Prof.

Chheang Sena, (DUR, Fr)

20-21/June/2011 Shangri-La in Jakarta, Indonesia

General Overview Non-communicable disease preventions strategic plan

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Discussion Conclusion

NONCOMMUNICABLE DISEASES PREVALENCE AND RISK FACTORS IN CAMBODIA

STEPS Survey
2010

More than 200 million people worldwide have diabetes ! Most of them do not receive the care they need !

Demographic Cham province status Population Pyramid of Kompong

0.3 0.3 0.5 0.7 0.9 1 1.2 1.5 1.6 2.7 3.1 3.7 3.4 5.8 7.4 7.8 6.4
10 8 6 4 2 0 0 4 10 14 20 24 30 34 40 44 50 54 60 64 70 74 80+

0.4 0.4 0.7 0.9 1.1 1.3 1.6 2.1 2.5 3.2 3.5 4 3.8 5.9 6.9 7.5 6.1

M
Data Source Ministry of Planning & Ministry of Health 2005

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 DESIGN
Three subsequent steps : Followed WHO Stepwise Approach to chronic disease risk factor surveillance methodology (closed supervision by HQ, WPRO and WHO-Cambodia
STEP 1: STEP 2: STEP 3: Biochemical Face-to-face interview Physical Information on: measurements of : measurements of (1) tobacco use, (1) body weight and capillary blood to (2) alcohol use, height, determine (3) intake of fruits and (2) waist and hip (1) glucose vegetables circumferences, (2) total cholesterol at (4) physical activities, (3) body fat, sites (5) previously diagnosed (4) blood pressure, and Using dry chemical hypertension and (5) physical fitness methods. diabetes. Using specific tests/ devices relevant to these measurements.

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 old Stratified 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.

SURVEY POPULATION AND SAMPLING

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 ACHIEVED BY THE RESPONDENTS

Percent
50 40 30 20 10 0 25-34 35-44 45-54 55-64 25-34 35-44 45-54 55-64

MaleNo school
Secondary school Post graduate

Less primary school Primary school High school College/University

Female

TOBACCO USE

BURDEN OF SMOKING
The two main tobacco indicators that are associated with an increased risk of developing chronic diseases are:
Percent
60 50 40 30 20 10 0 Daily tobacco users Current tobacco users 18 19.8 33.7 37 Men Women Both 55.1 50.2

FREQUENCY OF SMOKELESS TOBACCO USE

Percent
14 12 10 8 6 4 2 0 Sn uff by m ou th 1 .2 0.50.5 1 .2 0 0.1 2 .92 .8 0 .3 C hew ing to b acco Bete l q uid 8.9 Male Fe m a le Both 1 3.12 .8 1

Sn u ff b y n os e

PERCENTAGE OF RESPONDENTS EXPOSED TO ENVIRONMENTAL TOBACCO SMOKE

Percent
60 50 42 .8 40 30 20 10 0 H om e Wo rkpla ce H om e /w orkpla ce 33 .3 33.3 48.5 4 1.1 44.9 37.2 32.7 36.4 28.3 U rba n R ura l Male Fe m a le Both 56 .2 5655.2 54.4 50.7

Net alcohol content of a standard drink is approximately 10g of Ethanol 1 STANDARD

PREVALENCE OF ALCOHOL CONSUMPTION

Percent
3.5 3 2.5 2 1.5 1 0.5 0 Urban Rural Both 0.2 0.5 0.4 Male Fem ale 3.5 3.4 3.4

HEAVY EPISODIC DRINKING

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
50 45 40 35 30 25 20 15 10 5 0 Male 46.2 39.5 45.1

Urban Rural Both 3.5 4.8 4.6

Female

EATING PATTERN

FREQUENCY OF FRUITS AND /OR VEGETABLES CONSUMPTION PER DAY

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
Percent 50
45 40 35 30 25 20 15 10 5 0 None 1-2 serv ing 3-4 serving 5+ serv ing Urban Rural M ale Female Both sex e

TYPE OF OIL OR FAT MOST OFTEN USED FOR MEAL PREPARATION IN HOUSEHOLD

MEALS EATEN OUTSIDE HOME

PHYSICAL ACTIVITY

PHYSICAL 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 CLASSIFIED INTO TRHEE CATEGORIES OF PHYSICAL ACTIVITY

Percent
80 70 60 50 40 30 20 10 0 Low Moderate High Urban Rural Male Fem ale Both s exe

