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Presentation by Dr. Chheang Sena at the June 21, 2011 event "Meeting the chronic disease challenge: high-level regional workshop," co-hosted by the Partnership to Fight Chronic Disease and the Indonesian Ministry of Health in Jakarta.
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Prof. Chheang Sena, (DUR, Fr)
20-21/June/2011Shangri-La in
Jakarta, Indonesia
+**
+
General Overview
Non-communicable
disease
prevention’s strategic
plan
Discussion
Conclusion
More than 200 million people worldwide have diabetes !
Most of them do not receive the care they need !
NONCOMMUNICABLE DISEASES NONCOMMUNICABLE DISEASES PREVALENCE AND RISK FACTORS IN PREVALENCE AND RISK FACTORS IN
CAMBODIACAMBODIA
STEPS Survey 2010
Demographic statusPopulation Pyramid of Kompong Cham province
6.4
7.8
7.4
5.8
3.4
3.7
3.1
2.7
1.6
1.5
1.2
1
0.9
0.7
0.5
0.3
0.3
0246810
0 4
10 14
20 24
30 34
40 44
50 54
60 64
70 74
80+
Data Source Ministry of Planning & Ministry of Health 2005
6.1
7.5
6.9
5.9
3.8
4
3.5
3.2
2.5
2.1
1.6
1.3
1.1
0.9
0.7
0.4
0.4
0 2 4 6 8
FM
Goal: To estimate the prevalence of NCDs risk factors in order to establish the baseline information for the prevention and control of NCDs in Cambodia
Objectives:• To determine the prevalence of NCD risk factors including
tobacco, alcohol, fruits and vegetables consumption,
overweight and physical activity of the surveyed population;
• To estimate the prevalence of raised blood pressure,
diabetes and raised blood cholesterol among adult male and
female population;
• To compare NCDs prevalence and risk factors between
urban and rural population, men and women, and across age
groups.
SURVEY DESIGNSURVEY DESIGN
STEP 1:
Face-to-face interview
Information on:
(1) tobacco use,
(2) alcohol use,
(3) intake of fruits and vegetables
(4) physical activities,
(5) previously diagnosed
hypertension and
diabetes.
STEP 2:
Physical
measurements of :
(1) body weight and
height,
(2) waist and hip
circumferences,
(3) body fat,
(4) blood pressure, and
(5) physical fitness
Using specific tests/
devices relevant to
these measurements.
STEP 3: Biochemical
measurements of
capillary blood to
determine
(1) glucose
(2) total cholesterol at
sites Using dry chemical
methods.
Three subsequent steps :Followed WHO Stepwise Approach to chronic disease risk factor surveillance methodology (closed supervision by HQ, WPRO and WHO-Cambodia
SURVEY POPULATION AND SURVEY POPULATION AND SAMPLINGSAMPLING
In accordance to the NCD multi-stage cluster survey method:5,643 participants were selected; 5,433 responded (response
rate of 96.3 %)Cover age group of 25-64 years oldStratified urban and rural (covered all geographical areas of
Cambodia);Males and females
Selection of samples (WHO Kish Method):Primary sampling unit (PSU): commune level (Khum in rural
areas/Khan in urban area; Secondary sampling unit (SSU): villages (Phum); Elementary unit (EU) a household and was selected at random.
Prior to survey:Total sample size calculated was 5,760
During the survey period of data collection:
5,643 were available 117 (2.0%) households were missing, being away for farming or other purposes
Of 5,643 households:Overall response rates ranged from 96.3% in STEPS 1, to 94.2% in STEPS 2, and to 92.7 % in STEPS 3.
