Crude rates, Specific rates &

Standardized rates

PhD Research Methodology workshop - 2025

Dr. Muthukumar R
Assistant Professor
Department of Community Medicine

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 Overview

Crude rates
Specific rates
Standardization
• Direct Standardization
• Indirect Standardization

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 Learning objectives

At the end of the session, you should be able to:

• Describe about crude rates with formula
• List the types of specific rates with examples
• Explain the significance of the standardization
• Distinguish between Direct & Indirect Standardization

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 A) Crude Rate

• Simplest health indicator

• Summary measures of occurrences for a given population based on actual no. of
events over a defined period of time.

o Crude birth rate

o Crude death rate

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 1) Crude Birth Rate
It’s the simplest measure of fertility
“The number of live births per 1000 estimated mid year population, in a given year”
CBR = No. of live births in an area in a year x 1000
mid-year population of the area
It’s a measure of population growth and is an index of comparison with other countries.
Advantage – easy to construct
Disadvantage - Does not give a true idea of the fertility of a population

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 2) Crude Death Rate
It’s the simplest measure of mortality.
“The number of deaths (from all causes) per 1000 mid year population in one year, in a given place”
CDR = [Link] deaths in an area during the year x 1000
mid-year population of that area
Measures rate at which deaths occur and used for comparisons.
Advantage – summary measure, easy to calculate
Disadvantage – lack comparability for the communities with populations that differ by age, sex, race

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 B) Specific rates
They are measures of frequency for distinct sub-group within a defined population over a
specified period of time.
Types:
• Cause-specific : TB, accidents, cancer, etc
• Group-specific: age, sex, income, etc
• Period-specific: year, month, week, etc
Lung cancer is more common among males or females? Males
Ovarian cancer is more common among males or females? Question itself is wrong X

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 B) Specific rates
• Can we compare ovarian cancer death rates among 50-59 year old women with that among
60-69 year old women?
• Helps in planning a focussed intervention
• When comparing groups:
o Groups should not have small numbers
o They should represent relatively narrow age group (5-10 years)

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 MCQ - 1
Which of the following is NOT correct about Crude Birth Rate?
A) Numerator is no. of live births in an area in a year
B) It is an index of comparison with other countries
C) Denominator is mid-year population of the area
D) Multiplication factor is 100

ANSWER:
D) Multiplication factor is 100

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 MCQ - 2
Which of the following factor(s) is/are important while comparing specific death rates of 2 groups?
A) Groups should have small numbers
B) Groups should have large numbers
C) Age group interval should be wide
D) Age group interval should be narrow

ANSWER:
B) Groups should have large numbers
D) Age group interval should be narrow

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 How do you interpret this result?
COVID 19 Cases and deaths in June 2021 (Data from Public Health England)
Groups Cases Deaths Death rate
(81,014) (114) (Death /100k cases)
Vaccinated 27,192 70 257 (0.257%) Death rate 3.13 times
Unvaccinated 53,822 44 82 (0.082%) higher in vaccinated
Age > 50 years <50 Crude >50
Groups Cases Deaths COVID death rate
Vaccinated 0.010  0.257 0.907
(8475) (106) (Death /100k cases)
Unvaccinated Both age categories:
0.011  0.082 3.893
Vaccinated 7,499 68 907 (0.907%) Higher in unvaccinated
Unvaccinated 976 38 3893 (3.893%)
106/114 deaths among
Age < 50 years
>50 years age: 4.3 times
Groups Cases Deaths COVID death rate higher in unvaccinated
(72,539) (8) (Death /100k cases)
Vaccinated 19,693 2 10 (0.010%) 11

Unvaccinated 52,846 6 11 (0.011%)

 C) Standardized rate
Why standardized rate required?
A) Issue with crude rate: Comparison of crude mortality or morbidity rates is often biased
Crude rates affected by “confounder”
B) Issue with age specific: Too many strata – cumbersome
Standardized rate  Unbiased meaningful comparison
Standardization:
• Direct
• Indirect

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 1) Direct standardization

• Purpose: To compare age adjusted rates of 2 study populations

• Prerequisite: Age-specific rates in study population which are stable
• By applying the age-specific rates in each of the study population to the age distribution in
the standard population, we get age-adjusted rates
• Compare Age-adjusted rates  a single summary rate that reflects the number of events
that would have taken place if the populations being compared had identical distributions.

