Surveillance of NCD
Dr. Chaisri Supornsilaphachai
Bureau of Non-communicable Diseases; Department of
Diseases Control
In “Introductory Curse on Field Epidemiology” 8 June 2006
Main issues
• Growing burden of NCDs, Mental Ds and
Injury
• Impact of globalisation, urbanisation
• Greater emphasis on prevention
• Need for standard, comparable data
• Greater focus on trends in major risk factors
• WHO framework for surveillance (STEPS)
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Health
Risk
Factors
Health
Poor
Diet
Low
P.A.
Chronic
Condition
High Blood
Pressure
Chronic
Disease
Stroke
Death
Death
Non-communicable Disease Continuum
Definition of Surveillance
In 1968 the 21st World Health
Assembly described surveillance
as the “systematic collection and
use of epidemiologic information
for the planning, implementation,
and assessment of disease
control”; in this sense,
surveillance implies “information
for action”.
STEPS
page 9
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Surveillance as a core component
of NCD prevention
We miss the mark if data are collected and are not
linked to NCD prevention efforts, OR . . .
. . . if programmes and policies
are developed without data, failing
to show progress or outcomes.
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Surveillance as an integrated
component of NCD prevention
An essential “evidence” foundation
for effective NCD programme
and policy planning
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Difficult to link evidence in uneven,
nonintegrated vertical programming
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
WHO Global Strategy
on Prevention and Control of NCDs



Prevention: in the first place reduce major
risk factors through population strategy and
targeted high risk strategies
Case Management: cost-effective and
affordable interventions; health system
reform
Surveillance: assess the pattern and trends of
major risk factors (and major NCDs); link with
evaluation of preventive programs
World Health Assembly, 2000
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
NCD and CD Surveillance
Different Objectives, Different Data, Different
Programme monitoring
Health Status Monitoring
Methods
HP/DP Programme
indicators
HP/NCD Control
activities
Epidemic
response
Early warning
information (CD)
Epidemic Intelligence
Health indicators
Health
Policy
Resource
allocation
Administrative data
Health System Monitoring
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Levels of causation and corresponding types of intervention
SOCIAL STRUCTURE
• Social class
(social position)
• Age
HEALTHY PUBLIC POLICY
• Ethnicity
ENVIRONMENTAL
• Geographic location
INFLUENCES
• Housing Conditions
(places)
• Occupational risks
ORGANISATION AND
COMMUNITY INTERVENTION
• Access to services
LIFESTYLE
• Smoking
INFLUENCES
• Nutrition
(individual behaviours)
• Physical activity
PRIMARY AND SECONDARY
PREVENTION
• Psychosocial factors
PHYSIOLOGICAL
• Blood pressure
INFLUENCES
• Cholesterol
(the body)
• Obesity
PRIMARY AND SECONDARY
PREVENTION
• Blood glucose
Health care services
(the system)
Noncommunicable Diseases
Tertiary Prevention
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Chronic Disease Surveillance







Behavioral trend
Occupational
Environmental risk factors
Health condition Disability
Disease
Services Utilization
Death
Risk factors occupy a central place
because of the lag time between
exposure
disease
• Public health strategies have to be
driven by risk factor exposure
• Intervention at all risk factor levels
• Countries need to know the
distribution of risk in the population
• Better data lead to better
decisions
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Uses of surveillance data
 Provide prevalence of health risk behaviors
 Track trends over time
 Develop targeted programs, policy and
legislation
• Demonstrate progress in meeting
global/national health objectives
 Evaluate program and policy progress/
success (some part)
Leading 10 selected risk factors as
causes of disease burden (WHR 2002)
=
Major NCD risk factor
Developing countries
High Mortality
Low Mortality
Developed countries
1
2
3
4
Underweight
Unsafe sex
Unsafe water
Indoor smoke
Alcohol
Underweight
Blood pressure
Tobacco
Tobacco
Blood pressure
Alcohol
Cholesterol
5
6
7
8
Zinc deficiency
Iron deficiency
Vitamin A deficiency
Blood pressure
Body mass index
Cholesterol
Iron deficiency
Low fruit & vegetable intake
Body mass index
Low fruit & vegetable intake
Physical inactivity
Illicit drugs
Indoor smoke from solid fuels
Unsafe water
Underweight
Iron deficiency
9 Tobacco
10 Cholesterol
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Figure 2: Characteristics of a surveillance
system
influence
Research
Health policies
and programmes
Surveillance
evaluate
Information
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
กระบวนการทางานเพือ
่ การป้ องกันโรคไม่ตด
ิ ต่อ
THAILAND
Developm
ent and
Research
Surveillance
Health Policy,
Plan and
program
(Evidence based)
Information
for Action
Evaluation
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Information Sources for
Surveillance Purposes
Source
Surveys
Disease registries
Vital Statistics
Aggregate
consumption data
Hospital activity data
Administrative data
Information
Population-based data
Incidence and survival
Vital status, mortality data
Economic activity indicators
Morbidity and health service use
indicators
Insurance claims etc.
