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Overview of the STEPS Framework:

Overview of the STEPS Framework: . Rationale for Risk-Factor Selection. Chronic Disease Risk-Factor Surveillance. In 2020, chronic diseases responsible for 60% deaths globally and 47% of global burden of disease. 80% of chronic disease deaths occur in low- and middle-income countries.

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Overview of the STEPS Framework:

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  1. Overview of the STEPS Framework: Rationale for Risk-Factor Selection

  2. Chronic Disease Risk-Factor Surveillance • In 2020, chronic diseases responsible for 60% deaths globally and 47% of global burden of disease. • 80% of chronic disease deaths occur in low- and middle-income countries. • Common, preventable risk factors (RFs) underlie most chronic diseases. • The major risk factors account for 80% of deaths from heart disease and stroke.

  3. Objectives of STEPS Surveillance • Develop standardized tools to enable comparisons over time and across countries/sites. • Prevent chronic disease epidemics before they occur. • Help health services plan priority . • Collect consistent data across and within countries programmes and interventions. • Predict future caseloads of chronic diseases. • Monitor and evaluate population-wide interventions.

  4. Why Use the STEPwise Framework for Surveillance? • It is a very simple system. • It is hierarchical, depending on the need of the country. • It is a method with standardized tools. • It is flexible regarding risks, conditions, age groups, geographic areas, and cultural and local adaptations. • It can be added to existing systems.

  5. STEPS for Risk Factors Different levels: • Questionnaire • Physical measurement • Blood sample Different levels of evaluation of each RF: • Core-basic • Expanded • Optional

  6. STEPS 1: Core-Basic • Demography and behaviour: • Basic socio-demographic information • Tobacco use • Alcohol consumption • Fruit and vegetable consumption • Physical inactivity 1

  7. STEPS 2: Core-Basic • Physical Measurement: • Height • Weight • Waist circumference • Blood pressure 2 1

  8. STEPS 3: Core-Basic • Biochemical measurements: • Glucose • Cholesterol total

  9. STEPS 1: Expanded • Demography and behaviour: • Use of other types of tobacco • Tobacco cessation • Excessive use of alcohol • Consumption of Fat • Family history

  10. STEPS 2: Expanded • Physical measurement: • Hip circumference • Heart rate

  11. STEPS 3: Expanded • Biochemical measurements: • Triglycerides • Cholesterol HDL

  12. STEPS Methodology • Household survey • Representative sample of the population 25 – 64, stratified by 10-year age groups and sex • Use of standardized instrument to get comparative data • Biochemical measurement: Dry method (capilar blood) Wet method (vein blood)

  13. Available STEPS Materials • Reporting • Data Book • Fact Sheet • Site Report • Manual • Methodology for planning and implementing a study • Questionnaire • Q by Q guide • Data Analysis • STEPS database with Epi Info programmes • Fact Sheet Analysis Guide • Data Book

  14. The STEPS Surveillance Loop Survey Implementation Workshop • Sampling • Survey administration • Questionnaire • Data entry & management Recognize value of population information Begin STEPS Planning Implement Interventions Conduct STEPS Report Results Application and Program Planning Workshop • Policies • Programs • Other interventions • Analysis & Reporting Workshop • Epi Info training • Analysis of data • Report writing

  15. STEPS Risk Factors • Behavioural Risk Factors • Tobacco use • Harmful alcohol consumption • Unhealthy diet (low fruit and vegetable consumption) • Physical inactivity • Biological Risk Factors • Overweight and obesity • Raided blood pressure • Raised blood glucose • Abnormal blood lipids

  16. Rationale for STEPS Risk Factors • These RFs have greatest impact on chronic disease morbidity and mortality. • Modification is possible through effective prevention. • Measurement of RFs has proved to be valid. • Measurements can be obtained using appropriate ethical standards.

  17. The Causal Chain Behavioral RF • Tobacco • Alcohol • Physical inactivity • Nutrition • Disease • Outcomes • Heart disease • Stroke • Diabetes • Cancer • Respiratory • Physiological RF • BMI • Blood pressure • Blood glucose • Cholesterol

  18. Rationale for Tobacco Use as a Risk Factor for Chronic Disease • History of tobacco use • Current type of tobacco use • Current frequency of tobacco use *Tobacco is the fourth most common risk factor for disease and the second major cause of death worldwide. It is currently responsible for the death of one in ten adults worldwide (about 4.9 million deaths each year). *Smokers have a markedly increased risk of multiple cancers, particularly lung cancer, and are at far greater risk of heart disease, stroke, Chronic Obstructive Pulmonary Disease (COPD), diabetes, and other fatal and non-fatal diseases. People who chew tobacco risk cancer of the lip, tongue, and mouth.

