NCD surveillance in LMIC Melanie Cowan, Technical Officer Surveillance and Population-based Prevention Unit Dept. of Chronic Diseases and Health Promotion

NCD Surveillance at WHO STEPS GSHS NCD Country Capacity Survey (CCS) Assessment of national level capacity to respond to NCD's in all WHO Member States 3rd round of data collection in 2010; previous surveys in 2000 & 2005 Inclusion of results in 2010 progress report on the global status of prevention and control of NCDs

The STEPwise Approach to Chronic Disease Risk Factor Surveillance (STEPS)

What is STEPS? "The WHO STEPwise approach to chronic disease risk factor surveillance provides an entry point for low and middle income countries to get started on chronic disease surveillance activities. It is also designed to help countries build and strengthen their capacity to conduct surveillance."

Objectives Empower Member States to gather information on chronic disease risk factors for use in planning health programmes and interventions. Provide standardized questionnaire that allows for comparisons, but is flexible to meet Member States' needs. Build capacity in Member States in all aspects of national survey implementation; in particular, develop skills in sample design, data collection and data analysis.

# in field / data entry or analysis work Current Activity # planning # in field / data entry or analysis work # reporting completed Total # active # trained but inactive # with 1 or more repeats AFRO 10 18 15 43 (3) 7 AMRO 13 8 1 22 EMRO 2 9 (1) EURO (0) SEARO WPRO 3 11 25 120

Questionnaire Overview Different levels of risk factor assessment: STEP 1 – questionnaire STEP 2 – physical measurements STEP 3 – blood samples Three modules per Step: Core Expanded Optional

Questionnaire Overview, cont. Behavioural Risk Factors Tobacco use Harmful alcohol consumption Unhealthy diet (low fruit and vegetable consumption) Physical inactivity Biological Risk Factors Overweight and obesity Raised blood pressure Raised blood glucose Abnormal blood lipids Optional Modules on Injury and Violence, Oral Health, Sexual Health

*(Personal Digital Assistant) STEPS Methodology Targets a nationally representative sample of adults aged 25 – 64. STEP 1 (questionnaire) and STEP 2 (physical measures) are conducted in the household by trained interviewers. STEP 3 (biochemical measures) is typically clinic-based. Pocket PCs (PDAs*) are used for data collection: "eSTEPS" Repeat survey should be done every 3 - 5 years. *(Personal Digital Assistant)

eSTEPS Features / Benefits Improves quality of data collection with … automated Kish Method pre-defined skips automatic range checks immediate error checking Fewer materials for data collectors to carry No data entry needed Multiple languages supported English, French, Spanish, Arabic, Khmer, Georgian, Russian … PDAs can be charged where power is unreliable by AA battery (cheap) or solar-power (expensive). SD (external memory) cards provide data security in the event of PDA malfunction.

STEPS Methodology: The Surveillance Loop Recognize need for data on chronic disease risk factors STEPS Implementation Workshop Begin STEPS Planning STEPS Data Collection Workshop Conduct STEPS Implement Interventions Report Results STEPS Data Analysis & Reporting Workshop Data to Action Workshop

Training: Survey Implementation Scope of survey Identification of necessary resources Questionnaire design Sample design Data collection logistics Draft Survey Proposal

Training: Data Collection PDA Basics Locating and approaching households Kish Method Informed consent Interview skills Taking physical measurements Taking biochemical measurements Pilot Test

Training: Analysis & Reporting Weighting data Mapping data to generic STEPS Instrument (as needed) Epi Info Analysis training Half-day hands-on introduction Running provided analysis code for descriptive analysis Creation of STEPS Fact Sheet and Data Book (standardized reporting documents) Begin draft of report and discuss dissemination plan

Training: Data to Action Using STEPS survey results: Propose development of new programmes / services or elaboration of existing ones to address key findings of survey DPAS (Global Strategy on Diet and Physical Activity for Health) documents provide guidelines Inter-Ministry collaboration

Support Materials STEPS Manual Sampling Tools survey implementation plan template suggested timelines training guides for data collection and data entry staff data collection forms (e.g. participant information sheets, interview tracking forms) Generic STEPS Instrument Sampling Tools "STEPS Sampling Workbook" "STEPS sample size calculator"

Support Materials: Sampling Workbook

Support Materials: Sample Size Calculator

Support Materials: eSTEPS Software Questionnaire Designer Create (edit) Questionnaire on PC and transfer to PDA eSTEPS Pocket PC (PDA) Data entry Import data from PDA to PC eSTEPS Manager

Support Materials: eSTEPS Guides Installation Guide Reviews PDA requirements Provides step-by-step installation instructions for: all prerequisite software the 3 eSTEPS components User Manual Provides detailed instructions for: how to use each eSTEPS component how to manage the survey data and create the final dataset WHO provides assistance with the creation of the questionnaire for the PDA and provides ongoing support via phone and e-mail during data collection.

Support Materials, cont. Data Analysis & Reporting Tools Epi Info and SPSS analysis programs (Stata coming soon) standardized fact sheet and data book survey report template

Support Materials: Analysis Help From generic STEPS Questionnaire From Fact Sheet Analysis Guide From Fact Sheet Analysis Guide

Support Materials: Analysis Help, Cont. From STEPS Generic Instrument From Data Book Template Data Book ex. page

Support Materials: STEPS website http://www.who.int/chp/steps

Global School-based Student Health Survey (GSHS)

GSHS: Overview & Objectives System for surveillance of behavioural risk factors and protective factors in school-aged children Help countries develop priorities, establish programmes, and advocate for resources Establish trends in the prevalence of health behaviors and protective factors by country Allow countries and international agencies to make comparisons across countries

GSHS: Methods Self-administered questionnaire and generic answer sheet Targets grades with students aged 13 – 15 years Completed by students during one classroom period Anonymous and confidential 10 Question Modules are available, from which countries can select a minimum of 6: Alcohol, diet, drugs, hygiene, mental health, physical activity, protective factors, sexual behaviours, tobacco, violence & injury

GSHS: Training Analysis & Reporting Survey Implementation Workshop Sampling Survey administration Questionnaire Analysis & Reporting Workshop Epi Info training Analysis of data Report writing Data Application and Program Planning Workshop Policies Programmes Other interventions Conduct GSHS Report Data Repeat GSHS Implement School Health and Youth Health Programmes

GSHS: Current Implementation Worldwide, 104 countries across all six WHO regions have been trained and 60 have finished GSHS data collection (including 9 countries with repeat surveys).

Questions?