2008 STEPwise Approach to Chronic Disease Risk Factor Survey Report

Transcription

1 2008 STEPwise Approach to Chroic Disease Risk Factor Survey Report A baselie for o-commuicable disease surveillace i St Kitts No-Commuicable Disease Program Miistry of Health

2 St Kitts STEPS Report 2008 Chroic Diseases Risk Factor Survey REPORT COMPILED BY: Ms Petroella Edwards(NCD Program Coordiator); Dr. Hazel Williams-Roberts (Director of Health Istitutios); Dr. Bichara Sahely (Medical Iterist); Mr. William Turer (Epidemiologist); Ms. Juletta Fyfield (Health Educator); EDITORIAL AND TECHNICAL REVIEW BY: Mr. Elvis Newto, Permaet Secretary i the Miistry of Health, St Kitts ad Nevis ad Dr Licol L Carty of Le Maris Life Erichmet Systems, St Kitts 2

3 ACKNOWLEDGEMENTS Implemetig the St Kitts NCD STEPS survey required itesive work, log days, persistece ad dedicatio from the Miistry of Health team that udertook the survey. This importat activity would ot be successful without the cotributios ad iput of may parters i terms of the required resources, techical expertise ad time. The survey would ot be possible without the edorsemet of the Miistry of Health. We say thaks for staffig, laboratory facilities ad office resources. We thak Ms Beverly Harris ad Mr Delvi Harris, Plaig ad Statistical Uit of St Kitts, for assistace with prelimiary preparatio for the survey, icludig sample size calculatio ad selectio of households. Much appreciatio to Ms Alecia Blake of the St. Kitts & Nevis Iformatio Service ad maagemet of all local prit ad electroic media houses for their role i iformig the public about the survey. We ackowledge the statistical support, traiig, resources ad result geeratio provided by the WHO STEPS team (Ms Leae Riley ad Melaie Cowa) ad for further techical support from Dr. Gleis Adall-Brereto ad Sarah Quesel of CAREC ad Dr Braka Legetic of PAHO. We exted sicerest gratitude to all data collectio ad data etry officers, field supervisors ad coutry STEP coordiator for their reletless effort ad time to brig us the results of this survey. The draft report was compiled i sectios by a team of health professioals: Dr Hazel Williams- Roberts, (Director of Commuity Health); Dr Bichara Sahely (Iterist); Ms Juletta Fyfield (Health Educator); Mr William Turer (Epidemiologist); ad Ms Petroella Edwards (NCD Program Coordiator). Mr Clifford Griffi (Health Admiistrative Officer) collated the sectios for fializatio. The report received techical ad editorial review from Mr Elvis Newto ad Dr Licol Carty The St Kitts Govermet Pritery supported pritig of the report 3

4 TABLE OF CONTENTS ACKNOWLEDGEMENTS 3 TABLE OF CONTENTS 4 LIST OF TABLES AND FIGURES 6 EXECUTIVE SUMMARY INTRODUCTION 1.1 Backgroud to the NCD STEPS Surveillace NCDs i St Kitts Descriptio of STEPS Purpose of Study SURVEY METHODOLOGY AND OPERATION 2.1 Scope of Study Samplig ad Sample Calculatios The Istrumet ad Data Collectio Physical Measuremet Method of Data Collectio Data Etry ad Aalysis Challeges RESULTS 3.1 Socio-Demographic NCD Risk Factors (STEP 1) Fruit ad Vegetable Cosumptio Physical Activity Blood Pressure, Diabetes ad Cholesterol History Diabetes History Cholesterol History Family History of Chroic Disease Coditio Cacer Kowledge ad Screeig History NCD Risk Factors (STEP 2- Physical Measuremet) Height, Weight ad BMI BMI Categories 33 4

5 4.3 Waist Circumferece ad Waist/Hip Ratio Blood Pressure Check Respodets with Raised Blood Pressure Raised Risk Discussio of Fidigs Implicatios ad Recommedatios 44 Glossary of Terms ad Refereces 46 Appedices 47 5