HIGHEST LEVEL OF EDUCATION HIGHEST LEVEL OF EDUCATION ACHIEVED BY THE RESPONDENTSACHIEVED BY THE RESPONDENTS
0
10
20
30
40
50
25-34 35-44 45-54 55-64 25-34 35-44 45-54 55-64
No school Less primary school Primary school
Secondary school High school College/University
Post graduate
FemaleMale
Percent
TOBACCO USETOBACCO USE
BURDEN OF SMOKINGBURDEN OF SMOKING
50.2
18
33.7
55.1
19.8
37
0
10
20
30
40
50
60
Daily tobacco users Current tobacco users
Men
Women
Both
Percent
The two main tobacco indicators that are associatedwith an increased risk of developing chronic diseases are:
FREQUENCY OF SMOKELESS FREQUENCY OF SMOKELESS TOBACCO USETOBACCO USE
1.20.50.5
1.20 0.1 0.3
2.92.8
8.9
13.112.8
0
2
4
6
8
10
12
14
Snuff bymouth
Snuff bynose
Chewingtobacco
Betel quid
Male
Female
Both
Percent
PERCENTAGE OF RESPONDENTS EXPOSED TO PERCENTAGE OF RESPONDENTS EXPOSED TO ENVIRONMENTAL TOBACCO SMOKEENVIRONMENTAL TOBACCO SMOKE
33.3
42.8
33.3
48.5
41.1
32.737.2
44.9
28.3
36.4
50.7
56.254.45655.2
0
10
20
30
40
50
60
Home Workplace Home/workplace
Urban
Rural
Male
Female
Both
Percent
Net alcohol content of a standard drink is approximately 10g of Ethanol
1 STANDARD
PREVALENCE OF ALCOHOL PREVALENCE OF ALCOHOL CONSUMPTIONCONSUMPTION
3.5
0.2
3.4
0.5
3.4
0.4
0
0.5
1
1.5
2
2.5
3
3.5
Urban Rural Both
Male
Female
Percent
HEAVY EPISODIC DRINKINGHEAVY EPISODIC DRINKING
39.5
46.2 45.1
3.5 4.8 4.6
0
5
10
15
20
25
30
35
40
45
50
Male Female
Urban
Rural
Both
The consumption of 5 or more standard drinks for males and 4 or more standard drinks for females on any day on the past 30 days
EATING PATTERNEATING PATTERN
FREQUENCY OF FRUITS AND /OR VEGETABLES CONSUMPTION PER DAY
0
5
10
15
20
25
30
35
40
45
50
None 1-2 serving 3-4 serving 5+ serving
Urban
Rural
Male
Female
Both sexe
Percent
Eating less than five servings of fruit and/or vegetables per day is considered being a low fruit and vegetable intake and increases the risk to develop chronic diseases
TYPE OF OIL OR FAT MOST OFTEN USED TYPE OF OIL OR FAT MOST OFTEN USED FOR MEAL PREPARATION IN FOR MEAL PREPARATION IN
HOUSEHOLDHOUSEHOLD
MEALS EATEN OUTSIDE HOMEMEALS EATEN OUTSIDE HOME
PHYSICAL ACTIVITYPHYSICAL ACTIVITY
PHYSICAL ACTIVITYPHYSICAL ACTIVITY
A person not meeting any of the following criteria is
considered being physically inactive and therefore at risk of
chronic disease:
3 or more days of vigorous -intensity activity of at least 20
minutes per day; OR
5 or more days of moderate -intensity activity or walking of
at least 30 minutes per day; OR
5 or more days of any combination of walking, moderate- or
vigorous intensity activities achieving a minimum of at
least 600 MET-minutes per week
PERCENTAGE OF RESPONDENTS PERCENTAGE OF RESPONDENTS CLASSIFIED INTO TRHEE CATEGORIES CLASSIFIED INTO TRHEE CATEGORIES
OF PHYSICAL ACTIVITYOF PHYSICAL ACTIVITY
0
10
20
30
40
50
60
70
80
Low Moderate High
Urban
Rural
Male
Female
Both sexe
Percent
PHYSICAL MEASUREMENTPHYSICAL MEASUREMENT
PERCENTAGE OF BMI PERCENTAGE OF BMI ≥≥25kg/m25kg/m²²
0
5
10
15
20
25
30
35
40
25-34 35-44 45-54 55-64 25-34 35-44 45-54 55-64
Rural
Urban
MALE FEMALE
Percent
Overweight: having BMI ≥ to 25 kg/m2 and below 30 kg/m2Obesity: BMI greater than or equal to 30 kg/m2
WAIST CIRCUMFERENCE & RISK IN WAIST CIRCUMFERENCE & RISK IN DEVELOPING DEVELOPING NCDsNCDs
67.3
23.8
9
57.6
23.1 19.3
88.3
9.62.1
76
15.58.4
85
11.83.1
72.6
16.910.5
010
2030
