key: cord-0316112-ey7vxbev authors: Sharma, D.; Kiran, T.; Junaid, K.; Rajagopal, V.; Sharma, S. title: Comprehensive assessment of Age-Specific Mortality Rate and its incremental changes using a composite measure: A sub-national analysis of rural Indian women date: 2022-04-28 journal: nan DOI: 10.1101/2022.04.25.22274281 sha: b98b889c06094c019b5168987c9ca0ff8516be0f doc_id: 316112 cord_uid: ey7vxbev Abstract Background- Diverse socio-economic and cultural issues contribute to adverse health outcomes and increased mortality rates among rural Indian women across different age categories. The present study aims to comprehensively assess age-specific mortality rates and their temporal trends using a composite measure at the sub-national level for rural Indian females to capture cross-state differences. Methods- A total of 19 states were included in the study to construct a composite age-specific mortality index for 2011 (base year) and 2018 (reference year) and examine the incremental changes in the index values across these years at the sub-national level in India. Sub-index values were calculated for each component age group and were subsequently used to compute the composite ASMR index using the geometric mean method. Based on the incremental changes, the performance of states was categorized into four different typologies. Results- Improvement in mortality index scores in the 0-4 years age group was documented for all states. The mortality rates for the 60+ age group were recorded to be high for all states. Kerela emerged as the overall top performer in terms of mortality index scores, while Bihar and Jharkhand were at the bottom of the mortality index table. The overall mortality composite score has shown minor improvement from base year to reference year at all India level. Conclusions- An overall reduction in the mortality rates of rural Indian women has been observed over the years in India. The success of public health interventions to reduce the under-five mortality rate is evident as the female rural mortality rates have reduced sizably for all states. Nevertheless, there is still sizable scope for reducing mortality rates for other component age groups. Additionally, there is a need to divert attention toward the female geriatric (60+ years) population as the mortality rates are still high. Nearly 65% of the Indians predominantly reside in rural areas [1] , and half of them fall below the Programme (UNDP) [24, 29] 168 The index scores range from 0-to 100 for each indicator. A higher index score 169 (closer to 100) indicates a lower ASMR value, and a lower index score (closer to 170 zero) indicates a higher ASMR value. improved' (> 6 points increase). The categorization was done using the percentile method 178 (P 20 and P 40 determining cut off points for least improved and moderately improved, 179 respectively) and is based on the approach followed by the National Institution for 180 Transforming India (NITI Aayog-the apex public policy 'think tank' of the Government of 181 India) for categorizing health index scores. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 the highest variation in the 5-14 years age group and lowest variation in the 60+ years age group. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Age-specific Mortality Index scores of component age groups and its comparison between 211 the base year and reference year for rural Indian women 212 The study computed sub-indices for mortality with regard to each component age group and In the age group 5-14 years, the index scores of states were relatively higher than other component 225 age groups. However, there was a decline in the mortality index score for states that registered 226 high index values in the base year. Fourteen states reported an increase in the mortality score in 227 the reference year for this particular age group. A remarkable improvement was seen in 228 Chhattisgarh (13.8) and Odisha (10.8) (Fig. 1) . Meanwhile, Himachal Pradesh (-3.1), Jammu & 229 Kashmir (-3.1), Karnataka (-1.6), and Maharashtra (-1.6) recorded negative changes in the 230 mortality scores. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101/2022.04.25.22274281 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. Kashmir recorded the highest improvement (13.9) in this age group. It was followed by Odisha 252 (9.6) and Gujarat (9.0) (Fig. 1) . In contrast, Bihar (-27.5), Chhattisgarh (-16.0), and Tamil Nadu 253 (-6.1) documented notable negative changes in the mortality index values for this age group. At 254 all India level, the mortality scores sizably increased for both 0-4 (4.5) and 5-14 years age groups 255 (4.5), whereas it slightly improved and decreased for 15-59 (1.6) and 60+ (-0.8) age groups, 256 respectively for rural women. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101/2022.04.25.22274281 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. the reference year (Fig. 3) (S2 and S3 map) . