Swaziland Government Ministry of Health WHO STEPS. Noncommunicable Disease Risk Factor Surveillance Report

Transcription

1 Swazilad Govermet Miistry of Health WHO STEPS Nocommuicable Disease Risk Factor Surveillace Report SWAZILAND 2014

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3 Table of Cotets: List of Figures...v List of Tables...v List of Acroyms...vi Foreword...vii Ackowledgmets...viii Executive Summary...x Chapter 1: INTRODUCTION AND COUNTRY BACKGROUND INTRODUCTION COUNTRY BACKGROUND SIGNIFICANCE AND RATIONALE OF SURVEY THE GOAL AND OBJECTIVES OF THE STUDY Goal Objectives...2 CHAPTER 2: SUVERY DESIGN AND METHODOLOGY STEPWISE (STEPS) APPROACH STUDY POPULATION Iclusio criteria Exclusio criteria SAMPLE SIZE SAMPLING AND PROCEDURE SURVEY PERIOD THE SURVEY TEAM Natioal Team Field Team TRAINING OF INTERVIEWERS INSTRUMENT AND DATA COLLECTION The Tool Field Activities DATA MANAGEMENT Dowloadig ad mergig of data Data cleaig Weightig of data Data Aalysis Reliability ad Validity STUDY LIMITATIONS ETHICAL CONSIDERATIONS SURVEY RESULTS DEMOGRAPHIC INFORMATION Distributio of the participats by sex, age, marital status ad ethicity Distributio of the participats by level of educatio, employmet ad ecoomic status BEHAVIOURIAL RISK FACTORS Tobacco use Tobacco policy...10 iii

4 3.2.3 Harmful use of Alcohol Uhealthy diet Physical iactivity BIOCHEMICAL RISK FACTORS History of raised blood pressure History of raised blood sugar History of raised cholesterol History of cardiovascular Disease Lifestyle advice Cervical cacer screeig PHYSICAL MEASUREMENTS Blood pressure Height, Weight ad Body Mass Idex BIOCHEMICAL MEASUREMENTS Fastig blood glucose Cholesterol CARDIOVASCULAR RISK SUMMARY OF COMBINED RISK FACTORS OPTIONAL MODULES Metal Health Oral health Violece ad Ijury DISCUSSION Tobacco Use Alcohol Cosumptio Diet Physical Activity Cervical cacer Physical Measuremets Biochemical Measuremet Cardiovascular disease (CVD) risk Summary of combied risk factors Tobacco policy Metal Health Oral Health Violece ad Ijury CONCLUSION AND RECOMMENDATIONS Coclusio Recommedatios REFERENCES APPENDICES...24 iv

5 List of gures Figure 1: Primary Samplig Uits... 4 Figure 2: Frequecy of alcohol cosumptio by age amog those who drak i the past 12 moths Figure 3: Percet of servigs of fruits ad vegetables o average per day for both sexes Figure 4: Proportio always cosumig processed food high i salt Figure 5: Percetage ot meetig WHO recommedatios o physical activity for health List of tables Table 1: Time frame for the survey... 5 Table 2: Percetage of curret smokers Table 3: Alcohol cosumptio status Table 4: BMI classi catios Table 5: Summary of Combied Risk Factors v

6 List of Acroyms BMI CI COPD CVD CVD DBP DHS DM EA EHCP HBP HDL HMIS ICAP IFG IHM IGT MDG M&E MOH NCD PDA PSU RHM RTA SBP SEC SRH TB URC VIP WHO Body Mass Idex Co dece Iterval Chroic Obstructive Pulmoary Disease Cardio Vascular Diseases Cardiovascular Disease Diastolic Blood Pressure Demographic ad Health Survey Diabetes Mellitus Eumeratio area Essetial Health Care Package High Blood Pressure High Desity Lipoprotei Health Maagemet Iformatio System Iteratioal Cetre for Aids Care ad Treatmet Programs Impaired Fastig Glucose Istitute for Health Maagemet Impaired Glucose Tolerace Milleium Developmet Goals Moitorig ad Evaluatio Miistry of Health No Commuicable Diseases Persoal Digital Assistat Primary Samplig Uit Rural Health Motivators Road Traffic Accidet Systolic Blood Pressure Swazilad Ethics Committee Sexual Reproductive Health Tuberculosis Uiversity Research Coucil Violece ad Ijury Prevetio World Health Orgaizatio vi

7 Foreword vii

8 Ackowledgemet This Survey Report from this Natioal NCD risk factor study i Swazilad is a product of both acial ad techical iputs from multiple cotributors. The Miistry of Health would like to thak the World Health Orgaizatio (WHO),- Dr Kevi Makadzage, from Swazilad Cotry Office; Dr Prebo Barago form WHO Itercoutry Support Team; Dr Abdikamal Alisalad from WHO Africa regioal Office ; Melaie Cowe ; Regia Guthold; ad Luba Bhatti from WHO Headquarters. The Miistry also would like to thak ICAP, URC ad World Bak for the techical ad acial support give at differet stages of the survey.the success of the survey exercise was possible because of the commitmet of the seior authorities i the Miistry of Health. Special gratitude is exteded to Dr. Simo Zwae, the Pricipal Secretary; Dr. Vusi Magagula, the Director of Health Services; Dr. Velephi Okello, Deputy Director of Cliical Health Services ad Ms. Rejoice Nkambule, the Deputy Director of Public Health Services for their tireless participatio throughout the process which saw the completio of the exercise. The effective ivolvemet of various uits ad departmets i the Miistry of Health is highly appreciated. Also cotributig to the STEPs S u r v e y p r o c e s s w e r e D e v e l o p m e t a d Implemetig Parters of the Health Sector; their participatio ad iputs throughout the survey is commedable. We gratefully ackowledge the ivaluable cotributio of the STEPS Survey Steerig Committee. Ms Xolisile Dlamii (Epidemiologist), Lidiwe Tsabedze-Sibayoi (No-Commuicable Diseases Maager), Nokuthula Mahlalela (Violece ad Ijury Prevetio Cotrol) ad Sebetile Myei (Moitorig ad Evaluatio) deserve special metio for their tireless moitorig of the etire process from iceptio to report writig. It is because of the able leadership ad commitmet that such a quality report was produced. The Miistry is also grateful to our techical advisor Ms. Thabsile Nkambule, ad all those who were ivolved i the survey exercise such as the supervisors, data collectors, logistic officers ad drivers etc. viii

9 STATISTICIAN Choice Giidza DATA MANAGERS Sebetile Myei Nqaba Nhlebela Patrick Shabagu Thami Dlamii SUPERVISORS Priscilla Hlophe Voyivoyi Lukhele Thelma Fakudze Nokuthula Mahlalela Beryl Masuku Mavis Giidza Babazile Shogwe Sibogile Simelae Samukelisiwe Ndziisa TEAM LEADERS Nqobile Mamba Dudu Dlamii Elizabeth Simelae Thadi F. Zikalala Mirriam Dlamii Nokuthula Dlamii Joh Myei Bria Cidzi Nozipho Motsa Trevor Sithole Xolisiwe Dlamii Thembi Dlamii Gugulethu Madosela Lehle Dube Mpumelelo Mavimbela Thabag Masagae Maria Dlamii Liberty Tfwala Nokuthula Zwae DATA COLLECTORS Nokwethu Mkhumae Dumsile Nxumalo Adile Dlamii Mavis Ndzimamdze Mzwakhe Thwala Khayisile Dlamii Khabo Mkhatshwa Phidile Dlamii Mzwakhe Thwala Khethiwe O. Thwala Thelma Shogwe Gugulethu Dlamii Ncamsile Mmema Samukelisiwe Dlamii Lugile Dlamii Nomsa Tsabedze Thembisile Mdzebele Wiile Nkambule Nomsa Motsa Nozipho Vilakati Mxolisi Thabo Dlamii Nompumelelo Dlamii Nomvula Dlamii Mabuza Mcolisi Masuku Sibusiso Lushaba Welile Hlatshwayo Nokwethu Mkhumae Elijah Dlamii Ncamiso Shabagu Ntokozo Lagweya Nsikelelo Ndziisa Mzwakhe Thwala Jabulai Dlamii Khabo Mkhatshwa Busisiwe Khoza Valerie Leibbradt Nelisiwe Mhlaga Nsikelelo Ndziisa Lidekile Khumalo Mduduzi Dlamii Sebetile Zodo Valerie Leibbradt Bogekile Mdvoti Faele Masuku Xolile Mamba Fikelephi Dlamii Thulisile Fakudze Lidekile Khumalo Sebetile Zodo Zodwa Hlatshwako Bogekile Mdvoti Lehle Nhleko Mdei Hlatshwako Khabo Dlamii Faele Masuku Thulisile Fakudze Makhosaza Mokoea LOGISTICS OFFICER Smagele Masilela ix

10 Executive Summary The Miistry of Health with techical ad acial support from the World Health Orgaizatio (WHO) ad other parters coducted the Stepwise approach to surveillace (STEPS) survey i The WHO STEPS approach focuses o obtaiig core data o the established risk factors that determie the major o commuicable disease burde. This approach to chroic disease risk factor surveillace provides a etry poit for the coutry to get started o chroic disease surveillace activities. There are three differet levels of "steps" of risk factor assessmet. These steps are: questioaire (step 1); physical m e a s u r e m e t s ( s t e p 2 ) a d b i o c h e m i c a l measuremets (step 3). Step 1 covers questios o demographic iformatio, ad behavioural measuremets focusig o tobacco use, alcohol cosumptio, diet, physical activity, history of raised blood pressure, history of diabetes, history of raised total cholesterol, history of cardiovascular disease, lifestyle advice ad cervical cacer screeig for wome. Step 2 covers blood pressure measuremet, height, weight, waist circumferece ad heart rate. Step 3 focuses o blood glucose ad lipids measuremet. The istrumet cotais core ad optioal modules. The followig optioal modules were icluded: oral health, metal health, violece ad ijury ad tobacco policy. The broad objective of the survey was to determie the magitude of risk factors that attribute to o-commuicable diseases. The Survey methodology was a multi-stage cluster sample desig ad the sample was adult Swazis age years. The targeted sample size was The al sample was however 3281 for step 1 ad 2 with respose rate of 76. The al sample for step 3 was 3015 givig a respose rate of 70. The digs of the survey reveal that prevalece of tobacco smokig amog the adult populatio i Swazilad was 6.0. O average the start age of smokig was 19 years. Alcohol cosumptio, de ed as cosumig alcohol i the past 30 days, was As far as diet is cocered the respodets cosumed fruits o 3.5 days of the week o average ad ate vegetables o 4.8 days i a typical week. The proportio of the populatio that cosumed less tha 5 servigs of fruit ad/or vegetables per day stood at About 20 percet of the respodets reported that they always add salt before or whe eatig. Roughly a quarter of the populatio (24.5) had raised blood pressure or was o medicatio for raised blood pressure. A sizable proportio (17.3 wome ad 7.2 me) of this group had ucotrolled raised blood pressure (i.e. were uder treatmet but still had raised blood pressure) but a much greater percetage (87.0 of me ad 72.8 of wome) of those with raised blood pressure were ot o treatmet. Of the 2892 respodets who had blood glucose levels measured, about 14.2 of them had raised blood glucose. The overall proportio of idividuals with raised total cholesterol stood at About 20.5 of the populatio was foud to be obese ad i the overall a high percetage (59.9) of wome was foud to be overweight Just uder 3 percet (2.6) reported havig bee i a road traffic accidet i the past 12 moths ad, of these, just uder half (44.9) were seriously ijured. Six percet of respodets reported to have bee seriously ijured i o-traffic accidets. Ijuries through violece were ot reported to be a issue i commuities: three percet me (2.6) ad two percet wome (2.1) reported to have suffered serious ijuries from violet icidets. Less tha half of the populatio (48.5) has ever bee to a detist. Amog these, the majority (65.1) were foud to visit the detist due to pai or trouble with teeth or gums. Worth otig was that oly 8.7 of those who had ever bee to a detist visited as a precautioary measure for their last visit ad aother 7.7 visited for cosultatio/advice. The STEPS survey idicates a loomig epidemic of NCDs based o the digs of this survey. I all the age groups there was a high rate of wome who reported ot doig eough physical activity as per WHO recommedatio (20.5 for 15 29, 19.6 for ad 22 for 45-69); recommedatios have bee ideti ed for Govermet, the Miistry of Health ad other stakeholders. Sice NCDs are lifestyle diseases, idividuals ad the commuity have a big role i their cotaimet. Also prevetio should be icorporated i the health system through a multi-sectoral mechaism approach for plaig, guidig, moitorig ad evaluatio of NCDs i the coutry. x

