Introduction :

Community health nursing is concerned with rendering need based comprehensive

health and nursing care services to the people at large. It is necessary for every community
health nurse to study the community, make systematic assessment , diagnosis of health status
and nursing problems, plan and implement health and nursing care and evaluate care based
on predetermined goals and objectives..
The origin of Epidemiology has been traced back to Hippocrates who tried to explain
the association of lifestyle and environmental factors with the occurrence of disease.
However the foundation of modern epidemiology was laid during the late 19 th century and
early 20th century with the occurrence of infectious and communicable disease like Cholera,
Typhoid, Plague ,etc. While in the 20th century the many communicable diseases continue to
be a serious problem new non- communicable problems like, cardio – vascular disease,
cancer, accidents, etc have emerged. So, the current focus of the epidemiologist is to study
the prevalence, prevention and control of not only communicable diseases but of the non-
communicable diseases as well. The contribution made by Florence Nightingale in
reducing the morbidity and mortality of the soldier of Crimean War by studying the
distribution and patterns of disease among the soldiers made the application of study of
epidemiology in nursing. This approach of her has made nursing as a profession.
Therefore, the community health nurse has to apply the epidemiological measurements
and methods to deal with the health problems at various levels in the community settings.

Definition :
The word Epidemiology has come from the three Greek words; Epi – ‘among’, Demos –
‘people ‘ and logos – ‘ study or science ‘. The literal meaning is the study of events that
occur among the people.

Epidemiology is the study of the distribution and determinants of disease frequency in man.
------ Mac Mohan (1960)
Epidemiology is the study of the distribution and determinants of health related states of
events in specified populations and the application of this study to the control of health
problems.
--------- John M Last (1988)
Aims of Epidemiology :
The main aims of epidemiology as laid down by International Epidemiological
Association (IEA) are given below :-
 To describe the distribution and magnitude of health and disease problems among
individuals and groups.
 To identify the etiological factors in the pathogenesis of disease.
 To provide data for planning, implementation and evaluation of services for prevention ,
control and treatment of disease and in setting up of priorities among those services.

Measurement in Epidemiology :
The scope of measurement in epidemiology ate follows :-
 Measurement of mortality
 Measurement of morbidity
 Measurement of disability
 Measurement of natality
 Measurement of the presence, absence or distribution of the characteristic or attributes of
the disease.
 Measurement of medical needs, health care facilities utilization of health services and
other health related events.
 Measurement of the presence, absence or distribution of the environmental and other
factors suspected of causing the disease
 Measurement of demographic variables.

Tools of measurement
The most common basic tools of epidemiology are :-
 Rate
 Ratio
 Proportion

 RATE -
A rate measures the occurrence of some particular event in a population during a given
period of time. The event can be births, deaths, diseases , etc.
It is defined as a numerical statement of the frequency of an event obtained by
dividing the number of individuals experiencing the event during a specified time
period( the numerator) by the total mid year population who are capable of
experiencing the event (the denominator ) and multiply by a constant number which is
usually 1000, or some other round figure(10,000 or, 100,000).
 In formula it can be expressed as,
Rate = Number affected in a time period x 1000
Total population in a same area
A rate always contain – numerator (which is a part of denominator ), denominator,
multiplier and time period.
The various categories of rates are :-
a) Crude rate – these are the actual observed rates based on the entire population and not
reflective of any specific population group such as, female or male or any specific
group, etc. For example, crude birth rate and crude death rate. Crude rates are also
called as Unstandardized rate.

b) Specific rate – these are the actual observed rates based on specific population such as
sex wise groups, disease wise groups ,etc or during specific time period. For examples,
annual rates, age specific death rate, etc.

 RATIO –
A ratio expresses a relation in size between two random quantities . the numerator is
not a component of the denominator. Ratio is basically, the result of dividing one
quantity by another. It is expressed in the form of;
x : y or, x
y
For example, The ratio of white blood cells relative to red cells is 1:600 or, 1/600, meaning
that for each white cell, there are 600 red cells. There are other examples such as, Sex-ratio,
doctor-population ratio , etc.