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
The STEPs Framework in NCD
surveillance
NCD
Step 1
Step 2
Risk
factors
(the
future)
Questionnaire- Questionnaires plus
based report
physical measures
on key risk
factors
Step 3
Questionnaires
plus physical
measures plus
bio-chemical
measurements
Diseases Hospital or
(the
clinical
present) admissions, by
age and sex
Rates and principal
Cause-specific
condition in 3 groups:
disease incidence
communicable diseases, or prevalence
NCDs and injury
Deaths
Death rates by
(the past) age and sex
Death rates by age, sex
and cause (verbal
autopsy)
Death rates (age/
sex/cause) by
death certificate
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Some challenges
• Many countries do not have adequate baseline data
• Need trend data on major RF to map coming disease
burden and effect of interventions
• Continuous (for CD) vs periodic (for NCDs) surveillance
• Risk factors vs R markers: balance between behaviours
vs more – objective measures
• Funding mechanisms and resource mobilisation
• Making surveillance loop work
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Risk Factors Common to Major
Noncommunicable Conditions
Condition
Cardiovascular
Disease*
Diabetes
Cancer
Chronicobstructive
pulmonary
Disease
Risk factor
Smoking




Alcohol

Physical Inactivity



Nutrition



Obesity



Raised Blood pressure


Blood lipids



Blood glucose





* Including heart disease, stroke, hypertension
STEPS Document p 18 WHO
WHO STEPwise Approach to Surveillance of NCD Risk Factors
Rationale Why Certain Risk Factors
Have Been Selected
 They have the greatest impact on NCD mortality
and morbidity;
 There is evidence that their modification is
possible and effective in primary prevention;
 The measurement has been validated;
 The measurement can be applied in both
developed and developing countries, and
comparison across countries will be meaningful;
and
 The measurement can be obtained following
appropriate technical and ethical standards.
STEPS Document p 17 WHO
WHO STEPwise Approach to Surveillance of NCD Risk Factors
Why Standard Definition and Methods?
Valid comparisons between states
(populations, or countries) or years simply
cannot be made without standard definition
of terms and compatibility between public
health recommendations and the collection
and analyses of surveillance data.