6 LIST OF TABLES Table 1- Leadig Causes of Mortality i St Kitts ad Nevis 2004 Table 2 Prevalece of Smokig by Age-Groups ad Geder Table 3 Proportio that had Lifestyle Advice for Blood Pressure (BP) Table 4 Family History of Chroic Disease Coditios LIST OF FIGURES Figure 1 The WHO STEPwise Approach to Surveillace of NCDs Figure 2- Sample Size Calculatios Figure 3 Age Distributio by Geder Figure 4a Employmet Status Figure 4b Upaid Work /Uemploymet Status Figure 5 Proportio Exposed to Evirometal Tobacco Smoke (ETS) at Home Figure 6 Proportio Exposed to ETS at the Workplace Figure 7a Patter of Curret Alcohol Drikig Figure 7b - Frequecy ad Quatity of Alcoholic Driks Cosumed by Me Figure 7c Frequecy ad Quatity of Alcoholic Driks Cosumed by Wome Figure 7d Prevalece of Heavy Drikig Figure 8a Average Days Fruits Eate /week Figure 8b - Average Days Vegetables Eate /Week Figure 8c Number of Servigs of Fruit ad /or Vegetables Per Day Figure 9a Percetage Egaged i Physical Activity Figure 9a Average Time Spet i Physical Activities (both Sexes) Figure 10a Proportio of Blood Pressure ever Diagosed Figure 10b Proportio of Raised BP Diagosed (last 12 moths) Figure 11 Proportio Curretly Takig Prescribed Blood Pressure Drugs Figure 12 Respodets ever Diagosed with Diabetes Figure 13 Wome Receivig Lifestyle Advice for Diabetes (from Health Worker or Doctor) Figure 14a Proportio Diagosed as Havig Raised Cholesterol Figure 14b Proportio Receivig Lifestyle Advice for Raised Cholesterol 6

7 List if Figures cot d Figure 15a Proportio Show How to Examie the Breasts Figure 15b Last Time Breasts Examied Figure 16 Timig of Last Mammogram by Age Figure 17 Timig of Last Pap Smear by Age Figure 18 Proportio that had Colooscopy Figure 19a Average BMI of Respodets Figure 19b Average Weight (kg) of Respodets Figure 20 BMI Classificatio of Respodets Figure 21a BMI Status of Me Figure 21b BMI Status of Wome Figure 22a Waist Circumferece (cm) of Adults Figure 22b Hip Circumferece (cm) of Adults Figure 23a Mea Systolic Blood Pressure (SBP) of Adults Figure 23b Mea Diastolic Blood Pressure (DBP) of Adults Figure 24 Proportio Curretly o Medicatio for Raised Blood Pressure Figure 25a Stage 1 Hypertesio but ot Takig Medicatios Figure 25b Stage 1 Hypertesio or Curretly Takig Medicatios Figure 26 Family Member had Stroke Figure 27 Family Member had High Blood Pressure Figure 28 Proportio with Combied Risk Factors 7

8 Executive Summary The St Kitts STEPS Survey was a populatio-based coutry cross-sectioal assessmet of the key chroic diseases ad their risk factors i adults aged years. It was carried out from October 2007 Jauary 2008 usig the Pa America versio of the WHO STEPS surveillace methodology ad questioaire. The key premise for implemetig STEPS i St Kitts was to develop ad stregthe the coutry s capacity to better moitor o-commuicable diseases ad risk factors through cosistet data collectio. St Kitts ad Nevis adopted the STEPS guidelies to calculate the appropriate sample size ad the STEPS methodology to select a atioally represetative sample. The level of cofidece ad the correspodig margi of error used for the sample size calculatios for the survey were 95 ad 0.05, respectively. Due to isufficiet historical iformatio o baselie levels of the idicators, a estimated prevalece of 50 was utilized, esurig the most coservative sample size. Usig these values ad populatio estimates for each 10-year age group by sex cluster for the combied populatio of St. Kitts ad Nevis (based o the 2001 populatio cesus), sample size estimates (Fig 2.) were calculated for each age/sex strata. The total sample size estimate (obtaied by summig across the age/sex strata) was the adjusted for the desig effect ad for the expected o-respose rate. Sice radom samplig was coducted the desig effect for the survey was 1. The expected respose rate for the STEPS survey was 90. Therefore, the total sample size calculated for St. Kitts ad Nevis was 2,903. This total was the proportioately divided betwee St. Kitts ad Nevis, based o the results of the 2001 populatio cesus as follows: St. Kitts: 2,177 ad Nevis: 726. This calculatio allowed for accurate reportig of estimates for St. Kitts ad Nevis, separately. A total of 1501 households were visited ad data were obtaied from 1443 idividuals i the 9 parishes of St Kitts. Nevis opted to defer the survey after several weeks of iitiatio. The key fidigs of behavioural risks preset the baselie data o various health behaviours, icludig smokig, drikig alcohol, eatig fruits ad vegetables ad physical activity. The percetage that curretly smokes tobacco daily was 8.7 with a geder differece of 16.2 males ad 1.1 of females. The overall prevalece of curret alcohol cosumptio i the populatio was 29.8 with 45.1 of males ad 14.3 of females classified as curret drikers of alcohol. There were 20.1 of curret male cosumers of alcohol i the study ad 20.7 of curret female cosumers of alcohol that had participated i bige drikig. Bige drikig was defied as males havig had 5 or more stadard driks o at least oe day i the previous week, while females bige drikers had 4 or more stadard driks o at least oe day i the previous week. The mea umber of servigs of fruit eate per day was 0.7 for males ad 0.8 for females. The mea umber of servigs of vegetables eate per day was 0.8 for both males ad females. Overall, 97.3 of the respodets cosumed fewer tha 5 of the combied servigs of fruit ad vegetables per day. [Note that starchy vegetables or groud provisios are ot cosidered as vegetables i this study]. Of iterest is that 42.1 of the participats ate at least 1-2 meals outside the home o a weekly basis (males 39.4 ad females 44.7). 8