  19. Rationale for Tobacco Use as a Risk Factor for Chronic Disease (cont’d) *Intra-Uterine Growth Retardation, spontaneous miscarriages and low-birth-weight babies are known outcomes of smoking during pregnancy. *Non-smokers exposed to second-hand smoke have a 25% – 35% increased risk of suffering acute coronary diseases, and increased frequency of chronic respiratory conditions. *Small children whose parents smoke at home have an increased risk of suffering lower respiratory-tract infections, middle-ear infection and Sudden Infant Death Syndrome (SIDS). *The World Bank estimates that in high-income countries, smoking-related healthcare accounts for between 6% and 15% of all annual health-care costs.

  20. Unhealthy Diet as a Risk Factor for Chronic Disease • Fruit and vegetable consumption • Type of oil or fat used for cooking *Low intake of fruits and vegetables is estimated to cause about 19% of gastrointestinal cancer, 31% of ischemic heart disease and 11% of stroke worldwide. *The consumption of at least 400g of fruit and vegetables per day is recommended as a population intake goal, to prevent diet-related chronic diseases.

  21. Unhealthy Diet as a Risk Factor for Chronic Disease (cont’d) *Adequate consumption of fruit and vegetables reduces the risk for cardio vascular diseases, stomach cancer and colorectal cancer. *There is convincing evidence that high intake of high-energy foods such as processed foods high in fats and sugars promote obesity compared to low-energy foods such as fruits and vegetables. *Higher unsaturated fatty acids from vegetable sources and polyunsaturated fatty acids have been associated with a reduced risk of type 2 diabetes. *Replacement of saturated and trans fatty acids by polyunsaturated vegetable oils lower coronary heart disease risk.

  22. Physical Inactivity as a Risk Factor for Chronic Disease • Physical activity at work • Physical activity during travelling to and from places • Recreational physical activity • Sedentary behaviour *Physical inactivity causes about 1.9 million avoidable deaths per year worldwide. *Physically inactive persons have a 20% – 30% increased risk of all-cause mortality as compared to those who adhere to 30 minutes of moderate intensity physical activity most days of the week.

  23. Physical Inactivity as a Risk Factor for Chronic Disease (cont’d) *Globally, physical inactivity accounts for 21.5% of ischemic heart disease, 11% of ischemic stroke, 14% of diabetes, 16% of colon cancer, and 10% of breast cancer. *Physical inactivity is a major risk factor in promoting obesity, which itself is a risk factor for other chronic diseases. *Physical activity may have a protective effect against the development of cognitive impairment and dementia, and it reduces the severity of symptoms among the depressed. *Physical activity is associated with the prevention of osteoporosis and related fractures.

  24. Overweight and Obesity as Risk Factors for Chronic Diseases • Waist circumference • Hip circumference • Height • Weight *At least 2.6 million people die each year as a result of being overweight or obese. *Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. The risks of coronary heart disease, ischemic stroke and type 2 diabetes mellitus increase steadily with increasing BMI. *Raised BMI also increases the risks of cancer of the breast, colon, prostate, endometrium, kidney and gall bladder.

  25. Overweight and Obesity as Risk Factors for Chronic Diseases (cont’d) *Optimum health, the median BMI for an adult population range of 21 – 23 kg/m2. The goal for individuals should be to maintain BMI in the range 18.5 to 24.9 kg/m2. *There is slightly increased risk of co morbidities for BMI 25.0 to 29.9, and moderate to severe risk of co-morbidities for BMI greater than 30.4. *Waist circumference is an approximate index of intra-abdominal fat mass and total body fat. *Changes in waist circumference reflect changes in risk factors for cardiovascular disease and other forms of chronic diseases. *Waist circumference or waist-to-hip ratio are more powerful determinants of subsequent risk of type 2 diabetes than BMI.

