october 2006, cairo, egypt the who stepwise approach to chronic disease risk factor surveillance...

October 2006, Cairo, Egypt

The WHO STEPwise approach to The WHO STEPwise approach to chronic disease risk factor chronic disease risk factor

surveillance surveillance

Overview in EMR Overview in EMR



Introduction

Worldwide, NCD are major causes of disability and premature deaths

Currently in EMR, 45% of disease burden is attributed to NCD and will rise to 60% by 2020

This global and regional epidemic is attributed to population aging and high prevalence and exposure to NCD risk factors RF

Modifiable RF include: smoking, physical inactivity, low vegetables and fruit diet, diabetes, obesity, and high lipid profiles.

WHO’s efforts is primarily directed to prevention and control of NCD RF.


Challenges for surveillance in EMR

Lack of national NCD & RF surveillance systems

Inadequate national capacity in surveillance & methodologies in both low & middle income countries

Lack of reporting chronic diseases attributes (risk factors, morbidity and mortality) in the annual health reporting systems

No link of mortality data to NCD prevention and control


　 EMR% (N=15)

Tobacco use 40

Unhealthy diet 40

Physical inactivity 46.6

Alcohol consumption 6.6

Diabetes 46.6

Hypertension 53.3

Overweight and obesity 40

Heart diseases 20

Stroke 13.3

Cancer 40

Chronic respiratory diseases 20

Percentage of countries reported Percentage of countries reported covering NCD in their surveillance covering NCD in their surveillance

system system


Progress: percentage of countries reported having routine NCD surveillance system in EMR

42.950

0102030405060708090

100

Per

cent

age

(%)

2000 - 2001 2005 - 2006

Note: One country is excluded for best comparability between the 2 surveys


　 EMR% (N=15)

Health information system covering chronic diseases and major risk factors 60.0

Inclusion of chronic diseases in the annual health report system 73.3

Data included in the annual health report system

Cause-specific mortality 26.6

Cause-specific mortality/morbidity 13.3

Risk factors/cause-specific mortality /morbidity 13.3

Routine or regular surveillance system 53.3

Percentage of countries reported having Percentage of countries reported having annual health reporting system and annual health reporting system and

surveillance system for NCDsurveillance system for NCD


Objectives of workshopObjectives of workshop

To upgrade capacity to manage, analyse, interpret and report through: Training on data entry, verification, checking and

cleaning Sample design issues Descriptive and analytic statistics Weighting and clustering Skills in interpreting data (e.g confidence intervals) Standardization of reporting Keeping STEPS sustainability (interest, commitment and

political support)


Focus

Situation of Stepwise approach to NCD RF in Situation of Stepwise approach to NCD RF in EMR (Implementation & reporting )EMR (Implementation & reporting )

Sampling issuesSampling issues Remarks regarding:Remarks regarding:

MethodologyMethodology Documentation / Data presentationDocumentation / Data presentation Comparability of dataComparability of data Generalization and applicabilityGeneralization and applicability

DM as an exampleDM as an example


ImplementationImplementation & & reportingreporting in in EMREMR : :

54.54

36.4

0

10

20

30

40

50

60

70

80

90

100

Implemented Results reported

Per

cen

tag

e (%

)

Implemented: 12 out of 22 countriesImplemented: 12 out of 22 countriesReported results: 8 out of 22 countriesReported results: 8 out of 22 countries


