1. Measures of Mortality
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2. - Mortality is a term which means “death” or describes death and related issues.
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3. Why look at mortality rates?
1- Expressing mortality in quantitative terms allow comparison of death:
1- between people in different geographic areas or different countries.
2- between subgroups in the a population or country.
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4. 2- Mortality rates can serve as a disease Severity, and can help to determine of whether the treatment for a disease has become more effective over time.
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5. Refer to as crude because:
Crude rates:
How they calculated?
Crude rates are calculated for the entire population.
Refer to as crude because:
They ignore factors which may affect death rate such as: gender, age, race, economic status ….
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6. Mid-year population for the same year and same locality
Crude Death rate (CDR):
Number of all deaths due to all causes in a certain year and within certain locality
x 1000
Mid-year population for the same year and same locality
Example:
Suppose area X in 1432 H, we have:
deaths, all causes.
2- The area's mid year population was 150,000.
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7. 3-Find crude death rate in 1432H?
Numerator: number of deaths all causes
= 1200
Denominator: Mid-year population =150,000
CDR = x = 8/1000;
150,000
that is, 8 deaths per 1000 population.
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8. CMR By Sex And Nationality In The KSA (2004 to 2010)
السنة
سعوديون
غير سعوديين
الجملة
SAUDI
NON-SAUDI
TOTAL
YEAR
ذكور
اناث
جملة
MALE
FEMALE
2004
4.7
3.9
4.3
3.4 3
3.3
3.8 4
2005
2.9
4.2
3.7
2006
4.6
3.2
2007
2.8
3.6
2008
4.5
4.1
3.5
2009
2.7
2010
4.4
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9. Maternal mortality rate
Country
Crude death rate
Crude birth rate
Infant mortality rate
Maternal mortality rate
Per 1000
Per 100,000
Saudi Arabia
3.8
22.1
18.5 16
Yemen
7.0
38.6
53.3
200
Palestine
3.6
35.9
22.2
32 
Iraq
6.3
36.6
34.6 63
Bahrain
2.8
20.7 20
Emirates
1.4
14.0
10.9 12
Oman 11
Qatar
1.6
14.1
9.0 6
Jordon
26.4
4.1
21.0
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10. Why Mid-year population?
For example, for the crude death rate the number of persons exposed to the risk of dying (denominator): includes: Persons alive in Muharram 1 of the year previous year.
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11. adjustments made for persons who moved in or out.
plus all persons born during year minus all persons who die during year,
adjustments made for persons who moved in or out.
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12. The population at risk will be the population on Rajab1.
A common solution to this problem of determining the population at risk is to estimate the population at mid-year.
In our example (1432H):
The population at risk will be the population on Rajab1.
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13. Cause-specific Mortality Rate
• Is Mortality from a specified cause for a population during a specified time period.
• The numerator is the number of deaths from that cause.
The denominator remains the size of the population at the mid-point of the time period.
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14. Calculate mortality rate due to TB.
Example:
In the previous example: suppose the tuberculosis death in 1432H was 5.
Calculate mortality rate due to TB.
Numerator: number of deaths due to TB = 5
Denominator: Mid-year population 150,000
Mortality rate due to TB =
(5/150,000) x 100,000 = 3.3/100,000

15. The Age Specific Death Rate
Where:
ASDR= The Age Specific Death Rate.
Dx= Deaths for population at age x during
the year.
Px= Mid year Population for the population at age x
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16. Deaths Mid year Population Age Group 4143 73795 19 – 15 4740 48764
Deaths during the year and the population at the mid year for the different age groups
Deaths
Mid year Population
Age Group
4143
73795
19 – 15
4740
48764
24 – 20
4304
43635
29 – 25
3883
63337
34 – 30
4062
34423
39 – 35
4597
26983
44 – 40
5085
24548
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17. The age Specific Death Rates
ASDR
Death
Mid year Population
Age Group 56
4143
73795
19 – 15 97
4740
48764
24 – 20 99
4304
43635
29 – 25 61
3883
63337
34 – 30
118
4062
34423
39 – 35
170
4597
26983
44 – 40
207
5085
24548
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18. Why Age Specific Death Rates?