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12 Chapter 1: INTRODUCTION AND COUNTRY BACKGROUND 1.1INTRODUCTION The World Health Orgaizatio (WHO) projects that globally, deaths due to No-Commuicable Diseases (NCDs) will icrease by 17 over the ext te years. The greatest icrease will be see i the Africa regio (27) ad the Easter Mediterraea Regio (25). Accordig to the Global Status Report o NCDs 2010, of the 57 millio deaths that occurred globally i 2008, 36 millio (almost two thirds) were due to NCDs, comprisig maily of cardiovascular diseases, cacers, diabetes ad chroic lug diseases. About a quarter of global NCD-related deaths take place before the age of 60. The oted rise i NCDs to epidemic proportios i may Sub-Sahara Africa coutries will most likely facilitate a process of epidemiological trasitio towards a greater burde of NCDs. The chagig demographic dyamics, affluece ad the patter of food cosumptio are resposible for this tred. As a result, coutries are likely to advace towards a greater burde of o-commuicable diseases (NCDs), while still bearig a heavy commuicable diseases burde (Byass P.et al 2014). I Swazilad NCDs accout for 24 percet of aual deaths (WHO NCD Coutry Pro le 2014). Accordig to WHO Estimates Swazis suffer maily from diseases of lifestyle such as Cardio Vascular Diseases (CVD), Type-2 diabetes, cacer ad Chroic Obstructive Respiratory Diseases (COPDs). Accordig to the 2010 WHO report, most NCDs are strogly associated ad causally liked with four behavioral risk factors which are: tobacco use, physical iactivity, uhealthy diet ad the harmful use of alcohol. Itermediary risk factors iclude high blood pressure, high cholesterol, high blood glucose ad overweight. I order to prevet ad cotrol NCDs itervetios o the risk factors are crucial ad it is therefore, importat to kow the magitude of the NCD risk factors i the populatio. WHO has developed a Stadardized Risk Factor Surveillace Approach (Stepwise Approach) to eable compariso of data across regios over time. This approach is the most efficiet meas of providig evidece based data to pla for cotrol ad reductio of the impact of NCDs. The STEPS survey is coducted every ve years to esure well collected systematic atioal-data to determie the burde of the disease ad their risk factors ad to eable compariso over time. I 2007, the rst STEPS Survey was coducted i Swazilad COUNTRY BACKGROUND The Kigdom of Swazilad is a small ladlocked coutry i Souther Africa with a estimated area of square kilometres, of these 160 square kilometers is water. The coutry is located at the geographical coordiates S E. Accordig to the Swazilad Populatio Cesus, 2007, the populatio of Swazilad was with about 78.9 livig i the rural areas. 52 of the populatio was uder the age of 20 years. Females accouted for 53 of the populatio ad a estimated 4.6 of the populatio was 60 years of age ad above. The World Bak classi es Swazilad as a lower middleicome coutry because of its per capita icome estimated at US $3,725 ad about 69 of the populatio lives below the poverty lie (Poverty Reductio Strategy ad Actio Programme, Volume ) SIGNIFICANCE AND RATIONALE OF SURVEY I Swazilad NCD s are icreasigly beig prioritised ad therefore well collected systematic atio-wide data is required to determie the burde of the diseases ad their risk factors. This is crucial for ideti catio ad implemetatio of appropriate itervetios as well as justi catio of allocated resources. The evidece o the magitude of NCDs ad associated risk factors i Swazilad will guide the plaig ad implemetatio of itervetios o all levels. 1

13 1.4. THE GOAL AND OBJECTIVES OF THE STUDY Goal To determie the magitude of NCDs ad their risk factors for selected o-commuicable diseases i Swazilad Objectives The speci c objectives of the survey are to: 1. Assess the magitude of behavioural risk factors for NCDs such as physical iactivity, tobacco use ad harmful use of alcohol ad uhealthy diet. 2. Assess the magitude of biochemical risk factors such as raised blood glucose; raise cholesterol ad overweight/obesity. 3. Assess the risk factors for other ocommuicable coditio like cervical cacer screeig, violece ad ijuries; oral health ad metal health. 2

14 Chapter 2: SUVERY DESIGN AND METHODOLOGY The study was a household based cross-sectioal survey based o the WHO Stepwise Approach. This sectio covers the study desig ad the methodology used STEPWISE (STEPS) APPROACH This study employed a WHO STEPS approach, which is a sequetial process of data collectio usig a threestep process. Step1: Ivolved the collectio of demographic ad behavioural iformatio: this icluded iformatio o the level of educatio, employmet, icome, lifestyle risk factors that cotribute to NCDs such as tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical iactivity, history of raised blood pressure, diabetes, raised blood cholesterol, cardiovascular diseases, life style advice a d c e r v i c a l c a c e r s c reeig fo r wome respodets, metal health/suicide, oral health care ad violece ad ijuries. S t e p 2 : I v o l v e d t h e t a k i g o f p h y s i c a l measuremets: this icluded the takig of height, weight, girth (Waist, Hip), blood pressure ad pulse Rate; Step 3: Ivolved doig biochemical Measuremets: this icluded rapid testig of fastig blood glucose ad blood lipids (cholesterol) STUDY POPULATION The target group for this atioal household-based cross-sectioal survey was a sample from the adult Swazi populatio aged betwee 15 ad 69 years residig i ay oe of the four regios of the coutry Iclusio criteria: All family members that were eligible to participate i the study were: Aged betwee years both males ad females, Able to uderstad the iformatio give about the study, Whether already diagosed ad o treatmet of ay of the diseases of iterest, ad Able to give a verbal or siged iformed coset for participatio Exclusio criteria: All family members that were excluded i the study were those who were: Not capable to uderstad or comprehed the iformatio give Not capable of cosetig verbally ad were also ot i a state of respodig to the questioaires Severe/termial physical or metal illess that hidered participatio i the survey, ad Aged below 15years or above 69 years. 2.3 SAMPLE SIZE The followig procedure, formula, ad adjustmet p a r a m e t e r s w e r e a p p l i e d t o d e t e r m i e a represetative sample size for the survey. 2 z1 p(1 - p) = -a 2 d = {(1.96) 2 x {0.5} (1 0.5)} = (0.05) 2 Where: Level of Co dece Measure Margi of Error (MOE) Baselie levels of the idicators Desig effect (Deff )- 1.5 Expected Respose Rate Age/sex Estimate - 6 Therefore, the sample size was, (384.16*1.50*6)/0.80 = The age -sex estimate adjustmet was recommeded by WHO to be 6 (3 group per geder: 15-29, 30-44, 45-69) i order to balace optimizatio of precisio agaist time ad resources (huma ad acial) for coductig the survey SAMPLING AND PROCEDURE A Multi-stage cluster samplig desig was applied. The survey covered all the four regios of the coutry. The size of the coutry ad the distaces betwee the regios ad commuities made it possible for the survey to sample a populatio represetig all the 4 regios. The Multi-stage samplig procedure was implemeted i the followig procedural steps: Stage 1: All four regios were icluded as a samplig frame of our Primary Samplig Uit (PSU).The umber of the PSUs at this stage esured precisio i the survey estimates ad as a result 216 PSUs were selected usig probability proportioal to size samplig ( gure 1). 3

15 Primary Samplig Uits Figure 1: Primary Samplig Uits 4

16 Stage 2: The secod stage of cluster samplig procedure etailed listig, sortig ad radom systematic samplig of the Secodary Samplig Uits (Households) withi the PSUs selected i stage1 where 20 households were selected from each PSU. Based o cesus data, oly households with eligible participats were systematically sampled through radom systematic samplig. Stage 3: At this level, all the eligible participats withi a household were sequetially listed ito the PDAs ad oly oe participat per household was radomly sampled usig KISH method built ito the PDAs. The KISH method is a widely used techique that uses a pre-assiged table of radom umbers to idetify the perso to be iterviewed SURVEY PERIOD Data was collected over a period of 32 days from 17 November to 19 December Table 1 shows all the activities ad the period i which those activities were covered durig the survey. Activities Performed Durig Survey Period Activity July Aug Sept Oct Nov Dec Ja Feb Mar Apr May-Oct,15 Fializatio of protocol Prepare traiig of iterviewers sesitize EA s leaders ad Commuity groups i the selected areas Recruitmet ad iterviewers data collectors traiig, pilotig, alizig the tool Data collectio ad etry Data cleaig, aalysis ad report writig Fializatio of Report ad Dissemiatio of Results Table 1: Time frame for the survey 2.6. THE SURVEY TEAM The survey team comprised of the atioal ad eld team which were traied o the survey data collectio Natioal Team The atioal team cosisted of represetatives from the Epidemiology ad Surveillace Uit, NCDs programme, Violece ad Ijur y Prevetio Programme (VIP), Cliicias, Health Educatio Uit (MoH), Moitorig ad Evaluatio (M&E), Health Maagemet Iformatio System (MoH), Public Health Uit (MOH), Laboratory Diagostics (MoH), Natioal Statistical Office, World Health Orgaisatio, Uiversity of Research ad Co.,LLC (URC), Istitute of Health Measuremet (IHM) ad Iteratioal Cetre 5

17 For AIDS ad Treatmet Programs (ICAP). The members of the team joitly developed the research proposal, adapted the survey tools, sesitized stakeholders mobilized for resources ad participated i the traiig of the data collectors Field Team There were18 teams of 5 people each as follows: 1. A team leader who was traied to do all steps icludig the dry chemistry ad was r e s p o s i b l e f o r p l a i g, s e t t i g a p p o i t m e t s a d c h e c k i g t h e completeess of questioaires, 2. Three iterviewers/eumerators who were traied to do all the steps icludig the dry chemistry so that there would be more exibility i the duties ad roles, ad 3. Oe driver was resposible for trasportig the team members ad helpig with the carryig of the equipmet. Rural Health Motivators (RHMs) i each commuity assisted the teams i otifyig the commuity leaders i the selected commuities about the actual day ad time for data collectio, ad guided the survey team to the selected household. 2.7 TRAINING OF INTERVIEWERS All 72 data collectors ad 10 supervisors were traied over 6 days. The rst four days covered the followig sectios: (a) Overview of the study-what the study was all about, (b) Gaiig etry ito the study areas ad households (c) Coductig iterviews (d) Observig research ethics (e) Collectig data usig Persoal Digital Assistat (PDA) (f) Doig a ger prick (g) Keepig records (h) Esurig quality cotrol of all eld processes. Iterviewers coducted mock iterviews ad practiced takig both physical measuremets ad ger prickig for glucose ad cholesterol testig. Team supervisors were further traied o: (a) checkig ad correctig iterview data (b) editig questioaires i the PDA (c) problem solvig i the eld. The last two days of the traiig ivolved pilotig of the data collectio process i two PSUs that were ot part of the survey. STEP 1&2 was piloted o the fth ad STEP 3 o the sixth day. After the pilot, all the teams shared their stregths ad gaps the discussed strategies o how to address such durig the actual data collectio. 2.8 INSTRUMENT AND DATA COLLECTION The Tool The geeric WHO STEPS survey tools were adapted by the Natioal Team ad traslated ito siswati ad back traslated ito Eglish to make sure that it gave the same meaig as the origial questios. All the core, expaded ad selected optioal variables were collected. Data was collected usig PDAs, where 18 P D A s were p rogrammed fo r b i o c h e m i s t r y measuremets ad 36 PDAs were programmed for iterviews ad physical measuremets. Participats that were Eglish illiterate were iterviewed with the iterpreted SiSwati versio questioaire. Durig the survey period sampled idividuals were iterviewed usig the questioaire for STEP 1. This was followed by takig their physical measuremets usig stadard equipmet provided (STEP 2). Sice STEP 3, which icluded the testig for glucose ad cholesterol, had to be take after the participat had fasted overight, a appoitmet was set for the followig morig whe the respodet would have fasted the testig was doe. The middle ger was pricked with a eedle ad allowed to bleed a drop which was the tested for glucose ad cholesterol. Step1: Questioaire-based assessmet: Data for behavioural risk factors were collected usig a face-to-face structured iterview (Appedix A). The survey questioaire was programmed o the PDAs. It cosisted of the core (age, sex ad educatio i years ad curret exposure to tobacco ad alcohol, diet ad physical activity), expaded (occupatio, average household icome) ad optioal (marital status, medical ad health history, past history of smokig ad alcohol cosumptio) variables. The medical ad health history compoet icluded questios o medicatio, cigarette use, diabetes, hypertesio ad other cardiovascular coditios. Step 2: Physical measuremets The physical measuremets take icluded blood pressure, heart rate, height, weight, waist ad hip 6

