The Burden and Determinants of Non Communicable Diseases Risk Factors in Nepal

18 Pages·2015·0.29 MB·English

RESEARCHARTICLE
The Burden and Determinants of Non
Communicable Diseases Risk Factors in
Nepal: Findings from a Nationwide STEPS
Survey
KrishnaKumarAryal1☯*,SureshMehata2☯,SushhamaNeupane1,AbhinavVaidya3,
MeghnathDhimal1,PurushottamDhakal1,SangeetaRana1¤,ChopLalBhusal4,Guna
RajLohani5,FrankHerbertPaulin6,RenuMadanlalGarg7,ReginaGuthold8,
MelanieCowan8,LeanneMargaretRiley8,KhemBahadurKarki1
1 NepalHealthResearchCouncil(NHRC),GovernmentofNepal,Kathmandu,Nepal,2 NepalHealthSector
SupportProgramme(NHSSP),MinistryofHealthandPopulation,GovernmentofNepal,Kathmandu,Nepal,
3 KathmanduMedicalCollege,Kathmandu,Nepal,4 InstituteofMedicine,TribhuvanUniversityTeaching
Hospital,Kathmandu,Nepal,5 MinistryofHealthandPopulation,GovernmentofNepal,Kathmandu,Nepal,
6 WorldHealthOrganizationCountryOffice,Kathmandu,Nepal,7 WorldHealthOrganizationRegional
OfficeforSouthEastAsia,NewDelhi,India,8 WorldHealthOrganizationHeadquarter,Geneva,Switzerland
OPENACCESS ☯Theseauthorscontributedequallytothiswork.
¤ CurrentAddress:LondonBoroughofMerton,London,UnitedKingdom
Citation:AryalKK,MehataS,NeupaneS,VaidyaA, * [email protected]
DhimalM,DhakalP,etal.(2015)TheBurdenand
DeterminantsofNonCommunicableDiseasesRisk
FactorsinNepal:FindingsfromaNationwideSTEPS
Abstract
Survey.PLoSONE10(8):e0134834.doi:10.1371/
journal.pone.0134834
Editor:RudolfKirchmair,MedicalUniversity
Innsbruck,AUSTRIA Background
Received:January16,2015 WorldHealthOrganization(WHO)estimatesfordeathsattributedtoNonCommunicable
Accepted:July15,2015 Diseases(NCDs)inNepalhaverisenfrom51%in2010to60%in2014.Thisstudy
assessedthedistributionanddeterminantsofNCDriskfactorsamongtheNepaleseadult
Published:August5,2015
population.
Copyright:©2015Aryaletal.Thisisanopen
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,whichpermits MethodsandFindings
unrestricteduse,distribution,andreproductioninany
Anationallyrepresentativecross-sectionalsurveywasconductedfromJantoJune2013
medium,providedtheoriginalauthorandsourceare
credited. ontheprevalenceofNCDriskfactorsusingtheWHONCDSTEPSinstrument.Amultistage
clustersamplingmethodwasusedtorandomlyselectthe4,200respondents.Theadjusted
DataAvailabilityStatement:DataarefromtheNon
CommunicableDiseasesRiskFactors:STEPS prevalenceratio(APR)wasusedtoassessthedeterminantsofNCDriskfactorsusinga
SurveyNepal2013andareavailablewithinthepaper Poissonregressionmodel.Theprevalenceofcurrentsmoking(last30days)was19%
anditsSupportingInformationfiles.Theauthorscan (95%CI:16.6-20.6),andharmfulalcoholconsumption((cid:1)60gofpurealcoholformenand
becontactedat [email protected](KKA)and
(cid:1)40gofpurealcoholforwomenonanaverageday)was2%(95%CI:1.4-2.9).Almostall
[email protected](KBK)forfurtherclarificationif
required. (99%,95%CI:98.3-99.3)oftherespondentsconsumedlessthanfiveservingsoffruitsand
vegetablescombinedonanaveragedayand3%(95%CI:2.7-4.3)hadlowphysicalactivity.
Funding:ThisstudywasfundedbyGovernmentof
NepalandWHOCountryOfficeNepal. Around21%(95%CI:19.3-23.7)wereoverweightorobese(BMI(cid:1)25).Theprevalenceof
raisedbloodpressure(SBP(cid:1)140mmofHgorDBP(cid:1)90mmofHg)andraisedbloodglu-
CompetingInterests:Theauthorshavedeclared
thatnocompetinginterestsexist. cose(fastingbloodglucose(cid:1)126mg/dl),includingthoseonmedicationwere26%(95%
PLOSONE|DOI:10.1371/journal.pone.0134834 August5,2015 1/18
NCDRiskFactors:STEPSSurveyNepal
CI:23.6-28.0)and4%(95%CI:2.9-4.5)respectively.Almostonequarterofrespondents,
23%(95%CI:20.5-24.9),hadraisedtotalcholesterol(totalcholesterol(cid:1)190mg/dlorunder
currentmedicationforraisedcholesterol).hestudyrevealedalowerprevalenceofsmoking
amongwomenthanmen(APR:0.30;95%CI:0.25-0.36),andinthosewhohadhigheredu-
cationlevelscomparedtothosewithnoformaleducation(APR:0.39;95%CI:0.26-0.58).