Can compare mortality at different ages.
Can compare mortality in the same age groups over time and/or between countries and areas
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19. 3- Infant mortality rates (IMR):
Are the most common used rates for measuring the risk of dying during the first year of life.
These rates are the most frequently used measures for comparing health services among nations.
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20. Infant Mortality Rate , Saudi Arabia (2000-2011)
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21. IMR = High infant mortality rates are:
1- Reflection of poor economic conditions
2- unmet health care needs and
3- other unfavorable environmental factors.
IMR =
number of infant deaths age days X
1000
Number of live births during year
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22. Country Saudi Arabia Yemen Palestine Iraq Bahrain Emirates Oman Qatar
Infant mortality rate
Per 1000
Saudi Arabia
18.5
Yemen
53.3
Palestine
22.2
Iraq
34.6
Bahrain
7.0
Emirates
10.9
Oman
Qatar
9.0
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23. Suppose at KKU hospital, 20 infants died during 1432H
Suppose at KKU hospital, 20 infants died during 1432H. The number of live births for the same year was Calculate IMR
Numerator: number of infants died = 20
Denominator: Number of live births = 2600
IMR =
x 1000 = 7.7/1000
2600
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24. Neonatal mortality rate (NMR):
That is; 7.7 infant deaths per 1,000 live births in 1432H.
Neonatal mortality rate (NMR):
Measures risk of dying among new born infants under the age 28 days.
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25. NMR = x 1,000 Example: In the previous example:
number of deaths for infants under 28 days of age
x 1,000
Number of live birth in the
same year
Example: In the previous example:
suppose out of the 20 who died, 12 died in the first 28 days. Calculate NMR for 1432H.
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26. NMR = 12 x 1,000 = 4.6/1000 2600 4.6 deaths per 1,000 live births.
Numerator: number died in ( 0- 28) days = 12
Denominator: Number of live births = 2600
NMR =
12 x 1,000 = 4.6/1000
2600
4.6 deaths per 1,000 live births.
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27. Postneonatal mortality rate (PNMR):
Number who died after 28 days of age.
For the previous example:
The number of infants who died after 28 days of age is 8. ( = 8).
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28. deaths for infants more than 28 days old through the age of 1 year
PNMR =
deaths for infants more than 28 days old through the age of 1 year
x 1,000
Number of live birth in the same year 12
x 1,000 = 3.1/1000
PNMR =
2600
3.1/1000 deaths per 1,000 live births.
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29. Maternal Mortality Definition: ‘Maternal death’ is death of a woman
while pregnant ,or
within 42 days of termination of pregnancy.
Irrespective of the duration or site of the pregnancy.
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30. Not from accidental causes
From any cause related to, or aggravated by the pregnancy or its management
Not from accidental causes
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31. Maternal Mortality Indicators
Maternal mortality ratio (per 100,000 live births -or per 1000 live births)
Maternal mortality rate (per 100,000 women of childbearing age)
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32. Maternal Mortality Ratio
Number of women who die as a result of complications of pregnancy or childbearing in a given year per 100,000 live births in that year
Represents the risk associated with each pregnancy, i.e., the obstetric risk
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33. The denominator is the number of live births during the same year.
The numerator is the number of deaths in a year from puerperal causes. (complications of pregnancy, childbirth, puerperium).
The denominator is the number of live births during the same year.
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34. Total maternal deaths for a period (year) Number of live birth in the
MMRatio =
Total maternal deaths for a period (year)
x 100,000
Number of live birth in the
same year
Example:
The year-end of 1432H report from the obstetrical ward:
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35. MMRatio= 1- was 3 deaths (2 abortions, 1 pregnancy complications).
2- The number of live born was as before (2600).
Numerator: number of mothers died = 3
Denominator: Number of live births = 2600 3
x 1,000 = 1.15/1000
MMRatio=
2600
1.15/1000 maternal deaths per 1,000 live births
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36. Maternal Mortality Rate
Number of women who die as a result of complications of pregnancy or childbearing in a given year per 100,000 women of childbearing age in the population
Represents both the obstetric risk and the frequency with which women are exposed to this risk.