18 circumferece measuremets. Followig is the procedure for each assessmet: Measuremets Blood pressure Blood pressure measuremets were take usig battery powered digital blood pressure machie medicus uo (boso ). Three readigs were take 3-5 miutes apart ad the third readig was the recorded. Height Height was measured usig the stadiometers. Height was measured without the participat wearig foot or head gear. Before the readig was take, the respodet was requested to have his feet together, heels agaist the back board, kees straight, ad to look straight ahead. Height was recorded i cetimetres. Weight Weight measuremets were take o a pre-calibrated weighig scale (bathroom scale). The scales were calibrated daily usig a kow weight (1kg packet of sugar). Participats were weighed dressed i light clothig ad barefooted. Measuremets were take to the earest 0.1kg. Waist Circumferece The waist circumferece was measured usig a tapemeasure i cetimetres. Measuremet was made i the mid-auxiliary lie midway betwee the last rib ad the superior iliac crest. Measuremets were made to the earest 0.1 cm. Hip measuremet Hip measuremets were also made usig a tapemeasure placed horizotally at the poit of maximum circumferece over the buttocks. Measuremets were take to the earest 0.1cm. Step 3: Biochemical assessmet Fastig blood glucose ad total cholesterol comprised the targeted biochemical measures of health risks for NCDs. O the rst day of the survey after completio of STEP 1 ad STEP 2, participats were asked to fast overight of that day. i.e. people were asked ot to cosume ay food except for clear water after takig dier o that ight util the survey team came i the morig of the followig day (day 2). People i the selected EA were see i their various homesteads where a ger prick was R doe usig a CarioChek PA test system ad a drop of blood was tested for glucose ad total cholesterol. Those that complied with advice (fastig overight) were eligible for testig Field Activities Immediately after traiig, data collectors were divided ito the 18 teams. Each team was provided with a eld kit cotaiig: a carrier bag, letters for the relevat authorities (from Miistry of Ikhudla ad Ethics Committee) referral letter for those with abormal results, coset forms, checklist, list of the selected EAs, EA maps, team eld log book, operatioal maual, pes, pecils, clipboards, otebooks, tapes for measurig height ad girth, scales for weight, blood pressure machies, lacets for ger pricks, sharps disposal cotaiers, gloves ad PDAs. Each member of the research team had a project bag, idetity card ad a uique code DATA MANAGEMENT Dowloadig ad mergig of data Data was collected usig PDAs. There were two sets of PDAs used to collect data: oe set of PDAs was used to collect data for Step 1 (biographic ad lifestyle iformatio), ad Step 2 (height, weight, blood pressure, waist ad hip circumferece). Aother set of PDAs was used to collect Step 3 (biochemical measures) A total of 54 PDAs were used. Data o the PDAs were dowloaded ito the computer istalled with NCD STEPS software. The les of each participat (the Step 1, 2 ad 3) were the merged usig the participat idetity (PID) umber cross checked with participat ame, EA umber or towship ame ad other particulars where ecessary Data cleaig Although the PDAs esure resposes are iterally cosistet ad limit the rages of resposes to opeeded questios, the data were still checked to esure do't kow resposes ad questio-speci c refusals were appropriately recorded Weightig of data Sample weights were calculated for all records usig the probability of selectio at each stage of samplig. Thus, for each participat his/her weight was calculated by rst multiplyig the probability of EA 7

19 selectio, the probability of household selectio, ad the probability of selectio withi their household. Where household size was missig, the average household size of the EA was used to estimate the probability of selectio at this last stage of samplig. The participat's weight would the be equal to the iverse of this product. This weight was the adjusted to correct for over- or uder- represetatio of each perso's age-sex group i the sample versus the uderlyig age-sex distributio of the populatio i Swazilad Data Aalysis Data was aalyzed usig Epi Ifo, versio Simple descriptive statistics with meas, proportios ad frequecy distributios were doe. 95 Co dece Iterval (CI) was used as a measure of precisio o the estimated populatio parameters. Further aalysis was performed as follows: T-tests to compare cotiuous data such as systolic Blood Pressure, cholesterol level betwee groups. Chisquare tests were used to assess relatioships betwee variables ad aalysis of variace (ANOVA) for cotiuous variables for comparisos across more tha two groups. I situatios where the ormality assumptios were ot met, the o-parametric equivalets of the above tests were used (Fisher's exact test, Kruskal Wallis test, etc.). Logistic regressio aalysis was employed to assess predictors of diabetes ad hypertesio i each particular group cotrollig for potetial cofouders Reliability ad Validity The tools that were used i this study were based o the WHO guidelies o the STEPWISE APPROACH to NCD Surveillace. Reliability was assured by the use of traied data collectors with a supervisor per group to collect all data. PDAs were also used to esure uiformity i the way data was collected. Discussios of the data collectio tools; with researchers from S T E P S S u r v e i l l a c e d a t a t e a m f r o m W H O Headquarters who had expertise i the eld were also held to esure validity. A six day traiig workshop o the STEPS Survey was doe ad piloted to familiarize the data collectors with the tool ad o what to expect durig the data collectio exercise STUDY LIMITATIONS The method of iterviewig people had its ow limitatios i that it was highly time cosumig ad at the same time people had a tedecy of withholdig iformatio whe iterviewed (Freema 2013). Ø The survey was self-reportig ad also relied o recallig of past evets which was a limitatio. Ø Some of the residets i the EAs relocated just before data collectio commeced so this affected the respose rate. Ø Some of the respodets were ot available durig the visitatios ETHICAL CONSIDERATIONS The survey complied with ethical priciples of, bee cece, respect for persos ad justice, protectig the rights of the respodets as well as scieti c itegrity of the research. The priciple of bee cece meat that the iter viewers did ot harm the respodets itetioally through withholdig of iformatio or by egligece. The iterviewers were made aware of the importace of miimizig the subjects' level of axiety or stress, ad of the absolute requiremet of ot divulgig ay iformatio obtaied from survey (co detiality). The survey teams were traied to miimize the risks that were posed to the participats. Traiig for the team icluded discussios ad exercises o the meaig ad process of iformed coset, the importace of protectig the privacy of the subjects ad co detiality of obtaied iformatio. The team leaders supervised all survey teams o a cotiuous basis. Uscheduled supervisio visits were made to esure that the teams were followig pre-de ed protocols ad guidelies. The team leaders were also resposible for checkig data quality ad esurig that data was stored i a safe ad co detial locatio. The priciple of respect for persos ackowledgig autoomy ad protectio of those that had dimiished autoomy was emphasized. The survey teams esured that iformed coset was obtaied from the participats through givig accurate iformatio about the purpose of the survey ad procedures ivolved, esurig comprehesio ad volutary participatio. Iformed coset was 8

20 siged by the participats (Appedix B). Iformatio privacy ad co detiality was ecessary i order to show respect to the people ivolved ad this was esured durig primary data collectio ad secodary data aalysis. All participats were assured that the iformatio obtaied i the survey was co detial ad were give the optio of refusig or discotiuig their participatio at ay time. Whe recruitig, participats were oly kow by ideti ers. All data was kept uder secure coditios. Access to the survey data was limited to the supervisors. No ideti catio iformatio was disclosed i the al report. Fair treatmet of others ad avoidace of discrimiatio ad exploitatio was maitaied.this was the priciple of justice. A fair procedure for selectio of participats was used. The researcher was truthful with others ad maitaied co detiality (Herbst, 2000:88). The study proposal received approval from the Swazilad Ethics Committee (SEC), ad a clearace certi cate was received (Appedix C), Permissio to coduct the survey was sought from the Miistry of Health, the Miistry of Tikhudla ad Developmet as well as relevat commuity leaders through a writte correspodece. Through iformed coset the participats were also requested for permissio to use them as iformats. Iitiatig cotact with commuities Commuity leaders were iformed about the study ad ivolved durig the plaig processes. Local authorities were cosulted o iformatio regardig the most coveiet ad effective maer of visitig homesteads. They were also oti ed i advace of the date ad approximate time of the iterviews. Procedure followed o arrival at homestead The team carried a authority letter siged by the Pricipal Secretary from the Miistry of Health (MOH), approval letter by the SEC as well as ideti catio tags. The team met with the head of the household ad itroduced themselves the asked for permissio to go ahead with the survey. Maagemet of cliical cases ideti ed durig survey All idividuals foud durig data collectio that had abormal results were referred accordigly. 9

21 Chapter 3: SURVEY RESULTS This sectio covers the digs of the survey, which iclude demographic iformatio of the participats ad the results per module. 3.1 DEMOGRAPHIC INFORMATION The basic demographic ad socioecoomic iformatio iclude age, sex, marital status, ethicity, educatio levels, estimated household earigs ad employmet status Distributio of the participats by sex, age, marital status ad ethicity A total of 3534 participats respoded to the step 1 questioaire of which 2304(65.2) were wome ad 1230 (34.5) were me. Youg adults aged years were 40.8 whilst those aged years were 28.7 ad those aged years were Of the 3278 participats who respoded to the questio o marital status 42.3 were curretly married while those that were ever married were Accordig to the origi of the participats 97.2 were Swazi ad 2.8 were o-swazis Distributio of the participats by level of educatio, employmet ad ecoomic status The digs reveal that 10.4 of the participats had o formal educatio, 25.4 had completed primary educatio, ad 7.4 had completed uiversity level. Accordig to employmet status 6.2 were civil servats, 31.4 were either o-govermet employees or self-employed ad 62.4 were upaid which icluded persos who were o-paid, studets, homemakers, retired, ad uemployed. The mea aual per capita icome of the participats was E BEHAVIOURAL RISK FACTORS The followig sectio shows the distributio of the participats accordig to tobacco use, uhealthy diet, physical iactivity ad harmful use of alcohol. These are the four major behavioural risk factors for ocommuicable diseases Tobacco use Overall, the prevalece of the respodets who were curretly smokig was 6 (CI: ), which was 11.7 for me ad 1.2 for wome. Table 2 shows the distributio of the curret smokers disaggregated accordig to age ad sex. Amog curret smokers, youger respodets aged had a much higher daily smokig prevalece of 89.6 (CI: ) whe compared to older respodets (30-44 ad age groups). The mea age of startig smokig was 19.6 years (CI: ) amog curretly smokig respodets. About 92.2 ( ) of curret smokers ad 93.1 (CI: ) of the daily smokers used maufactured tobacco. Amog those who curretly used tobacco 52.2 (CI: ) had tried to stop smokig i the past 12 moths. About 2.2 (CI: ) of re s p o d e ts u s e d s m o k e l e s s tobacco. The percetage of respodets exposed to secod-had smoke i the home i the past 30 days was 17.3 (CI: ). Some of the respodets were exposed to secod-had smoke i the workplace i the past 30 days as reported by 13.3 (CI: ) of them Tobacco policy As far as ati-cigarette iformatio is cocered, the respodets reported havig oticed iformatio i ewspapers or magazies, televisio or radio about the dagers of smokig or that ecouraged quittig durig the past 30 days. About 30.8 (CI: ) of the respodets reported that they had oticed iformatio i ewspapers or magazies about dagers of smokig or that ecouraged quittig ad 27.5 (CI: ) said they have oticed the iformatio o televisio. However 44.6 (CI: ) of the respodets got the iformatio o the radio. The proportio of all respodets who oticed Table 2: Percetage of curret smokers Percetage of curret smokers Me Wome Both Sexes Curret Curret Curret smoker smoker smoker

22 advertisemets or sigs promotig cigarettes i stores where they were sold durig the past 30 days was 10.4 (CI: ). Oly 1.1 (CI: ) of the respodets reported that they had oticed free samples of cigarettes i the past 30days ad 3.3 (CI: ) said they had the sale prices o cigarettes withi the same time period. About 0.6 (CI: ) ad 0.9 (CI: ) of the respodets said they oticed coupos for cigarettes ad free gifts or special discout offers o other products whe buyig cigarettes respectively. Of ote was that about 5.9 (CI: ) of the study populatio had oticed clothig or other items with a cigarette brad ame or logo i the past 30 days. Oly 0.6 (CI: ) of the respodets reported that they oticed cigarette promotios i the mail About 79.1 (CI: ) of curret smokers reported that they had oticed health warigs o cigarette packages durig the past 30 days ad 74.0 (CI: ) of these said they thought of quittig. The average price for 20 maufactured cigarettes package was 37.7 Emalagei (CI: ) based o the last purchase Harmful use of Alcohol The respodets were asked to idicate their alcohol cosumptio status, that is, if they cosumed alcohol ad if so, the frequecy ad quatity cosumed. Respodets who reported havig cosumed alcohol withi the past 30 days were de ed i the survey as curret drikers ad were 13.0 (CI: ), the majority (17.5) beig adults aged years. About 4.7 (CI: ) of those who cosumed alcohol i the past 12 moths drak daily. The percetage of respodets who had six or more driks o ay occasio i the past 30 days durig a sigle occasio amog the total populatio was 8.3 (CI: ). The mea umber of times i the past 30 days i which curret (past 30 days) drikers cosumed six or more driks durig a sigle occasio was 2.0 (CI: ). The survey results showed that the majority of respodets who drik daily, 5-6 days per week, 1-2 days per week was high amogst those adults aged years (15.4 (CI: ), 3.0 (CI: ), 30.3 (CI: ) respectively ad these group has a sigi catly more curret drikers tha the other two age groups.. About 2.9 (CI: ) of all respodets had problems with family or parter due to someoe else's drikig i the past 12 moths. Amog past 12 moths drikers, the proportio of those eedig a rst drik i the morig to get goig after a heavy drikig sessio o a mothly or more frequet basis was 16.8 (CI: ). Table 3: Alcohol cosumptio status Curret driker (past 30 days) Alcohol cosumptio status Drak i past 12 moths, ot curret Both Sexes Past 12 moths abstaier Lifetime abstaier

