported health status, and systematically missing certain populations.
When we focus on the reasons why we want to understand the health of a population, there are clear areas
where health indicators fall short. Health indicators are the crux of epidemiological research, but they can be
enhanced with GIS mapping of demographics and disease. Health indicators contribute to our understanding of how
health systems should be planned or improved, but GIS mapping, and an understanding of transportation
infrastructure and culture can ensure that appropriate health care is available to all sections of a population. Lastly,
effectively implementing an intervention requires examining reliable health indicators as well as having a knowledge
of existing interventions and the culture of health. Examining health indicators is a great way to understand the overall
health of the population, but depending on ones purpose, examining additional knowledge is necessary for utmost
understanding.

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