Brownson et al 2000
Surveillance, NMH
STEPS Framework
The framework is the distinction
between the different levels of
risk-factor assessment:
 health behaviours (SR)
 physical measurements
 blood samples
and the three modules involved
in describing each risk factor:
 core
 expanded and
 optional
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
WHO STEPS a tool for NCD risk factor assessment
Step 3: Blood samples
•Blood glucose/diabetes
•Cholesterol
Step 2: Physical measures
•Height /Weight/Waist
•Blood Pressure
Step 1: Behaviours
•Tobacco Use
•Physical Inactivity
•Intake fruit/veg
•Alcohol Use
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Key Premises for implementing
STEPS: Global focus
• STEPS-basic surveillance sites
• Modular approach -‘appropriate’ STEPS
according to country needs and
resources
– Focus on essential information
– Ensure power to detect trends
– Contribute to comparable data
Implementation in countries through WHO Regional
Offices and linked to Regional NCD Networks
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Key Premises for implementing
STEPS: Local Focus
– Building local capacity for surveillance
– Understanding of ‘surveillance’ as:
information for public health policy
– Strengthening baseline systems with
plans for continuity
– Link to existing systems where feasible
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
WHO STEPS partnership
WHO - HQ
Co-ordination
WHO - CC
Countries
Technical Support Centre
WHO Regions
Training
Technical assistance
Donor
Support
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
WHO STEPS Technical Support
Activity
• Quality control
• Streamline STEPS
implementation
process
• Templates for
Summary reports
and transfer of
aggregate data
Outcome
• Comparability of
data
• Efficiency,
capacity for
planning, data
management and
analyses
• Accessibility in
reports and WHO
WHO
WHO STEPwise Approach to Surveillance
of NCD
Risk Factors
NCD
InfoBase
Table 1. Communicable and NCD Surveillance
COMMON
CHARACTERISTICS
DIFFERENCES
CD SURVEILLANCE
NCD SURVEILLANCE
PURPOSE
Describe problem
Monitor trends
Emphasis on weekly or monthly Emphasis on trends over years
variations to detect outbreaks
Estimate health burden
Focus is on identifying
individuals
Focus is on population
Evaluate programmes for
Prevention and control
Short time frame between
exposure and disease
Rapid response
Longer time frame between
exposure and disease
Planned response
Source: Berkelman et al. (2001).
Table 1. Communicable and NCD Surveillance (cont’)
COMMON
CHARACTERISTICS
DATA
Regular
DATA ANALYSIS
Descriptive statistics for time,
Place, person
DIFFERENCES
CD SURVEILLANCE NCD SURVEILLANCE
Reliance on notification by
health-care providers
and/or
laboratories
Greater use of existing
databases
(eg vital statistics, hospital
discharges); population surveys
Emphasis often on case Emphasis usually on rates,
counts
population means
DATA DISSEMINATION
Regular; frequency reflects data More frequent
Collection and audience targeted
Less frequent
Source: Berkelman et al. (2001).
The NCD in top ranks
THAILAND
DALYs
- Stroke
- CA liver
- Diabetes
- COPD
- IHD (male)
- Depression (Female)
- LBW (Female)
Deaths
-
Stroke
CA liver
IHD
LBW
CA Lung (male)
DM (Female)
Evolution of Thai NCDs Surveillance :
Can’t answer for prevention action
efficiently and effectively
Information reliability
and validity !!!
Source Introduction to Modern Epidemiology by Ahlbom A, Norell S. p. 36
34
Data set considered in Thai
Community
for NCDs Epidemic
THAILAND
 Mortality/Morbidity Patterns since 1975
 Prevalence data
 Demographic Patterns
 Change of Related Behavioral & socioeconomic
risk and tentative determinants
 Change of Related Biological Risk
Source of Data set for
extent of problems
THAILAND
 Existing Vital Statistics
 Related epidemiological and pilot studies
 Population data from Office of the National
Economic and Social Development Board (NESDB)
Source of Data set for risk
determinants
THAILAND
 Related epidemiological and pilot studies
 National Nutritional Survey since 1964
 National Health Interview Survey since 1976
Other data sources such as economic data,
consumption data etc.
Create New Specifie
Surveillance and Information
Source for High Priority NCDs
THAILAND
• Cancer surveillance ……...initiated
in 1987
• National Health Examination
Survey …... initiated in 1990
• Injury surveillance ……...initiated in
1994
Source of Data set for
extent of problems
THAILAND
 Existing Vital Statistics
 Related epidemiological and pilot studies
 Population data from Office of the National
Economic and Social Development Board (NESDB)
Source of Data set for risk
determinants
THAILAND
 Related epidemiological and pilot studies
 National Nutritional Survey since 1964
 National Health Interview Survey since 1976
Other data sources such as economic data,
consumption data etc.
Create New Specifie
Surveillance and Information
Source for High Priority NCDs
THAILAND
• Cancer surveillance ……...initiated in
1987
• National Health Examination Survey
…... initiated in
1990
• Injury surveillance ……...initiated in 1994
Collaborative in Burden of
Disease Study
• Aim at comparative risk assessment
THAILAND
( integrated risks)
• Identify the burden attributable to the important
risk and behavioral factors
• The burden is measured in unit of DALYs, YLL
(Year life lost), Number &rate of deaths and
illness
Correction Process Experiences for
Information reliability and validity !!!