4050
6070
8090
100
<85cm 85-94cm
>94cm <81cm 81-88cm
>88cm
Urban
Rural
Both
Male Female
Percent
PREVALENCE OF HYPERTENTIONPREVALENCE OF HYPERTENTION
16.9
9.110
3.7
12.8
4.8
9.6
4.5
11.2
4.6
0
2
4
6
8
10
12
14
16
18
Urban Rural Male Female Both
SBP≥140mmHg/DBP≥90mmHg SBP≥160mmHg/DBP≥100mmHg
Percent
PREVALENCE OF DIABETESPREVALENCE OF DIABETES
1.7
5.6
3.6
1.4
2.3
0.8
1.82.5
1.1 1
3.3
1.5 1.4
2.9
1.3
0
1
2
3
4
5
6
Urban Rural Male Female Both
Impaired fasting glycemia Raised blood glucose
Current medication for Diabetes
Percent
PREVALENCE OF RAISED BLOOD PREVALENCE OF RAISED BLOOD CHOLESTEROLCHOLESTEROL
32.5
7
18.3
2.5
17
2.5
24.2
3.9
20.7
3.2
0
5
10
15
20
25
30
35
Urban Rural Male Female Both
Total cholesterol≥5.0 mmol/L Total cholesterol≥6.2 mmol/L
Percent
COMBINED RISK FACTORS OF NCDs COMBINED RISK FACTORS OF NCDs
10.3
73.8
15.96.7
84.2
9.15.9
80
14.18.7
84.8
6.58.1
84.5
7.35.8
78.5
15.7
0
10
20
30
40
50
60
70
80
90
0 risk factor 1-2 risk factors 3-5 risk factors
Urban Rural Male Female 15-44 45-64
Percent
DISCUSSION DISCUSSION
The current survey found that the prevalence of
diabetes was 2.9% for the total respondents, not
significantly different between men and women (2.5 vs.
3.3%); twice higher in the urban than in the rural area
(5.6 vs. 2.3%), and increased with age,
This prevalence of diabetes is by half lower than that
found by a survey in 2004 in a semi-urban ( 5.6 vs
11.4%) and rural ( 2.3 vs 4.8% ) province of Cambodia.
This difference might be mainly due to the fact that:
The survey 2004 had the sample population from 25 to
65 years and above, the prevalence of diabetes based
on non- fasting blood glucose, and only 4 villages
were selected to present rural and semi-urban areas
DISCUSSION cont. DISCUSSION cont.
In the present survey the sample population were limited to
25-64 years of age, blood samples were tested in the early
morning by trained laboratory technicians using Accutrend
Plus instruments and solutions purchased by the WHO
Geneva, and 180 surveyed villages were stratified and
randomly selected from the recent sampling frame to represent
the urban and rural areas, and data were properly weighted and
finalized by using the WHO STEPS EpiInfo program
In regards to blood pressure, the present survey found that 11.2% of
the total population had raised blood pressure or hypertension
(SBP≥140 and/or DBP≥90mmHg), and this prevalence was higher in
men than in women (12.8 vs. 9.6%), was also higher in the urban
than in the rural area (16.9 vs 10.0 % ) and was increasing with age.
DISCUSSION cont. DISCUSSION cont.
This prevalence of hypertension was lower than that reported 5
years ago by a survey in a semi-urban and rural province of
Cambodia where up to 25% and 11.7% of the surveyed population
had raised blood pressure respectively.
The prevalence of tobacco smoking in the current survey was
54.1% men and 5.9% women; it was higher than country-wide
survey in 2005-2006 where only 48% of men and 3.6% of women
smoked cigarettes
The high prevalence of alcohol consumption ( 1 in every 2
respondents were current drinkers; with men drink more often and
much more than women
The high prevalence of alcohol drinking found by the current survey
might be partly resulted from aggressive advertisements of beer and
other alcohol products throughout the country in recent decades
DISCUSSION cont. DISCUSSION cont.