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37. Maternal mortality rate
Country
Maternal mortality rate
Per 100,000
Saudi Arabia 16
Yemen
200
Palestine
32 
Iraq 63
Bahrain 20
Emirates 12
Oman 11
Qatar 6
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38. Total maternal deaths for a period (year)
MMRate =
Total maternal deaths for a period (year)
x 100,000
Number of women age
Example:
The year-end of 1432H report from the obstetrical ward:
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39. 1- was 10 deaths (2 abortions, 8 pregnancy complications).
2- The number of women aged was: (250000). 10
MMRate =
x 100,000
250000
= 4/100,000
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40. Number of individuals with the specified disease
Case- fatality rate (CFR):
(expressed usually as percent):
CFR =
Number of deaths during a specified period of time after disease diagnosed
x 100
Number of individuals with the specified disease
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41. Example 1: At X city:
1) 110 cases of cancer in 1433H
2) 29 died in 1433H.
Find CFR:
Numerator: # died of cancer = 29
Denominator: Number with cancer = 110
CFR = x = 26.4%
110

42. Proportionate Mortality (PM):
The proportionate of mortality from specified disease is defined as:
PM =
Number of deaths from a disease during a specified period of time
x 100
Total deaths in the same time period
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43. 1) 10 deaths from cardiovascular disease in 1427
Example 1: At X city:
1) 10 deaths from cardiovascular disease in 1427
2) 500 deaths from all diseases in 1427
Find PM:
PM = x = 2%
500
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44. Years of potential life lost (YPLL) Is a measure of early deaths.
Death occurring in the same person at a younger age involves a greater loss of future productive years than death occurring at an older age.
Steps in calculation of YPLL:
1- subtract each person’s death from predetermined age (differs according to country).
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45. For example a person died at age 32, and suppose the predetermined age is 65, then this person has lost (65 – 32) = 33 years of life.
The younger the age at which death occurs, the more years of potential life are lost.
2- ‘YPLL’ for each individual are then added together to yield the total YPLL.
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46. 5 workers died because of exposure to toxic chemical.
Example:
5 workers died because of exposure to toxic chemical.
The ages of death were 20, 25, 30, 35, and 40 years.
Use age 65 as the predetermined age.
Calculate the YPLL for these 5 workers. And so find the mean YPLL.
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47. YPLL = (65 – 20) + (65 – 25) + (65 – 30) + (65 – 35) + ( 65 – 40) = 175.
2- The mean YPLL = 175/5 = 35
On average, the number of years of premature death among those workers who died is 35 years.
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48. Country
Sex ratio
Life expectancy
Total fertility rate
Male
Female
Saudi Arabia
105 : 100 71 75
3.03
Yemen 61 60
5.48
Palestine
106 : 100 73 77
4.65
Iraq 70
4.86
Bahrain
103 : 100 76 81
2.63
Emirates 80
2.36
Oman
2.52
Qatar
102 : 100 74
1.92
Jordon 79 82
3.27
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49. Sex differentials:
The average life expectancy of females is greater than that of males, partly due to biological factors and partly because of behavioral differences.
Men smoke more tobacco, drink alcohol, have more motor vehicle accidents, engage in more
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50. dangerous occupation and are more prone to suicide.
There is an Excess male mortality in many countries.
Comparing the number of male deaths with the number of female deaths can be misleading due to sex ratio (more male babies being born and hence more deaths.
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51. Male excess mortality = x 100 Male death rate at age x
To avoid the effect of sex ratio in mortality rate comparisons, the sex ratio of the age specific death rate, which is used to measure male excess mortality.
This is obtained as:
Male excess mortality =
x 100
Male death rate at age x
female death rate at age x
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52. For example, a male excess mortality of 150 would denote that the male death rate was 50% higher than the corresponding death rate for females.
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53. Male excess mortality Deaths Mid year Population females Males Females
females
Males
Females
2.85 12 36
8651
9103
3.09 15 48
9345
9676
2.83 21 60
10617
10696
2.69 27 72
10986
10877
2.59 33 84
10061
9902
1.98 45 90
8924
8692
1.80 57 99
7062
6811
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54. Sources of statistics on mortality 1- Death certificate:
Specifies a number of demographic and social characteristics of the deceased and details about the cause of death.