THAILAND
• Make sense of data with considerable for source
of information
• Analysis with comprehensive picture on ongoing
epidemiological course and critical approach
comparable with other population’s
epidemiological course as possible
• Systemically reanalysis with more other
information sources
• Validity unaccurate information resources
..Existing Vital Statistics ……….Verbal autopsy (1997)
THAILAND
Multiple sources of data needed for composing
of systematic and comprehensive picture
correlated with long natural courses of diseases
considerably identified. The data has to be
concerned about comparing overtime and with
other population’s epidemiological data as
possible while using systemic and
comprehensive approach with integration based
for identifying minimum data set
Outline of National database for
comprehensive NCD surveillance system
NCD
After2001
Basic Core
Expanded Core
THAILAND
Deaths
Death rates by age, sex and
cause of death (death
certificate)…quality improvment
Death rates by age, sex and cause
of death (verbal autopsy) will be
done as necessity
Diseases
Hospital or clinic number of visit or
admissions, rates by age and sex
and principal cause-specific
disease and specific condition in 3
groups:
communicable diseases,
NCDs and injury ….. coverage
improvement
-Cause-specific disease
incidence or prevalence
- Cause-specific burden of disease
Risk factors
Questionnaire-based report on
key risk factors, plus physical
measurements plus bio-chemical
measurements …standardized
and comparable between regional
and internationally.
Questionnaire-based report on key
risk factors (:..Other health-related
behaviours, mental health, plus
physical measurements (:…) plus
bio-chemical measurements (.HDLcholesterol,triglycerides)
Ongoing
collection,
analysis and use
of health data
-Aggregation consumption data
(:.sugar, salt, …etc)
-Economic activity data
-Administrative data (:… service
-Administrative data (:……insurance
claims etc.)
THAILAND
Thai National NCD Surveillance Networks
agreed to improve quality of the network
be the important part of program
development and evaluation and also
concerning linked with policy maker for
reinforcing and enabling process for
prevention and control
(RESOLUTION OF POLICY DEVELOPMENT FOR SUSTAINABLE THAI
SURVEILLANCE NETWORKS OF MAJOR NCD AND THEIR RISK
FACTORS )
Tentative Conceptual Model
HSRI
for Thai NCD Surveillance NetworkHlth Status and Trend
Identifying diseases for surveillance… Health Information Center;
Bureau of Health Policy
and Planning; MOPH
Health
Promoti
onon
Fund
Review Sampling
frame
Specific Disease
Management Center
THAILAND
NCD Surveillance
Network
…- Specific disease collection/information Center
- related risk data collection/information center
Specific Risk Mx and
Control Center
- Increase
collaborative
Increase
collaborative
and
and
communication
communication activities
activities by mail, small
by mail, small meetings etc
meetings etc
capacityofof
--Increase
Increase capacity
analyzing information
information
analyzing
for actions
for actions
Standardized data
- -Standardized
data
- Increase capacity of
Increase capacity of
analyzing and
analyzing
and synthesizing
synthesizing
information
actions
information
forfor
actions
Collaborative or Comprehensive
information center for action
(Control for common risk, multiple
risk factors and conditions, multiple
diseases control)
N.B.: .- Establish a focal point for major NCDs and their risk factors surveillance at MOPH level
- .Each information center has a complete process of data collection, data analysis and data dissemination
NCD
Information
Center
Refined
Refined
Objective
Objective
The goal achievement for Thai
NCDs prevention and control
THAILAND
• Reduce premature death both in number
and rate
• Reduce the disease burden( morbidity,
disability, cost) from NCDs
• Increase years of quality of life
List of the tentative name and organization in
National NCD Surveillance Networks
Health Information Center,
Bureau of Health Policy and
Planning, MOPH
Epidemiology Division, Office of
the Permanent Secretary, MOPH
Health System Research Institute,
MOPH
National Cancer Institute, Department
of Medical Services
Social Statistics Division, National
Statistics Office
Mental Health Department,
MOPH
Nutrition Division, Department of
Health, MOPH
Nutrition Institute, Mahidol
University
Thai Health Research Institute,
Thai Public Health Foundation
Social and Behavioral Medicine
Division, Department of Medical
Services, MOPH
The Focal Points
• The comprehensive NCD information center was
established in the Bureau of NCD control,
Department of Disease Control.