The high prevalence of raised total blood cholesterol ( 1in every 5
respondents)
The low prevalence of fruit and vegetable consumption ( 8 in
every 10 respondents ate less than five servings of fruit and/or
vegetables on average per day).
The proportion of overweight and/or obese population ( BMI ≥ 25kg/m² )
was twice in the urban area as compared to the rural area (26.7 vs.
13.0%) and was 1.6 times higher in women than in men ( 19.0 vs. 11.6% ).
The prevalence of respondents with 3 or more risk factors for NCDs was
twice higher in men than in women ( 14.1 vs. 6.5% ), also twice higher
for ages 45-64 than for ages 25-44 ( 15.7 vs. 7.3% ), and significantly
higher in the urban than rural areas ( 15.9 vs. 9.1% )
CONCLUSION CONCLUSION The Cambodian STEPs survey results provided
valuable baseline information for the prevalence of
major NCDs and their associated risk factors at the
national level as well as at urban and rural levels of
Cambodia.The survey revealed that the prevalence of diabetes and
hypertension in Cambodia were lower than that reported
in previous surveys in Cambodia and in some
neighboring countriesEven though, major risk factors for NCDs were alarmingly
prevalent, including alcohol consumption and tobacco
use, especially among urban and male population, and
overweight among women and aging population
+**
+
VISION STATEMENTVISION STATEMENT
To prevent and control the significant and growing burden of noncommunicable diseases and their risk factors
To address the effects it has on individuals, families and society.
PRE-SURVEY IN CAMBODIAPRE-SURVEY IN CAMBODIA
Objective of the survey: Diabetes prevalence determination
Date of activity: started from 2004 to 2005
Survey site: Kompong Cham, Battam Bong, Siem Reap
Criteria adopted: WHO, 1999
Results: in Kg Cham, Battambang and Phnom Penh:10 %
adults have diabetes, ¼ adult: high blood pressure, poor
rural community surveyed in Siem Reap: 5% of adults had
diabetes and 12% were hypertensive patients.
Non-communicable diseases is become the top problem of developing country !
Epidemiology of CambodiaEpidemiology of Cambodia
In Cambodia, noncommunicable diseases In Cambodia, noncommunicable diseases are are not well knownnot well known..
With With integratedintegrated Cambodia in Asian Cambodia in Asian country and if the estimated prevalence country and if the estimated prevalence 2.1%2.1% is true, by the year is true, by the year 20252025 we believe we believe that more than that more than 283 000283 000 Cambodian Cambodian people ( 45-64 years old) will be affected people ( 45-64 years old) will be affected by diabetes.by diabetes.
It is not so early to act from now !
Historic of diabetes activities in CambodiaHistoric of diabetes activities in Cambodia 1998 a group of health professional initiated to conduct a preliminary study on 1998 a group of health professional initiated to conduct a preliminary study on
diabetes prevalence.diabetes prevalence.
CDA was set up and start to perform their activities from 1998 .CDA was set up and start to perform their activities from 1998 .
In 1999, Preliminary study, for determining the Diabetes prevalence in In 1999, Preliminary study, for determining the Diabetes prevalence in Kompong Cham province, was initialized ( Sena C, et al. 2002)Kompong Cham province, was initialized ( Sena C, et al. 2002)
In 2001 first world diabetes day was celebrated in Cambodia.In 2001 first world diabetes day was celebrated in Cambodia.
In 2004,Pre-survey on diabetes prevalence was conducted by MOH of In 2004,Pre-survey on diabetes prevalence was conducted by MOH of Cambodia and CDA.Cambodia and CDA.
In 2006, national strategy of non-communicable diseases was established In 2006, national strategy of non-communicable diseases was established and adopted by MHO and first World Diabetes Day celebration in Kg Cham and adopted by MHO and first World Diabetes Day celebration in Kg Cham province.province.
2007, IDF training in Phnom Penh2007, IDF training in Phnom Penh
About 80 % of diabetes people are undiagnosed !
