Community-Based Study of Risk Factors for Stroke in Da Nang, Viet Nam

Annette L. Fitzpatrick, PhDDept. of Epidemiology, Adjunct Global Health

University of Washington

Quang Van Ngo, MD, MPHDa Nang Department of Health

Da Nang, Vietnam

Da Nang Department of Health

Acknowledgments

Kiet A. Ly, MD, MPH, Northwest Center To Reduce Oral Health DisparitiesThanh G N. Ton, PhD, Department of Neurology

David L. Tirschwell, MD, Department of NeurologyW.T. Longstreth, MD, MPH, Department of Neurology

Tung T. Vo, MD, Department of Health, Da NangChien H. Pham, Director, Department of Health, Da Nang

Da Nang Department of Health

Contents of Presentation

• Need to Study CVD in Developing Nations• Burden of Stroke• Introduction to our Project in Da Nang• Community Survey Methodology• Community Survey Preliminary Results

Why Study CVD in Developing Countries?

• Life expectancy is increasing in absolute and relative terms worldwide

• Majority of CVD mortality and morbidity occurs in older adults

• CVD may differ in risk factors, presentation, and course across gender, age, ethnicity, geography

• CVD = primary cause of death worldwide• Neurological diseases = highest burden of

disease as measured by DALYs

CVD = Global IssueSource: WHO

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

HIV/AIDS Tuberculosis Malaria CardiovascularDisease

Cancer ChronicRespiratory

Disease

Diabetes

Deat

hs (m

illio

ns)

Estimated Global Deaths by CauseAll Ages 2005

Not Just an Issue in High Income Countries

Projected Global Distribution of Chronic Disease Deaths

By World Bank Income Group, 2005

Low Income Countries 35%

Lower Middle Income Countries37%

Upper Middle Income Countries 8%

High Income Countries 20%

Impact of Stroke Globally

•1:3 persons will experience a stroke, dementia or both (Hashchinski, Stroke 2006)

•Stroke will kill about 10% of the world’s population of 6.5 billion people and leave millions of others disabled (Lancet 2007)

•Cerebrovascular diseases = highest in number of DALY’s in the developing world (WHO 2006)

• Stroke is a costly disease:– Large numbers of premature deaths,– Ongoing disability in many survivors,– Impact on families or caregivers – Impact on health services (WHO Stroke STEPS)

Stroke in Vietnam

• Health Transition from Infectious to Chronic Disease

• Stroke = #1 Cause of Death (20-27%) (Minh 2003, Scand J Pub Health; Hoang 2006, Prev Chron Dis)

• Prevalence of Key Risk Factors High – Smoking– Hypertension

Stroke in VietnamResults for adults aged 25-64 years (incl. 95% CI)

Both Sexes Males Females

Step 1 Tobacco Use

Percentage who currently smoke tobacco 29.7(± 1.1) 60.0(± 1.8) 1.7(± 0.3)

Percentage who currently smoke tobacco daily 28.4(± 1.1) 57.3(± 1.9) 1.6(± 0.3)

Mean number of manufactured cigarettes smoked per day

11.1(± 0.4) 11.2(0.4) 7.0(± 1.3)

Stroke in Vietnam

• What are characteristics of stroke in Da Nang ?

Results for adults aged 25-64 years (incl. 95% CI)

Both Sexes Males Females

Step 2 Physical Measurement

Percentage with raised BP (SBP ≥140 and/or DBP ≥90 mmHg or currently on medication for raised BP)

19.2(± 0.9) 23.1(± 1.6) 15.4(± 1.0)

Percentage with raised BP (SBP ≥160 and/or DBP ≥100 mmHg or currently on medication for raised BP)

11.9(± 0.8) 12.4(± 1.2) 11.5(± 0.9)

FIC R21 Grant: 06/99 – 05/11Collaborated between UW and DOH

Evaluation of stroke risk factors in Da Nang, Viet Nam

OBJECTIVES

• To assess the situation of stroke and its risk factors in Da Nang

• To enhance the capacity of health staff in stroke care, treatment, and research.