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 Steps of Direct standardization
1. Calculate the age-specific mortality rates for each age group in 2 study population
2. Then choose the standard (reference) population
3. Multiply the (age-specific mortality rates of the study population) and (age distribution in
each age group of the standard population)
4. You will get the expected deaths for each age group of population and add them all.
5. Age-adjusted mortality rates obtained by dividing the (total number of expected deaths) by
the (standard population )
6. Now you can conclude by comparing the age-adjusted mortality rates of two populations

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 Direct standardization
Age (years) Population A Population B
Population No. of Age Population No. of Age
Deaths specific Deaths specific
death rate death rate
30-39 1,000 24 0.024 5,000 140 0.028
40-49 4,000 16 0.004 2,000 14 0.007
50-59 6,000 121 0.020 500 10 0.020
All ages 11,000 161 7,500 164

Crude death rate of A = Crude death rate of B =15

161/11,000 = 14.6 per 1000 164/7,500 = 21.6 per 1000
 Making standard population
Population
Age
A B “Standard”
A+B
30-39 1,000 5,000 6,000
40-49 4,000 2,000 6,000
50-59 6,000 500 6,500
All ages 11,000 7,500 18,500

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 Direct Standardization
Age Population Population
A B
“Standard” Age Expected “Standard” Age Expected
Population specific Deaths Population specific Deaths
death rate death rate
30-39 6,000 0.024 144 6,000 0.028 168
40-49 6,000 0.004 24 6,000 0.007 42
50-59 6,500 0.020 130 6,500 0.020 130
All ages 18,500 298 18,500 340

Age adjusted death rate of A = Age adjusted death rate of B =

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298/18,500 = 16.1 per 1000 340/18,500 = 18.3 per 1000
 Direct standardization
Age (years) Population A
Population No. of Age “Standard” Expected
Deaths specific Population Deaths
death rate
30-39 1,000 24 0.024 6,000 144
40-49 4,000 16 0.004 6,000 24
50-59 6,000 121 0.020 6,500 130
All ages 11,000 161 18,500 298

Crude death rate of A = 161/11,000 = Age adjusted death rate of A = 18

14.6 per 1000 298/18,500 = 16.1 per 1000
 Direct Standardization
Age Population Population Comparison parameter
A B
Crude death 161/11,000 = 164/7,500 = Ratio of crude rate =
rate 14.6 per 1,000 21.6 per 1000 (CDR of B) / (CDR of A)
= (21.6 per 1000) / (14.6 per 1,000) = 1.47

Age adjusted 298/18,500 = 340/18,500 = Comparative Mortality Ratio =

death rate 16.1 per 1,000 18.3 per 1000 (Adjusted rate of B) / (Adjusted rate of A)
= (18.3 per 1000) / (16.1 per 1,000) = 1.14

Interpret: Comparative Mortality Ratio of B = 1.14

Age-adjusted mortality rate of B is 14% higher than A
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 2) Indirect standardization
This method is used when
a) Age-Specific death rate of the population is not known
b) Age-Specific death rate of the population is unstable
Purpose: To assess whether the observed outcome in a study population is more or less than
the expected based on a reference population

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 Steps of Indirect standardization

• The age-specific rates of disease from a standard population is applied to observed age
distribution of the study population.
• This gives us the expected no of deaths in the population if they had the same rates of
disease as the standard population.
• We then calculate Standardized Mortality Ratio to compare the populations.

