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Combining risk factors and demographic surveillance: potentials of WHO STEPS and INDEPTH methodologies for assessing epidemiological transition.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.ORCID iD: 0000-0003-0556-1483
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2006 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 34, no 2, 199-208 p.Article in journal (Refereed) Published
Abstract [en]

AIMS: Demographic surveillance systems (DSSs) create platforms to monitor population dynamics. This paper discusses the potential of combining the WHO STEPwise approach to Surveillance (STEPS) within ongoing DSSs, to assess changes in non-communicable disease (NCD) risk factors. METHODS: Three DSSs in Ethiopia, Vietnam, and Indonesia have collected NCD risk factors using WHO STEPS, focusing on self-reported lifestyle risk factors (Step 1) and measurement of blood pressure and anthropometric parameters (Step 2). RESULTS: DSSs provide sampling frames for NCD risk factor surveillance, which reveals the distribution of risk factors and their dynamics at the population level. The WHO STEPS approach with its add-on modules is feasible and adaptable in DSS settings. Available mortality data in the DSSs enable mortality assessment by cause of death using verbal autopsy, which is relevant in estimating the impact of NCDs. DSSs as well as risk factor surveillance data may potentially be a lever for hypothesis-driven research to address specific a priori hypotheses or research questions. CONCLUSION: Combining DSSs with the WHO STEPS approach can potentially address basic epidemiological questions on NCDs, which can be used as a powerful advocacy tool in public health decision-making for NCD prevention.

Place, publisher, year, edition, pages
2006. Vol. 34, no 2, 199-208 p.
Keyword [en]
Adult, Chronic Disease/*epidemiology, Developing Countries/statistics & numerical data, Ethiopia/epidemiology, Female, Humans, Indonesia/epidemiology, Life Style, Male, Middle Aged, Population Surveillance/methods, Risk Factors, Vietnam/epidemiology, World Health
Identifiers
URN: urn:nbn:se:umu:diva-16189DOI: 10.1080/14034940500204506PubMedID: 16581713OAI: oai:DiVA.org:umu-16189DiVA: diva2:155862
Available from: 2008-01-11 Created: 2008-01-11 Last updated: 2017-10-12Bibliographically approved
In thesis
1. Chronic disease risk factors in a transitional country: the case of rural Indonesia
Open this publication in new window or tab >>Chronic disease risk factors in a transitional country: the case of rural Indonesia
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The epidemic of chronic diseases is largely neglected. Although a threatening burden of chronic diseases is emerging, developing public health efforts for their prevention and control is not yet a priority for trans-national and national health policy makers. Understanding the population burden of risk factors which predict chronic diseases is an important step in reducing the impact of the diseases themselves.

Objective: This thesis responds to the increasing burden of chronic diseases worldwide, and aims to illustrate the gap in chronic disease risk factor research in developing countries. The thesis describes and analyses the distribution of chronic disease risk factors in a rural setting in Indonesia. It also describes how smoking, one of the most common risk factors, is viewed by rural Javanese boys. Ultimately, therefore, this thesis aims to contribute to policy and programme recommendations for community interventions in a rural setting in Indonesia

Methods: The studies were conducted in Purworejo District, where a Demographic Surveillance System (DSS) has been running since 1994. The Purworejo DSS is part of the INDEPTH network (International Network of field sites for continuous Demographic Evaluation of Populations and Their Health in developing countries). Two representative cross-sectional studies (in 2001 and 2005) were conducted to assess the chronic disease risk factors (including smoking, elevated blood pressure, and overweight and obesity). The first cross-sectional study was followed up in 2002 and 2004. In each study, a total of 3 250 participants (approximately 250 individuals in each sex and age group among 15–74 year olds stratified into 10-year intervals) were randomly selected from the surveillance database from each enumeration area in the surveillance area. Instruments were adopted from the WHO STEPS survey and adapted to local setting. Since many Indonesians start to smoke at an earlier age, a qualitative study using a focus group discussion approach was conducted among school boys aged 13-17 years old to describe and explore beliefs, norms, and values about smoking in a rural setting in Java.

Result: Both the rural and urban populations in Purworejo face an unequal distribution of risk factors for chronic diseases. The burden among the most well-off group in the rural area has already reached a level similar to that found in the urban area. Most of the risk factors increased in all age, sex and socioeconomic groups during the period of 2001 to 2005. However, women and the poorest group experienced the greatest increase in risk factor prevalence. The qualitative study showed that cultural resistance against women smoking in Indonesia remains strong. Smoking is being viewed as a culturally internalised habit that signifies transition into maturity and adulthood for boys. Smoking is utilised as a means for socialisation and signifies better socioeconomic status. The use of tobacco in the construction of masculinity underlines the importance of gender specific interventions. National tobacco control policy should emphasise a smoking free society as the norm, especially among boys and men, and regulations regarding the banning of smoking should be enforced at all levels and areas of the community.