A. Evaluate stroke and its risk factors in Da Nang2 Projects

• Designed and conducted a household survey to evaluate risk factors of stroke: approx. 900 households – 1621 participants 35 yrs and older

• Develop a stroke registry patients hospitalized in Da Nang Hospital (using WHO STEPS questionnaire)

497 cases were collected from Mar – Nov. 2010. Lists of stroke patients from other hospitals will also be collected to evaluate the burden of the disease.

B. Building capacity:

• Established a local Advisory Committee to provide guidance on methodological approaches and other issues of importance in conducting research on stroke in Da Nang and potentially other chronic diseases in the future;

• Organized training courses to enhance capacity for local health staff in stroke care and research (6 courses: Clinical Stroke, Imaging, Epidemiology, EpiInfo, Field Data Collection, Stroke Registry Training).

• Organized meetings between experts from the UW and local staff to exchange idea on establishing a better stroke care system/ unit at Da Nang hospital.

• Provided equipment (computers, projector, books) to Da Nang Hospital and DN Health Staff Training Center.

Maps of Viet Nam & Da Nang

Geographic information of Da Nang

• AREA: 1,255.5 km2 Seattle: 1,245 km2

• POP: 890,000 (2009) = 602,000• 7 districts: - 4 urban,

- 2 half urban-rural- 1 rural-mountainous

• 56 communes:

• Literacy # 95%• Income per capita per year: #1,500 USD • Number of physician: 761 (2009) # 1/1200

DA NANG HEALTH NETWORK

7 District Health Centers

Da Nang Health Department

56 commune Health Stations (CHS). Each has 5-7 staff. Provide primary health care, first -aid, and basic treatment.

Each DHC has from 50 to 100 in-patient beds and also supervise primary health care activities of CHSs in the district

Provincial Institutes Main functions Da Nang Hospital The biggest central hospital in Da Nang with about 1,200 in-patient beds Training Center for Medical Staff Organize continuing training courses for medical staff Health Information & Education Center Design and conduct health information and education programs Center for Reproductive Health Treatment, management mother and child health care programs Mental hospital Treatment, management of the national program of mental care Rehabilitation Center Treatment, management of Community Based Rehabilitation program Preventive Medical Center National vaccination programs, nutritional program, epidemic controls, etc HIV/AIDS Control Center HIV/ AIDS control programs Eye Hospital Treatment, management of community eye care programs Dental Care Center Treatment, management of dental care programs in school & communities. Tuberculosis Hospital Treatment, management of the national tuberculosis program Dermatological Hospital Treatment, management of the national leprosy program Food Safety and Hygiene Agency Food and hygiene inspection Forensic Medicine Center Provide forensic examination Traditional Medicine Hospital. Treatment. Da Nang Pharmaceutical company

Beside the treatment functions, provincial institutes also provide their accordant specialty support and supervision to primary health care programs conducted at DHCs and CHSs (for ex: the community mental care program, CBR, child malnutrition, prenatal care, etc.)

4 private hospitals: 50-150 patient beds /each

Detail Sampling Schema

Da Nang = 7 Districts:

• 4 Urban

• 2 Rural/Urban

• 1 Rural

3 Urban D = 30 C

1 Rural/Urban D = 4 C

1 Rural D = 11 C

Name of Districtsand number of Communes

Number of Hamlets in selected Commune

Hamlets x Households

Number of households

Hai Chau = 13C 1C =56H 5H x 30hh 150hh

Thanh Khe = 10C 1C =32H 5H x 30hh 150hh

Son Tra = 7C 1C =73H 5H x 30hh 150hh

NHSon = 4C 1C =53H 5H x 30hh 150hh

Hoa Vang = 11C1C =15H 5H x 30hh 150hh

1C =13H 5H x 30hh 150hh

Sampling: Community Survey

• Sampling: Stratified 50% Urban, 50% rural

• Randomly Selected: 3 (of 30) urban communes2 (of 11 ) rural1 (of 4) rural/urban