Harmfulalcoholusewasalsolowerinwomenthanmen(APR:0.26;95%CI:0.14-0.48),and
inTerairesidentscomparedtohillresidents(APR:0.16;95%CI:0.07-0.36).Physicalinactiv-
itywasloweramongwomenthanmen(APR:0.55;95%CI:0.38-0.80),howeverwomen
weresignificantlymoreoverweightandobese(APR:1.19;95%CI:1.02-1.39).Beingover-
weightorobesewassignificantlylessprevalentinmountainresidentsthaninhillresidents
(APR:0.41;95%CI:0.21-0.80),andinruralcomparedtourbanresidents(APR:1.39;95%
CI:1.15-1.67).Lowerprevalenceofraisedbloodpressurewasobservedamongwomen
thanmen(APR:0.69;95%CI:0.60-0.80).Higherprevalenceofraisedbloodglucosewas
observedamongurbanresidentscomparedtoruralresidents(APR:2.05;95%CI:1.29-
3.25).Ahigherprevalenceofraisedtotalcholesterolwasobservedamongtherespondents
havinghighereducationlevelscomparedtothoserespondentshavingnoformaleducation
(APR:1.76;95%CI:1.35-2.28).
Conclusion
Theprevalenceoflowfruitandvegetableconsumption,overweightandobesity,raised
bloodpressureandraisedtotalcholesterolismarkedlyhighamongtheNepalesepopula-
tion,withvariationbydemographicandecologicalfactorsandurbanization.Prevention,
treatmentandcontrolofNCDsandtheirriskfactorsinNepalisanemergingpublichealth
probleminthecountry,andtargetedinterventionswithamulti-sectoralapproachneedtobe
urgentlyimplemented.
Introduction
Theemergingpandemicofnon-communicablediseases(NCDs)iscreatingmajorhealthchal-
lengesworldwide.Ofthe56millionglobaldeathsin2012,38million(68%)wereattributedto
NCDs,withalmostthreequarters(74%)ofthesedeathsoccurringinlowandmiddleincome
countries[1].TheWorldHealthOrganization(WHO)estimatesthatdeathsattributedto
NCDsinNepalhaverisenfrom51%in2010to60%in2014[2,3].Ahospital-basedstudyin
NepalestimatedtheprevalenceofNCDsinnon-specialisthealthinstitutionstobe31%,indi-
catingthatNepal,likeotherdevelopingnations,isfacingthegrowingburdenofNCDs[4].
Thesediseasesaredrivenbymanyfactorsincludingageing,rapidunplannedurbanisationand
unhealthylifestyles[5].AlthoughNCDsconstituteamajorpublichealthprobleminNepal,
howbesttoaddressNCDsattheprimaryhealthcarelevelinNepalisnotunderstood[6].
Eightmajorriskfactors(fourbehaviouralandfourbiological)contributemosttothedevel-
opmentofNCDs[7].Tobaccouse,harmfuluseofalcohol,unhealthydiets(highinsalt,sugar
andfatandlowinfruitsandvegetables)andphysicalinactivityareestablishedmodifiable
behaviouralriskfactorsforNCDs[7].Amongthese,useoftobaccoandalcoholismostcom-
moninNepal[8].Previousstudieshavereportedahighprevalenceoftobaccouseinanyform,
especiallyamongmen(52%inmalesand13%infemales)[9].Unhealthydietisanothermajor
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NCDRiskFactors:STEPSSurveyNepal
challengeinNepal.Highsaltintakeismoreprominentamongtheruralpopulation,whomake
up83%ofthetotalpopulationofthecountry[9].Lowfruitandvegetableconsumptionis
attributedtopoverty,lackofpurchasingpowerandincreasingage[10].Inaddition,although
physicalinactivityisnotamajorprobleminthegeneralpopulation,itisclusteredinurbanand
semi-urbanpopulations[11],includinginchildrenandadolescents.Thismaybeduetorapid
andunplannedurbanisation,changesinlifestyleandglobalization[12].The2007/08national
surveyofNCDriskfactorsgaveanationalpictureofbehaviouralandselectedbiologicalrisk
factors(overweight,obesityandraisedbloodpressure)usingSTEPIandII[8].Periodicevi-
denceincludingadditionalbiologicalriskfactorsusingallthreestepswasfeltnecessaryto
developanationalactionplanforpreventionandcontrolofNCDs,andimprovethedesign
andimplementationofpreventivemeasuresandpublichealthinterventionstoreducethebur-
denofNCDsinNepal.Theneedwasfurtherwarrantedasthereareincreasingreportsofout-
patientvisitsandinpatientadmissionsattributedtoNCDswith84%oftotalOPDvisitsand
90%oftotalinpatientsdischargedfromhospitalsaccountingforNCDsaspertheannualreport
ofdepartmentofhealthservicesfortheyear2011/12[13].