Death certificate can also include:
birth place, marital status, education, residence, occupation.
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55. 3- Cross-national data:
2- Vital statistics:
Include mortality data on the number and causes of deaths, together with the age and sex of the deceased.
3- Cross-national data:
Comparative data on mortality are published in the United Nation Yearbook and WHO Health Statistics Annual.
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56. Standardization
A principal role in demography is to compare the mortality between two or more populations.
The comparison of crude mortality rates is misleading.
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57. If the populations being compared differ greatly with respect to , for example, age or sex, that will affect the overall rate of morbidity or mortality.
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58. For example, age is an important determinant of mortality.
An older population will have a higher overall mortality rate than a younger population.
As a result, variations in age will complicate any comparison between two or more populations that have different age structures.
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59. This is achieved by using methods of standardization.
One way to overcome this problem is to combine category specific rates into a single summary rate that has been adjusted to take into account its age structure.
This is achieved by using methods of standardization.
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60. Methods of Standardization
There are two methods of standardization commonly used:
1- Direct method
2- Indirect method).
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61. Direct Adjusted Rates
Requires a standard population, to which the estimated age-specific rates can be applied
Choice of the standard population may affect the magnitude of the age-adjusted rates, but not the ranking of the population

62. How to calculate standardized crude death rate?
1- Select a standard population, whose age distribution will be the standard for comparison.
2- calculate age specific death rate for the two populations (A and B).
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63. 3- Calculate the expected number of deaths that would occur in a year if the standard population experienced the age-specific death rates (ASDR) of populations A and B.
4- Multiply each age group in the standard population by the corresponding ASDR for populations A and B.
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64. 6- To calculate the age-standardized crude rate for each population:
5- Add the columns of the expected deaths for the two populations (A & B) to obtain the total expected deaths in the standard population.
6- To calculate the age-standardized crude rate for each population:
Divide the total expected deaths for each population by total standard population.
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65. Population, Deaths, and Death Rate by Community and by Age
Community B
Age
(year)
Population
Deaths
Death Rate
(per 1000)
Under 1
1,000 15
15.0
5,000
100
20.0
1 – 14
3,000 3
1.0
20,000 35
15 – 34
6,000 6
35,000
35 – 54
13,000 52
4.0
17,000 85
5.0
55 – 64
7,000
105
8,000
160
Over 64
1,600
80.0
15,000
1,350
90.0
All ages
50,000
1,781
35.6
100,000
1,740
17.4
Death Rate
(per 1000)
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66. Age – adjusted death rate (per 1000)
(years)
Standard population
Death rate
in A
(per 1,000)
Expected deaths at
A’s rate
in B
B’s rate
Under 1
6,000
15.0 90
20.0
120.0
1 – 14
23,000
1.0 23
0.5
11.5
15 – 34
41,000 41
41.0
35 – 54
30,000
4.0
120
5.0
150.0
55 – 64
15,000
225
300.0
Over 64
35,000
80.0
2,800
90.0
3,150
Total
150,000
35,6
3,299
17.4
3,772.5
Age – adjusted death rate (per 1000)
22.0
25.0
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67. x 1000 Calculation of standardized death rate
Total standard population = 150,000
Expected deaths for pop A = 3299
Standardized death rate for pop A =
Expected deaths pop A
x 1000
Total standard population
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68. standardized death rate for pop A:
3299
x 1000
= per 1000
150,000
The result indicates that pop A crude death rate would be 21.99/1000 if it has the same age structure as the standard population which far less than the observed crude death rate 35.6/1000.
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69. standardized death rate for pop B:
Total standard population = 150,000
Expected deaths for pop B = 3,772.5
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70. Standardized death rate for pop B =
Expected deaths pop A
x 1000
Total standard population
3,772.5
x 1000
= per 1000
150,000
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71. The result indicates that pop B crude death rate would be 25
The result indicates that pop B crude death rate would be 25.15/1000 if it has the same age structure as the standard population which far more than the observed crude death rate 17.4/1000.