STEPS Implementation Results documentation

Afghanistan No

Bahrain No

Djibouti No

Egypt √ Yes

Iraq √ Yes

Iran √ Yes

Jordan √ Yes

Kuwait √ Not yet

Lebanon √ Yes

Libya No

Morocco No

Oman √ Not yet

Pakistan √ Yes

Palestine No

Qatar No

Saudi Arabia √ Yes

Somalia No

Sudan √ Not yet

Syrian Arab Republic √ Yes

Tunisia √ Not yet

United Arab Emirates No

Yemen No

STEPS in EMR countries


Implementation issues of 8 EMR countries according to STEPS reporting

Year Age range

Egypt 2005 15 - 65

Iraq 2003 - 2004 25 - 64

Iran 2005 25 - 64

Jordan 2004 18 +

Pakistan * 18 - 65

Saudi Arabia 2005 15 - 64

Lebanon * 25 +

Syrian Arab Republic 2003 - 2004 15 - 64

** Not mentioned


Sampling issues of 8 EMR countries according to STEPS reporting

Probability Design Sampling frame National

Egypt √ * Population Census Yes

Iraq √ * Duhok Governorate census Sub-national

Iran √ * Iranian National Databank Yes

Jordan √ * Population Census Yes

Pakistan √ *Rawalpindi District (1998

census) Sub-national

Saudi Arabia √ * Population Census Yes

Lebanon No Convenient - Yes

Syrian Arab Republic √ * Population Census Yes


Sample size Response rate %

STEP I & II STEP III STEP I & II

Egypt 10000 2500 97.8

Iraq 1000 1000 -

Iran 89000 70961 -

Jordan 3520 880 -

Pakistan 2040 Not conducted -

Saudi Arabia 5000 5000 98.18

Lebanon 3000 500 not applicable

Syrian Arab Republic 10020 5000 91.7

Sample size and response rate


Remarks in methodology:

Inclusion criteria of target population except for age Phases of the study and time intervals Sample size:

Basis of determination Non-response rate in prevalence studies (at different levels)

Sample design: Multi-stage cluster sample with stratification Basis of stratification was not clear Clusters, sampling units (primary) or enumeration areas EA

were selected in PPS Households units (individuals, or legible family members)

were selected in a systematic way in some countries (e.g Jordan and Pakistan)

Tools and instruments: Generic or modified, version Variable lists, codes, values


No specific format for documentation /data presentation

Summary was there, far away from fact sheet Sequence of results, Step I, II, III Tabulations was not ideal sometime invalid

Numbers & % Row, column %, Confidence intervals (small numbers) ,

Totals

Remarks in documentation and data presentation:


Table ( ) Prevalence of Diabetes in some EMR countries according to STEPS survey results

Prevalence of DM in some EMR countries according to STEPS results

Country DM (♂) DM (♀) DM (all)

Year Age Cur-off level / units% (95%CI), or number

Syria 2003 15-64 >110+ mg% 22.9 (1784) 18 (2958) 19.9 (4742)

SA 2005 15-64 >=7 mmoL 19.2 (2152) 16.6 (2237) 17.9 (4389)

Iraq2003-2004 25-64 >125+ mg%

11.8 (3.6 - 20)(59)

15.2 (7.1 – 23.3) (76)

13.5 (7.7 – 19.3) (135)

Iran 2005 25-64 >125+ mg% 5.6 (25320) 6.1 (27345) 5.9 (52665)

Lebanon ? 25+ >125+ mg% 8.35 (?) 9.5 (?) 9 (500)

Egypt 2005 15-65 >=7 mmoL 6.2 (4.8 – 7.6) 8.2 ( 6.6 – 9.8) 7.2 ( 6.1 – 8.3)

Jordan 2004 18+ >=7 mmoL 11 (229) 13 (476) 12.5 (705)

Pakistan ? 18-65 Step 3 was not

conducted (history) 4.76 (841) 5.44 (1177) 5.15 (2018)


Comparability and generalization

Clinical vs subcinical diabetes Age categories are not the same; prevalence

increases with age Cut-off points for diagnosing diabetes were

not standardized. Sample size is too small to generalize (Iraq) National vs sub-national. Although sample size was

relatively large in Pakistan study , yet sub-national. In Iraq sample

size was too small and study sub-national to be representative.


Conclusions

KI interview with NCD focal points after the GS for assessing national capacity for NCD showed the ultimate need for technical support in chronic diseases and risk factor surveillance by both low & middle income countries in EMR

Appropriate sampling is crucial for reliable and valid survey results

Standardized methodologies, tools, instruments could yield reliable and comparable estimates nationally and regionally

A good surveillance and survey system covering NCDs and related risk factors without question is still a key investment shaping the evidence-based decision making in NCD prevention and control

october 2006, cairo, egypt the who stepwise approach to chronic disease risk factor surveillance...

Documents

ncd slide

egypt slide

egypt emr

surveillance system

egypt implementation

ncd prevention

control of ncd

control slide