23 Frequecy of alcohol cosumptio by age amog those who drak i the past 12 moths; by age Figure 2: Frequecy of alcohol cosumptio by age amog those who drak i the past 12 moths Daily 5-6 days/week 3-4 days/week 1-2 days/week 1-3 days/moth <oe a moth Uhealthy diet The respodets reported that o average they had fruits i about 3.5 (CI: ) days of the week ad o average they ate vegetables i 4.8 (CI: ) days a week. About 92.1 (CI: ) of the respodets cosumed less tha ve servigs of fruit ad/or vegetables o average per day as show i gure 3 below. Ad worth otig is that over half of the populatio is oly gettig 1-2 servigs of fruits o average per day ad early 20 eat oe. The majority of the respodets (53.7 (CI: )) reported to be havig 1-2 servigs per day, very few (7.9 (CI: )) reported to be havig more tha 5 servigs per day. Percet of servigs of fruits ad vegetables o average per day for both sexes, o fruits ad/or vegetables 1-2 servigs 3-4 servigs >5 servigs Figure 3: Percet of servigs of fruits ad vegetables o average per day for both sexes 12

24 As far as salt cosumptio was cocered 19.8 (CI: ) of the respodets always or ofte added salt or salty sauce to their food before eatig or as they were eatig. About 71.7 (CI: ) of the respodets reported that they always or ofte added salt to their food whe cookig or preparig foods at home. Percet Always Cosumig Processed Food High i Salt, by Age ad Sex, Me Wome 5 o Age Figure 4: Percet of always cosumig processed food high i salt Those who always or ofte ate processed foods high i salt were 16.7 (CI: ). Amogst the 16.7 respodets who always of ofte ate processed food high i salt the majority are i the youger age groups (20.3 aged 15-29, 15.6 aged ad oly 7.4 aged 45-69). Worth oted, is that, as the respodet aged they cosumed less of the processed food. About 14.3 (CI: ) felt they cosumed far too much processed food or too much salt. The results revealed that 93.4 (CI: ) of the respodets used vegetable oil for cookig Physical iactivity The digs revealed that 15.3 (CI: ) of r e s p o d e t s w e r e o t m e e t i g W H O recommedatios o physical activity for health (respodets doig less tha 150 miutes of moderate-itesity physical activity per week, or equivalet) Percet ot meetig WHO recommedatios o physical activity for health, by Age ad Sex Me Wome Figure 5: Percetage ot meetig WHO recommedatios o physical activity for health 13

25 The average umber of miutes the respodets spet o physical activity was (CI: ) per day. The media umber of miutes spet o total physical activity per day was 120.0(IQ: ). The proportio of the respodets ot egagig i vigorous physical activity was 46.9 (CI: ) beig 29.4 (CI: ) i me ad 62.0 (CI: ) i wome. 3.3 BIOCHEMICAL RISK FACTORS Biological or biochemical risk factors iclude history of raised blood pressure, raised total cholesterol, raised blood glucose, overweight ad obesity, cardiovascular disease ad screeig for cervical cacer for wome. Lack of testig is a issue i both sexes prevalece of ever measured is equally high i both, Blood Pressure is the oly exceptio where wome are more likely to have bee measured (ad a lot more were diagosed). So there is a geder gap for Blood Pressure but ot for the others History of raised blood pressure About 45.3 (CI: ) of the respodets reported that they had ever take a blood pressure measuremet ad 8.7 (CI: ) had bee diagosed with raised blood pressure i the past 12 moths. The proportio of those curretly takig drugs (medicatio) for raised blood pressure prescribed by doctor or health worker amog those diagosed was 37.4 (CI: ). Of the 45.3 who had ever take a blood pressure measuremet, 55.1 of those were me ad 37 were wome. This idicates that the majority of me do ot visit health facilities as frequetly as wome do History of raised blood sugar A total of 80.6 (CI: ) of the respodets reported that they had ever had their blood sugar measured. About 2.0 (CI: ) of the respodets had bee diagosed with raised blood glucose. Of those curretly diagosed with raised blood sugar 69.6 (CI: ) were curretly takig drugs (medicatio) prescribed for diabetes ad 22.2 (CI: ) of those previously diagosed with diabetes were o isuli History of raised cholesterol The results showed that 98.1 (CI: ) of the respodets had ever had their cholesterol levels measured. Oly 0.4 (CI: ) had bee diagosed with raised cholesterol i the past 12 moths ad oly (72.7) respodets previously diagosed reported beig o treatmet for raised cholesterol History of cardiovascular Disease The percetage of respodets who had ever had a heart attack or chest pai from heart disease (agia) or a stroke amog all respodets was 4.4 (CI: ). Oly 0.9 (CI: ) percetage of respodets were curretly takig aspiri regularly to prevet or treat heart disease whereas 0.1 (CI: ) were o statis Lifestyle advice Some of the respodets reported havig received lifestyle advice from a doctor or health worker durig the past three years. About 35.8 ( CI: ) had bee advised by doctor or health worker to quit usig tobacco or ot to start altogether ad 43.2 ( ) were advised by doctor or health worker to reduce salt i the diet. As far as diet was cocered 54.9 (CI: ) had bee advised by doctor or health worker to eat at least ve servigs of fruit ad/or vegetables each day. Ad 52.8 (CI: ) were advised by doctor or health worker to reduce fat i the diet. A proportio of about 52.9 (CI: ) of the respodets had bee advised by doctor or health worker to start or do more physical activity. Advise by doctor or health worker to maitai a healthy body weight or to lose weight was received by 42.9 (CI: ) of the respodets Cervical cacer screeig A total of 13.4 (CI: ) of female respodets reported to had ever had a screeig test for cervical cacer i their lifetime ad 21.7 ( CI: ) were ever screeed amog those aged betwee 30 ad 44 years. 3.4 PHYSICAL MEASUREMENTS As part of Step 2 blood pressure, height, weight ad body mass idex (BMI) were measured Blood pressure The mea Systolic Blood Pressure (SBP) was 124.0mmHg (CI: ) amog the respodets ad the mea Diastolic Blood Pressure (DBP) was 14

26 79.7mmHg (CI: ). About 20.4 (CI: ) of the respodets excludig those o medicatio for raised blood pressure had SBP 140 ad/or DBP 90 mmhg. The proportio of the respodets excludig those o medicatio for raised blood pressure, with SBP 160 ad/or DBP 100 mmhg, was 6.3 (CI: ). About 11.2 (CI: ) of the respodets had SBP 160 ad/or DBP 100 mmhg or curretly o medicatio for raised blood pressure. About 78.9 (CI: ) of those with SBP 140 ad/or DBP 90 were ot o medicatio ad oly 8.1 (CI: ) were o treatmet with SBP<140 ad DBP<90. About 12.9 (CI: ) were o treatmet but had SBP 140 ad/or DBP 90. The mea heart rate amog the respodets was 74.4 beats per miute (CI: ). Table 4: BMI classi Age Group catios Uderweight <18.5 Normal weight BMI classi catios Both Sexes BMI Obese = Height, Weight ad Body Mass Idex The average height amog the male respodets was 168.4cm (CI: ) ad 158.9cm (CI: ) amog the females. The average weight amog the males was 66.7kg (CI: ) ad lesser tha the females which was 69.4kg (CI: ). As far as the Body Mass Idex (BMI) was cocered the 2 average amog all the respodets was 25.7kg/m (CI: ). I all the age groups, wome recorded high BMI idex either i the overweight or obese category. Of the 23.4 of respodets who were overweight, 59.9 were wome ad 26 were me. A total of 20.5 respodets were categorized as obese (49.9 wome ad 20.8 me) ad i additio of these obese respodets, 37.1 were aged betwee 45 ad 69 years, table 4. The average waist circumferece for the male respodets was 79.4cm (CI: ) ad 86.6cm (CI: ) for the females. The mea hip circumferece for me was 94.6cm (CI: ) ad 105.3cm (CI: ) for wome. The mea hipwaist ratio was 0.8(CI: ) for both males ad females. 3.5 BIOCHEMICAL MEASUREMENTS The biochemical measuremet icluded fastig blood glucose ad total cholesterol levels Fastig blood glucose The mea fastig blood glucose level i the study populatio was 5.1 mmol/l (CI: ). About 9.8 ( ) of the respodets had impaired fastig glycaemia de ed as capillary whole blood value: 5.6mmol/L ad <6.1mmol/L. About 14.2 (CI: ) of the respodets had raised blood glucose or were curretly o medicatio for diabetes. Raised blood glucose is de ed as capillary whole blood value: 6.1 mmol/l. About 1.8 (CI: ) of the respodets were o medicatio for diabetes Cholesterol The mea total cholesterol amog all respodets icludig those who were curretly o medicatio for raised cholesterol was 3.7mmol/L (CI: ). About 10.9 ( CI: ) of the respodets had total cholesterol 5.0 mmol/l or were curretly o medicatio for raised cholesterol. A total of 2.4 ( CI: ) had total cholesterol 6.2 mmol/l or were curretly o medicatio for raised cholesterol. The mea HDL was 1.2 mmol/l (CI: ) amog all the respodets. About 43.7 (CI: ) of the male had HDL <1.03mmol/L ad 60.5 (CI: ) had HDL <1.29mmol/L. 3.6 CARDIOVASCULAR RISK About 8.8 (CI: ) of the respodets aged years had a 10-year cardiovascular disease (CVD) risk 30 or with existig CVD. A 10-year CVD risk of 30 is de ed accordig to age, sex, blood pressure, smokig status (curret smokers OR those who quit smokig less tha 1 year before the assessmet), total 15

27 cholesterol, ad diabetes (previously diagosed OR a fastig plasma glucose cocetratio >7.0 mmol/l (126 mg/dl)). Of the 8.8, about 43.4 (CI: ) of all eligible persos were receivig drug therapy ad couselig to prevet heart attacks ad strokes. 3.7 Summary of Combied Risk Factors A total of 20.3 (CI: ) of the respodets had 3-5 of the followig risk factors: curret daily smokig; less tha ve servigs of fruit ad/or vegetables per day; ot meetig WHO recommedatios o physical activity for health (<150 miutes of moderate activity per week, or equivalet); overweight or obese (BMI 25 kg/m2) ad raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP). At least 2.8 (CI: ) did ot have ay risk factor whilst respodets with 1 0r 2 risk factors were 76.8 (CI: ). Table 5: Summary of Combied Risk Factors Summary of Combied Risk Factors Both Sexes with 0 with 1-2 with 3-5 risk factors risk factors risk factors OPTIONAL MODULES The optioal modules selected were metal health, oral health, violece ad ijury. Fidigs uder these modules are preseted i this sectio Metal Health About 9.3 (CI: ) of the respodets reported that they had seriously cosidered attemptig suicide i the last 12 moths. Of these, oly 27.6 (CI: ) of sought professioal help. About 3.6 (CI: ) of the respodets had ever attempted suicide, of whom 59.8 (CI: ) attempted i the past 12 moths. About 37.3 of the respodets reported that they used poisoig with pesticides ad 29.6 (CI: ) reported to use overdose of medicatio or drugs. About 11.3 (CI: ) of [the respodets reported that they had ever had ayoe i their close family attempt suicide ad 7.6 (CI: ) actually reported that they had ever had someoe i their close family die from suicide Oral health About 96.2 of the respodets had 20 or more atural teeth. About 13.1 (CI: ) reported havig poor or very poor state of teeth amog those havig atural teeth ad 9.0 (CI: ) reported havig a poor or very poor state of gums amog those havig atural teeth. About 3.7 (CI: ) had detures. About 28.1 (CI: ) reported havig had pai or discomfort caused by their teeth or mouth i the past 12 moths. Oly 12.7 (CI: ) reported havig see a detist i the past 12 moths ad 51.5 (CI: ) reported that they had ever received detal care i the past 12 moths. A total of 96.3 (CI: ) of the respodets reported cleaig their teeth at least oce a day.. The proportio of those who used tooth paste amog those who cleaed their teeth was 98.1 (CI: ). About 18.1 (CI: ) had difficulty i chewig foods, Females has bee reported to have a high prevalece 11.6 (CI: ) tha males 8.3 (CI: ) reported to have a difficulty sleepig due to tooth pai amog the most prevalece, ad 6.5 (CI: ) had problems prooucig words durig the past 12 moths due to the state of their teeth. About 8.2 (CI: ) felt tese because of problems with teeth or mouth durig the past 12 moths. 5.9 (CI: ) were embarrassed about the appearace of their teeth durig the past 12 moths. Less tha 5 of the respodets reported havig reduced participatio i social activities, bee less tolerat of spouse or people close to them; difficulty doig usual activities, days ot at work because of teeth or mouth problems durig the past 12 moths Violece ad Ijury The percetage of drivers or passegers of a motor vehicle who did ot always use a seat belt or were otherwise urestraied durig the past 30 days was 51.4 (CI: ). The survey results also idicate that the majority (95.8) of respodets who use motorcycle ad scooter did ot wear helmets (93 were me ad 98.2 were wome). Of the respodets who reported to use bikes, 97.3 of them did ot wear helmets. 16