Preliminary survey in Kompong Cham provincePreliminary survey in Kompong Cham province
Objective of the survey: Diabetes prevalence Objective of the survey: Diabetes prevalence Date of activity: started from 1999 to 2002Date of activity: started from 1999 to 2002 Sample size: 520 subjectsSample size: 520 subjects Survey site: Kompong Cham districtSurvey site: Kompong Cham district Criteria adopted: WHO, 1999Criteria adopted: WHO, 1999 Result: 13.4 % ( age category: 34y-64y)Result: 13.4 % ( age category: 34y-64y) ConclusionConclusion::
- Diabetes prevalence of Cambodia probably higher than the one that generally known by extrapolation calculation.
- However this results highlight the interest of the national survey in the future.
Diabetes care is for every one in the worldwide !
Preliminary Diabetes prevalence study in Kompong Cham Preliminary Diabetes prevalence study in Kompong Cham province 2002province 2002
RESULTS
Tranche d’âge(année)
Nombre total de sujets
Nombre de sujet ayant une glycémie (mg/dl)
<100 100-109 >110
Homme + FemmeHomme + Femme Homme + Femme
N % N % N %
<34 23 22 95,6 0 0 1 4,3
34-64 440 365 83,0 16 3,6 59 13,4
>64 57 41 71,9 5 8 ,8 11 19,3
N : nombre des personnes % : pourcentages déterminés en fonction du nombre de sujets de la tranche d’âge
““SRATEGY OF THE PREVENTION ” AND CONTROL OF SRATEGY OF THE PREVENTION ” AND CONTROL OF NONCOMMUNICABLE DISEASES,NONCOMMUNICABLE DISEASES,
CAMBODIA 2007-2010CAMBODIA 2007-2010
MOH WORKSHOPMOH WORKSHOP (02-03/ 10/ 2006) (02-03/ 10/ 2006)
VISION STATEMENTVISION STATEMENT
To prevent and control the significant and growing burden of noncommunicable diseases in the province
To address the effects it has on individuals, families and society.
OVERAL GOALS OF NATIONAL STRATEGY AND OVERAL GOALS OF NATIONAL STRATEGY AND POLYCY FOR NCDsPOLYCY FOR NCDs
To develop and strengthen the institutional management and implementation structure for non communicable diseases.
To develop a surveillance system for NCD risk factors and selected diseases.
To stall the epidemic of NCDs through the population reduction in the main risk factors of poor diet, physical inactivity, smoking, harmful alcohol use and the aggressive management of high risk individuals.
To strengthen and equip health delivery systems to provide affordable, equitable and quality management of non communicable diseases through the public health system.
Critical issues facing diabetes care and diabetes Critical issues facing diabetes care and diabetes control in control in the provincethe province
1-Lack of net work and diabetes institutional management: Provincial structure
Infrastructure National guideline… Provincial strategy
2-Lack of human resources : Health professional, Experiences,
diabetes care and control knowledge
3-Traditional myth behavior: Life style, traditional drug using…
4-Diabetes is not well known in the country: National prevalence,
Diabetes selves care and prevention…
5-Disadvantaged and vulnerable community: Concerning to equitable health services
and diabetes care people at risk…
OVERALL GOALSOVERALL GOALS
The significant and growing burden of diabetes must be prevented and controlled in the country.
NCDs care is for everyone
Critical Matrix AnalysisCritical Matrix Analysis
Criteria
Impact
Low Significant Major
URGENT
Low5-Disadvantaged and vulnerable of community
3-Traditional myth behavior.
Significant2-Lack of human resource
1- Lack of net work and diabetes institutional management
Pressing4-NCDs is not well known in the country.
5 4
23
1
PLANNING WORKSHEET-1
CAMBODIA Plan Period: Jan/2009-Dec/2011
Issue 4-Diabetes is not well known in the country and province
With assumption The detail is in appendix-1,2,3
Objective-1: Promote the public awareness on NCDS burden and healthy lifestyle in the Community.
Strategies Action steps ResponsibleOrganization
Time Targets Resource /Bud-get
1-Raise public awareness of NCDs burden and healthy lifestyles
1-Celebrate the yearly World Diabetes Day
2-Running monthly outreach education in community and public health facilities.
