Demography and Health

Dr.Rajkumar Patil
Asstt. Prof., Community Medicine
AVMCH, Pondicherry

Demos + graphein
Demography is scientific study
of human population

It focus its attention on Three readily observable

phenomena
phenomena in Demography
Changes in population size (growth or decline)
Composition of population
Population distribution in space
Five demographic processes
Fertility
Mortality
Marriage
Migration
Social mobility
These five processes are continuously at work within a
population determining size and composition and
distribution

Community Medicine and Demography

Community medicine is vitally concerned with
population as the health of the people depends
upon:
the
the
the
for

number of people
space they occupy
skill that they have acquired in providing
there needs

There are four ways in which the number of people

in an area can change during the time periods

Population Growth
Natural Increase (Births-Deaths)
+
Net Migration

(Immigration-emigration)

Demographic cycle
Phase/

BR

Stage
High
Stationary
Early
Expanding

DR

Natural
Increase

Examples

0-very slow

India was in
this stage till 1920

rapid

South Asia & Africa

Late
Expanding

Slow
increase

India, China,

Low
Stationary

Slow

Singapore
UK, Denmark,
Sweden, Belgium

Declining

Declining

Germany & Hungary

Demographic transition (DT)

Demographic transition (DT) refers to
the transition from high birth and
death rates to low birth and death rates as
a country develops from a pre-industrial to
an industrialized economic system.
This is typically demonstrated through
a demographic transition model (DTM).

Old Balance: (High fertility & High Mortality)

A large supply of births was necessary to
compensate for the large number of deaths. MMR
& IMR extremely high
New Balance: (Low fertility & Low Mortality)
Represents an improved condition of human
efficiency & health, with fewer deaths considerably
less efforts required to bring a generation to
maturity. Production of agricultural & industrial
commodities is greater & life style is more
comfortable
Imbalance: (High Fertility & Low Mortality)
In between old & new balance is the period of
rapid natural increase. This growth is helpful for
under-populated nations. Too fast growth of
population leading economic, social & political
chaos ( being faced by numerous developing
countries including Pakistan)

World population trends

At the beginning of Christian era, nearly
2000year ago world population was estimated to
be around 250 million. Subsequent estimates of
world population given in table below.
It require all the human history up to the year
1800 for the world population to reach one
billion. The second billion came in 130 years,
third in 30 years fourth in15years the fifth in
12years and sixth in 12 years. On oct12th 1999
world population became 6 billion and expected
to reach 8 billion by 2025.

World Population Trend

Year

Population

1800

978 million

1900

1650 million

1950

2.5 billion

1970

3.6 billion

1980

4.4 billion

1985

4.8 billion

2000

6 billion

 About three fourth of worlds population lives in

developing countries
USA rank 3rd in world after India.
United nation estimates the world population grew
at annual rate 1.2% during 2000-2008.
China registered a much lower annual growth rate
of 0.7% comparable to that of USA 1.0% during
2000-2008 as compared to India 1.54%. At
present India population is second to china.
According to UN projections India's population will
reach 1.53 billion by 2050 and will be the highest
population in the world.

10 most populous countries of the world

(2001 estimates)

1. China 20.43%
2. India 17.01%
3. U.S.A. 4.61%
4. Indonesia 3.42%
5. Brazil 2.81%
6. Pakistan 2.39%
7. Russia 2.25%
8. Bangladesh 2.21%
9. Nigeria 2.20%
10.Japan 2.01%

Population trend in India

On 2.4% of worlds land area,17% of the worlds

population (2004-1080 million)

1921-Year of big divide, Indias population has

been steadily increasing since 1921

India will become the most populous country by the

year 2050 (1.53 billion)

Birth and death rate

Birth and death rates are two main indicators used
in demographic cycle and demographic transition
model.
The worlds birth rate fall below 30 for the first time
around 1975 and had declined to about 23.7%
during 2010, reflects global trend regarding smaller
families
Key factors in declining fertility included changes in
govt attitude toward growth, the spread of education,
increased availability of contraceptives, extension of
services through family planning programs, as well
as marked changes in marriage pattren

 Death rate have also declined worldwide over the last

decades. The global death rate decline from 11.0 (between
1975-1980) to 8.4 per thousand population during 2010, a
reduction of 23%
Crude death rates are mainly effected by infant and child
mortality. with improvement in MCH services, successful
implementation of EPI diarrheal disease and ARI control
program, as well as with the control of other infectious
diseases, there has been marked reduction in infant and
child mortality which are reflected in declining crude death
rate

