1. DEMOGRAPHIC INDICATORS Assoc. Prof. Petko Salchev, MD, PhD

2. The science of demography „Demography” comes from demos – people and grapho – to write Demography is a science dealing with types, methods and nature of population reproduction and factors affecting this process

3. Structure of the demographic science Demographic theory Pure (formal) demography Analytic demography Historical demography Sociological demography

4. The demographic cycle Stationary stage Early growth stage – characterized by a decline in mortality and unchanged birth rate. Late growth stage – mortality continues to decrease, but there is also a tendency for a decrease in birth rate, although still higher than mortality. Stationary stage – characterized by low levels of birth rate and mortality. Decline stage – birth rate lower than mortality.

5. Types of stages in Bulgarian population Late growth stage Stationary stage Decline stage Early growth stage

6. Population and population reproduction Population, people – natural, historically set and constantly renewing itself in the course of life sum of people, the fundamental material component of human society Population reproduction – this is one of the main processes of reproduction of society and represents a probability process, formed by a mass of random single events of birth and death

7. Reproductive behavior Psychic regulator of behavior, personal predisposition governing the harmonization of a stream of activities, subject to positive or negative attitudes towards the birth of a given number of children Readiness for a certain outcome of a walk of life, the acceptance from the individual of the necessity for giving birth to a given number of children

8. Main groups of demographic indicators According to complexity: – simple – reflecting a count (population, births, etc.) – complex – expressing ratios (birth rate, mortality, etc.) – integral – the integration of several health events (life expectancy, healthy life expectancy, etc.) According to the type of study subject: – static – number, composition and structure of the population in a given moment – dynamic – related to vital processes in human life or population transitions in territory and time.

9. Indicators of population static Population number Average yearly population number Р 0 + Р 1 Р= ----------------- 2 Where Р 0 is the population number at the beginning of the year, Р 1 is the population number at the end of the year

10. Population number Present population according to address registration (Population de fait) Population according to place of residence (Population reference) Risk exposed population (Population exposee ou risque) – the population with the highest probability of occurrence and development of a certain disease

11. Demographic transition Stages Traditional – characterized by high and balanced levels of birthrate and mortality Transitory – characterized by diminishing the level of mortality while keeping the birthrate Stable – characterized by low and balanced birthrate and mortality Population ageing – characterized by a growing proportion of aged people as a result of a lowered birthrate and higher life expectancy Depopulation – characterized by high migration and mortality among people in active age as a result of trauma, chronic heart diseases, AIDS, wars, etc.

12. Rate of demographic ageing (T i ) The rate of increase of the relative share of population above work age (according to the defined boundary for men and women) towards the preceding year. Calculated as a percentage.

13. Changes in the average population number in Bulgaria for the period 1970-2004 г. Source: World Health Organization, Regional Office for Europe. European health for all database (HFA-DB)

14. Population structure Population structure according to gender Population structure according to age Analysis of the correlation of dependant contingents Population structure under, in and above work age Analysis of the relative shares of persons aged 0-14, 15- 49 and above 50 Ethnic composition, religion, maternal language Population structure according to level of education

15. Population gender structure Population as of 31.12.2005 YearTotalMenWomen 19908 669 2694 269 9984 399 271 19958 384 7154 103 3684 281 347 20008 149 4683 967 4234 182 045 20017 891 0953 841 1634 049 932 20027 845 8413 816 1624 029 679 20037 801 2733 790 8404 010 433 20047 761 0493 767 6103 993 439 20057 718 7503 743 3273 975 423 Source: NSI,2006

16. Population age structure Age classifications WHO classification  0-14 – infant age  15-44 – juvenile age  45-59 – middle age  60-74 – aged persons  75-89 – old people  Above 90 – longevity Classification for the needs of education and healthcare  Under 1 – nursing age  1-3 – early infant age  4-6 – before school age  7-14 – school age

17. The population age structure may be characterized in four basic ways 1. Through building and analyzing of an age pyramid 2. Through correlation of dependant contingents (relation of children and persons above 65 to working population) 3. Through comparison of relative shares of persons in the three main groups 0-14, 15-49 and above 50. 4. Through relative shares of persons above 60 or above 65.