 PROPORTION-
A proportion is a ratio which indicates the relation in magnitude of apart of the whole.
The numerator is always a part of denominator with no time factor. A proportion is
always expressed in percentage %.. For example,

Proportion = The number of children with malnutrition

at a certain time in a community x 100
The number of total children at the same time
In that community
  Measurement of Mortality
Traditionally and universally, most epidemiological studies begins with mortality data.
Mortality data are relatively easy to obtain and in many countries it is reasonably accurate.
Mortality data provide the starting point for many epidemiological studies. In fact they are
major resources for the epidemiologist.
International Death Certificate recommended by WHO has the following features.
o It is the basis of mortality data`
o For ascertaining the frequency of death
o Need to ensure National and International comparability.
o Requires uniform recording and classification of deaths which is periodically
updated.
The international certificate has ;
1. Line a – immediate cause of death
2. Line b – first antecedent cause
3. Line c – underlying cause , which forms the essence of the death certificate. It is
defined as the disease or injury which initiated the train of morbid events
leading directly to death.
4. Line d – associated condition which may directly or indirectly contributed to the
mortality.

Death certificate used in India

The death certificate used in India has a set of questions added to the
International Death certificate which are :-
1. If deceased was a female, was the pregnancy the death associated with –
i. Yes ii. No
2. If Yes, was there a delivery? i.Yes ii. No
These questions were provided to serve as an alternative source of maternal
mortality data.

Sources of mortality data-

There are two main sources of mortality data :-
1. Direct source
 Registration of Vital Events
 Sample Registration Survey
 National Family Health Survey
 2. Indirect source
 Age data of two consecutive census may be used to estimate death
rates
 Demographic year book: UN Publication
 WHO also provides data.

Limitations of mortality data –

The limitations of mortality data includes the following:-
 Incomplete reporting of death in some countries.
 Medical certification of death is not universal.
 Where certification is done there may be a lack of accuracy.
 Incorrect recording of age
 Incorrect entry of the underlying cause
 Lack of diagnosis- inadequate lab. Facilities or lack of post mortem.
 Inexperienced certifying doctor
 Choosing a single cause of death- only the underlying cause.
 Disease with low mortality cannot be studied.

The commonly used mortality indicators are:-

1. Crude death rate – it is the simplest measurement of mortality. It is defined as the
number of deaths ( for all cases ) per 1000 estimated mid- year population, in one
year, in a given place.. The formula for crude rate is;

Crude death rate = Number of deaths during one year x 1000

Mid year population

2. Specific death rate – it is cause or disease specific – e.g, tuberculosis, cancer ,

accident . It is also related to specific groups- e.g, age, sex, income, religion , etc.
The formula of specific death rate are :-

 Cause specific death rate – mortality rate for a specified cause of death. The formula
is,

Cause specific death rate = Number of deaths from specific

cause in an area x 1000
Estimated mid-year population
in the same area during the same year
 Age Specific Death Rate – mortality rate for a specified age . The formula is;

Age specific death rate = Number of deaths of a specified age group

in an area during the year x 1000
Estimated mid-year population of that age group
In the same area during the same year.

3. Case Fatality Rate – it represents the killing power of a disease. It is simply the ratio
of deaths to cases. The time interval is not specified. Case fatality rate is typically
used in acute infectious diseases. Like food poisoning, cholera, etc. The formula is;

Case Fatality Rate = Number of deaths due to a particular disease x 1000

Number of cases due to the same disease

4. Proportional Mortality Rate – it helps to know what proportion of total deaths are
due to a particular cause or what proportion of deaths are occurring in a particular age
group. Proportional mortality rate expresses the number of deaths due to a particular
cause per 1000 total deaths. The formula is given below;

Proportional Mortality Rate = Number of deaths from the specific

cause in a year x 1000
Total deaths from all causes in the same year.

5. Survival Rate – is the proportion of survivors in a group studied and followed over a
period. It is a method of describing prognosis in certain conditions. Survival
experiences can be used as a yardstick for the assessment of standards of therapy latio
they are mostly used in research . The formula is ;

Survival Rate = Total number of patients alive after 5 years x 1000

Total number of patients diagnosed or treated

6. Adjusted or Standardized rates – helps to compare the death rate of two

populations with different age compositions, where the crude death rate will not be
able to do so. The rates are comparable if the populations up on which they are based
are comparable. It is cumbersome to use a series of age specific death rates.
Therefore, age standardization helps to remove the confounding effect of different age
structures and yields a single standardization or adjusted rate, by which the mortality
experience can be compared directly. The adjustment can be made not only for age,
but also sex, race , etc. -thus one can generate age, sex, race adjusted rates.
7. Perinatal mortality rate- the sum of neonatal deaths per 1000 births. The formula is;