CBR & CDR of selected countries (2004)

Country

CBR

CDR

India

(per1000
mid yr pop.)
24.1

( per1000
mid yr pop.)
7.5

Bangladesh

27

Pakistan

31

Sri Lanka

16

Thailand

16

Nepal

30

China

13

Japan

Singapore

UK

11

10

USA

14

Worlds average birth rate is 21/1000 population

Growth rate
Rate at which a given population is
expected to increase in a given period of
time
When the crude death rate is subtracted from
crude birth rate the net residual is current annual
growth rate
CBR-CDR = GR (in %, excluding migration)
10
Approximately 95% of population growth
occurs in developing countries

Population Doubling Time

refers to the time that would take for a
population to double. Because the population
increase is on the compound interest formula, a
1% per year increase would cause the
population to double in about 70 years. If the
population is increasing at 3% per year, than
the doubling time will be 23.3 years
Doubling time is the amount of time it takes for a
given quantity to double in size or value at a constant
growth rate. We can find the doubling time for
a population undergoing exponential growth by using
the Rule of 70. To do this, we divide 70 by the growth
rate

Relation between growth rate & population

Rating
Stationary Population

Annual rate of
growth %
No growth

Population doubling
time in years
-

Slow growth

Less than 0.5

More than 139

Moderate growth

0.5 to 1.0

139-70

Rapid growth

1.0 to 1.5

70-47

Very rapid growth

1.5 to 2.0

47-35

Explosive growth

2.0 to 2.5

35-28

Explosive growth

2.5 to 3.0

28-23

Explosive growth

3.0 to 3.5

23-20

 It is said that population growth rates like

railway trains are subjected to momentum.
They start slowly and gain momentum.
Once in motion it takes time to bring the
momentum under control. In case of train
the control factors are mass and inertia; in
population, they are age distribution,
marriage customs and numerous cultural,
social, and economic factors.

 Population Momentum The tendency for

population growth to continue beyond the
time that replacement-level fertility has
been achieved because of the relatively
high concentration of people in the
childbearing years.

 The worlds population growth rate was at

or near its peak around 1970, when the
human population grew by an estimated
1.92%. The most recent data shows a
slight decline since then to 1.2% in 2008.

Demographic indicators
Demographic characteristics provide an
overview of its population size,
composition, territorial distribution, changes
therein and the components of change
such as nativity, mortality and social
mobility.
Demographic indicators have been divided
into two parts population statistics and vital
statistics.

 Population statistics: that measures the

population size, sex ratio, density and
dependency ratio.
Vital statistic: include indicators such as
birth rate, death rate, natural growth rate,
life expectancy at birth, mortality and
fertality rates.
These indicators help in identifying areas
that need policy and program intervention,
setting near and far term goals and
deciding priorities

Age & Sex composition

a population refers to the proportion of males &
females in different age-groups. It has a direct
bearing on social, economic, health needs of
communities or countries. In an old population,
for example, the society has to arrange for the
care of the elderly, & the countrys health system
must be organized accordingly. In a young
population, on the other hand, the country has to
provide more schools, immunizations, &
economic support for the young.

Table-Distribution of population by age & sex (SRS2003)

Age group (yr) Male (%)

Female (%)

Total (%)

0-4

11.3

10.8

11.0

5-9

10.6

10.3

10.5

10-14

11.0

10.7

10.9

15-19

11.0

10.4

10.7

20-24

9.5

9.7

9.6

25-29

8.4

8.3

8.3

30-34

7.4

7.5

7.5

35-39

6.6

7.0

6.8

40-44

5.8

5.7

5.7

45-49

4.9

5.0

4.9

50-54

3.9

3.7

3.8

55-59

3.1

3.2

3.2

60-64

2.3

2.5

2.4

65-69

1.9

2.2

2.0

70+

2.5

3.1

2.8

Total

100

100

100

Age pyramid
It is a pictorial presentation (double histogram) of the age-sex
composition of a population
Male & Female are compared for age
Under-developed/developing country: Broad base & tapering top
(pyramid shape)
Developed countries: Bulge in the middle and has a narrow base
(spindle shape)

 A population pyramid, also called an age

pyramid or age picture diagram, is a graphical
illustration that shows the distribution of various age
groups in a population (typically that of a country or
region of the world), which forms the shape of a
pyramid when the population is growing.
It typically consists of two back-to-back bar graphs,
with the population plotted on the X-axis and age on
the Y-axis, one showing the number of males and
one showing females in a particular population in
five-year age groups (also called cohorts). Males
are conventionally shown on the left and females on
the right, and they may be measured by raw
number or as a percentage of the total population.