28 Percet Drivers Not Always Usig Seatbelt Me Wome Figure 6: Drivers Not Always Usig Seatbelt The percetage of respodets who had bee ivolved i a road traffic crash durig the past 12 moths was 2.6 (CI: ) ad 44.9 (CI: ) of these had serious ijuries requirig medical attetio. Those that sustaied ijuries due o-road traffic related accidet that required medical attetio were 6.3 (CI: ). The proportio of respodets who drove a motorized vehicle after havig had 2 or more alcoholic driks was 2.1 ( CI: ) About 9.4 (CI: ) of respodets who rode i a motorized vehicle where the driver had 2 or more alcoholic driks. As far as violece is cocered about 2.4 (CI: ) of respodets were ivolved i a violet icidet durig the past 12 moths resultig i a ijury. The prevalece of beig physically abused durig childhood by a paret or other adult i the household amog the respodets was 28.2 (CI: ). A total of 4.7 (CI: ) of respodets reported to have bee sexually abused durig childhood about 1.5 (CI: ) of me ad 7.5 (CI: ) of wome. About 3.0 (CI: ) of respodets reported beig sexually abused durig adulthood, 1.5 (CI: ) of me ad 4.3 (CI: ) of wome. About 13.1 (CI: ) of respodets reported beig frighteed for the safety of themselves or their families because of the ager or threats of aother perso. The percetage of respodets carryig a loaded rearm outside the home durig the past 30 days for protectio was 1.3 (CI: ). 17

29 Chapter 4: DISCUSSION The digs of the survey revealed that the Swazi populatio is exposed to risk factors for NCDs. The exposure is actually icreasig as evideced by comparig the 2007 survey ad the results of this 2014 survey. The higher the prevalece of the risk factors, the higher the prevalece of the major NCDs, leadig to higher morbidity ad mortality due to these diseases. This i tur strais the health system ad the ecoomy of the coutry as a whole. The major modi able risk factors for NCDs are tobacco use, harmful use of alcohol, uhealthy diet (low fruit ad vegetable cosumptio) ad physical iactivity which lead to itermediate risk factors like raised blood pressure, raised blood lipids, raised blood glucose, overweight ad obesity which the maifest as cardiovascular diseases, diabetes mellitus, chroic obstructive pulmoary diseases ad cacers. The major risk factors together accout for approximately 80 of deaths from heart disease ad stroke. 4.1 Tobacco Use The prevalece of smokig amog the adult populatio i Swazilad was at 6.0. This was ot very high compared to other coutries. The smokig was higher i males at 11.7 ad oly 1.2 i females. Me ted to smoke more tha wome ad this is cosistet dig from other STEPs surveys like i Botswaa (2007) it was 32.8 me ad 7.8 wome, Zazibar (2012) it was 14.6 me ad 0.7 wome, ad Vauatu (2013) it was 45.8 me ad 4.0 wome. The wome ad childre were more exposed to secod had smokig, 17.3 (CI: ) reported to have bee exposed to secod-had smoke i home durig the past 30 days. The average age of startig smokig was 19 years. Smokig daily icreases the risk of developig chroic o-commuicable diseases. About oe i every twety adult populatio i Swazilad smokes o daily basis ad the average umber of cigarettes smoked a day is ve. The majority (93.1) of those who smoke tobacco daily use maufactured cigarettes. 4.2 Alcohol Cosumptio Harmful cosumptio of alcohol is also a major risk factor for o-commuicable diseases. The digs revealed that 13 of the adult populatio i Swazilad drik alcohol ad cosumptio is much higher i males (22.1) tha i females (5.3). Oe i every ve me drak alcohol i the past 30 days compared to oe i every 20 wome. About oe i every te adults drak 6 or more driks o ay occasio with oe i every six me compared to oe i every thirty wome beig heavy drikers. 4.3 Diet Cosumptio of sufficiet amout of fruits ad vegetables is key to the prevetio ad cotrol of chroic o-commuicable diseases. O average the adult populatio cosumed oe servig of fruits per day for half of the week. People ate about oe ad half servigs of vegetables per day i about 5 days of the week. The majority (92.1) of the adult populatio i Swazilad ate less tha ve servigs of fruits ad/or vegetables o average day per day. A fth of the populatio always added salt to food as well as cosumed processed food high i salt. Diet rich i tras-fat acids ad salt cotributes to the risk for NCDs. Accordig to WHO recommeded stadards (2014): High sodium cosumptio (>2 grams/day, equivalet to 5 g salt/day) ad isufficiet potassium itake (less tha 3.5 grams/day) cotributes to high blood pressure ad icreases the risk of heart disease ad stroke. Salt itake of less tha 5 grams per day for adults helps to reduce blood pressure ad risk of cardiovascular disease, stroke ad coroary heart attack. The pricipal bee t of lowerig salt itake is a correspodig reductio i high blood pressure. WHO Member States have agreed to reduce the global populatio's itake of salt by a relative 30 by Reducig salt itake has bee ideti ed as oe of the most cost-effective measures coutries ca take to improve populatio health outcomes. Key salt reductio measures will geerate a extra year of healthy life for a cost that falls below the average aual icome or gross domestic product per perso. A estimated 2.5 millio deaths could be preveted each year if global salt cosumptio were reduced to the recommeded level. 4.4 Physical Activity Sufficiet physical activity, de ed as more tha two ad half hours of moderate-itesity activity per week, is eeded to reduce the risk of developig chroic o commuicable diseases. About 85 of t h e r e s p o d e t s i S w a z i l a d m e t W H O recommedatios. Oe i every te me compared to oe i every ve wome lacked sufficiet physical activity. About half of the adult Swazi populatio did 18

30 ot egage i vigorous activity. This was higher i wome whereby about two thirds of wome did ot egage i vigorous physical activity compared to about oe third of me. Leisure-related activities had the least cotributio to the total physical activity for both me ad wome. However, for me, physical activity from leisure time accouts for 25.8 percet (CI: ) of physical activity agaist 10.4 percet (CI: ) for wome. 4.5 Cervical cacer Access to cervical cacer screeig is ecessary for the prevetio ad cotrol of oe of the leadig cacers i Swazilad. About oe i every ve wome aged years had ever had a screeig test for cervical cacer. 4.6 Physical Measuremets Physical measuremets reveal the biological risk factors for chroic o-commuicable diseases which iclude overweight ad obesity as well as raised blood pressure. The average body mass idex 2 amog the adult populatio was at 25.7 kg/m, beig kg/m i me ad 27.6 kg/m i wome. About half of the adult populatio was overweight. Oe quarter of adult males compared to early two thirds of wome were overweight. About oe fth of the populatio was obese, oe teth of me ad oe third of wome. The average waist circumferece was 79.4cm i me ad 86.6cm i wome. Wome were at a higher risk i as far as overweight ad obesity is cocered. The prevalece of raised blood pressure ( 140/90 or o medicatios) amog the adult populatio was 24.5.Of the people with raised blood pressure 78.9 of them were ot o medicatio which was 87.0 for males ad 72.8 for females. The results are showig that the Swazi adult populatio do ot regularly check their Blood pressure ad it is eve worse if we cosider regular checkup for blood sugar ad cholesterol. Regular screeig for these itermediate risk factors for o-commuicable disease is crucial for early detectio of these disease which ca improve treatmet outcomes. 4.7 Biochemical Measuremet Raised blood sugar ad cholesterol cotribute towards the developmet of o-commuicable diseases. The average blood sugar level amog the populatio was 5.1 mmol/l (CI: ). The prevalece of raised blood sugar was 4.6 mmol/l (CI: ). ad the prevalece of raised cholesterol ( 5 mmol/l or o medicatio) was Cardiovascular disease (CVD) risk The percetage of those aged years with a 10 year cardiovascular risk of greater tha 30 or with existig CVD was 8.7 beig 6.8 for males ad 10.1 for females. Geerally, aspiri ad statis are both kow to be effective for primary ad secodary prevetio of cardiovascular diseases. However, oly less tha 1 of the participats reported takig either aspiri or statis for the prevetio ad treatmet of CVDs. 4.9 Summary of combied risk factors Some people ca have a combiatio of the major risk factors for chroic o-commuicable diseases. These risk factors are curret daily smokers; less tha 5 servigs of fruits ad vegetables per day; isufficiet physical activity; overweight (BMI 25 kg/m2) ad raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP). About 3 of the adult populatio (2.8) was free of ay of the above metioed risk factors. The results revealed that 14.6 of the populatio aged 15 to 44 years compared to 45.6 of those aged 45 to 69 years had three or more of the above risk factors. Roughly twice as may females (27.1) tha males (13.2) had three or more of the risk factors 4.10 Tobacco policy About 5 i 10 adults had either see or heard aticigarette smokig iformatio o the televisio or radio. There was high cotemplatio about quittig tobacco use amog curret smokers sice 7 i 10 curret smokers thought about quittig because of warig labels o cigarette packages. Advertisig ad promotio of tobacco was low i the coutry with 1 i 10 adults havig oticed cigarette marketig i stores where cigarettes were sold ad 1 i 10 adults oticed cigarette promotios. The average mothly expediture o maufactured cigarettes was SZL Metal Health Metal health problems are o the icrease globally ad the results revealed that about 1 i every 10 of the study populatio had seriously cosidered 19

31 attemptig suicide i the last 12 moths ad 3.6 had actually attempted suicide. Of those who cosidered attemptig suicide oly a third (27.6) sought professioal help. It showed that there were a lot of metal health challeges i the coutry as more tha oe i te (11.3 ) of the respodets reported that they ever had ayoe i their close family attemptig suicide ad 7.6 actually reported that they had ever had ayoe i their close family die from suicide Oral health Geerally the majority (96.2) of the populatio had 20 or more atural teeth though about 13.1 had poor or very poor state of teeth. ad about oe i every te had poor or very poor state of gums. Just over a quarter of the respodets had pai or discomfort caused by their teeth or mouth durig the past 12 moths. Oly 3.7 had detures. As far as receivig detal care was cocered, like havig regularly checkup, oly 12.7 had see a detist durig the past 12 moths. More tha half of the adult populatio had ever received detal care. Oral hygiee was high as the majority (96.3) of the people cleaed their teeth at least oce a day usig toothpaste cotaiig uorides. The problems associated with poor state of teeth, gums ad geeral oral health icluded difficulties i chewig foods, prooucig words, feelig tese embarrassmet as well as havig reduced participatio i social activities, less tolerace of spouse or people close to them; difficulty doig usual activities ad days ot at work Violece ad Ijury Geerally i Swazilad more tha half (51.4) of the participats did ot always use a seat belt or were urestraied whe drivig. The prevalece of road traffic crashes was at 2.6 ad close to half (44.9) of those ivolved i road crashes sustaied serious ijuries requirig medical attetio. The prevalece of other types of ijuries besides road crashes was actually higher at 6.3 ad 77.8 of these crashes resulted i serious ijuries that required medical attetio. It was also oted that 2.1 of the populatio drove motorized vehicles after havig had 2 or more alcoholic driks ad about oe i te people were exposed to the risk of ridig i a motorized vehicle where the driver had had 2 or more alcoholic driks. About oe i three (28.2) had bee physically abused durig childhood by a paret or other adult i the household. whilst 4.7 had bee sexually abused durig childhood ad this was more for females (7.5) tha males(1.5). The prevalece of sexual abuse amog adults was 3.0 maily wome suffered sexual abuse. 20