• Randomly Selected 5 hamlets in each commune

• Randomly Selected 30 HH in each hamlet

• Interviewed Adults 35+ in each HH

Data Collection• Verbal Informed Consent• Home Interview – WHO Steps

– Demographics (age, education, religion, SES ownership questions

– Medical History (CVD, hypertension, diabetes, hyperlipidemia, cancer, arthritis, COPD

– MI Chest Pain (derived from Rose Angina Q) – Questionnaire for Verifying Stroke-Free Status– Health Behaviors (Tobacco, Alcohol, PA, Limited Diet)– Cognitive Function– Stress and Anxiety

Data Collection

• Examination

– Vital Signs : Seated BP, Heart rate– Anthropometry: Height, Weight, Waist, Hips, Knee-Heel

Length– Spirometry (Peak Flow and FEV)– Gait Speed– Timed Chair Stands– Balance Stands– Blood Spot (Whatman cards)

Centralized Training

• 12 Commune Health Workers (2 per site)

• 4 Data Supervisors

• 3-Day Training at Da Nang Center for Medical Staff Education and Training

• Finalized From based on Feed-back

• Pre-test using Community Volunteers

• Follow-up Monitoring at Each Site

RESULTS

• Visits Completed at 883 Households

• N = 1621 Adults

• 712 (43.9%) Men, 909 (56.1 %) Women

• Mean Age: 51.8 years ( + 12.5)

• Minimum: 35 years, maximum: 93 years

• 838 (51.7%) urban, 492 rural (30.4%) and 291 (18.0%) urban/rural

General Characteristics of Sample

Characteristic Men (N=712)

Women(N=909)

Total (N=1621) p

n† % n† % n† %Age (years) 0.20

<40 125 17.6 124 13.7 249 15.440-49 230 32.4 303 33.4 533 32.950-59 192 27.0 278 30.6 470 29.060-69 80 11.3 100 11.0 180 11.170+ 83 11.7 103 11.3 186 11.5Mean ± SD 51.8 ± 12.5 52.2 ± 12.4 52.0 ± 12.5 0.33

Region* 0.004Urban 389 54.6 449 49.4 838 51.7Rural 220 30.9 272 29.9 492 30.4Mixed urban-

rural103 14.5 188 20.7 291 18.0

General Characteristics of Sample

Characteristic Men (N=712)

Women (N=909)

Total (N=1621) p

n† % n† % n† %INCOME (monthly)

0.001

<2 million dong 113 16.1 212 23.8 325 20.42-3.9 235 33.5 270 30.3 505 31.74-5.9 148 21.1 198 22.2 346 21.7>6 (300 USD) 205 29.2 211 23.7 416 26.1

EDUCATION <0.001No schooling 8 1.1 76 8.4 84 5.2Grade school 544 76.4 716 78.8 1260 77.7College 48 6.7 63 6.9 111 6.8University /Post-grad

112 15.7 54 5.9 166 10.2

General Characteristics of Sample

CharacteristicUrban

(N=838)Rural

(N=492)Mixed

Urban-rural (N=291)

Total (N=1621) p

n† % n† % n† % n† %INCOME <0.001

<2 million dong 46 5.5 243 50.4 36 12.9 325 20.42-3.9 205 24.7 169 35.1 131 46.8 505 31.74-5.9 206 24.8 54 11.2 86 30.7 346 21.7>6 373 44.9 16 3.3 27 9.6 416 26.1

EDUCATION <0.001No schooling 8 1.0 46 9.3 30 10.3 84 5.2Grade school 590 70.4 433 88.0 237 81.4 1260 77.7College 82 9.8 9 1.8 20 6.9 111 6.8University/Post-grad

158 18.9 4 0.8 4 1.4 166 10.2

Self-Reported DiseaseDISEASE Men Women < 40 40-49 50-59 60-69 70+

Hypertension101

(14.2%)131

(14.4%)14

(5.6%)44

(8.3%)81

(17.2%)47

(26.1%)46

(24.7%)