Thisstudyassessedtheepidemiologicdistributionanddeterminantsofriskfactorsfor
NCDsintheadultNepalesepopulation;specifically,theprevalenceanddeterminantsofbeha-
viouralandbiologicalriskfactorsforselectedNCDsinNepal.
Methodology
Studydesignandsamplingtechnique
Anationallyrepresentativecross-sectionalsurveywasconductedfromJantoJune2013onthe
prevalenceofNCDriskfactorsusingtheWHONCDSTEPSinstrument.Amultistagecluster
samplingmethodwasusedtoselect4,200respondentsaged15to69years.Samplesizewascal-
culatedusingtheprevalenceoflowfruitsandvegetablesintake(61.9%)fromthe2007STEPS
survey[8]withanexpectedresponserateof80%assuggestedintheSTEPssurveyguideline
[14].Theprimarysamplingunit(PSU)ofthissurveywastheIlaka(anadministrativeunitat
thesub-districtlevel).EachIlakacomprisesofeithera.4to6villagedevelopmentcommittees
(VDCs)b.4to8wardsofmunicipalitiesorc.2to3VDCswith4to6wardsofmunicipalities
combinedtogether.Outofthe921IlakasinNepal,70wereselectedusingprobabilitypropor-
tionatetosize(PPS).The70IlakaswereproportionatelydistributedacrossNepal’sthreeeco-
logicalbelts;mountains(5Ilakas),hills(30Ilakas)andtheTerai(35Ilakas),basedonthe
populationproportionaccordingtotheNationalPopulationandHousingCensus2011of
Nepal[9].MountainsreferstothehighmountainHimalayanregion,hillsreferstoadjacent
regioninaloweraltitudinalbeltwhiletheTeraireferstothelowestterraininthecountry
rangingfrom70to700metresabovethesealevel.IndividualwardsinVDCsormunicipalities
wereconsideredasclustersandtheseclustersweretakenasthesecondarysamplingunit
(SSU).AwardisthelowestlevelintheadministrativedivisionandeachVDCiscomposedof9
wards,whereasnumberofwardsineachmunicipalityrangesfrom9to35.Threeclusterswere
selectedfromeachofthesampledIlakasusingthePPSsamplingmethod,leadingtotheselec-
tionof210wards.Twentyhouseholdswereselectedfromeachclusterusingsystematicrandom
sampling.Oneparticipantoftheeligiblecandidates(15–69years)ineachselectedhousehold
wasselectedtotakepartinthesurveyusingtheKishmethod[14].Ofthe4,200adults(15–69
years)targeted,wehad4143adultsparticipateinSTEPI(responserate98.6%),4,124inSTEP
II(responserate98.2%)and3,772inSTEPIII(responserate89.8%).
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NCDRiskFactors:STEPSSurveyNepal
DataCollection
ThesurveywasconductedusingtheWHONCDSTEPSinstrumentversion2.2[15],which
prescribesthreestepsformeasuringNCDriskfactors.STEPImeasuresbehaviouralriskfac-
tors,STEPIIcoversphysicalmeasurements,andSTEPIIImeasuresbiologicalriskfactors.
Socio-demographicinformationonageandgender,education,maritalandworkstatus,aswell
asinformationontobaccouse,alcoholconsumption,fruitandvegetableconsumption,physi-
calactivity,andhistoryofchronicconditionswascollectedbytrainedinterviewersinface-to-
faceinterviews.Weusedwetchemistrytomeasurebiologicalriskfactors.
Currentsmoking. Questionsandpictorialshowcardsoftobaccoproductswereusedto
identifycurrentusers(thosewhohadsmokedinthepast30days).
Alcoholconsumption. Questionswereaskedtodeterminethepercentageoflifetime
abstainers,past12monthsabstainersandcurrentusersofalcoholusingtheWHOprotocol.
Consumptionof(cid:1)60gmofpurealcoholformenand(cid:1)40gmofpurealcoholforwomenon
anaveragedayinthepast30dayswasconsideredharmfuluse[14].Toencouragerespondents
todisclosethealcoholandtobaccoconsumptionhabits,wemaintainedprivacyduringinter-
viewsandensuredrespondentsthatresponseswouldbereportedanonymously.
Diet. Informationwasrecordedonthenumberofdaysthatrespondentsconsumedfruit
andvegetablesinatypicalweek,andthenumberofservingsoffruitandvegetablesconsumed
onaverageperday.Lessthanfiveservingsoffruitsandvegetablesperdaywasconsidered
insufficientfruitandvegetableintake[14].
Physicalactivity. PhysicalactivitywasassessedusingtheGlobalPhysicalActivityQues-
tionnaire(GPAQ)[16].TheGPAQasksrespondentsaboutactivityfortransportpurposes,vig-
orousandmoderateactivityatwork,andvigorousandmoderateactivityinleisuretime,and
timespentsitting.Show-cardswithculturallyrelevantexampleswereusedtoaidrespondents
inclassifyingactivities.Analysisandcategorizationfollowedexistingguidelines[15,17],and
thosewhodidnotmeetthecriteriaforvigorousandmoderateintensityactivitieswerecatego-
risedashavinglowphysicalactivity.