32 Chapter 5: CONCLUSION AND RECOMMENDATIONS 5.1 Coclusio There is a high prevalece of modi able risk factors of o-commuicable diseases i Swazilad. Tobacco use is relatively low overall but high amog the me. Alcohol cosumptio is high especially amog males. Other lifestyle factors such as overweight ad cetral obesity were oted to be geerally high especially amog females. The prevalece of both diagosed ad udiagosed hypertesio ad diabetes mellitus was foud to be high. I this survey the prevalece of abormal lipids was oted to be sigi cat. 5.2 Recommedatios The followig recommedatios were developed based o the survey results. 1. Idividuals, families ad commuities should be empowered to take cotrol of their health ad modify their lifestyles as well as scree for early detectio of NCDs through a life cycle approach. 2. The miistry of health especially the reproduc tive health program should ecourage ad emphasize the icrease rates of cervical cacer screeig 3. There is a urget eed to reduce modi able risk factors for NCDs ad create a safe ad health promotig eviromet 4. Stregthe ad oriet health systems to address the prevetio ad cotrol of ocommuicable diseases especially ad the uderlyig social determiats through people-cetered primary health care ad uiversal health coverage which will iclude: a. icrease cosumptio of fruits ad vegetables; b. icrease leisure time activity, c. raise rates of screeig for Blood Pressure, glucose, cholesterol; d. address the dagers of secod had smoke i the workplace; 5. The surveillace ad moitorig system eeds to be stregtheed to eable routie reportig agaist NCD risk factors. 6. There is eed to develop ad stregthe atioal multi-sectoral strategies targetig reducig tobacco use, harmful use of alcohol, cosumptio of uhealthy diet ad icrease physical activity amog the Swazi populatio. 7. There is eed to adopt the best buys for the prevetio ad cotrol of NCDs. 21

33 REFERENCES 1. Australia Istitute of Health ad Welfare (AIHW) 2015: Authoritative iformatio ad statistics to promote better health ad wellbeig 2. Bicego GT, Nkambule R, Peterso I, Reed J, Doell D, Giidza H, Duog YT, Patel H, Bock N, Philip N: Recet Patters i Populatio-Based HIV Prevalece i Swazilad.PloS oe 2013, 8(10):e Bull F, Armstrog T, Dixo T, Ham S, Neima A, Pratt M. Physicaliactivity. I: Ezzati M, Lopez A, Rodgers A, Murray C (eds)comparative quati catio of health risks: global ad regioal burde ofdisease attributable to selected major risk factors. Geeva, World HealthOrgaizatio, 2004: Ekpeyog C. E., Udokag N. E., Akpa E.E. ad Samso T. K. (2012). Double burde, o-commuicable diseases ad risk factors evaluatio i Sub-Sahara Africa: The Nigeria experiece. Europea Joural of Sustaiable Developmet (2012, 1, 2, ) 5. Elwood P C et al. Smokig, drikig, ad other lifestyle factors adcogitive fuctio i me i the Caerphilly cohort. Joural ofepidemiology ad Commuity Health, Vol 53, 1999: Global health risks: mortality ad burde of disease attributable to selected major risks. Geeva, World Health Orgaizatio, IlkkaVuori. Physical iactivity as a disease risk ad health bee ts o creased physical activity. I: Oja P, Borms J (eds) Perspectives-Themultidiscipliary series of physical educatio ad sport sciece: Healthehacig physical activity. Vol 6, 2004: Impaired cotrol over alcohol use: A uder-addressed risk factor for problem drikig i youg aduts. Exp Cli Psychopharmacol Apr;20(2): doi: /a Epub 2011 Dec 19. Leema RF, Patock- Peckham JA, Poteza MN 9. J a S h e e h a, D e m a d M e d i a H e a l t h y E a t i g : T h e F u c t i o s o f F r u i t s & Vegetables Jo's Cervical cacer trust. Factsheet: Cervical cacer. December Leoe A, Ladii L, Leoe A (2010: 16(23): ). What is tobacco smoke? Sociocultural dimesios of the associatio with cardiovascular risk 12. Miistry of Health, Swazilad: Health Maagemet Iformatio System (HMIS) database Mutrie N. The relatioship betwee physical activity ad cliicallyde ed depressio. I Biddle S J H, Fox K R, Boutcher S H. (eds)physical activity ad Psychological Well-beig. Lodo:Routledge, No-commuicable WHO. Factsheet, Jauary Nutritio Foudatio Ehacig the quality of life of New Zealaders by ecouragig iformed, healthy ad ejoyable food choices as part of a active lifestyle ( ) d 16. Official list of MDG idicators: 62 Geeral Assembly, effective Jauary Peter Byass, Do de Savigy ad Ala D Lopez (2014). Essetial evidece for guidig health system priorities ad policies: aticipatig epidemiological trasitio i Africa. 18. Stewart R et al. Vascular risk ad cogitive impairmet i a older,british, Africa-Caribea populatio. Joural of the America GeriatricsSociety, Vol 49, 2001:

34 APPENDICES

35

36 19. Swazilad Cesus Report, Cetral Statistics Office. Ecoomic Plaig. 20. Swazilad STEPS Survey Fact Sheet The Miistry of Health - Health Iformatio Systems Report The Swazilad Aual Health Statistics Report(2011) 23. The W.H.O Global Pla of Actio The World Health Report 2002: Reducig risks, promotig health life.geeva, World Health Orgaizatio, WHO - Physical activity Fact sheet No 385 (Jauary 2015) 26. World Health Orgaizatio: STEPwise approach to Surveillace (STEPS) of NCD risk factors,

37 9.0 APPENDICES Appedix A: Site speci c STEPS istrumet (questioaire) Survey Iformatio Locatio ad Date Respose Code Ikhudla ID I1 Regio/Ikhudla I2 Iterviewer ID Date of completio of the istrumet dd mm year I3 I4 Coset, Iterview Laguage ad Name Respose Code Yes 1 Coset has bee read ad obtaied I5 No 2 If NO, END Eglish 1 Iterview Laguage[Isert Laguage] SiSwati 2 [Add others] 3 I6 [Add others] 4 Time of iterview (24 hour clock) hrs : mis I7 Family Surame I8 First Name I9 Additioal Iformatio that may be helpful Cotact phoe umber where possible I10 24

38 Step 1 Demographic Iformatio CORE: Demographic Iformatio Questio Respose Code Sex (Record Male / Female as observed) Male 1 C1 Female 2 What is your date of birth? Do't Kow? If kow, Go to C4 dd mm year C2 How old are you? Years C3 I total, how may years have you spet at school ad i full-time study (excludig pre-school)? Years C4 25

39 EXPANDED: Demographic Iformatio What is the highest level of educatio you have completed? No formal schoolig 1 Less tha primary school 2 Primary school completed 3 Secodary school completed 4 High school completed 5 C5 College/Uiversity completed 6 Post graduate degree 7 Refused 88 What is yourorigi? Swazi 1 No-Swazi 2 Refused 88 Never married 1 Curretly married 2 C6 Separated 3 What is your marital status? Divorced 4 C7 Widowed 5 Cohabitatig 6 Refused 88 Which of the followig best describes your mai work status over the past 12 moths? (USE SHOWCARD) How may people older tha 18 years, icludig yourself, live i your household? Govermet employee 1 No-govermet employee 2 Self-employed 3 No-paid 4 Studet 5 Homemaker 6 Retired 7 Uemployed (able to work) 8 Uemployed (uable to work) 9 Refused 88 Number of people C8 C9 26

40 EXPANDED: Demographic Iformatio, Cotiued Questio Respose Code Takig the past year, ca you tell me what the average Per week Go to T1 C10a earigs of the household have bee? OR per moth Go to T1 C10b (RECORD ONLY ONE, NOT ALL 3) OR per year Go to T1 C10c Refused 88 C10d If you do t kow the amout, ca you give a estimate of the aual household icome if I read some optiosto you? E500 1 More tha E500.00, 2 More thae , 3 More tha E2, , 4 More tha E Do't Kow 77 Refused 88 C11 27

41 Step 1 Behavioural Measuremets CORE: Tobacco Use Now I am goig to ask you some questios about tobacco use. Questio Respose Code Do you curretly smoke ay tobacco products, Yes 1 such as cigarettes, cigars or pipes? T1 (USE SHOWCARD) No 2 If No, go to T8 Do you curretly smoke tobacco products daily? Yes 1 No 2 T2 How old were you whe you first started smokig? Age Do t kow 77 If Kow, go to T5a/T5aw T3 Do you remember how log ago it was? OR I Years i Moths If Kow, go to T5a/T5aw If Kow, go to T5a/T5aw T4a T4b (RECORD ONLY 1, NOT ALL 3) OR i Weeks T4c DAILY WEEKLY Maufactured cigarettes T5a/T5aw Had-rolled cigarettes T5b/T5bw O average, how may of the followig products do you smoke each day/week? Pipes full of tobacco T5c/T5cw (IF LESS THAN DAILY, RECORD WEEKLY) Cigars, cheroots, cigarillos T5d/T5dw (RECORD FOR EACH TYPE, USE SHOWCARD) Number of Shisha sessios T5e/T5ew Do t Kow 7777 Other If Other, go to T5other, else go to T6 T5f/T5fw 28

42 Figure 1: Primary Samplig Uits Other (please specify): T5other/ T5otherw Durig the past 12 moths, have you tried tostop smokig? Durig ay visit to a doctor or other health worker i the past 12 moths, were you advised to quit smokig tobacco? I the past, did you ever smoke ay tobacco products? (USE SHOWCARD) Yes 1 No 2 Yes 1 If T2=Yes, go to T12; if T2=No, go No 2 If T2=Yes, go to T12; if T2=No, go No visit durig the past 3 If T2=Yes, go to T12; if T2=No, go Yes 1 No 2 If No, go to T12 T6 T7 T8 I the past, did you ever smoke daily? Yes 1 If T1=Yes, go to T12, else go to T10 T9 No 2 If T1=Yes, go to T12, else go to T10 EXPANDED: Tobacco Use Questio Respose Code How old were you whe you stopped smokig? Age T10 Do t Kow 77 If Kow, go to T12 How log ago did you stop smokig? Years ago If Kow, go to T12 T11a (RECORD ONLY 1, NOT ALL 3) OR Moths ago If Kow, go to T12 T11b Do t Kow 77 OR Weeks ago T11c Do you curretly use ay smokeless tobacco products such as [suff, chewig tobacco, betel, Do you curretly use smokeless tobaccoproducts daily? Yes 1 No 2 If No, go to T15 Yes 1 No 2 If No, go to T14aw T12 T13 29

43 DAILY WEEKLY O average, how may times a day/week do you use. Suff, by mouth T14a/ T14aw T14b/ (IF LESS THAN DAILY, RECORD WEEKLY) Suff, by ose T14bw (RECORD FOR EACH TYPE, USE SHOWCARD) Chewig tobacco T14c/ T14cw Do t Kow 7777 T14d/ Betel, quid T14dw Other T14e/ If Other, go to T14other, if T13=No, go T14ew to T16, else go to T17 Other (please T14other/ specify): If T13=No, go to T16, else go to T14otherw T17 I the past, did you ever use smokeless tobacco products such as [suff, chewig tobacco, or betel]? I the past, did you ever use smokeless tobacco products such as [suff, chewig tobacco, or betel] daily? Durig the past 30 days, did someoe smoke i your home? Durig the past 30 days, did someoe smoke i closed areas i your workplace (i the buildig, i a work area or a specific office)? Yes 1 No 2 If No, go to T17 Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 Do't work i a closed area 3 T15 T16 T17 T18 30

44 Tobacco Policy Tobacco Policy You have bee asked ques os o tobacco cosump o before. The ext ques os ask about tobacco Questio Respose Code Durig the past 30 days, have you oticed iformatio about the dagers of smokig cigarettes or that ecourages quittig through Yes 1 TP1a Newspapers or magazies No 2 Do't kow 77 Televisio Yes 1 TP1b No 2 Do't kow 77 Radio Yes 1 TP1c No 2 Do't kow 77 Durig the past 30 days, have you oticed ay Yes 1 TP2 No 2 advertisemets or sigs promotig cigarettes i Do't kow 77 Durig the past 30 days, have you oticed ay of the followig types of cigarette promotios? Free samples of cigarettes Yes 1 TP3a No 2 Do't kow 77 Cigarettes at sale prices Yes 1 TP3b No 2 Do't kow 77 Coupos for cigarettes Yes 1 TP3c No 2 Do't kow 77 Free gifts or special discout offers o other Yes 1 TP3d No 2 products whe buyig cigarettes Do't kow 77 Clothig or other items with a cigarettebrad ame or logo Yes 1 TP3e No 2 Do't kow 77 Cigarette promotios i the mail Yes 1 TP3f No 2 Do't kow 77 The ext questios TP4 TP7 are admiistered to curret smokers oly. Yes 1 Durig the past 30 days, did you otice ay health warigs o cigarette packages? Durig the past 30 days, have warig labels o cigarette packages led you to thik about The last time you bought maufactured cigarettes for yourself, how may cigarettesdid you buy i total? No Did ot see ay cigarette packages Do't kow 2 If o, go to TP6 3 If "did ot see ay cigarette packages", go to TP6 77 If Do't kow, go to TP6 TP4 Yes 1 TP5 No 2 Do't kow 77 Number of cigarettes Do't kow or Do't smoke or If "Do't kow or do't smoke or TP6 purchase mauf. cigarettes 7777 purchase mauf. cig.", ed sectio I total, how much moey did you pay for this purchase? (DIGITS TO BE ADAPTED TO COUNTRY NEEDS) Amout Do't kow 7777 Refused 8888 TP7 31