Types of population pyramid

Stable pyramid: A population pyramid showing an unchanging

pattern of fertility and mortality.
Stationary pyramid: A population pyramid typical of countries with
low fertility and low mortality, very similar to a constrictive pyramid.
Expansive pyramid: A population pyramid that is very wide at the
base, indicating high birth and death rates.
Constrictive pyramid : A population pyramid that comes in at the
bottom. The population is generally older on average, as the
country has long life expectancy, a low death rate, but also a low
birth rate. This pyramid is becoming more common, especially
when immigrants are factored out, and is a typical pattern for a
very developed country, a high level of education, easy access to
and incentive to use birth control, good health care, and few
negative environmental factors.

Sex Ratio
number of females per 1000 males
Ratio of males to females in the population
Sex Ratio = Number of Males X 1000
Number of Females

Sex ratio of:

India
Kerala
Punjab

: 933 females/1000 males

: 1058 females/1000 males
: 874 females/1000 males

Factors affecting sex ratio:

1. Difference in mortality conditions of males & females
2. Sex selective migration
3. Sex ratio at birth
2. Female foeticide and infanticide
Female foeticide is the act of aborting a foetus because it is female
Female infanticide is the deliberate killing of newborn
female children or
the termination of a female fetus
through selective abortion.

Dependency Ratio
Dependency Ratio is the ratio of economically dependant
population to economically independent population
Total Dependency Ratio
= Children (<15 yr) + Elderly (>65 yr) X 100
Working Age(15-64)
Young age dependency ratio
Old age dependency ratio

Density of population
Number of persons living per square kilometer
Density in India:
Year 1901 77 persons/km2
Year 2001 324 persons/km2
Year 2004 363 persons/km2

Family Size

Commonly family size refer to the total number of persons

in a family, in demography family size means
Total number of children borne by a women during
her child bearing age (15 to 45 years)
Total fertility rate (TFR) gives an idea of total family size
TFR in India: 2.68 (NFHS-3)
Family size depends upon
Duration of marriage
Education of couple
No. of live births
No. of living children
Preference of male child
Desired family size

Literacy & education

A person (7 yr or more) is considered as literate if he or

she can read & write with understanding in any language.
Crude literacy rate: the literacy rate taking in account
the total population in denominator
Effective literacy: the literacy rate taking in account
the 7yr and above population in denominator

Life expectancy
Expectation of life at a given age is the average number of years
which a person of that age may expect to live, according to the
mortality pattern prevalent in that country
best Indicator of country development & overall health
Expectation of life at birth World
1950-1955 : 46.5 years (for both sexes)
Five decades lator by 2008:69 years. An increase
Of 22.5yrs
More marked in less developed region
Expectation of life at birth India
Year

Males

Females

Total

1901

23.63

23.96

23.8

2001

63.90

66.90

65.4

Population Explosion
Approximately 95% of population growth is in
developing countries
Currently,1/3 of the world population is under 15yr,
& will soon enter the reproductive bracket, giving
more potential for population growth
The expected number of births per woman, at
current fertility rate is:

Africa

6.1

Asia

3.2

Latin America

3.4

North America

2.0

Europe

1.6

Economic implications: Due to population

explosion there are
Short term pressure affects during 2-3
decade
Long term over next century and
beyond economic affects
Demographic Implications: In population with
low birth and death rate, 20-30% of
population is under 15; 9-13% is 65 or
more. The median age for this population is
32 and there is increased demand for
senior citizen
Environmental / Ecological Implications:
Social / Political Implications

Fertility:

Meant Actual bearing of child

Some demographer prefer to use word natality

A woman married at 15 and living till 45 with her
husband is exposed to risk of pregnancy for 30yrs and
may give births to 15 children,rarely achieved
Factors affecting fertility
1. Age at marriage
2. Duration of married life
3. Spacing of children
4. Education
5. Economic status
6. Caste & religion
7. Nutrition
8. Family planning
9. Others biological, physical, social, cultural, housing, breast feeding,
industrialization, urbanization, health conditions etc.

 Great impact on fertility

Early marriages-before
18yrs: increased births
Age of marriage:
In 1930s:13 years
In 2001: 21years

 Studies indicate that

YEARS AFTER
MARRIAGE

% OF BIRTHS

1-5

10-25 %

5-15

50-55 %

25

very few

So family planning efforts

should concentrated in
first few yrs of married life
to achieve tangible results

Spacing of children
Studies shown that when all births are
postponed by one yr, in each age group
there was decline in total fertility.