18. Building and analyzing an age pyramid

19. Analysis of the correlation of dependant contingents Coefficient of age dependency (V) shows the number of people in „dependant" ages (population under 15 and above 65) in relation to 100 people in „independent" age (from 15 to 64). Calculated in percent.

20. Population structure under, in and above work age YearsTotal Age groups Under work age - %In work age - %Above work age - % 199010021.655.522.9 199510019.156.624.3 200010016.858.324.9 200110016.359.224.5 200210015.960.124.0 200310015.560.823.7 200410015.161.623.3 200510014.862.422.8 Source: NSI,2006

21. Coefficients of dependency 2000-2005 Source: Hr. Mitreva, NII, 2006 Population as of 31.12. Population above work age as of 31.12. Retired - total Insured persons Relation of retired to insured persons 2000 г.8 149 4682 027 9762 379 3242 303 726103.3% 2001 г.7 891 0951 929 6832 370 8712 311 091102.6% 2002 г.7 845 8411 887 0362 350 9002 170 061108.3% 2003 г.7 801 2731 845 1752 336 8062 393 92797.6% 2004 г.7 761 0491 804 8682 327 8072 491 82993.4% 2005 г.7 718 7501 759 8752 313 7442 597 06189.1% Population, insured persons and retired for the period 2000-2005

22. Analysis of the relative shares of persons in ages 0-14, 15-49 and above 50. Progressive type – persons aged 0-14 are above 30% of the total number of population, and these above 50 are under 20%; Stationery type – the number of persons in the two age groups 0-14 and above 50 is approximately equal and their percent relation to the total population number is respectively 25% to 25%; Regressive type – persons in the age group 0-14 constitute under 20% of the total population number, and those above 50 – more than 30%.

23. Coefficient of demographic replacement The ratio of the population numbers of incoming in the working contingent age group 15-19 and exiting from the working contingent age group 60-64.

24. Analysis of the relative share of persons above 60 or 65 Age structurePersons above 60Persons above 65 YoungBelow 10%Below 5% Ageing10-15%5-10% AgedAbove 15%Above 10%

25. Marriage and divorce The marriage coefficient (b) shows the number of marriages per 1 000 people. It is calculated (per thousand) as the ratio of the number of marriages (B) throughout the year and the average population throughout the same year. The divorce coefficient (p) shows the number of divorces per 1 000 people. It is calculated (per thousand) as the ratio of the number of divorces throughout the year and the average population throughout the same year.

26. MAIN DEMOGRAPHIC INDICATORS FOR 2001, 2004 and 2005 Indicator 200120042005 TotalCityRuralTotalCityRuralTotalCityRural Sex ratio (number of women per 1000 men)1 0541 0661 0281 0601 0751 0261 0621 0771 028 Marriage (per 1000 people)4.04.53.14.04.62.64.34.93.0 Divorce (per 1000 people)1.31.60.61.92.21.21.92.21.2 Mean age (in years): Population age40.438.644.641.039.345.041.239.545.2 Age of mother at birth: of first child23.824.422.024.525.222.424.825.622.5 of child25.125.623.925.826.424.326.226.824.4 Age at first marriage: Men28.128.228.128.829.127.529.129.428.0 Women24.824.924.425.525.924.125.826.224.5 Age at divorce: Men39.1 39.440.640.541.341.140.842.1 Women35.8 35.737.237.137.6 37.438.4

27. Ethnic composition Source: NSI, 2005 Distribution of ethnic groups in Bulgaria as of 2001 in % Turks 9% Bulgarians 84% Roma 5% Not shown 0% Others 2%

28. POPULATION DISTRIBUTION ACCORDING TO RELIGION Religion1910192019261934194619922001 Numbers Total 4 337 5134 846 9715 478 7416 077 9397 029 3498 487 3177 928 901 East-orthodox 3 643 9184 062 0974 569 0745 128 8905 967 9927 274 5926 552 751 Islam 602 078690 734789 296821 298938 4181 110 295966 978 Catholic 32 15034 07240 34745 704-53 07443 811 Protestant 6 3355 6176 7358 371-21 87842 308 Judaism 40 06743 23246 43148 39843 3352 580653 Armenian-gregorian 12 25910 84825 40223 476-9 6726 500 Others and not shown 7063711 4561 80279 60415 2267 784 Undefined ------308 116 Source: NSI, 2005