3-Develop and print IEC materials regarding to diabetes and its risk factors : - poster, self-management, leaflet, palm let, brochure, Gazette…etc
-CDA
-CDA & PHD-MOH
14 Nov
Every month
-Feb-09
-400 participants had attended
- Report of activity at two HC every month
- Diet pyramid poster Leaflet, Brochure, T-Shirt, and Newsletters was print out.
-NGOs-CDA-MOH
-NGOs-CDA-MOH
PLANNING WORKSHEET-2
CAMBODIA Plan Period: Jan/2009-Dec/2011
Issue1- Lack of net work and diabetes institutional management
With assumption The detail is in appendix-4
Objective-2: Enhancing to form the network and infrastructure of NCDs and risk factor management
Strategies Action steps Responsible organization
Time Indicatortargets
Resource /Bud-get
1-Advocate among health professional and donors to increase awareness of the diabetes burden for starting up the program activity
1- Arrange an orientation workshop
2-Conduct partner meeting
-CDA- Drug food bureau of PHD-DDF
Jan of year
Quarterly
-Provincial net work was formed & Structure and role of working group was received.
CDANB &NGOs
2-Devolep framework for Providing care of patients in the hospitals
1-Select a hospital as pilots 2-Running NCDs clinics 3-Staff spplement.4-Develop protocol of care and prevention protocol for the clinics5-Peer education & care6-Create HIS network
-CDA-PHD working group-And referral hospital director
-Feb-10
-Feb-09
-Nov-10
-Mar-09
-QTR
Report of activities
NB &NGOsCDA
PLANNING WORKSHEET-3
CAMBODIA Plan Period: Jan/2009-Dec/2011
Issue-2:Lack of human resource With assumption The detail is in appendix-5,6
Objective-3: Develop and strengthening the quality of equip health delivery system among RH and PHD staffs to provide affordable care and equitable diseases management
Strategies Action steps Responsible persons
Time Targets Resource /Bud-get
1-Enforce to run NCDs program in the province
Establish a PHDworking group for running NCD program
PHD Director
Sep-11 A working group that has a secretariat from nutrition unit
NB
1-Providing the quality of NCDs education and care skill to medical practitioners, clinic staffs.
1-Develop curriculum of the training2-select the trainers3-select the trainees4-Financial support request5-Monitoring and evaluation program
-NCDs working group
Oct-11 -25 trainees from RH & HC were trained
WDFNGOsNB
2-Strengthening the quality of diabetes educator and medical practitioner skill.
1-Provide the regular update and refreshment training in diabetes
-NCD working group
-Dec ofevery year
-25 trainees from RH & HC were attendedIn the training
WDFNGOsNBCDA
PLANNING WORKSHEET-3CAMBODIA Plan Period: Jan/2009-Dec/2011
Issue-5: Disadvantaged and vulnerable of community
With assumption The detail is in appendix-7,8
Objective 4: Enhancing equitable diabetes care and prevention for disadvantage and vulnerable people.
Strategies Action steps Responsible persons
Time Targets Resource /Bud-get
1-Advocating for financial support for poor patients from government and others donors
1-Develop health equity fund and health insurance schemes2-Request the support the program from MOH
-NCD working group
2009-2011
-Schemes were drafted
- The program was approve by MOH
NBNGOsNB
2-Strengthening the quality of diabetes care including health insurance and equity fund Skill among health professional
1-Establish a workshop for running the program 2-Providing the training to key staff for running the program
-NCD working group
2009-2011
-15 trainees from RH & HC were attendedIn the training
WDFNGOsNB
3- Establishing the Community Foundation for supporting and sustaining program
1-Governmental Authorization2-Action plan3-Implementate4-Quality Improvement
-NCD working group-CDA
Dec-2011
-Authorize letter
-Reports
WDFNGOsNBCDA
CONCLUSIONCONCLUSION
This strategic plan is only an idea or a model for reducing the burden of NCDs
An effective way to prevent and control NCDs is through the community outreach program designed to inform and educate local people about the NCDs, and to create an effective NCDs management system from national level to the community level.
THANK YOU !