Dr. Chheang Sena - Non-communicable Diseases' Strategic Plan

Prof. Chheang Sena, (DUR, Fr)

20-21/June/2011Shangri-La in

Jakarta, Indonesia

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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


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


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.


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


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

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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



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



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


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


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 !

Documents

Dr. Chheang Sena - Non-communicable Diseases' Strategic Plan