Historyofraisedbloodpressureandbloodglucose. Participantswereaskedabouttheir
historyofraisedbloodpressureorbloodglucoseandtreatmentadvisedbyadoctortocontrol
these(suchasmedicinesprescribed,aspecialdiettobefollowed,advicetoreducesaltintake,
loseweight,stopsmoking,ordomoreexercise).
Physicalmeasurements. UsingtheSTEPSprotocolandrecommendedinstruments
ensuredaccuracyofheightandweightmeasurements,BMIcalculationsandbloodpressure
measurements.Heightandweightweremeasuredandbodymassindex(BMI)calculated
accordingtotheprotocol.Heightwasrecordedincentimetresusingaportablestandardstature
scale.Weightwasrecordedinkilogramsusingaportabledigitalweighingscale(Seca,Ger-
many).Waistandhipcircumferencewasmeasuredincentimetresusingconstanttensiontapes
(Seca,Germany)[14].ABMIof(cid:1)30.0andbetween25.0and29.9wasconsideredobeseand
overweight,respectively.
Bloodpressuremeasurement. Bloodpressurewasmeasuredusingadigital,automated
bloodpressuremonitor(OMRONdigitaldevice,OMRON,Netherlands)withanappropriate
sizedcuff.Raisedbloodpressurewasdefinedashavingsystolicbloodpressure(cid:1)140mmHg
and/ordiastolicbloodpressure(cid:1)90mmHgduringthestudy,orbeingpreviouslydiagnosedas
havinghypertension.Thiswasdeterminedbydocumentationsuchasatreatmentrecordbook,
orparticipanthistoryofmedicationforhighbloodpressure[14].
Biochemicalmeasurements. Amobilelaboratorywasusedindatacollection.Themobile
laboratorycontainedlogisticsandhumanresourcesrequiredincludingasemi-autoanalyser
andallofthechemicalsrequiredforbloodglucosetestingandlipidprofilemeasurements.For
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NCDRiskFactors:STEPSSurveyNepal
preservationofthechemicalsusedforthetestsandensuringthatthecoldchainwasmain-
tainedforcollectedsamples,continuousrefrigerationwasensuredusinganelectricgenerator.
Fastingsamplesweretakentomeasurebloodglucoseandbloodlipidsandmeasuredusingthe
wet(liquid)method.Participantswereinstructedtofastovernightfor12hoursanddiabetic
patientsonmedicationwereremindedtobringtheirmedicine/insulinwiththemandtake
theirmedicineafterprovidingthebloodsample.Avenousbloodsample(4mlofblood)was
takenusingaflashbackneedlewithanaseptictechniqueandkeptinplainandfluoridetreated
tubes.Thosesampleswerekeptinanicepackcarrierandbroughttothemobilelaboratory
withinonehour.Biochemicalmeasurementsofbloodglucoseandlipidsweredoneusingsemi-
automatedprocedures(Bioanalyzer,Analyticon,Germany)andcommerciallyavailablekits
(Analyticon,Germany).PlasmaglucosewasestimatedusingtheGOD-PAP(glucoseoxidase/
peroxidise–phenol-4-amenophenazone)method.Serumtotalcholesterolwasdeterminedby
anenzymaticendpointmethodusingtheCHOD-PAP(cholesteroloxidase/peroxidase–4-phe-
nol-aminoantipyrine)method[18].Participantswithbloodglucoselevel(cid:1)126mg/dlorcur-
rentlyundermedicationforraisedbloodglucosewereconsideredashavingraisedblood
glucose.Thelipidprofileincludedtotalcholesterol,triglyceridesandHDLcholesterol.LDL
cholesterolcalculatedusingtheaforementionedthreeparametersofcholesterol.Thecutoff
pointforraisedtotalcholesterolwas(cid:1)190mg/dl.Ateamofmedicallaboratorytechnologists,
medicallaboratorytechniciansandpathologistusedapredefinedprotocolincludingroutine
calibrationforensuringtestaccuracy.
Datawascollectedelectronicallyusingpersonaldigitalassistants(PDAs)programmedwith
WHOe-STEPSsoftware.
Dataprocessingandanalysis
DatacollectedonPDAswasdownloadedontocomputersusingaWindowsMobileDevice
Centre.Filesoneachparticipant(questionnaire,bodymeasurements,biochemicalmeasure-
mentsandKishdata)werethenmergedusingtheparticipantidentity(PID)numbercross-
checkedwithparticipantnameandidentificationnumber.Aftermerging,commonvariables
inthedatasetwerematchedandinconsistencieswerecorrected.Datacleaningwasdoneusing
SPSSandanalysiswasdonewithSTATA12.0SEversion.