Within the demographic surveillance setting, it is possible to assess the population and health dynamics. Utilisation of a standardised methodology across sites in INDEPTH will produce comparable population-based data in developing countries. Such comparisons are important in global health. A comparison of smoking transition patterns between a Vietnamese DSS and an Indonesian DSS shows that Indonesian men started smoking regularly earlier and ceased less than Vietnamese men. Compared with Vietnam, which has already signed and ratified the Framework Convention on Tobacco Control, tobacco control activities in Indonesia are still deficient.

Conclusion: The thesis concludes that the rural population is not spared from the emerging burden of chronic disease risk factors. The patterning of risks across different socioeconomic groups provides a macro picture of the vicious cycle between poverty and chronic diseases. Understanding of risk factors in a local context through a qualitative study provides insight into cultural aspects relating to risk factor adoption, and will allow the fostering and tailoring of culturally appropriate interventions. Combining data from demographic surveillance sites with the WHO STEP approach to chronic disease risk factor Surveillance addresses basic epidemiological questions on chronic diseases. The use of such data is a powerful advocacy tool in public health decision-making for chronic disease prevention in developing countries. With substantial existing evidence on the effectiveness of chronic disease prevention and intervention programmes, it is vital that Indonesia to starts planning intervention programmes to control the impending chronic disease epidemic, and most importantly, to translate all this evidence into public health action.

Keywords: chronic disease, risk factor, demographic surveillance system, smoking, elevated blood pressure, overweight and obesity, population-based intervention

Place, publisher, year, edition, pages
Umeå: Folkhälsa och klinisk medicin, 2006. 155 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1017
Keyword
Chronic disease, risk factor, demographic surveillance system, smoking, elevated blood pressure, overweight and obesity, population-based intervention
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-775 (URN)91-7264-048-0 (ISBN)
Public defence
2006-05-19, 135, 9 B, Norrlands universitetssjukhus, 901 85 Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2006-04-26 Created: 2006-04-26 Last updated: 2015-04-29Bibliographically approved
2. Epidemiology of cardiovascular disease in rural Vietnam
Open this publication in new window or tab >>Epidemiology of cardiovascular disease in rural Vietnam
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In the context of transitional Vietnam, although cardiovascular disease (CVD) has been shown to cause a large burden of mortality and morbidity in hospitals, little is known about the magnitude of its burden, risk factor levels and its relationship with socio-demographic status in the overall population. This thesis provides a preliminary insight into population-based knowledge of the CVD epidemiology in rural Vietnam and contributes to the development of methodologies for monitoring it. The ultimate goal of the work is to facilitate the formulation of evidence-based health interventions for reducing the burden of the CVD epidemic in Vietnam and elsewhere.

This work was located in Bavi district, a rural community in the north of Vietnam. Studies on cause-specific mortality and risk factors were conducted within the framework of an ongoing Demographic Surveillance System (DSS) (called FilaBavi). The cause-specific mortality study used a verbal autopsy (VA) approach to identify causes of death in FilaBavi during 1999-2003. The risk factor study, conducted in 2002, employed the WHO STEPwise approach to surveillance of non-communicable disease (NCD) risk factors (WHO STEPS).

Findings indicated that Bavi district, as an example of rural Vietnam, was already experiencing high rates of CVD mortality and associated risk factors. Mortality results indicated a substantial proportion of deaths due to CVD, which was the leading cause of death (20% and 25.7% of total mortality in 1999 and 2000, respectively and 32% of adult deaths during 1999-2003), exceeding infectious diseases. Hypertension was found to be a serious problem in terms both of its magnitude (14% of the population) and widespread unawareness (82% of the hypertensives). Smoking prevalence was very high among men (58% current daily smokers) and might be expected to cause a considerable number of future deaths without urgent action. CVD mortality and some risk factors seemed to be rising among disadvantaged groups (women, less educated people and the poor). The combination of DSS and WHO STEPS methodologies was shown to have potential for addressing basic epidemiological questions as to how NCD and CVD mortality and associated risk factors are distributed in populations.

Given this evidence, actions to prevent CVD in Bavi and similar settings are clearly urgent. Interventions should be comprehensive and integrated, including both primary and secondary approaches, as well as policy-level involvement. Further studies, continuing on similar lines, plus qualitative approaches and deeper cross-site comparisons, are also needed to give further insights into CVD epidemiology in this type of setting.

Place, publisher, year, edition, pages
Umeå: Folkhälsa och klinisk medicin, 2006. 74 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1018
Keyword
Cardiovascular disease, epidemiology, risk factors, rural Vietnam
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-779 (URN)91-7264-049-9 (ISBN)
Public defence
2006-05-19, Sal 135, 9B, Allmänmedicin, Norrlands Universitetssjukhus, 901 85 Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2006-04-28 Created: 2006-04-28 Last updated: 2009-10-20Bibliographically approved

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