Fetal death (7th month or <) + Death under

Perinatal mortality rate = 1 week of birth in an area during the year x 1000
Total live births and late fetal deaths in the
same area during the same year

8. Maternal mortality rate – is the death of a woman while pregnant or within 42 days
of termination of pregnancy, irrespective of the duration and site of pregnancy, from
any cause related to or aggravated by the pregnancy or its management, but not from
accidental or incidental causes . The formula is,

Total number of female death due to

complications of pregnancy, child birth
Maternal mortality rate = or within 42 days delivery from the given year x 1000
Total number of live births in the same area and year

9. Infant mortality rate – is the number of deaths of children less than 1 year per 1000
live births. The formula is,

Number of deaths under 1 year of age in a

Infant mortality rate = defined population in a year x 1000
Number of live births in the same population
in the same year

10.Child mortality rate – is the number of deaths of children less than 5 year old per
1000 live births. The formula is ;

Number of deaths under 5 years of

Child mortality rate = age in a defined population in a year x 1000
Number of live births in the same population
in the same year

Measurement of Morbidity

Morbidity has been defined as “ any departure, subjective or objective, from a state of
physiological well – being”. The term is used equivalent to such terms as sickness,
illness or disability.
 The WHO Committee on Health Statics noted that morbidity could be measured in
terms of 3 units –
i) Persons who are ill
ii) The illnesses ( periods or spells of illness) that these persons experienced
iii) The duration (days, weeks, etc) of these illnesses.
Three aspects of morbidity are commonly measured as Morbidity Rates or
Morbidity Ratio namely frequency, duration and severity.
a) Disease frequency is measured – Incidence and Prevalence rates.
b) Duration of illness – is expressed in terms of the average number of days of
disability per person and measured as disability rate.
c) Severity is measured as Case fatality rate.

Need for morbidity measurement

The morbidity measurement is important for the following:-
 The morbidity value describe the extent and nature of the disease load in the
community and thus assist in the establishment of priorities.
 They serve as a starting point for the etiological studies and thus play a crucial
role in disease prevention.
 They are needed for monitoring and evaluation of disease control activities.
 They usually provide more comprehensive, accurate and clinically relevant
information on patient characteristics, than can be obtained from mortality data,
and are therefore essential for basic research.

Incidence and Prevalence .

The incidence rate and prevalence rate are the two most commonly used morbidity
rates in community health.
 Incidence Rate:
Incidence rate is defined as the number of NEW case occurring in a defined
population during a specified period of time.It is given by the formula:

Number of new cases of specific disease

Incidence rate = during a given time period x 1000
Population at risk during that period
*note: Incidence Rate must include the unit of time. For eg, if there had been 500 new cases
of an illness in a population of 30,000 in a year, the incidence rate would be :
= 500 / 30,000 x 1000
= 16.7 per 1000 per year.
 Incidence rate is helpful in monitoring the occurrence of new cases in a given
population over time. For that reason it is preferred to mortality rate. Any increase or
decrease in incidence rate helps in determining the causative / risk factors associated with the
disease

Incidence rate refers to :-

 Only to new cases
 During a given period
 In a specified population or ‘ population at risk ‘
 To new spells or episodes of disease arising in a given period of time, per 1000
population. For eg, a person may suffer from common cold more than once a year.
If he had suffered twice , he would contribute 2 spells of sickness in that year. The
formula in this case would be:
Number of spells of sickness starting
Incidence rate(Spells) = in a defined period x 1000
Mean number of persons exposed
to risk in that period
Incidence measures the rate at which new cases are occurring in a population. It is not
influenced by the duration of the disease. The use of incidence is generally restricted to acute
conditions.

Special Incidence Rates

It includes; Attack rate and Secondary Attack rate.
 Attack rate – is an incidence rate usually expressed as a per cent, used only when the
population is exposed to risk for a limited period of time such as during epidemic. It
also reflects the extent of the epidemic.It is given in the formula;

Number of new cases of a specified disease

Attack rate = during a specified time interval x 100
Total population at risk during the same interval

 Secondary attack rate – is the number of exposed persons, developing the disease
within the range of ONE incubation period. It measures how many of the exposed and
susceptible got the infection from the primary case itself (ie, to how many did the first
case past the infection).
 It is given by the formula ;
Number of susceptible individuals developing
the disease within one incubation period
Attack rate = following the exposure to the primary case x 100
Total number of those who were not only exposed
but also susceptible

Hence,
o Subtract the primary case from both the numerator and the denominator
o Also subtract the immunized (or not susceptible) from the denominator.