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. The study computed mortality index scores for four major component age groups and a composite 302 Age-specific mortality index for rural Indian women at the sub-national and national levels. Rural 303 Indian women face several difficulties due to gender disparity and discrimination. Issues 304 concerning lack of educational opportunities, financial inclusion, proper medical care, hygiene, 305 and sanitation are widespread in rural areas and are encountered more by women than men [14, 15] . Incremental changes in the index scores from the base to reference years have also been calculated. Based on the incremental changes, the performance of states was categorized into four levels for 308 each component age group. Out of the four age groups, the highest mean death rate was observed for the 60+ age group, while 310 the lowest was for 5-14 years. The increase in mortality with age can be attributed to many factors. Irrespective of gender, the possibility of getting a chronic disease and disability increases with age, 312 immunity, and strength also dwindle gradually, thus making the elderly more vulnerable to health 313 problems and increasing the risk of mortality [31] [32] [33] . Further, studies on treatment-seeking 314 behaviour in India revealed that the large majority of the elderly rural Indian population has unmet 315 healthcare needs, thereby further substantiating the high mean death rates for elderly females as 316 revealed by the present study [34] . Most deaths in the age group 5-14 years generally result from 317 communicable diseases. However, a rapid decline in mortality due to infectious diseases in this 318 age group has contributed to lower death rates [35] . Further, a study revealed that females have 319 better survivorship in the under-five age group in India [36]. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10. 1101 /2022 Looking at the sub-national level, the state of Madhya Pradesh documented the highest mean death 321 rates among the states in the age groups 0-4 and 5-14 years, which can be attributed to women's 322 low literacy and the common practice of child marriage, especially in the rural areas of this state. The state is among the backward states and trails behind the rest of India with regard to the CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 determinants contributing to increased life expectancy include better healthcare delivery services, 343 improved health infrastructure, development of supply chain mechanisms, and quality medical 344 education in the state [45, 46] . The study calculated the sub-indices for all component age groups. The index scores for 0-4 years 346 of all states increased from base year to reference year. It indicates that the mortality rates for the is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 allopathic doctors at the Primary Healthcare Centres (PHCs) has also increased significantly [12] . To add to it, it is a front runner in female literacy rates [53] and maternal education in India [54] . In context to the present study results, Kerela registered high mortality index scores, but the 368 incremental change from base to reference year for each age group has been negligible [50] . The Kerela has remained at the top of its game, thereby emerging as the best-performing state in terms 415 of overall rural female mortality scores in both the base and reference years. The probable reasons 416 for this consistent performance have already been discussed earlier in this study. Additionally, the 417 overall mortality composite score has shown minor improvement from base year to reference year 418 at all India level. It indicates that there is still room for improvement as the composite score 419 achieved by India (83.6.) in the reference year is still noticeable points away from the maximum 420 potential (100) achievable. The current study faces a few limitations. Due to the non-availability of data for all states, 19 out 422 of 28 states were included in the study, leaving the scope for future studies to be conducted 423 incorporating the left-over states as and when the data is made available by the Indian government. Since the data on age-specific mortality groups (0-4, 5-14, 15-59, 60+) from 1971 to 2001 was 425 disaggregated into various small age groups (5-9, 10-14, 15-19, etc.) , the average values of the 426 death rates were taken to concise them into four major component age groups to identify the 427 threshold values for data normalization. Therefore, these threshold values for specific component 428 age groups need to be used with caution in similar future research work. Nevertheless, the present study has some strengths to offer. The 'composite Age-specific Mortality 430 Index' is a pioneer endeavor to comprehensively quantify the mortality levels pertaining to rural 431 Indian women at the sub-national level. The scope of usage of this unique 'composite index' is vast 432 as it provides concise information from the complex and extensive data, which is more convenient . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 to communicate and report for policy plans. The index summarizes the overall performances of 434 the states and performances specific to component age groups, thus highlighting those age groups 435 which need attention from the policymakers and the government. This will facilitate the reduction 436 in mortality rates of rural Indian women at the national level as well. Further, the study has 437 categorized the Indian states into different typologies (not improved, least/moderately/highly 438 improved) based on their temporal performance from base to reference year. It will facilitate the 439 laggard states to initiate customized policies/interventions to follow the performance trajectory of Robust policies and interventions should be developed at the state level to identify and address the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 of Action. 2021. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101/2022.04.25.22274281 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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