Allestimateswereweightedbysampleweightsandpresentedwith95%ConfidenceInter-
vals(CIs).Furtherstratificationbyindividualcharacteristics(age,gender,educationandmari-
talstatus)andclustercharacteristics(ecologicalzoneandplaceofresidence)wereincludedin
thisanalysis.Prevalenceestimateswiththeir95%CIswerecalculatedusingTaylorseriesline-
arization.Chi-squarestatisticswereusedtotestassociationsbetweencovariatesandriskfac-
tors.Adjustedprevalenceratio(APR)wascalculatedusingmultiplePoissonregression,with
allcovariates(age,gender,education,maritalstatus,ecologicalzoneandplaceofresidence)
includedsimultaneouslyinthemodelinordertoassessthedeterminantsofNCDriskfactors.
TheAPRsratherthanoddsratiosallowedustocomparetherelativestrengthsofassociationin
amannerthatwasnotbiasedbywhetherariskfactorswasrareorcommon[19].Toreflect
clusteringwithinindividuals,weconsideredthenumberofriskfactorsthateachrespondent
hadatthetimeofthesurvey(from0to8)andexaminedthemeannumberandCIsofriskfac-
torsbycovariates.Weexaminedtheindependenteffectsofcovariatesonriskfactorclustering
withinindividualsbymodelingamultiplePoissonregression,withthenumberofriskfactors
asthedependentvariable.Alltheanalysiscarriedoutwasusingcomplexsurveydesign;wards
wereconsideredasclusterandecologicalzonesasstrata.Ap-value<0.05wasconsideredas
statisticallysignificant.
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NCDRiskFactors:STEPSSurveyNepal
EthicalConsiderations
ThisstudywasapprovedbytheEthicalReviewBoard(ERB)oftheNepalHealthResearch
Council(NHRC).Formalpermissionwastakenfromauthoritiesintheselecteddistricts,
VDCsandmunicipalities.Informedwrittenconsentwasobtainedfromallparticipants.Inthe
caseofminors(<18yearsold),writtenconsentwasfirstobtainedfromthenextofkinand
thenfromallchildparticipants.Theobjectivesoftheresearchwereexplainedinsimplelan-
guage,andparticipantswerealsoprovidedwithaninformationsheetcontainingtheresearch
objectives,datacollectionmethods,theroleofparticipants,personalandcommunitybenefits,
aswellasanypotentialharmtoparticipants.Aparticipantfeedbackformwasalsoprovidedto
allparticipantsaftertakingtheirphysicalandbiochemicalmeasurements.Theconfidentiality
oftheinformationgatheredwasmaintained.Anywastegeneratedduringthelaboratoryproce-
dureswasproperlydisinfectedusingaseptictechniquesandsafelydisposedof.Allbloodsam-
pleswerediscardedaftercompletingbiochemicalmeasurements.
Results
Characteristicsofparticipantsenrolledinthestudy
Thesocio-demographiccharacteristicsofthesamplepopulationarepresentedin"Table1".
Thesamplepopulationwasjustovertwothirdswomen(68%women;32%men).Theage
rangeofthesamplewas24%inthe15–29yearsagegroup,38%inthe30–44yearsagegroup
and39%inthe45–69yearsagegroup.Therural/urbanmakeupofparticipantswas82%from
ruralareasand18%fromurbanareas.Theproportionofrespondentsfromthemountains,
hillsandTeraibeltswassimilartotheirnationalproportions,withabout50%fromtheTerai,
43%fromthehilland7%fromthemountainregion.Nearlyhalfofparticipants(45%)didnot
haveanyformalschooling,and86%werecurrentlymarried.
Behaviouralriskfactors
Tobaccoconsumption. Theoverallprevalenceofcurrentsmokingwas19%(95%CI:
16.6–20.6)"Table2",withthehighestprevalenceamongadultsaged45–69yearsold(29%,
95%CI:25.8–31.6).Moremen(27%)smokedthanwomen(10%).Theprevalenceofsmoking
washigherinresidentsofruralareas(20%,95%CI:17.8–22.2)comparedtothoseinurban
areas(12%,95%CI:9.1–16.7),andhigheramongthosewhohadprimaryeducation(26%,95%
CI:21.7–30.2)comparedtothosewhohadhighereducation(10%,95%CI:6.5–13.8).
Alcoholconsumption. Harmfulalcoholconsumptionwasobservedin2%(95%CI,1.4–
2.9)ofparticipants"Table2".Ahigherprevalencewasobservedamongmen(3%,95%CI:2.1–
4.6)comparedtowomen(1%,95%CI:0.5–1.6),andinmountains(6%,95%CI:2.1–14.7)
comparedtotheTerai(<1%,95%CI:0.3–1.0).
Fruitsandvegetablesintake. Almosttheentirestudypopulation(99%)hadinsufficient
fruitandvegetableintakeaccordingtoWHOrecommendations"Table2".Urbanrespondents
hadaslightlylowerprevalenceofinsufficientfruitandvegetableintake(97%,95%CI:94.8–
98.4)comparedtothosefromruralareas(99%,95%CI:98.7–99.6).
