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

2. 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

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

4. 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."

5. 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.

6. # 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

7. 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

8. 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

9. *(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 years.
*(Personal Digital Assistant)

10. 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.

11. 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

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

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

14. 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

15. 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

16. 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"

17. Support Materials: Sampling Workbook

18. Support Materials: Sample Size Calculator

19. 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

20. 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 during data collection.

21. 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

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

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

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

25. Global School-based Student Health Survey (GSHS)

26. 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

27. 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

28. 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

29. 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).

30. Questions?