 Education is inversely
proportional to
fertility

 economic status is
inversely proportional
to fertility
Economic development
is the best
contraceptive

Total fertility rate

1. Muslims ---3.09
2. Hindus

---2.65

3. Christians ---2.35

 Well fed societylow fertility

Poorly fed societyhigh fertility
The effect of nutrition on
fertility is largely
indirect

Physical, social, and cultural

factors such as

Place of women in society

Opportunities for women and local
community involvement
Value of children in society
Widow remarriage

 Breast feeding
Customs and beliefs
Industrialization and urbanization
Better health conditions

Replacement Level Fertility

When a couple has two births during their reproductive
life, just enough to replace themselves.
Replacement level is considered when there are, on the
average, 2.1 births per woman (TFR), to compensate for
child deaths

Fertility Indicators
a. Original rates
b.1.Crude Birth rate (CBR)
CBR=Live Births x 1000/mid year population
Unsatisfactory measure because total population is not
exposed to child bearing
2.General fertility rate (GFR)

GFR = Live Births x 1000/mid year female pop. (15-49yr)

Better measure than CBR. The major weakness is that not all
women in denominator exposed to the risk of child birth
3.General marital fertility rate (GMFR)
GMFR= Live Births x 1000
mid year married female pop.(15-49yr)

4. Age specific fertility rates (ASFR)

A more precise measure of fertility
Indicator of Fertility pattern & family planning
Live births in specific age group x 1000
Midyear population of women in that age group
5. Age specific marital fertility rate (ASMFR)
Live births in specific age group x 1000
Midyear population of married women in that age group

b. Derived rates
6. Total fertility rate (TFR)
Average number of live births a woman is expected
to undergo during her reproductive life.
TFR = 5 x ASFR
1000
7. Total marital fertility rate (TMFR)
TFR = 5 x ASMFR
1000

8. Gross reproduction rate (GRR)

Average number of girls born to a woman during
her reproductive life, if she experiences the
current fertility pattern throughout the
reproductive life (15-49) assuming no mortality
GRR = 5 x ASFR for female Live Births
1000
GRR = TFR x newborn sex ratio

9. Net reproduction rate (NRR)

Average number of girls born (and survived) to a
woman during her reproductive life, if she
experiences the current fertility pattern throughout
the reproductive life (15-49) and assuming current
mortality pattern

NRR = Number of girls born and survived

Number of the women survived
after the end of reproductive life

c. Related rates and ratios

10. Child-woman ratio
Number of children < 4 yrs of age per 1000 women of
child bearing age.

11. Pregnancy rate

Ratio of no. of pregnancy in a year to married women in
the ages (15 49)

12. Abortion rate

No. of abortions per 1000 women of
child bearing age group.
13. Abortion ratio
No. of abortions performed/ no. of live births
14. Marriage rate
Crude MR = Number of marriages in a yr x 1000
Mid Year Population
General MR = Number of marriages in a yr x 1000
Number of unmarried persons in 1549 age gp.

Exercise-I
In a PHC with a population of 28000,the age wise
break up of women population in reproductive age group
and the live births in these age groups are given below.
Age (yr)

Women population Live births

15-25

1850

140

25-35

3210

352

35-45

1400

72

Calculate:
1.Age specific fertility rates
2.General fertility rate
3.Crude birth rate

Exercise-II
Following are the age specific fertility rates among
reproductive age group women in 1991 and 2001 in a country.
a. Calculate Total Fertility Rate (TFR) for 1991and 2001yr.
b. Whether this country has achieved replacement level fertility
in the year 2001?
Age group
(years)
15-19

ASFR
(1991)
70.1

ASFR
(2001)
58.2

20-24

220.0

188.2

25-29

179.0

165.5

30-34

112.0

98.0

35-39

64.5

52.1

40-44

28.7

18.9

45-49

12.4

6.3

Fertility trends

TFR and CBR in Indian states(2003-04)

Reasons for High Birth Rate in India

universality of marriage
early marriage
early puberty
low standard of living
low rate of literacy
additional customs and habits
absence of family planning
habit

Reasons for declining Death Rate

1.
2.
3.
4.
5.
6.
7.
8.

Absence of natural checks

Mass control of diseases
Advance in medical science
Better health facility
Impact of national programmes
Improvements in food supply
International aid
Development of social
consciousness among masses