  26. Raised Blood Pressure as a Risk Factor for Chronic Disease • History of blood pressure • Repeated elevated systolic and diastolic blood pressure *Blood pressure levels have been shown to be positively and continuously related to the risk of stroke and coronary heart disease. *The risk of cardiovascular disease doubles for each increment of 20/10 mm Hg of blood pressure, starting at 115/75. Reference 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. Journal of Hypertension 2003; 21: 1983-1992. Chobanian A V, Bakris G L, Black H R et al. The Seventh Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Journal of American Medical Association, 2003; 289(19): 1206-1252. Williams B, Poulter N R, Brown M J et al. British Hypertension Society guidelines for hypertension management 2004 (BHS IV): summary. British Medical Journal, 2004; 328: 634-640.

  27. Raised Blood Pressure as a Risk Factor for Chronic Disease (cont’d) *Treating systolic blood pressure and diastolic blood pressure to targets that are less than 140/90 is associated with a decrease in cardiovascular complications. *Stage 1/Grade 1 hypertension: Mean blood pressure is => 140/90 and < 160/100 on two or more measurements on each of two or more visits on separate days. *Stage 2/Grade 2 hypertension: Mean blood pressure is => 160/100 and < than 180/110 on two or more measurements on each of two or more visits on separate days. *Stage 3/Grade 3 hypertension: Mean blood pressure is =>180/110 during two or more measurements on each of two or more visits on separate days. Reference 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. Journal of Hypertension 2003; 21: 1983-1992. Chobanian A V, Bakris G L, Black H R et al. The Seventh Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Journal of American Medical Association, 2003; 289(19): 1206-1252. Williams B, Poulter N R, Brown M J et al. British Hypertension Society guidelines for hypertension management 2004 (BHS IV): summary. British Medical Journal, 2004; 328: 634-640.

  28. Raised Cholesterol & Triglycerides • Total cholesterol • Cholesterol HDL • Triglycerides • Raised cholesterol is estimated to cause • 18% of the global stroke disease and • 56% of global ischemic heart disease. • *This amounts to about 4.4 million deaths (7.9% of total) and 40.4 million DALYs (2.8% of total).

  29. Raised Cholesterol & Triglycerides (cont’d) A 10% reduction in serum cholesterol in men aged 40 can result in a 50% reduction in heart disease within 5 years; an average of 20% reduction in heart disease occurs within 5 years in men aged 70 years. *Plasma HDL cholesterol is inversely related to coronary artery disease incidence, and the relationship is independent of total cholesterol, LDL and triglyceride levels. *Increased triglycerides are an independent risk factor for coronary heart disease after controlling for LDL and HDL cholesterol.

  30. Raised Blood Glucose as a Risk Factor for Chronic Diseases • History of diabetes • Fasting blood glucose *Impaired glucose tolerance and impaired fasting glycaemia are risk categories for future development of diabetes and cardiovascular disease. *There is a long asymptomatic period during which diabetes can be detected.

  31. Raised Blood Glucose as a Risk Factor for Chronic Diseases (cont’d) *Clinical trials have shown that almost two-thirds of type 2 diabetes can be prevented or postponed. *The excess mortality attributable to diabetes in the year 2000 was estimated to be 2.9 million deaths, equivalent to 5.2% of all deaths. In people 35–64 years old, 6%–27% of deaths were attributable to diabetes. *The age-adjusted mortality, mostly due to coronary heart disease in many populations, is 2–4 times higher than in the non-diabetic population. * People with diabetes have a twofold increase risk of stroke.

  32. Optional Modules • Family history • History of diabetes, hypertension, elevated cholesterol, and elevated sugar • Women’s health • Mental health • Violence and unintentional injury • Oral health • Any other behaviour

  33. STEPSAdvantages • Standardized methods • Capacity-building on a national and international level • Human Resources • Equipment • Data analysis • Continues aces and technical support • Comparable data at international level • Use for policy and planning

  34. What do we as WHO-PAHO-CAREC offer? • Instrument and standardized methodology, proved in over 90 countries. Flexible to respond to various needs • STEPS Manual • STEPS Tools (software for data entry, data analysis and report templates) • Workshop for planning and field work and data management • Workshop for data analysis and interpretation

  35. Conclusions • The STEPwise framework is flexible to meet the needs of any site or country. • STEP Tools guide through data analysis and reporting and can be adjusted as the site requires. • The STEPS team is always available to help with planning and data or reporting needs.

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