• The center is most likely to act as a focal point of
NCD surveillance in Thailand and will work
closely with Division of Epidemiology,
Department of Disease Control.
• National Interagency Coordinating Committee
for Surveillance will be proposed to MOPH.
In “Health Management for ASEAN Health Executives” Thailand; 9.00-12.00; 3-21-March 2003;
Trend of Future Burden NCDs
• Rapidly economic and social development in this area
into more western-lifestyle since at least ten years ago
• Size of ASEAN Population and change of population structure
• All of these countries are low and middle economic countries
• The present Infrastructure of Health service system
inappropriately and inadequately of coming burden problems
Prior Important Problems to be answered
•What main objectives of surveillance ? Are the same ??
….different in the stage of diseases
….different in the existing information system
….different in each stakeholders concern
….different stage of prevention program
• Is population attributed risk of NCDs alike among
countries?
• limit resources……Initiative budget…..by whom? how ?
• Focal Point and Capacity of resource persons
•…………etc.
Suggestive Surveillance
Information Characterestics
Needed for Actions
• Multiple sources of data
• Systemic and comprehensive
picture correlated with long natural
courses of diseases with
considerably information sources
and comparable with other
population’s epidemiological course
as possible
Past risk - current disease : Current risk - future disease
• Reinforce links with policy makers
Suggestive Surveillance
Information Characterestics
Needed for Actions
• Population based
• Ongoing/ repeated
measures
• Practical, relevant,
Timely
Including
Which minimum set of NCDs determinants
has to be focused
both risk factors & determinants and
positive factors that are preventable and
exist in our communities.
• National NCD control program since 1987
• NCD strategic plan 1997-2006
• Medium term plan 2002-2006
• Different approach: 2 focal points
– NCD surveillance
– Health Survey
The Focal Points
• The comprehensive NCD information center was
established in the Bureau of NCD control,
Department of Disease Control.
• The center is most likely to act as a focal point of
NCD surveillance in Thailand and will work
closely with Division of Epidemiology,
Department of Disease Control.
• National Interagency Coordinating Committee
for Surveillance be proposed to MOPH.
Health Survey
• The survey will be carried out by newly
founded center “Health Survey Center”
under Health System Research Institute.
• Thailand already adopts STEPS approach
to risk factor surveillance.
• Expanded core module of questionnaire,
physical measurement, blood samples for
biochemical analyses will be included in
the Third national health exam survey.
Thai 3rd National Health
Examination Survey
• Executive committee and working group of
the third NHES has been appointed since
June 2002.
• Expanded Core module of STEP approach
was introduced to the committee and
working group
• Working plan is established.
• Activities
– Sampling Frame & Sampling Method
– Sampling size is more than 10,000 (depend
on government budget and other sources)
– Test the questionnaire
– Launch the national survey in June 2002
– Report by the end of 2003
Public Health Approach
for Disease Control
Implementation:
(How do you
do it?)
Intervention &
Evaluation:
(What
works?)
Surveillance:
(What
is the
problem?)
Problem
Risk Factor
Identification:
(What is the
cause?)
Response
“Because behaviours can be
modified, promoting positive
health behaviour choices,
through education and through
community policies and practices,
is essential to reducing the
overall NCD burden.”