45 CORE: Alcohol Cosumptio The ext questios ask about the cosumptio of alcohol. Questio Respose Code Have you ever cosumed ay alcohol such as beer, wie, spirits or home brew[add other local examples]? Yes 1 No 2 If No, go to A16 A1 Have you cosumed ay alcohol withi the past 12 moths? Yes 1 If Yes, go to A4 No 2 A2 Have you stopped drikig due to health reasos,such as a egative impact o your health or o the advice of your doctor or other health worker? Yes 1 If Yes, go to A16 No 2 If No, go to A16 A3 Durig the past 12 moths, how frequetly have you had Daily 1 at least oe stadard alcoholic drik? 5-6 days per week days per week 3 A4 1-2 days per week days per moth 5 (READ RESPONSES, USE SHOWCARD) Less tha oce a moth 6 Have you cosumed ay alcohol withi the past 30 days? Yes 1 A5 No 2 If No, go to A13 Durig the past 30 days, o how may occasios did you have at least oe stadard alcoholic drik? Number Do't kow 77 A6 Durig the past 30 days, whe you drak alcohol, how may stadard driks o average did you have durig Number A7 oe drikig occasio? Do't kow 77 (USE SHOWCARD) Durig the past 30 days, what was the largest umber of stadard driks you had o a sigle occasio, coutig all Largest umber A8 types of alcoholic driks together? Do't Kow 77 Durig the past 30 days, how may times did you have six or more stadard driks i a sigle drikig occasio? Number of times Do't Kow 77 A9 32

46 Moday A10a Durig each of the past 7 days, how may stadard driks did you have each day? Tuesday A10b Wedesday A10c (USE SHOWCARD) Thursday A10d Friday A10e Do't Kow 77 Saturday A10f Suday A10g 33

47 CORE: Alcohol Cosumptio, cotiued I have just asked you about your cosumptio of alcohol durig the past 7 days. The questios were about alcohol i geeral, while the ext questios refer to your cosumptio of homebrewed alcohol, alcohol brought over the border/from aother coutry, ay alcohol ot Questio Respose Code Durig the past 7 days, did you cosume ay homebrewed alcohol, ay alcohol brought over the border/from aother coutry, ay alcohol ot iteded for drikig or other utaxed alcohol? Yes 1 No 2 If No, go to A13 Homebrewed spirits, e.g. mooshie A11 A12a O average, how may stadard driksof the followig did you cosume durig the past 7 days? Homebrewed, beer or wie, e.g. beer, palm or fruit wie A12b Alcohol brought over the border/from aother coutry A12c (USE SHOWCARD) Alcohol ot iteded for drikig, e.g. alcohol-based medicies, perfumes, after A12d Do't Kow 77 shaves Other utaxed alcohol i the coutry A12e 34

48 EXPANDED: Alcohol Cosumptio Daily or almost daily 1 Durig the past 12 moths, how ofte have you foud that you were ot able to stop drikig oce you had started? Weekly 2 Mothly 3 Less tha mothly 4 A13 Never 5 Daily or almost daily 1 Durig the past 12 moths, how ofte have you failed to do what was ormally expected from you because of drikig? Weekly 2 Mothly 3 Less tha mothly 4 A14 Never 5 Daily or almost daily 1 Durig the past 12 moths, how ofte have you eeded a first drik i the morig to get yourself goig after a heavy drikig sessio? Weekly 2 Mothly 3 Less tha mothly 4 A15 Never 5 Yes, more tha mothly 1 Durig the past 12 moths, have you had family problems or problems with your parter due to someoe else s Yes, mothly 2 A16 drikig? Yes, several times but less tha mothly 3 Yes, oce or twice 4 No 5 35

49 CORE: Diet The ext questios ask about the fruits ad vegetables that you usually eat. I have a utritio card here that shows you some examples of local fruits ad vegetables. Each picture represets the size of a servig. As you aswer these questios please thik of a typical week i the last year. Questio Respose Code I a typical week, o how may days do you eat fruit? (USE SHOWCARD) Number of days Do't Kow 77 If Zero days, go to D3 D1 Number of servigs How may servigs of fruit do you eat o oe of those days? (USE SHOWCARD) Do't Kow 77 D2 I a typical week, o how may days do you eat Number of days D3 vegetables? (USE SHOWCARD) Do't Kow 77 If Zero days, go to D5 How may servigs of vegetables do you eat o oe of those days? (USE SHOWCARD) Number of servigs Do t kow 77 D4 Dietary salt With the ext questios, we would like to lear more about salt i your diet. Dietary salt icludes ordiary table salt, urefied salt such as sea salt, iodized salt, salty stock cubes ad powders, ad salty sauces such as soya sauce or fish sauce (see showcard). The followig questios are o addig salt to the food right before you eat it, o how food is prepared i your home, o eatig processed foods that are high i salt such as [isert coutry specific examples], ad questios o cotrollig your salt itake. Please aswer the questios eve if you cosider yourself to eat a diet low i salt. How ofte do you add salt or a salty sauce such as soya sauce to your food right before you eat it or as you are eatig it? How ofte is salt, salty seasoig or a salty sauce added i cookig or preparig foods i your household? How ofte do you eat processed food high i salt? By processed food high i salt, I mea foods that have bee altered from their atural state, such as packaged salty sacks, caed salty food icludig pickles ad preserves, salty food prepared at a fast food restaurat, How much salt or salty sauce do you thik you cosume? 36 Always 1 Ofte 2 Sometimes 3 Rarely 4 Never 5 Do't kow 77 Always 1 Ofte 2 Sometimes 3 Rarely 4 Never 5 Do't kow 77 Always 1 Ofte 2 Sometimes 3 Rarely 4 Never 5 Do't kow 77 Far too much 1 Too much 2 Just the right amout 3 Too little 4 Far too little 5 Do't kow 77 D5 D6 D7 D8

50 EXPANDED: Diet Questio Respose Code How importat to you is lowerig the salt i your diet? Do you thik that too much salt or salty sauce i your diet could cause a health problem? Very importat 1 Somewhat importat 2 Not at all importat 3 Do't kow 77 D9 Yes 1 D10 No 2 Do't kow 77 Do you do ay of the followig o a regular basis to cotrol your salt itake? (RECORD FOR EACH) Limit cosumptio of processed foods Yes 1 D11a No 2 Look at the salt or sodium cotet o food labels Buy low salt/sodium alteratives Yes 1 D11b No 2 Yes 1 D11c No 2 Use spices other tha salt whe cookig Yes 1 D11d No 2 Avoid eatig foods prepared outside of a home Yes 1 D11e No 2 Do other thigs specifically to cotrol your salt itake Yes 1 If Yes, go to D11f No 2 Other (please specify) D11other The ext questios ask about the oil or fat that is most ofte used for meal preparatio i your household, ad about meals that you eat outside a home. Vegetable oil 1 Lard or suet 2 What type of oil or fat is most ofteused for meal preparatio i your household? (USE SHOWCARD) (SELECT ONLY ONE) Butter or ghee 3 Margarie 4 Other 5 If Other, go to D12 other Noe i particular 6 Noe used 7 D12 Do t kow 77 37

51 Other D12other O average, how may meals per week do you eat that were ot prepared at a home? By meal, I mea breakfast, luch ad dier. Number Do t kow 77 D13 CORE: Physical Activity Next I am goig to ask you about the time you sped doig differet types of physical activity i a typical week. Please aswer these questios eve if you do ot cosider yourself to be a physically active perso. Thik first about the time you sped doig work. Thik of work as the thigs that you have to do such as paid or upaid work, study/traiig, household chores, harvestig food/crops, fishig or hutig for food, seekig employmet. [Isert other examples if eeded]. I aswerig the followig questios 'vigorous-itesity activities' are activities that require hard physical effort ad cause large icreases i breathig or heart rate, 'moderate-itesity activities' are activities that require moderate physical effort ad cause small icreases i breathig or heart rate. Questio Respose Code Work Does your work ivolve vigorous-itesity activity that causes large icreases i breathig or heart rate like [carryig or liftig heavy loads, diggig or costructio Yes 1 No 2 If No, go to P 4 P1 I a typical week, o how may days do you do vigorousitesity activities as part of your work? Number of days P2 How much time do you sped doig vigorous-itesity activities at work o a typical day? Hours : miutes : hrs mis P3 (a-b) Does your work ivolve moderate-itesity activity, that causes small icreases i breathig or heart rate such as brisk walkig [or carryig light loads] for at least 10 Yes 1 No 2 If No, go to P 7 P4 I a typical week, o how may days do you do moderate- Number of days P5 itesity activities as part of your work? How much time do you sped doig moderate-itesity activities at work o a typical day? Hours : miutes : hrs mis P6 (a-b) 38

52 Travel to ad from places The ext questios exclude the physical activities at work that you have already metioed. Now I would like to ask you about the usual way you travel to ad from places. For example to work, for shoppig, to market,to place of worship. Do you walk or use a bicycle (pedal cycle) for at least 10 miutes cotiuously to get to ad from places? Yes 1 No 2 If No, go to P 10 P7 I a typical week, o how may days do you walk or bicycle for at least 10 miutes cotiuously to get to ad Number of days P8 How much time do you sped walkig or bicyclig for travel o a typical day? Hours : miutes : hrs mis P9 (a-b) 39

53 CORE: Physical Activity, Cotiued Questio Respose Code Recreatioal activities The ext questios exclude the work ad trasport activities that you have already metioed. Now I would like to ask you about sports, fitess ad recreatioal activities (leisure),[isert relevat terms]. Do you do ay vigorous-itesity sports, fitess or recreatioal (leisure) activities that cause large icreases i breathig or heart rate like [ruig or football] for at Yes 1 No 2 If No, go to P 13 P10 I a typical week, o how may days do you do vigorousitesity sports, fitess or recreatioal (leisure) activities? Number of days P11 How much time do you sped doig vigorous-itesity sports, fitess or recreatioal activities o a typical day? Hours : miutes : hrs mis P12 (a-b) Do you do ay moderate-itesity sports, fitess or Yes 1 recreatioal (leisure) activities that cause a small icrease P13 i breathig or heart rate such as brisk walkig, [cyclig, No 2 If No, go to P16 swimmig, volleyball] for at least 10 miutes cotiuously? I a typical week, o how may days do you do moderateitesity sports, fitess or recreatioal (leisure) activities? Number of days P14 How much time do you sped doig moderate-itesity sports, fitess or recreatioal(leisure) activities o a typical day? Hours : miutes : hrs mis P15 (a-b) 40

54 EXPANDED: Physical Activity Sedetary behaviour The followig questio is about sittig or recliig at work, at home, gettig to ad from places, or with frieds icludig timespet sittig at a desk, sittig with frieds, travelig i car, bus, trai, readig, playig cards or watchig televisio, but doot iclude time spet sleepig. [INSERT EXAMPLES] (USE SHOWCARD) How much time do you usually sped sittig or recliig o a typical day? Hours : miutes : hrs mis P16 (a-b) CORE: History of Raised Blood Pressure Questio Respose Code Have you ever had your blood pressure measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? Have you bee told i the past 12 moths? Yes 1 H1 No 2 If No, go to H6 Yes 1 H2a No 2 If No, go to H6 Yes 1 H2b No 2 I the past two weeks, have you take ay drugs (medicatio) for raised blood pressure prescribed by a doctor or other health worker? Yes 1 No 2 H3 Have you ever see a traditioal healer for raised blood pressure or hypertesio? Yes 1 No 2 H4 Are you curretly takig ay herbal or traditioal remedy for your raised blood pressure? Yes 1 H5 No 2 41