Diabetes 26 (3.7%)

37 (4.1%)

6 (2.4%)

8(1.5%)

26 (5.6%)

14 (8.0%)

9 (4.9%)

Heart Attack 2 (0.2%)

2 (0.3%)

0(0.0%)

1(0.2%)

0(0.0%)

2(1.1%)

0(0.0%)

SevereChest Pain

30 (4.2%)

48 (5.3%)

11 (4.4%)

21(3.9%)

26 (5.5%)

14 (7.8%)

6 (3.2%)

Stroke 2 (0.3%)

2 (0.2%)

0 (0.0%)

0 (0.0%)

1 (0.2%)

2 (1.1%)

1 (0.5%)

High cholesterol

41 (5.8%)

58 (6.4%)

8(3.2%)

18(3.4%)

40 (8.5%)

24 (13.3%)

9(4.8%)

Red indicates p <.01

Risk Factors for CVD

DISEASE Men Women < 40 40-49 50-59 60-69 70+

Hypertension 34.4% 21.8% 18.3% 22.4% 31.3% 38.9% 32.3%

Tobacco Use 51.1% 6.7% 30.3% 26.3% 28.1% 17.8% 24.2%

BMIUnderweightNormalOverweight Obese

11.2%72.6%15.1%1.1%

13.4%70.6%14.9%1.1%

9.2%81.6%8.8%0.4%

10.3%72.7%15.6%1.3%

10.9%69.7%18.6%0.9%

13.1%67.0%17.0%2.8%

26.4%62.6%10.4%0.5%

Unaware of Hypertension

Measured hypertensionSelf-reported hypertension

No (N=1177)

Yes (N=443)

Total (N=1620) p

n % n % n %No 1085 92.3 302 68.2 1387 85.7 <0.001

Yes 91 7.7 141 31.8 232 14.3

Reported HTN and Taking Medications

*Told had HTN in past 12 months** Reported taking antihypertensive med in last 2 weeks

Self-Reported Hypertension*Took HTN

Medications**No

(N=23)Yes

(N=206)Total

(N=229) pn % n % n %

No 20 87.0 56 27.2 76 32.2 <0.001

Yes 3 13.0 149 72.3 152 66.4

AHA Q for Verifying Stroke-Free Status

HAVE YOU EVER HAD…..• Sudden painless weakness on one side of your body? • Sudden numbness or a dead feeling on one side of your

body? • Sudden painless loss of vision in one or both eyes? • Suddenly lost one half of your vision ? • Suddenly lost the ability to understand what people are

saying? • Suddenly lost the ability to express yourself verbally or in

writing?

Negative Predictive Value: 96%, Positive Predictive Value: 71%

Stroke Symptoms by Gender

Number of Stroke SymptomsNone 1 2 3+ p

n % n % n % n %

Men 555 79.2 76 10.7 49 6.9 20 2.8 .002

Women 646 71.6 121 13.4 88 9.8 47 5.2

TOTAL1211 75.1 197 12.1 137 8.5 67 4.2

% = row percent

* p< .05** p < .001

Any Stroke Symptoms by Hypertension Status

Measured HypertensionYes No TOTAL p

n % n %Men 47 19.2 98 21.0 145 20.4 .32

Women 69 34.8 187 26.3 256 28.2 .01

Next Steps: Community Surveillance

• Have submitted Follow-up R01

• Longitudinal Follow-up of Community Cohort

• Community Education – Hypertension – Stroke Symptoms

• Intervention of Educational Materials– Interactive Educational Tool vs Written Material

Next Steps: Stroke Registry

• Develop and Implement Standards of Care for Stroke– Medication– Rehabilitation– Education

• Expand to Include Hanoi and Ho Chi Minh City

• Intervention: Cell-Phone Surveillance of Follow-up Care

THANK YOU FOR YOUR ATTENTION

Are there any questions?

Da Nang Department of Health