3. Conduct surveillance rather than
surveys
We need a systematic approach to:
 Maintain infrastructure visibility and support for data
collection over time
 Increase efficiencies for sustaining surveillance efforts
 Provide routinely-collected trend data that are
consistent and comparable
 Incorporate emerging health issues into the system
quickly, as they arise
Bridging
the gap
Surveys
Research driven
Theory based
Surveillance
Public health driven
Atheoretical--helps
develop theory
Focuses on
categorical health
issues
Focuses on multiple
health issues
Goes into depth
within categorical
health issue
Looks at broad
trends and patterns
across health issues
Surveys
Shows relationships
between behaviours
within single health
issue
One point in time
Subpopulation-based
Results point to the
way things were
Surveillance
Shows actual
changes in behaviour
across multiple
health issues
Continuous
Population-based
Results point to the
way things are
Surveys
Surveillance
Less efficient:
re-starting & retraining are required;
does not generate
capacity building
Ongoing system
generates efficiencies
with start-up, training,
and capacity building
A separate survey is
developed to address
an emerging health
issue
Emerging health issues
are integrated into the
system fairly quickly
(Indonesia)
(Mexico)
Definition of Surveillance/Monitoring
 Public health surveillance is the ongoing collection
and timely analysis, interpretation, and
communication of health information for public
health action
 Public health surveillance provides an important
“evidence-based” foundation for programme and
policy development
Ultimate goal is to strengthen country infrastructure
for establishing and maintaining surveillance
Close-up on surveillance
Data
Interpretation
Data
Analysis
Data
Collection
Program
Evaluation
Information
Dissemination
Program
Implementation
Program
Planning
Kathy Douglas, PhD; Department of NCDs Prevention and Health Promotion; WHO
Public health surveillance loop
Data
Interpretation
Data
Analysis
Data
Collection
Program
Evaluation
Information
Dissemination
Program
Implementation
Program
Planning
Kathy Douglas, PhD; Department of NCDs Prevention and Health Promotion; WHO
INTEGRATED DISEASE SURVEILLANCE
Definition
• Integration of various surveillance
activities with similar functions, nature
and common public service in one
system
ADVANTAGE OF IDS
• Cost saving and cost-effective
• Sustainable
• Comprehensive information on health
status
• Easy to access and to use for policy
decisions
LIMITATIONS OF IDS
• Different nature of diseases (acute,
chronic) and diagnosis methodology
require different approaches
• Reliability of surveillance information
• Different purpose of using surveillance
information
Causal Pathway of Disease
• Environment, Hazard/agent in
environment (pre-exposure)
• Behavior/risk factor
• Exposure
• Pre-symptomatic phase
• Apparent disease
• Disability or Death
LEVEL OF INTEGRATION
• No integration (vertical surveillance)
• Partial integration (separate from HIS)
– Integrated CD surveillance
– Integrated NCD surveillance
• Full integration (within national health
information system)
SURVEILLANCE: NO INTEGRATION
Communicable
Diseases (CD)
Activity
Reports
Morbidity,
Mortality
Noncommunicable
Diseases (NC D)
Morbidity,
Mortality
Activity
Reports
PARTIAL INTEGRATION
OF SURVEILLANE
Communicable
Diseases (CD)
Activity
Reports
Noncommunicable
Diseases (NC D)
Morbidity,
Mortality
Activity
Reports
INTEGRATED
HEALTH INFORMATION SYSTEM
Others
Disease
morbidity,
mortality
Activity reports
(immunization,
ORT, IUD, etc.)
Admin./
finance
Risk factors
Definition of Advocacy
Advocacy is a combination of
individual and social actions
designed to gain political and
community support for a particular
health goal or program.
Action may be taken by/or on
behalf of individuals and groups to
create living conditions which
promote health and healthy
lifestyles.
Health Promotion Glossary, WHO,
Geneva. 1998:5
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Why advocacy?
NCD prevention depends on action
beyond the health sector, and
requires appropriate policies
and investments from
government, industry, and
community organisations.
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Making the Burden of NCD understood
 Provide key messages that the general public, opinion
leaders, and the health and medical communities can
easily interpret and understand.
 Focus on topics that affect the peoples health in
important ways.
 Highlight problems that can be changed and will have
a substantial impact on the health of the population.
 Chose key messages that can be used in directing
public policies and programs.
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO
Keeping a Population-wide Focus
with choosing Risk Factors
• Focus on the mean or median, not % at high risk
• “Abnormal” is arbitrary
• Potential impact of screening is inevitably limited:
– Screening is expensive and difficult
– Treatment is imperfect
– Most cases derive from the “normal” range
• Primary prevention is cheap, safe, universally
applicable and potentially more effective
WHO STEPwise Approach to Surveillance of NCD Risk Factors
WHO