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 Indirect Standardization
Age Population Population
A B
Population No. of Deaths Standard No. of Deaths
Population
30-39 1,000 12 4,000 85
40-49 2,000 20 250 Not available
50-59 3,000 91 750 Not available
All ages 6,000 123 5,000 95

Crude death rate of A = Crude death rate of B = 22

123/6,000 = 20.5 per 1000 95/5,000 = 19.0 per 1000
 Indirect Standardization
Age Reference Study
Population A Population B

Population No. of Age Population Specific Expected

Deaths specific rate from Deaths
death rate reference
30-39 1,000 12 0.012 4,000 0.012 48.0
40-49 2,000 20 0.010 250 0.010 2.5
50-59 3,000 91 0.030 750 0.030 22.5
All ages 6,000 123 5,000 73.0

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 Indirect Standardization
Age Population Population Comparison parameter
A B
Crude death CDR = CDR = Ratio of crude death rate =
rate 123/6,000 = 95/5,000 = (CDR of B) / (CDR of A) =
20.5 per 1000 19.0 per 1000 (19.0 per 1000) / (20.5 per 1,000) = 0.93

No. observed 123 95 SMR (Standardized Mortality Ratio) =

death (No. observed death in B /
No. expected 73 No. expected death in B)
death 95/73 = 1.30

Interpret: Standardized Mortality Ratio of B = 1.30

Observed death of B is 30% higher than expected death
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 Interpretation of results for indirect standardization
Before standardization After standardization
(with age’s confounding effect) (without age’s confounding effect)

Ratio of crude death rate = 0.93 Standardized Mortality Ratio of 1.3

Crude death rate (B) / No. of observed death in B/ Age under-estimated the
Crude death rate (A) No. of expected death in B death rate of Population B
(Negative confounder)

Crude death rate of population B is Observed death rate is

0.93 times or 7% lower than 1.3 times or 30% higher than
Crude death rate of A expected rate in study population B

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 Interpretation of results for direct standardization
Before standardization After standardization
(with age’s confounding effect) (without age’s confounding effect)

Ratio of crude death rate = 1.47 Comparative Mortality Ratio = 1.14

Crude death rate (B) / (Age adjusted death rate of B) / Age over-estimated the
Crude death rate (A) (Age adjusted death rate of A) death rate of Population B
(Positive confounder)

Crude death rate of population B is Age adjusted death rate of B is 1.14

1.47 times or 47% higher than times or 14% higher than Age
Crude death rate of A adjusted death rate of A

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 Summary: Crude & Specific Rates
Rate Advantages Disadvantages

Crude Easy to calculate Magnitude affected by Confounder

Overall summary measure Comparison is often difficult, biased
Specific Unbiased comparison Difficult to compare if more strata
Not representative of overall measure

Adjusted Overall summary measure Hypothetical measure based on study population

Unbiased comparison Difficult to perform

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Summary: Direct & Indirect Standardization

DIRECT STANDARDIZATION
Ratio of Crude (CDR of B) /
death rate (CDR of A)
Comparative (Adjusted rate of B) /
Mortality Ratio (Adjusted rate of A)

INDIRECT STANDARDIZATION
Ratio of Crude (CDR of B) /
death rate (CDR of A)
Standardized SMR = Observed28
Mortality Rate death / Expected death
Summary: Confounding status after standardization

Relation between 2 rates Confounding status

Crude rate > Adjusted rate Positive confounder
(over-estimation)
Crude rate < Adjusted rate Negative confounder
(under-estimation)
Crude rate = Adjusted rate No confounding effect

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 MCQ - 3
What is the interpretation of Standardized Mortality Ratio (SMR) value of 0.8?
A) Observed death rate is 20% higher than the expected rate
B) Observed death rate is 20% lower than the expected rate
C) Expected death rate is 20% higher than the observed rate
D) Expected death rate is 20% lower than the observed rate

ANSWER:
 Recommended
B) Observed death rate is 20% lower than the expected rate
C) Expected death rate is 20% higher than the observed rate
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 MCQ - 4
What is the final step of direct standardization?
A) Comparing the age-specific mortality rates of two populations
B) Estimating the standardized mortality ratio
C) Comparing the age-adjusted mortality rates of two populations
D) Estimating the expected no of deaths in the population

ANSWER :
C) Comparing the age-adjusted mortality rates of two populations

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 Further reading
Textbooks Sources of health indicators

• Gordis Epidemiology 6th edition MOHFW, India

• Epidemiology in medicine by Hennekens National Family Health Survey – 5
• Oxford textbook of Global Public health SRS Bulletin
World Bank data
Sources of standardized population data

• WHO World Standard Population

• European standard population

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Any questions?

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