29. Population distribution according to religion as of 2001 in % Catholic 0,55 Muslim 12,20 Protestant 0,53 Other 0,19 Not defined 3,57Not shown 0,31 East- orthodox 82,64

30. Population distribution according to education Source: NSI, 2005 Population distribution according to education in % Higher 24% No education 0% Primary 20% Secondary 56%

31. Demographic indicators for population dynamics Dynamic demographic indicators Mechanical movement of population External migration Immigration Emigration Internal migration Urbanization Cyclic movement Natural population movement (vital processes) Birthrate Mortality Natural growth Integral indicators AALE Age adjusted life expectancy HALE Health adjusted life expectancy DFLE Disability free life expectancy QALY Quality adjusted life years DALY Disability adjusted life years

32. Indicators for mechanical movement of population External migration Internal migration Cyclic movement

33. Indicators for natural movement of population Main concepts  “Childbirth" means is the process at the end of a human pregnancy that results in a baby being born pregnancybaby  A live birth occurs when a fetus, whatever its gestational age, exits the maternal body and subsequently shows any signs of lifefetusgestational agematernal  Stillbirth is considered the delivery of child that by the termination of pregnancy didn’t show any signs of life and the pregnancy has lasted no less than 28 weeks  Abortion is considered the delivery of child that by the termination of pregnancy didn’t show any signs of life and the pregnancy has lasted less than 28 weeks

34. Birth rate Children born alive through the year х 1000 Birth rate = Average yearly number of population Birth rate is assessed using a three-stage scale:  low – below 15%,  medium – 15-25%  high – above 25%.

35. General fertility rate Children born alive х 1000 Fertility = Average yearly number of women aged 15 - 49 Birthrate and general fertility rate (1990 - 2005) 1.319.22005 1.299.02004 1.238.62003 1.218.52002 1.248.62001 1.279.02000 1.238.61995 1.8112.11990 General fertility rate 3 Birthrate (per 1000) Year Source: NSI, 2006

36. Age-specific fertility rate Represents the number of live births per 1000 women of a specified age in one year.

37. Age-specific fertility rate in Bulgaria for 1980-2000 Source: NSI, 2006 Age-specific fertility rate 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 Age Coefficient 1980 80,3192,892,832,29,72,10,1 1990 68,3159,478,328,89,41,80,1 1995 53,5100,661,822,47,51,50,1 1997 45,185,256,922,47,31,60,1 2000 45,589,772,932,39,51,90,1 15-1920-2425-2930-3435-3940-4445-49

38. Specific indicators for assessment of population reproduction Total fertility rate – represents the average number of children, that a woman would give birth to, through her entire fertile period, if the age-specific fertility rate remains the same as at the present moment for which it is calculated; Gross fertility rate of population is a complex indicator, representing the average number of girls born of a mother in her fertile age; Net fertility rate of population is the average number of girls born of a mother in her fertile age (15-49), which will live up to the age their mother had by the moment of their birth.

39. An example of calculating total fertility rate and gross fertility rate We use the data for age-specific fertility rate for each year. The coefficients for each age group are multiplied by 5 (column 3 of the table), which will give us information ho many live births would produce 1000 women for the 5-year interval. The products of column 3 are summed (the sum is 1259,6) – this is the number of live births per 1000 women for the next 5- year interval after 2000. AgeYear 2000 Multiplied by 5 123 15-1945,5227,5 20-2489,7448,5 25-2972,9364,5 30-3432,3161,5 35-399,547,5 40-441,99,5 45-490,10,5

40. An example of calculating total fertility rate (continuation) Finally, we divide this sum by 1000 and get the total fertility rate, which is 1,26, meaning that if no changes occur in age-specific fertility rate, a woman from the offspring of 15-year old, which by 2000 have reached reproductive age, will have an average of 1.26 children by their 49 anniversary. If we keep in mind that a family couple reproduces if it has at least to children, it becomes clear that by the year 2000 Bulgaria is in the stage of narrowed reproduction. The sum of column (3) is 1259,6. 1259,6 : 1000 = 1,26. Total fertility rate = 1,26. The gross rate is calculated by multiplying the total fertility rate by the relative share of girls in the structure of live born for the year. For 2000 the relative share of girls is 0,488. Consequently, the gross rate for the year 2000 is: Gross fertility rate = 1,26 х 0,488 = 0,61.