 Prevalence :
The term disease prevalence refers specially to all current cases(old and new)
existing at given point in time or over a period of time in a given population.
The prevalence rate is defined as the total number of all individuals who have an
attribute or disease at a particular time (or during a particular period) divided by
the population at risk of having the attribute or disease at this point in time or mid-
way through the period. Although referred to as rate, prevalence rate is really a
ratio.
Prevalence is of two types :- a) Point prevalence
b)Period prevalence
a) Point prevalence
Point prevalence of a diseases defined as the number of all current cases (old and
new) of a disease at one point of time, in relation to a defined population. The point in
point prevalence, may for all practical purposes consist of a day, several days or even a
few weeks, depending upon the time it takes to examine the population sample. The
formula is,
Number of all current cases(old + new)
of a specified disease existing at a given
Point prevalence = Point in time x 100
Estimated population at the same point in time

Point prevalence can be made specific for age, sex and other relevant factors or
attributes.

b)Period prevalence
A less commonly used measure of prevalence is period prevalence. It measures the
frequency of all current cases(old and new) existing during a defied period of time
expressed in relation to a defined population. It includes cases arising before but
extending into or through to the year as well as those cases arising during the year. It is
given by the formula
 Number of existing cases (old & new) of a
specified disease during a given period of
Period prevalence = time interval x 100
Estimated mid- interval population at risk

Uses of Incidence and Prevalence

1. Incidence gives the actual rate of fresh occurrence of the disease in the specified
population, therefore :
 Incidence can be used as indicator of health services.
 Used in research for identifying risk and etiological factors.
 Used for checking the efficacy of therapeutic or preventive measures.
2. Prevalence measures the magnitude of the disease load in the population, therefore:-
 Helps in prioritizing the health problems of the population under study.
 Prevalence rates are needed for planning establishing and evaluating health
services, like number of beds, doctors, nurses, etc i.e, for administrative purposes.

Relationship between Incidence and Prevalence:

Prevalence depends upon 2 factors, the incidence and duration of illness. Given the
assumption that the population is stable and incidence and duration are unchanging. The
relationship between incidence and prevalence can be obtained as ;
P=IxD
Where P = prevalence , I = incidence and D = duration.
For eg.
1. Tuberculosis has a long duration. Hence, prevalence of TB>> incidence of TB
2. Food poisoning has short duration, Hence, incidence>> prevalence

Paradoxically, improved treatment of a disease may increase the prevalence if it

prevents death without curing the disease.
If the new treatment leads to rapid recovery, the prevalence will decrease even if the
incidence does not change.

Conclusion
The epidemiologist and health personnel working in the community are interested to
study health status of population at large, identify morbidity and mortality pattern, determine
the factors affecting health and disease and utilize these information in planning to provide
need based health care services. Epidemiologists make use of various measurements to study
the frequency and distribution and determinants of various diseases and health problems .
The science of epidemiology which deals with the study of health related state and events
occurring in defined community, equip community health nurse with a body of knowledge
and skills in making health assessment, planning and implementing need based care to
community as a whole. It provides a frame of reference for investigative approach to deal
with any problem in the family, group and community
References :
1. Park K.Preventive and Social Medicine. 25th Edition. Jabalpur : M/s Banarasidas
Bhanot Publishers ; 2019.p.62-69.

2. Basheer P Shebeer and Khan Yaseen S. A Concise Text Book of Advanced Nursing
Practice. 2nd Edition. Bangalore: EMMESS Medical Publishers; 2017.p. 174 – 176

3. Gulani Kumari Krishna. Community Health Nursing( Principles and Practices).2nd

Edition. Delhi: Kumar Publishing House; 2013.p.199 – 203

4. Swarnkar Keshav. Community Health Nursing. 3rd Edition. Indore: N.R. Brothers
Publishers; 2011.p.65 and 69-70

*
 PRESENTATION
ON
MEASUREMENTS IN
EPIDEMIOLOGY

Submitted to:
Dr. Prof. Uma Adhikari
Senior lecturer
CON- MCH, Kolkata Submitted by :
Saluja Chettri
MSc. Nsg 1ST Year
CON-MCH, Kolkata