9 I geeral 38.3 of the study populatio was classified to be moderately iactive, or with low levels of physical activity (28.3 of males ad 48.5) of females). The results suggest that males ad females udertake the majority of their physical activity durig work time. The amout of physical activity udertake durig leisure time was smaller tha that durig work time for both males ad females. The summary of physical measuremets icludes weight, height, waist ad blood pressure measuremets. The overall proportio of those that are overweight or obese (defied as BMI 25kg/m 2 ) i the study populatio was 78.5 ad the proportio of those with obesity (BMI 24kg/ m 2 ) was For males, 74.1 were classified as either overweight or obese with 37.9 beig obese. For females, 83.0 were classified as either overweight or obese with 52.5 beig classified as obese. Mea waist circumfereces for males ad females were 94.0 cm (37 iches) ad 95.1cm (37.1 iches) respectively. Of these values the waist circumferece of males are at acceptable measuremet; but the value for females exceed the accepted 80cm (31.5 iches) cosidered to ifer icreased risk for cardiovascular disease. The total prevalece of high blood pressure amogst males i the survey was 33.2 while that amogst females was The mea systolic ad diastolic blood pressure was 132.4/78.9mmHg i males ad 123.5/76.7mmHg i females. There are 5 commo risk factors for NCDs icludig curret daily smokers, overweight or obese (BMI 25kg/ m 2 ), raised blood pressure (SBP 140 ad /or DBP 90mmHg or curretly o medicatio for raised BP), less tha 5 servigs of fruits ad vegetables per day ad low level activity (<600MET miutes per week). The study populatio that were at low risk for NCDs (that is with oe of the 5 risk factors) was 0.1 while 45.4 of those uder 45 years old were also at icreased risk for NCDs with at least three of the key risk factors. Opportuities for itervetio ad actio Data from the diabetes, cardiovascular diseases ad cacer were already amog leadig morbidity ad mortality statistics of St Kitts. However the high level of risk factors observed i the survey ca oly result i more disability ad reduced quality of life if prevetive measures are ot effective. The fidigs also provide a opportuity for a risk approach to NCD surveillace ad cotrol with a shift i emphasis from idividual to public health. High priority must be give to review of systems ad the executio of actios ecessary for ogoig surveillace, prevetio ad cotrol of o-commuicable diseases. Specific recommedatios emaatig from the survey are: Dissemiate ad utilize fidigs of survey to iform NCD plaig ad actios Set up a commuity-based risk factor surveillace system Set up a morbidity ad mortality data collectio ad aalysis system Iclude step 3 of the STEPS survey (biochemical measures) i future surveys to determie the prevalece of diabetes ad dyslipidemias i the coutry for a more complete picture. 9