41. Stillbirth and abortion rate Number of stillbirths х 1000 Stillbirth rate = Number born (alive and stillbirths) Number of abortions for a given territory in a given period х 1000 Abortions rate = Number of women (15-49) on the same territory for the same period

42. 0 50000 100000 150000 200000 19701975198019851990199520002004 Total number of abortions in all ages Source: World Health Organization, Regional Office for Europe. European health for all database (HFA-DB)

43. Reasons for death „All those ailments, pathological states or trauma that have lead to the occurrence of death or have facilitated death, as well as circumstances that have lead to incidents or acts of violence causing such trauma”

44. Primary cause of death Primary cause of death can be defined as : „а) illness or trauma causing a number of pathological processes directly leading to death or б) circumstances that have lead to an incident or act of violence causing mortal trauma.”

45. International form of medical certificate for cause of death Death reason Approximate time interval between onset of pathological process and death І. Disease or state that have directly lead to death * а) ………………………….. caused (or attributed to)………………………….. …………………………… ……………………………. Preceding causes Pathological states, if any, that have lead to the emergence of the above stated cause; The leading cause of death is shown last b) ………………………….. caused (or attributed to) c)…………………………… caused (or attributed to) d)…………………………… ІІ. Other important states contributing to death, unrelated to the illness or the pathological state.....…………………………. ………………………………. * Symptoms and signs accompanying death (mechanism of death) like heart failure, breathing disorders, are not included here. Only ailments, trauma and complications that have lead to death are included.

46. An example of defining the cause of death The medical certificate of death, comprising four events in a chain leading directly to death, should be filled in the following way [1] : [1] а) Pulmonary artery embolism б) Pathological fracture в) Secondary femoral cancer г) Mammal cancer [1][1] Example from ICD-X, tome ІІ.

47. Mortality Groups of indicators Not standardized – intensive indicators, measuring the frequency of a health event in a given year and territory. Standardized – when comparing gross coefficients or specific indicators by reasons (calculated for the entire population), but under existing differences in age structure of the population in compared populations. Standardization aims to eliminate the differences in these factors and show what would be the health event if the compared populations would have identical age structure. Specific coefficients – measuring the frequency of health events in different subgroups of population or by different causes. Proportions – structural or extensive indicators showing the distribution of causes of death

48. Not standardized indicators of mortality Number of deceased х 1000 Total mortality = Yearly average number of population When assessing total mortality a scale of three stages may be used :  low – below 10 ‰,  medium – 10-15 ‰  high – above 15 ‰.

49. Total mortality in ‰ in Bulgaria (1965-2005) with calculated trend Source: NSI, 2006

50. Standardized mortality indicators Source: World Health Organization, Regional Office for Europe. European health for all database (HFA-DB)

51. Standardization of frequencies The standardization of frequencies is a set of techniques used for eliminating, as far as possible, the influence of different age and sex distributions when comparing the mortality or morbidity of population of one or more countries. For the purpose of comparing frequencies from different groups, a standard population with known age and gender structure is used. Standardization may be fulfilled through direct or indirect method. Direct method of standardization This method is applied when the age-specific indicators of the compared groups are known. These indicators are applied to the standard population for calculating the expected number of cases (deceased, diseased) in each age group in case their age distribution is the same as in the standard population. Obtained numbers are summed and divided by the total number of standard population. Indirect method of standardization This method is used when the age-specific frequencies for mortality in a given population are missing or the numbers in some age groups are too small. The expected number of cases calculated in this way is compared to the actually observed number of cases from a certain health event. The ratio observed/anticipated is multiplied by 100 in order to obtain standardized ratio, which shows comparisons without biasing factors such as different age structure. Example. Mortality from disease х in youngsters from region у. Total number observed 3850. Total number of deceased with illness х (in corresponding age-specific mortality among entire population) 32О. Anticipated deaths 0,14. Standardized mortality 32/0,14=228,6 Standardized mortality rate (SMR) Number of cases observed Number of cases anticipated = х 100