55 CORE: History of Diabetes Have you ever had your blood sugar measured by a doctor Yes 1 H6 or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood sugar or diabetes? No 2 If No, go to H12 Yes 1 H7a No 2 If No, go to H12 Have you bee told i the past 12 moths? Yes 1 No 2 H7b I the past two weeks, have you take ay drugs (medicatio) for diabetes prescribed by a doctor or other health worker? Yes 1 No 2 H8 Are you curretly takig isuli for diabetes prescribed by a doctor or other health worker? Yes 1 No 2 H9 Have you ever see a traditioal healer for diabetes or raised blood sugar? Yes 1 No 2 H10 Are you curretly takig ay herbal or traditioal remedy for your diabetes? Yes 1 No 2 H11 CORE: History of Raised Total Cholesterol Questio Respose Code Have you ever had your cholesterol (fat levels i your blood) measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker Yes 1 H12 No 2 If No, go to H17 Yes 1 H13a that you have raised cholesterol? No 2 If No, go to H17 Have you bee told i the past 12 moths? Yes 1 H13b No 2 I the past two weeks, have you take ay oral treatmet (medicatio) for raised total cholesterol prescribed by a Have you ever see a traditioal healer for raised cholesterol? Are you curretly takig ay herbal or traditioal remedy for your raised cholesterol? Yes 1 H14 No 2 Yes 1 H15 No 2 Yes 1 H16 No 2 42

56 CORE: History of Cardiovascular Diseases Have you ever had a heart attack or chest pai from heart disease (agia) or a stroke (cerebrovascular accidet or Are you curretly takig aspiri regularly to prevet or treat heart disease? Are you curretly takig statis (Lovastati/Simvastati/Atorvastati or ay other stati) Yes 1 H17 No 2 Yes 1 H18 No 2 Yes 1 H19 No 2 CORE: Lifestyle Advice Durig the past three years, has a doctor or other health worker advised you to do ay of the followig? (RECORD FOR EACH) Quit usig tobacco or do t start Reduce salt i your diet Yes 1 H20a No 2 Yes 1 H20b No 2 Eat at least five servigs of fruit ad/or vegetables each day Yes 1 No 2 H20c Reduce fat i your diet Yes 1 No 2 H20d Start or do more physical activity Yes 1 No 2 H20e Maitai a healthy body weight or lose weight Yes 1 If C1=1 go to M1 No 2 If C1=1 go to M1 H20f 43

57 CORE (for wome oly): Cervical Cacer Screeig The ext questio asks about cervical cacer prevetio. Screeig tests for cervical cacer prevetio ca be doe i differet ways, icludig Visual Ispectio with Acetic Acid/viegar (VIA), pap smear ad Huma Papillomavirus (HPV) test. VIA is a ispectio of the surface of the uterie cervix after acetic acid (or viegar) has bee applied to it. For both pap smear ad HPV test, a doctor or urse uses a swab to wipe from iside your vagia, take a sample ad sed it to a laboratory. It is eve possible that you were give the swab yourself ad asked to swab the iside of your vagia. The laboratory checks for abormal cell chages if a pap smear is doe, ad for the HP virus if a HPV test is doe. Questio Respose Code Have you ever had a screeig test for cervical cacer, usig ay of these methods described above? Yes 1 No 2 Do t kow 77 CX1 Metal health / Suicide Metal health / Suicide The ext questios ask about thoughts, plas, ad attempts of suicide. Please aswer the questios eve if o oe usually talks about these issues. Questio Respose Code Durig the past 12 moths, have you seriously cosidered attemptig suicide? Did you seek professioal help for these thoughts? Durig the past 12 moths, have you made a pla about how you would attempt suicide? Have you ever attempted suicide? Durig the past 12 moths, have you attempted suicide? What was the mai method you used the last time you attempted suicide? Yes 1 MH1 No 2 If No, go to MH3 Refused 88 Yes 1 MH2 No 2 Refused 88 Yes 1 MH3 No 2 Refused 88 Yes 1 MH4 No 2 If No, go to MH9 Refused 88 Yes 1 MH5 No 2 Refused 88 Razor, kife or other sharp istrumet 1 Overdose of medicatio (e. g. prescribed, over-the-couter) Overdose of other substace (e.g. heroi, crack, alcohol) Poisoig with pesticides (e.g. rat poiso, isecticide, weed-killer) Other poisoig (e.g. plat/seed, MH6 household product) Poisoous gases from charcoal 6 (SELECT ONLY ONE) Other 7 If Other, go to Refused 88 44

58 Other (specify) Mh6ot her Did you seek medical care for this attempt? Were you admitted to hospital overight because of this attempt? Has ayoe i your close family (mother, father, brother, sister or childre) ever attempted suicide? Yes 1 MH7 No 2 If No, go to MH9 Refused 88 Yes 1 MH8 No 2 Refused 88 Yes 1 No 2 Refused 88 MH9 Has ayoe i your close family (mother, father, brother, sister or childre) ever died from suicide? Yes 1 MH10 Violece ad Ijury CORE: Ijury The ext ques os ask about differet experieces ad behaviours that are related to road traffic ijuries. Questio Respose Code All of the time 1 Sometimes 2 Never 3 I the past 30 days, how ofte did you use a seat belt whe you were the driver or passeger of a motor vehicle? Have ot bee i a vehicle i past 30 days 4 V1 No seat belt i the car I usually am i 5 Do't Kow 77 Refused 88 I the past 30 days, how ofte did you wear a helmet whe you drove or rode as a passeger o a motorcycle or motorscooter? All of the time 1 Sometimes 2 Never 3 Have ot bee o a motorcycle or motor-scooter i past 30 days 4 V2 Do ot have a helmet 5 Do't Kow 77 Refused 88 45

59 Yes (as driver) 1 Yes (as passeger) 2 I the past 12 moths, have you bee ivolved i a road traffic crash as a driver, passeger, pedestria, or cyclist? Yes (as pedestria) Yes (as a cyclist) 3 4 No 5 If No, go to V5 Do t kow 77 If do't kow, go to V5 Refused 88 If Refused, go to V5 Did you have ay ijuries i this road traffic crash which Yes 1 No 2 required medical attetio? Do't kow 77 Refused 88 The ext questios ask about the most serious accidetal ijury you have had i the past 12 moths. V3 V4 Yes 1 I the past 12 moths, were you ijured accidetally, other tha the road traffic crashes which required medical attetio? Do't kow No 2 If No, go to V8 77 If do't kow, go to V8 V5 Refused 88 If Refused, go to V8 Please idicate which of the followig was the cause of this ijury. Fall 1 Bur 2 Poisoig 3 Cut 4 Near-drowig 5 Aimal bite 6 Other (specify) 7 Do't kow 77 Refused 88 V6 CORE: Ijury, Cotiued Other (please specify) V6othe Questio Respose Code Where were you whe you had this ijury? Home 1 School 2 Workplace 3 Road/Street/Highway 4 Farm 5 Sports/athletic area 6 Other (specify) 7 Do t kow 77 Refused 88 Other (please specify) V7 V7oth 46

60 EXPANDED: Uitetioal Ijury The ext questios ask about behaviours related to your safety ad whether or ot you drik alcohol while drivig or beig a passeger. Questio Respose Code I the past 30 days, how ofte did you wear a helmet whe you rode a bicycle or pedal cycle? I the past 30 days, how may times have you drive a motorized vehicle whe you have had 2 or more alcoholic driks? I the past 30 days, how may times have you ridde i a motorized vehicle where the driver has had 2 or more alcoholic driks? Always 1 Sometimes 2 Never 3 Did ot ride i the past 30 4 Do't Kow 77 Refused 88 Number of times Do't Kow 77 Refused 88 Number of times Do't Kow 77 Refused 88 V8 V9 V10 Step 2 Physical Measuremets CORE: Blood Pressure Questio Respose Code Iterviewer ID M1 Device ID for blood pressure M2 Cuff size used Small 1 M3 Medium 2 Large 3 Systolic ( mmhg) M4a Readig 1 Diastolic (mmhg) M4b Systolic ( mmhg) M5a Readig 2 Diastolic (mmhg) M5b Systolic ( mmhg) M6a Readig 3 Diastolic (mmhg) M6b Durig the past two weeks, have you bee treated for raised blood pressure with drugs (medicatio) prescribed by a doctor or other health worker? Yes 1 M7 No 2 47

61 CORE: Height ad Weight For wome: Are you pregat? Yes 1 If Yes, go to M 16 No 2 M8 Iterviewer ID M9 Height M10a Device IDs for height ad weight Weight M10b Height Weight If too large for scale CORE: Waist i Cetimetres (cm) i Kilograms (kg).. M11 M12 Device ID for waist Waist circumferece i Cetimetres (cm). M13 M14 Step 3 Biochemical Measuremets CORE: Blood Glucose Questio Respose Code Durig the past 12 hours have you had aythig to eat or drik, other tha water? Yes 1 No 2 B1 Techicia ID Device ID B2 B3 Time of day blood specime take (24 hour clock) Hours : miutes : hrs mis B4 Fastig blood glucose [MMOL/L Today, have you take isuli or other drugs (medicatio) that have bee prescribed by a doctor or other health worker for raised blood glucose? mmol/l. Yes 1 No 2 B5 B6 48

62 CORE: Blood Lipids Device ID B7 Total cholesterol MMOL/L mmol/l. B8 Durig the past two weeks, have you bee treated for raised cholesterol with drugs (medicatio) prescribed by a doctor or other health worker? Yes 1 No 2 B9 49

63 Appedix B Show cards used Mai Work Show Card Tobacco Show Card Maufactured cigarettes. Roll-your-ow (RYO) cigarettes. Suff, available i wet ad dry form. Cigars, e.g., cigarillos, double coroas, cheroots, stumpe, chutts ad dhumtis. Pipe. 50

64 Alcohol - Stadard drik 1 stadard drik = 1 stadard bottle of regular beer (285ml) 1 sigle measure of spirits (30ml) 1 medium size glass of wie (120ml) Note: et alcohol cotet of a stadard drik is approximately 10g of ethaol. 51

65 Typical Fruit ad Vegetables ad Servig Sizes VEGETABLES are cosidered to be: 1 Servig = Examples Raw gree leafy vegetables 1 cup Spiach, salad, etc. Other vegetables, cooked or chopped raw ½ cup Tomatoes, carrots, pumpki, cor, Chiese cabbage, fresh beas, oio, etc. Vegetable juice ½ cup FRUIT Is cosidered to be: Apple, baaa, orage 1 Servig = Examples 1 medium size piece Chopped, cooked, caed fruit ½ cup Fruit juice ½ cup Juice from fruit, ot arti cially avoured Servig size Oe stadard servig = 80 grams (traslated ito differet uits of cups depedig o type of vegetable ad stadard cup measures available i the coutry). Note: Tubers such as potatoes ad cassava should ot be icluded. 52

66 Dietary Salt Table salt ad sea salt Salty stock cubes ad powders Soya sauce ad sh sauce Examples for processed food high i salt Packaged salty food ad sacks, caed salty food, salty food prepared at a fast food restaurat. 53

67 Physical Activity Vigorous Physical Activity at Work Examples for vigorous activities at WORK VIGOROUS Itesity Activities Make you breathe much harder tha ormal Other examples for VIGOROUS activities at WORK Forestry (cuttig, choppig, carryig wood) Sawig hardwood Ploughig Cuttig crops (sugar cae) Gardeig (diggig) Loadig furiture (stoves, fridge) Istructig sports aerobics Moderate Physical Activity at Work Examples for MODERATE activities at work MODERATE Itesity Activities Make you breathe somewhat harder tha ormal Other examples for MODERATE activities at WORK Cleaig (vacuumig, moppig, polishig, scrubbig, sweepig, iroig)washig (beatig ad brushig carpets, wrigig clothes (by had) Gardeig, Milkig cows (by had), Platig ad harvestig crops, Diggig dry soil (with spade), Weavig, Woodwork (chisellig, sawig softwood), Mixig cemet (with shovel) Labourig (pushig loaded wheelbarrow, operatig jackhammer) Walkig with load o head, Drawig water, Tedig aimals Vigorous Physical Activity durig Leisure Time Examples for VIGOROUS activities durig LEISURE TIME VIGOROUS Itesity Activities Make you breathe much harder tha ormal Other examples for VIGOROUS activities durig LEISURE TIME Soccer, Rugby, Teis,High-impact aerobics, Aqua aerobics,ballet dacig, Fast swimmig 54

68 Moderate Physical Activity durig Leisure Time Examples for MODERATE activities durig LEISURE TIME MODERATE Itesity Activities Make you breathe somewhat harder tha ormal Other examples for MODERATE activities at WORK Cyclig, Joggig, Dacig, Horse-ridig, Tai chi, Yoga, Pilates, Low-impact aerobics,cricket 55