Physicalactivity. Lowphysicalactivitywasprevalentamong3%(95%CI:2.7–4.3)ofthe
respondents"Table2".Thoseaged45–69hadthehighestprevalence(6%,95%CI:5.0–8.0).
Comparedtowomen(2%,95%CI:1.9–3.1),menhadahigherprevalenceoflowphysicalactiv-
ity(5%,95%CI:3.3–6.1).Likewise,lowphysicalactivitywasmoreprevalentinTerairesidents
(5%,95%CI:3.7–6.3)comparedtomountainresidents(<1%,95%CI:0.1–1.9).
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NCDRiskFactors:STEPSSurveyNepal
Table1. Characteristicsofparticipantsenrolledinthestudy.
Characteristics Un-weightednumber Un-weightedPercent(%) WeightedPercent(%)
Agegroup
15–29 972 23.5 46.5
30–44 1,558 37.6 26.8
45–69 1,613 38.9 26.7
Gender
Men 1,336 32.2 49.1
Women 2,807 67.8 50.9
Levelofeducation
Noformal 1,851 44.7 30.6
Primary 1,021 24.6 25.4
Secondary 773 18.7 25.3
Higher 498 12.0 18.6
MaritalStatus*
Nevermarried 336 8.1 18.7
Currentlymarried 3,567 86.1 78.0
Divorced/Widowed/Separated 237 5.8 3.3
Ecologicalzone
Mountain 297 7.1 6.5
Hill 1,768 42.9 42.8
Terai 2078 50.0 50.6
Placeofresidence
Rural 3,366 81.5 80.9
Urban 777 18.5 19.1
*2refusedtoanswerhencetotalresponseis4,141
doi:10.1371/journal.pone.0134834.t001
Biologicalriskfactors
Bodymassindex. Overweightandobesitycombinedwasobservedin21%ofparticipants
"Table2".Almost30%(95%CI:26.2–33.7)ofrespondentsaged30–44yearshadabodymass
index(cid:1)25kg/m2.Ahigherprevalenceofoverweightandobesitywasobservedamongrespon-
dentswhoresidedinthehills(26%,95%CI:22.5–30.3),urbanareas(31%,95%CI:25.4–37.1)
andthosecurrentlymarried(25%,95%CI:22.1–27.2)comparedtothosewhoresidedinthe
mountains(9%,95%CI:4.6–17.0),ruralareas(19%,95%CI:17.0–21.6)andthosenevermar-
ried(8%,95%CI:5.4–12.1),respectively.
Bloodpressure. Theprevalenceofraisedbloodpressure,includingthosewhowere
onmedicationforhypertensionwas26%(Table2).Higherprevalencewasobservedamong
thoseaged45–69years(47%,95%CI:43.4–50.0),men(31%,95%CI:27.8–34.6),andthose
divorced/widowed/separated(41%,95%CI:33.6–49.1)comparedtothoseaged15–29years
(13%,95%CI:10.7–16.4),women(21%,95%CI:18.6–22.8)andthosenevermarried(13%,
95%CI:9.6–18.5),respectively.
Bloodglucose. Fourpercentofthestudyparticipantshadraisedbloodglucose"Table2".
Theprevalencewashigheramongthoseaged45–69years(9%,95%CI,7.1–10.6)andresidents
fromurbanareas(7%,95%CI:4.5–9.1)comparedtothoseaged15–29years(1%,95%CI:0.4–
2.0)andthosefromruralareas(3%,95%CI:2.3–3.8)respectively.
Serumcholesterol. Raisedtotalcholesterolwasobservedin23%(95%CI:20.5–24.9)of
participants"Table2".Higherprevalencewasobservedamongthoseaged45–69years(33%,
PLOSONE|DOI:10.1371/journal.pone.0134834 August5,2015 7/18
NCDRiskFactors:STEPSSurveyNepal
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o 8.