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72. The result indicates that pop A crude death rate would be 21
The result indicates that pop A crude death rate would be 21.99/1000 if it has the same age structure as the standard population which far less than the observed crude death rate 35.6/1000.
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73. This ratio is called the Comparative Mortality Ratio (CMR).
We can calculate: The ratio of the directly standardized rates to provide a single summary measure of the difference in mortality between the two populations.
This ratio is called the Comparative Mortality Ratio (CMR).
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74. Comparative Mortality Ratio (CMR)
calculated by dividing the overall age adjusted rate in country B by that of B.
In our example:
Comparative Mortality Ratio (CMR)
= 25.15/21.99 = 1.14
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75. This CMR is interpreted as:
after controlling for the affects of age, the mortality in Country B is 14% higher than in country A.
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76. Example 2:
Table 2 presents crude mortality data for two populations (countries A and B).
The overall crude mortality rate is higher for country A (10.5 deaths per 1,000 person years)
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77. compared with country B (7 deaths per 1,000 person years).
Notice the ASDRs rates being higher among all age-groups in country B.
For example, 18% of the population in country A are aged over 60 years compared with 6% in country B.
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78. Table 2. Crude mortality rates stratified by age for two populations (country a, B).
Country B
Age group
# deaths/
1000
Pop (M)
Death rate
# deaths
Pop
Death rate/
0 - 29
7,000 6
1.2
6,300
1,500,000
4.2
20,000
5.5
3.6
3,000
550,000
60+
120,000
2.5 48
6,000 50
Total
147,000 14
10.5
15,300
2,170,000 7

79. Country A has a much older population than country B.
The reason for the difference between the crude mortality rates between country A and country B is that these two populations have markedly different age-structures.
Country A has a much older population than country B.
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80. Table 3. Standard population
Age group
Pop
0 - 29
100,000
65,000
60+
20,000
Total
185,000
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81. Age
(years)
Standard population
Death rate
in A
(per 1,000)
Expected deaths at
A’s rate
in B
B’s rate
0 - 29
100,000
1.2
120
4.2
420
65,000
3.6
234
5.5
357.5
60+
20,000 48
960 50
1,000
Total
185,000
10.5
1,314 7
1,777.5
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82. x 1000 Calculation of standardized death rate
Total standard population = 185,000
Expected deaths for pop A = 1314
Standardized death rate for pop A =
Expected deaths pop A
x 1000
Total standard population
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83. 1314 x 1000 = 7.1 per 1000 185,000 standardized death rate for pop A:
The result indicates that pop A crude death rate would be 7.1/1000 if it has the same age structure as the standard population which is less than the observed crude death rate 10.5/1000.
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84. x 1000 Calculation of standardized death rate
Total standard population = 185,000
Expected deaths for pop A =
Standardized death rate for pop B =
Expected deaths pop A
x 1000
Total standard population
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85. standardized death rate for pop B:
1777.5
x 1000
= 9.6 per 1000
185,000
The result indicates that pop A crude death rate would be 9.6/1000 if it has the same age structure as the standard population which is more than the observed crude death rate 7/1000.
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86. We can calculate the Comparative Mortality Ratio (CMR) as:
= 9.6/7.1 = 1.35
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87. CMR is interpreted as:
After controlling for the affects of age, the mortality in Country B is 35% higher than in country A.
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88. Indirect Adjustment of Rates
Used if age-specific rates cannot be estimated.

89. Indirect Adjustment of Rates
Based on applying the age-specific rates of the standard population to the population of interest to determine the number of “expected” deaths.
Steps in calculation:
1- Choose standard population and list its age-specific death rate.
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90. Suppose we selected population B as the standard population.
List ASDR for population B.
List the age distribution of the pop A in the next column.
Calculate expected deaths for pop A by multiplying each age group by the corresponding ASDR for the standard population.
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91. Sum the column of the expected deaths.
This total shows the number of deaths that would occur if population A experienced the ASDR of pop B.