PHYSICAL MEASUREMENT

PERCENTAGE OF BMI 25kg/m

Overweight: having BMI to 25 kg/m2 and below 30 kg/m2 Obesity: BMI greater than or equal to 30 kg/m2
Percent 40
35 30 25 20 15 10 5 0 25-34 35-44 45-54 55-64 25-34 35-44 45-54 55-64 Rural Urban

MALE

FEMALE

WAIST CIRCUMFERENCE & RISK IN DEVELOPING NCDs

Percent
100 8 88 5 .3 90 80 6 7 .3 70 60 50 40 2 3 .8 30 20 9 1 1 .8 9 .6 3 10 2 .1 .1 0 < 8 5 cm 8 5 - >9 4 cm 9 4 c m M a le 77 2 .6 6 5 7 .6 U rb a n R u ra l 2 3 .1 16 1 5 .5 .91 9 .3 81 0 .5 .4 B o th

<81cm

8 1 - >8 8 cm 8 8 c m Fe m a le

PREVALENCE OF HYPERTENTION
Percent
18 16 14 12 10 8 6 4 2 0 16.9 12.8 9.1 10 9.6 4.8 4.6

11.2

3.7

4.5

U rban

R ural

Male

Fem ale

Both

SBP 140m m H g/D BP 90m m H g SBP160m m H g/D BP100m m H g

PREVALENCE OF DIABETES
Percent 6
5 4 3 2 1 0 U rb a n R u ra l Ma le Fe m a le B o th 1 .7 3 .6 2 .3 1 .4 0 .8 2 .5 1 .8 1 .1 3 .3 1 .5 2 .9 1 .4 1 .3 5 .6

Im p a ire d fa s tin g g lyce m ia

R a is e d b lo o d g lu co s e

C u rre n t m e d ica tio n fo r D ia b e te s

PREVALENCE OF RAISED BLOOD CHOLESTEROL

Percent
35 30 25 20 15 10 5 0 Urban Rural Male Fem ale Both 7 2.5 2.5 3.9 3.2 18.3 17 24.2 20.7 32.5

Total choles terol5.0 m m ol/L Total choles terol6.2 m m ol/L

COMBINED RISK FACTORS OF NCDs

Percent
90 80 70 60 50 40 30 20 10 0 8 8 4 .2 8 4 .84 .5 80 7 8 .5 7 3 .8

1 0 .3 6 .7 5 .98 .78 .15 .8 0 ris k fa cto r 1 -2 ris k fa cto rs

1 5 .9 1 4 .1 1 5 .7 9 .1 6 .57 .3 3 -5 ris k fa cto rs

U rb a n R u ra l Ma le Fe m a le 1 5 -4 4 4 5 -6 4

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.
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 (SBP140 and/or DBP90mmHg), 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.
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.
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/m ) 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
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 countries Even 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 STATEMENT

To

prevent and control the significant and growing burden of noncommunicable diseases and their risk factors address the effects it has on individuals, families and society.

To

PRE-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, 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 Cambodia
In

Cambodia, noncommunicable diseases are not well known. integrated Cambodia in Asian country and if the estimated prevalence 2.1% is true, by the year 2025 we believe that more than 283 000 Cambodian people ( 45-64 years old) will be affected by diabetes.
It is not so early to act from now !

With

Historic of diabetes activities in Cambodia

1998 a group of health professional initiated to conduct a preliminary study on diabetes prevalence. CDA was set up and start to perform their activities from 1998 . In 1999, Preliminary study, for determining the Diabetes prevalence in Kompong Cham province, was initialized ( Sena C, et al. 2002) In 2001 first world diabetes day was celebrated in Cambodia. In 2004,Pre-survey on diabetes prevalence was conducted by MOH of Cambodia and CDA. In 2006, national strategy of non-communicable diseases was established and adopted by MHO and first World Diabetes Day celebration in Kg Cham province. 2007, IDF training in Phnom Penh

About 80 % of diabetes people are undiagnosed

Preliminary survey in Kompong Cham province

Objective of the survey: Diabetes prevalence Date of activity: started from 1999 to 2002 Sample size: 520 subjects Survey site: Kompong Cham district Criteria adopted: WHO, 1999 Result: 13.4 % ( age category: 34y-64y) Conclusion:

- 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

Preliminary Diabetes prevalence study in Kompong Cham province 2002

RESULTS
Tranche dge (anne) Nombre total de sujets Nombre de sujet ayant une glycmie (mg/dl) <100 Homme + Femme N % 100-109 Homme + Femme N % >110 Homme + Femme N %

