October 2006, Cairo, Egypt The WHO STEPwise approach to chronic disease risk factor surveillance Overview in EMR October 2006, Cairo, Egypt

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.

October 2006, Cairo, Egypt 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

October 2006, Cairo, Egypt 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 covering NCD in their surveillance system

October 2006, Cairo, Egypt Progress: percentage of countries reported having routine NCD surveillance system in EMR Note: One country is excluded for best comparability between the 2 surveys

October 2006, Cairo, Egypt 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 annual health reporting system and surveillance system for NCD

October 2006, Cairo, Egypt Objectives 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)

October 2006, Cairo, Egypt Focus Situation of Stepwise approach to NCD RF in EMR (Implementation & reporting ) Situation of Stepwise approach to NCD RF in EMR (Implementation & reporting ) Sampling issues Sampling issues Remarks regarding: Remarks regarding:  Methodology  Documentation / Data presentation  Comparability of data  Generalization and applicability DM as an example DM as an example

October 2006, Cairo, Egypt Implementation & reporting in EMR : Implemented: 12 out of 22 countries Reported results: 8 out of 22 countries

October 2006, Cairo, Egypt STEPS ImplementationResults documentation AfghanistanNo BahrainNo DjiboutiNo Egypt√Yes Iraq√Yes Iran√Yes Jordan√Yes Kuwait√Not yet Lebanon√Yes LibyaNo MoroccoNo Oman√Not yet Pakistan√Yes PalestineNo QatarNo Saudi Arabia√Yes SomaliaNo Sudan√Not yet Syrian Arab Republic√Yes Tunisia√Not yet United Arab EmiratesNo YemenNo STEPS in EMR countries

October 2006, Cairo, Egypt Implementation issues of 8 EMR countries according to STEPS reporting YearAge range Egypt Iraq Iran Jordan Pakistan * Saudi Arabia Lebanon * 25 + Syrian Arab Republic ** Not mentioned

October 2006, Cairo, Egypt Sampling issues of 8 EMR countries according to STEPS reporting ProbabilityDesignSampling frameNational Egypt√*Population CensusYes Iraq√*Duhok Governorate censusSub-national Iran√*Iranian National DatabankYes Jordan√*Population CensusYes Pakistan√* Rawalpindi District (1998 census)Sub-national Saudi Arabia√*Population CensusYes LebanonNoConvenient -Yes Syrian Arab Republic√*Population CensusYes

October 2006, Cairo, Egypt Sample sizeResponse rate % STEP I & IISTEP IIISTEP I & II Egypt Iraq Iran Jordan Pakistan2040Not conducted - Saudi Arabia Lebanon not applicable Syrian Arab Republic Sample size and response rate

October 2006, Cairo, Egypt 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

October 2006, Cairo, Egypt 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:

October 2006, Cairo, Egypt 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) YearAgeCur-off level / units % (95%CI), or number Syria >110+ mg%22.9 (1784)18 (2958)19.9 (4742) SA >=7 mmoL19.2 (2152)16.6 (2237)17.9 (4389) Iraq >125+ mg% 11.8 ( ) (59) 15.2 (7.1 – 23.3) (76) 13.5 (7.7 – 19.3) (135) Iran >125+ mg%5.6 (25320)6.1 (27345)5.9 (52665) Lebano n?25+>125+ mg%8.35 (?)9.5 (?)9 (500) Egypt >=7 mmoL6.2 (4.8 – 7.6)8.2 ( 6.6 – 9.8)7.2 ( 6.1 – 8.3) Jordan >=7 mmoL11 (229)13 (476)12.5 (705) Pakistan?18-65 Step 3 was not conducted (history)4.76 (841)5.44 (1177)5.15 (2018)

October 2006, Cairo, Egypt 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.

October 2006, Cairo, Egypt 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