Calculate the standardized mortality ratio as:
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92. ____________________
Standardized Mortality Ratio(SMR)=
Total observed deaths
In population (A)
____________________
Total expected deaths
in a population (A)
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93. Standard death rate pop B Expected deaths in A at standard rates
Age
(years)
Standard death rate pop B
(per 1,000)
Total population A
Expected deaths in A at standard rates
Observed Deaths A
Under 1
20.0
1,000 15
1 – 14
0.5
3,000
1.5 3
15 – 34
1.0
6,000
6.0 6
35 – 54
5.0
13,000
65.0 52
55 – 64
7,000
140.0
105
Over 64
90.0
20,000
1,800.0
1,600
Total
17.4
50,000
2,032.5
1,781
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94. SMRA = 1781 / = 0.876
SMRB = 1.0
The result shows that the observed deaths in A were 12% lower than they would have been if A ASDR were the same as those of pop B.
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95. Standardized Mortality Ratio
The ratio is exactly 1 if the observed and expected deaths are the same.
If the SMR is greater than 1, more deaths have occurred than anticipated.
If SMR is less than 1, fewer deaths have occurred than anticipated.
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96. We could also obtain an indirect standardized death rate (ISDR).
This could be obtained by multiplying CDR of the standard population by SMR.
CDR of B = 17.4
SMR = 0.876
ISDR = 17.4 x = 15.24
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97. Example 2:
Table 2 presents crude mortality data for two populations (countries A and B).
The overall crude mortality rate is higher for country A (10.5 deaths per 1,000 person years)
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98. compared with country B (7 deaths per 1,000 person years).
Notice the ASDRs rates being higher among all age-groups in country B.
For example, 18% of the population in country A are aged over 60 years compared with 6% in country B.
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99. Table 2. Crude mortality rates stratified by age for two populations (country a, B).
Country B
Age group
# deaths/
1000
Pop (M)
Death rate
# deaths
Pop
Death rate/
0 - 29
7,000 6
1.2
6,300
1,500,000
4.2
20,000
5.5
3.6
3,000
550,000
60+
120,000
2.5 48
6,000 50
Total
147,000 14
10.5
15,300
2,170,000 7

100. Country A has a much older population than country B.
The reason for the difference between the crude mortality rates between country A and country B is that these two populations have markedly different age-structures.
Country A has a much older population than country B.
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101. Table 3. Standard population
Age group
Pop
0 - 29
100,000
65,000
60+
20,000
Total
185,000
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102. Age standard rate ratio (B : A) = 9.6/ 7.1 = 1.35
Table 3. - calculation of the number of expected deaths for countries A and B applied to a standard population.
Country A
Country B
Expected deaths
0 - 29
x 100,000 = 120
x 100,000 = 420
x 65,000 = 234
x 65,000 = 357.5
60+
0.048 x 20,000 = 960
0.05 x 20,000 = 1000
Total expected deaths
1,314
1,777.5
Age adjusted rate
1,134/185,000 = 7.1/1,000
1,777.5/185,000 =9.6/1000
Age standard rate ratio (B : A) = 9.6/ 7.1 = 1.35
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103. Comparative Mortality Ratio (CMR)
For our example:
Comparative Mortality Ratio (CMR)
= 9.6/7.1 = 1.35
This CMR is interpreted as:
after controlling for the affects of age, the mortality in Country B is 35% higher than in country A.
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104. Total expected deaths (E) 9,540
Table 4. Number of expected deaths if the population B had the same age-specific mortality rates as Country A.
Country B
Expected deaths
0 - 29
x 1,500,000 = 1,800
x 550,000 = 1,980
60+
0.048 x 120,000 = 5,760
Total expected deaths (E)
9,540
Total observed deaths (O)
15,300
Standardized Mortality Ratio (O/E) x 100
160
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105. The expected deaths in Country A are calculated by multiplying the age specific rate for Country A by the population of Country B in the corresponding age group.
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106. The sum of the age categories gives the total number of deaths that would be experienced in country A if it had the same mortality experience as country B.
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107. An overall summary measure can then be calculated, that is, the standardized mortality ratio (SMR), which is the ratio of the observed number of deaths to the expected number of deaths.
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108. SMR =
Observed number of deaths (O) X 100%
Expected number of deaths (E)
SMR = 160 = 1.6 X 100 =
This means: The number of observed deaths in Country B is 60% higher than the number we would expect if Country B had the same mortality experience as Country A.
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