<34 34-64 >64

23 440 57

22 365 41

95,6 83,0 71,9

0 16 5

0 3,6 8 ,8

1 59 11

4,3 13,4 19,3

N : nombre des personnes % : pourcentages dtermins en fonction du nombre de sujets de la tranche dge

SRATEGY OF THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES, CAMBODIA 2007-2010

MOH WORKSHOP (02-03/ 10/ 2006)

VISION 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 POLYCY 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 control in the 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 GOALS
The

significant and growing burden of diabetes must be prevented and controlled in the country. care is for everyone

NCDs

Critical Matrix Analysis

Criteria Low Impact Significant Major

U R G E N T

Low

5-Disadvantaged and 3-Traditional myth vulnerable of behavior. community

Significant

2-Lack of human 1- Lack of net resource 3 work and diabetes 2 institutional management

Pressing

4-NCDs is not 1 well known in the country.

PLANNING WORKSHEET-1
CAMBODIA
Issue 4-Diabetes is not well known in the country and

Plan Period: Jan/2009-Dec/2011

With assumption The detail is in appendix-1,2,3

province

Objective-1: Promote the public awareness on NCDS burden and healthy lifestyle in the Community. Strategies Action steps
Responsible Organization

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, selfmanagement, leaflet, palm let, brochure, Gazetteetc

-CDA

14 Nov

-400 participants had attended - Report of activity at two HC every month

-NGOs -CDA -MOH

-CDA & PHD-MOH

Every month

-Feb-09

- Diet pyramid -NGOs poster Leaflet, -CDA Brochure, T-MOH Shirt, and Newsletters was print out.

PLANNING WORKSHEET-2
CAMBODIA
Issue1- Lack of net work and diabetes institutional management

Plan Period: Jan/2009-Dec/2011

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 Jan of year

Indicator targets

Resource / Bud-get

1-Advocate among 1- Arrange an -CDA health professional and orientation - Drug food donors to increase workshop bureau of awareness of the PHD-DDF diabetes burden for 2-Conduct partner meeting starting up the program activity

-Provincial net work was formed & Structure Quarterly and role of working group was received. Report of activities

CDA NB & NGOs

2-Devolep framework for 1-Select a hospital as Providing care of pilots patients in the hospitals 2-Running NCDs clinics 3-Staff spplement. 4-Develop protocol of care and prevention protocol for the clinics 5-Peer education & care 6-Create HIS network

-CDA -Feb-10 -PHD working group -Feb-09 -And referral hospital -Nov-10 director -Mar-09 -QTR

NB & NGOs CDA

PLANNING WORKSHEET-3
CAMBODIA
Issue-2:Lack of human resource

Plan Period: Jan/2009-Dec/2011

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 Establish a PHD PHD Director Sep-11 program in the province working group for running NCD program

A working group NB that has a secretariat from nutrition unit -25 trainees from WDF RH & HC were NGOs trained NB

1-Providing the quality of NCDs education and care skill to medical practitioners, clinic staffs.

1-Develop curriculum of the training 2-select the trainers 3-select the trainees 4-Financial support request 5-Monitoring and evaluation program 1-Provide the regular update and refreshment training in diabetes

-NCDs working group

Oct-11

2-Strengthening the quality of diabetes educator and medical practitioner skill.

-NCD working -Dec of group every year

-25 trainees from WDF RH & HC were NGOs attended NB In the training CDA

CAMBODIA
community

PLANNING WORKSHEET-3

Plan Period: Jan/2009-Dec/2011

With assumption The detail is in appendix-7,8

Issue-5: Disadvantaged and vulnerable of

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 1-Develop health equity -NCD working 2009financial support for fund and health group 2011 poor patients from insurance schemes government and others 2-Request the support the donors program from MOH

-Schemes were NB drafted NGOs NB - The program was approve by MOH

2-Strengthening the quality of diabetes care including health insurance and equity fund Skill among health professional

1-Establish a workshop for -NCD working 2009running the program group 2011 2-Providing the training to key staff for running the program

-15 trainees from WDF RH & HC were NGOs attended NB In the training

3- Establishing the 1-Governmental Community Foundation Authorization for supporting and 2-Action plan sustaining program 3-Implementate 4-Quality Improvement

-NCD working Dec-2011 -Authorize letter WDF group NGOs -CDA -Reports NB CDA

CONCLUSION

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 !