o – – – – – – – – – 1 – – – – –
years. sedblssure%CI) 3(10.74) 6(23.31) 7(43.40) 001 1(27.86) 6(18.68) 001 6(26.58) 8(21.46) 5(19.50) 7(19.11) 73 –4(9.6 0(25.75) 1(33.61) 001 9(22.46) 2(16.88) 1(23.22) 30
–69 Raipre(95 13.16. 26.30. 46.50.<0. 31.34. 20.22.<0. 29.32. 24.28. 23.28. 23.29. 0.0 13. 28.30. 41.49. <0. 25.29. 22.28. 26.29. 0.6
5
1
esamongaged Overweightorobesity(95%CI) –13.4(11.116.0) –29.8(26.233.7) –26.9(23.730.4) <0.001 –21.0(18.224.3) –21.8(19.524.2) 0.661 –18.8(16.121.8) –21.8(18.525.5) –23.2(19.527.4) –22.8(18.627.6) 0.212 –8.2(5.412.1) –24.5(22.127.2) –22.9(17.130.0) <0.001 –26.2(22.530.3) –9.0(4.617.0) –18.9(16.421.7) <0.001
s
a
municabledise Lowphysicalactivity(95%CI) –2.3(1.34.0) –2.5(1.54.0) –6.4(5.08.0) <0.001 –4.5(3.36.1) –2.4(1.93.1) 0.001 –3.9(2.95.1) –3.2(2.14.9) –2.6(1.44.9) –4.0(2.46.6) 0.562 –3.0(1.46.2) –3.3(2.64.3) –8.1(5.012.7) 0.099 –2.2(1.43.5) –0.5(0.11.9) –4.8(3.76.3) <0.001
m
o
c
forselectednon- fiInsufcientfruitandvegetableintake(95%CI) –99.0(97.899.5) –99.0(97.899.5) –98.7(97.799.2) 0.787 –98.9(97.899.4) –98.9(98.199.4) 0.889 –99.6(98.699.9) –99.1(98.199.6) –99.0(97.499.6) –97.4(97.498.7) 0.012 –98.3(95.699.4) –99.0(98.499.4) –98.7(95.899.6) 0.404 –98.7(97.699.3) –99.3(96.999.8) –99.0(98.099.5) 0.760
s
r
gicalriskfacto Harmfuluseofalcohol(95%CI) –1.1(0.42.8) –2.9(1.75.0) –2.7(1.84.1) 0.082 –3.1(2.14.6) –0.9(0.51.6) <0.001 –1.9(1.23.0) –2.9(1.74.9) –2.2(1.04.7) –0.7(0.14.4) 0.287 –0.7(0.14.7) –2.3(1.63.3) –2.4(0.96.8) 0.224 –3.1(2.05.0) –5.7(2.114.7) –0.6(0.31.0) <0.001
o
ol
bi – –6 –8 –8 – –3 –7 –4 – –9 –7 –9 –0 –2
vioraland Currentsmoking(95%CI) 11.4(8.914.6) 20.7(17.24.2) 28.6(25.31.6)<0.001 27.0(23.30.5) 10.3(8.812.0)<0.001 22.1(19.25.1) 25.7(21.30.2) 13.5(10.17.3)–9.5(6.513.8)<0.001 10.2(6.814.9) 20.0(17.22.3) 29.1(21.37.8) <0.001 19.9(16.23.2) 24.6(15.37.5) 16.5(14.19.1) 0.147
a
h d
ofbe ghter(N)
ce(%) Un-weinumbe 972 1,558 1,613 1,336 2,807 n 1,851 1,021 773 498 336 3,568 237 1,800 300 2,100
n o
Table2.Prevale Agegroup–1529 –3044 –4569 P-value Gender Men Women P-value Levelofeducati Noformalschooling Primary Secondary Higher P-value Maritalstatus Nevermarried Currentlymarried Divorced/Widowed/SeparatedP-value Ecologicalzone Hill Mountain Terai P-value
PLOSONE|DOI:10.1371/journal.pone.0134834 August5,2015 8/18
NCDRiskFactors:STEPSSurveyNepal
5) 7) 9)
4. 0. 4.
otalrol –62 –63 –52
dtsteCI) 19. 20. 20.
Raisechole(95% 22.0( 25.3( 0.234 22.6(
d
sedbloocose%CI) –(2.33.8) –(4.59.1) 001–(2.94.5)
Raiglu(95 2.9 6.5 <0. 3.6
d
o
o – – –
dblureCI) 22.7 23.7 23.6
sess% 9(3) 1(2) 73 7(0)
Raipre(95 24.27. 29.35. 0.1 25.28.
or%CI) 1.6) 7.1) 3.7)
ht5 –2 –3 –2
g9 0 4 3
Overweiobesity( 19.2(17. 30.9(25. <0.001 21.4(19.
sical95% 4.1) 7.4) 4.3)
y( – – –
hy 4 1 7
LowpactivitCI) 3.1(2. 4.8(3. 0.101 3.4(2.
fiInsufcientfruitandvegetableintake(95%CI) –99.3(98.799.6) –97.1(94.898.4) <0.001–98.9(98.399.3)
se 4) 3) 9)
uol 3. 2. 2.
Harmfulofalcoh(95%CI) –2.3(1.5 –0.9(0.4 0.065–2.0(1.4 ence
al
v
e
–8 – –6 pr
Currentsmoking(95%CI) 19.9(17.22.2) 12.4(9.116.7) 0.003 18.5(16.20.6) erencesin
ContinuedTable2.() Un-weightednumber(N) Placeofresidence Rural3,422 Urban778 P-value Total4,143 NoteP:-valuesarefortestfordiff doi:10.1371/journal.pone.0134834.t002
PLOSONE|DOI:10.1371/journal.pone.0134834 August5,2015 9/18
NCDRiskFactors:STEPSSurveyNepal
Table3. Determinantsofbehavioralandbiologicalriskfactorsforselectednon-communicablediseasesamongaged15–69years.