52. Example Mortality from disease х in youngsters in region у Total number of observed3850 Cases of death from disease х (in corresponding age-specific mortality among entire population) 32 Expected deaths0,14 Standardized mortality 32/0,14=228,6

53. Specific indicators of mortality Mortality according to habitation Mortality according to gender Mortality according to age Mortality by causes

54. Mortality according to residence 0,0 5,0 10,0 15,0 20,0 25,0 19651970197519801985199019952000 UrbanRural Bulgarian population mortality according to residence (1965-2000) Source: NSI, 2006

55. Mortality according to gender 0,0 5,0 10,0 15,0 1970198019902000 Gender - standardized mortality in Bulgaria (1970-2000) TotalMenWomen Source: NSI, 2006

56. Maternal mortality Maternal mortality reflects the frequency of death in pregnant women up to the 42 day after pregnancy termination, regardless of its duration, complications during pregnancy or the course of delivery. Number of pregnant or lying-in women dead х 1000 000 Maternal mortality = Number of children born alive

57. Leading causes of maternal mortality Direct obstetrics reasons – deaths as a result of complications of pregnancy, delivery or post-delivery period; omissions; incorrect treatment or a chain of events following some of the mentioned above factors; Extra-genital reasons – deaths as a result of preceding disease or condition, manifested during pregnancy, which is not due to direct obstetrics cause but is aggravated by physiologic consequences of pregnancy.

58. Infant mortality Groups of indicators: Uncorrected (simple) coefficient – calculated as the number of deceased children for a given period on a certain territory to the number of children born alive for the same period and same territory Corrected coefficient – it is used when the birthrate in two consecutive years differs considerably and because part of the deceased children from the age group 0-1 were born in the previous year, the number of born alive in this year should also be taken into account. The classic way of correction is to use 2/3 of the born alive in the current year plus 1/3 of the born alive from the preceding year in the denominator. Other authors suggest that the coefficient should be corrected by 4/5 of the born alive through the present year and 1/5 from the previous one. Age-specific indicators – reflecting mortality through the sub-periods of infant’s life from 1 year on. Specific indicators – measure the frequency of dying among children from concrete anomalies or diseases Others – according to residence, gender, maturity and other criteria

59. Uncorrected (simple) coefficient Common coefficient of infant mortality Infant mortality Number of newborns dying under 1 year of age Number of live births during the year =х 1000 Comparative analyses are based on a five-stage scale very low – below 10 ‰; low – 10-14 ‰; average – 15-24 ‰; high – 25-49 ‰; very high – над 50‰.

60. Periods in infancy before 1 year of age Perinatal – (from lat. peri – around and natus – delivery) – from 22 week of gestation (154 of the intrauterine development – weight approximately 500 g) up to the 7 th day after delivery Neonatal – this period starts with the delivery and ends to the 28 th day after delivery. This period is subdivided to: – Early neonatal – from 0 to 6 days from delivery – Late neonatal – from the 7 th day to the 28 th day from delivery Post-neonatal - from day 29 after delivery to 1 year

61. Age-specific indicators of infant mortality Perinatal infant mortality Stillbirths + born alive, dying in the first 6 days after delivery Newborns (dead- and alive) = х 1000 Neonatal infant mortality Infant deaths from 0 to 28 days Born alive =х 1000 Early neonatal infant mortality Infant deaths from 0 to 6 days Born alive =х 1000 Late neonatal infant mortality Infant deaths from 7 to 27 days Born alive minus born dead up to day 6 =х 1000 Post-neonatal infant mortality Infant deaths from day 28 to year 1 Born alive minus deceased until day 27 = х 1000

62. Other coefficients and indicators Coefficient of intrauterine mortality Coefficient of stillbirth rate Coefficient of stillbirth rate accounting for weight Coefficient of early neonatal mortality accounting for weight Coefficient of perinatal mortality accounting for weight Coefficient of neonatal mortality accounting for weight

63. Natural growth Number of born alive minus deceased Yearly average number of population = х 1000