Current Harmfuluse Insufficientfruitand Physical Overweightor Raisedblood Raisedblood Raisedtotal
smokingAPR ofalcohol vegetableintake inactivityAPR obesityAPR pressureAPR glucoseAPR cholesterolAPR
(95%CI) APR(95%CI) APR(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI)
Agegroup
15–29 1 1 1 1 1 1 1 1
30–44 1.36(1.01– 1.81(0.65– 0.99(0.98–1.01) 1.28(0.57– 2.01(1.60–2.52)* 1.95(1.49– 4.63(1.82– 1.86(1.43–2.41)*
1.85)* 5.04) 2.87) 2.56)* 11.76)**
45–69 1.62(1.19– 1.60(0.62– 0.99(0.98–1.00) 3.08(1.43– 2.02(1.60–2.55)* 3.47(2.65– 15.62(6.31– 2.54(1.96–3.29)*
2.20)* 4.10) 6.64)* 4.55)* 38.63)*
Gender
Men 1 1 1 1 1 1 1 1
Women 0.30(0.25– 0.26(0.14– 0.99(0.98–1.01) 0.55(0.38– 1.19(1.02–1.39)* 0.69(0.60– 0.86(0.58– 0.97(0.83–1.14)
0.36)* 0.48)* 0.80)* 0.80)* 1.28)
Ecologicalzone
Hill 1 1 1 1 1 1 1 1
Mountain 1.01(0.70– 1.44(0.49– 0.99(0.98–1.01) 0.28(0.07– 0.41(0.21–0.80)* 0.91(0.67– 0.84(0.25– 0.72(0.49–1.05)
1.44) 4.21) 1.12) 1.23) 2.84)
Terai 0.79(0.64– 0.16(0.07– 1.00(0.99–1.01) 2.43(1.46– 0.80(0.67–0.96)* 1.08(0.91– 1.50(0.97– 1.23(0.99–1.51)
0.99)* 0.36)* 4.07)* 1.28) 2.30)
Placeofresidence
Rural 1 1 1 1 1 1 1 1
Urban 0.73(0.52– 0.46(0.14– 0.98(0.96–1.00) 1.57(0.89– 1.39(1.15–1.67)* 1.14(0.92– 2.05(2.29– 1.03(0.81–1.31)
1.01) 1.45) 2.75) 1.41) 3.25)*
Levelofeducation
Noformal 1 1 1 1 1 1 1 1
schooling
Primary 0.93(0.78– 1.09(0.63– 0.99(0.98–1.00) 0.92(0.57– 1.46(1.21–1.76)* 1.00(0.86– 2.30(1.48– 1.25(1.04–1.50)*
1.11) 1.89) 1.49) 1.18) 3.59)*
Secondary 0.54(0.41– 1.06(0.49– 0.98(0.97–1.01) 0.79(0.43– 1.85(1.49–2.29) 1.14(0.93– 2.11(1.18– 1.47(1.18–1.82)*
0.70)* 2.31) 1.44) ** 1.39) 3.79)*
Higher 0.39(0.26– 0.38(0.07– 0.97(0.95–0.99) 1.30(0.70– 1.94(1.51–2.47)* 1.24(1.00– 3.11(1.65– 1.76(1.35–2.28)*
education 0.58)* 2.03) 2.40) 1.55) 5.87)*
Maritalstatus
Never 1 1 1 1 1 1 1 1
married
Currently 1.32(0.81– 2.21(0.41– 1.00(0.99–1.02) 0.83(0.32– 2.31(1.47–3.63)* 1.24(0.84– 0.78(0.24– 1.43(0.94–2.16)
married 2.16) 12.03) 2.13) 1.83) 2.59)
Divorce/ 1.51(0.85– 1.93(0.23– 1.00(0.98–1.03) 1.61(0.57– 2.22(1.35–3.65)* 1.36(0.87– 1.03(0.23– 1.32(0.80–2.16)
Widow/ 2.67) 16.48) 4.54) 2.12) 4.64)
Separated
*statisticallysignificantatp<0.05
doi:10.1371/journal.pone.0134834.t003
95%CI:29.7–36.4),inhabitantsoftheTerai(25%,95%CI:21.3–27.9),andamongthose
divorced/widowed/separated(26%,95%CI:19.8–33.3)comparedtothoseaged15–29years
(14%,95%CI:11.4–17.7)inhabitantsofmountains(14%,95%CI:10.0–19.3)andamongthose
nevermarried(13%,95%CI:8.4–18.6),respectively.
Determinantsofbehavioralandbiologicalriskfactors
TheAPRfordeterminantsofbehavioralandbiologicalriskfactorsispresentedin"Table3".
Thestudyrevealedalowerprevalenceofsmokingamongwomenthanmen(APR:0.3;95%CI:
0.25–0.36),andinthosewhohadhighereducationlevelscomparedtothosewithnoformal
education(APR:0.39;95%CI:0.26–0.58).Harmfulalcoholusewaslowerinwomenthanmen
PLOSONE|DOI:10.1371/journal.pone.0134834 August5,2015 10/18