10 Coduct further aalyses of the data, such as explorig correlatios betwee educatio/literacy status ad other results or employmet status ad fruit cosumptio or alcohol cosumptio. Desig a atioal media pla to iform the public o the NCDs ad their risk factors. Brig awareess to the health risks associated with smokig ad beefits of smoke cessatio. Itegrated approach risk maagemet for tacklig hypertesio, diabetes ad cardiovascular diseases. Stregthe ad support programs that aim to prevet youths from egagig i substace use ad abuse, icludig alcohol. Istigate strategies that ecourage healthy eatig across all age groups by promotig the availability ad cosumptio of more fruits ad vegetables. Create a supportive eviromet that promote weight reductio ad promote physical activity especially durig trasportatio ad leisure. Adopt/adapt guidelies ad algorithms for the maagemet of specific major NCDs. Provide basic equipmet to the differet health facilities depedig o the techical level. Esure that the health system adequately moitors compliace with atioal stadards for the maagemet of hypertesio, performs moitorig ad treatmet of hypertesio, diabetes ad cardiovascular disease. Explore policy measures for decreasig cosumptio of salt ad fatty foods. 10

11 1. INTRODUCTION 1.1 Backgroud to the Implemetatio of NCD STEPS Surveillace Chroic o-commuicable diseases (NCDs) are a icreasig global challege. Globally, 60 of all deaths ad 47 of disease burde are attributed to them. I fact it is projected that by 2020 they will be resposible for 73 deaths ad 60 of the global burde 1. I developig coutries, the burde caused by chroic diseases is rapidly icreasig ad will have sigificat social, ecoomical ad health cosequeces. St. Kitts is o exceptio to this tred as its epidemiological profile is domiated by these NCDs. There are some commo prevetable risk factors which uderlie most chroic diseases. These modifiable risk factors, which are lifestyle-related, iclude tobacco use, harmful alcohol cosumptio, low fruit ad vegetable cosumptio ad physical iactivity; while the major biological risk factors are overweight, obesity, raised blood pressure, raised blood sugar ad raised cholesterol. Together, these major risk factors accout for 80 of deaths from heart disease ad stroke 2. The eight major behavioural ad biological risk factors ivestigated i risk factor surveys usig the methodology. Heart disease, stroke, cacer, chroic respiratory diseases ad diabetes are some of the chroic diseases to which such risk factors cotribute. The key to cotrollig this global epidemic of chroic diseases is primary prevetio based o comprehesive populatiowide programmes. The aim is to avert these epidemics wherever possible ad, to cotrol them as quickly as possible where they are already preset. The basis therefore, for the prevetio of chroic diseases is the idetificatio of major risk factors i the populatio ad implemetatio of iitiatives to facilitate prevetio ad cotrol NCDs i St. Kitts The Federatio of St. Kitts ad Nevis occupies the orther part of the Leeward Islads chai: the area of the twi-islad state is 261 square kilometres (km 2 ) with Sait Kitts occupyig a surface area of km 2 ad Nevis spas 93 km 2. The twi-islad atio is a idepedet Commowealth Caribbea coutry, havig assumed full sovereigty from Great Britai i WHO. (2002) STEPS: Framework for Surveillace. WHO STEPwise Approach to Surveillace of No-commuicable Disease. (STEPS) World Health Orgaizatio. 2 World Health Orgaizatio. Prevetig Chroic Diseases : A Vital Ivestmet (WHO, Geeva, 2005) 11

12 The ecoomy of St. Kitts ad Nevis experieced strog growth for most of the 1990s. It is domiated by the tertiary sector, which accouts for approximately 50 of the work force. The leadig employmet area was the service idustry (36.5), which is heavily domiated by tourism-related activities, followed by professioal ad techical services (13.6), agriculture ad fishig (12.9), ad costructio ad maufacturig (12.7). The GDP growth rate was 6.4 i 2004, followed by 4.1 growth i The crude death rate for Sait Kitts ad Nevis durig the period was 9.2 per 1,000 populatio. Betwee 1992 ad 1995, the ifat mortality rate fluctuated betwee a low of 22.4 per 1,000 live births i 1993 to a high of 25.1 per 1,000 i Accordig to the "Aual Digest of Statistics, 1994," life expectacy at birth for both sexes was estimated at 68.9 years at the ed of The Federatio is curretly faced with several developmet challeges fuelled by ew techology, ad the burde of maagig chroic o-commuicable diseases. Over the last three decades there has bee a epidemiological profile shift from ifectious diseases of to lifestylerelated chroic o-commuicable diseases. The St. Kitts ad Nevis Strategic Pla for Health cites NCDs to be amog the leadig causes of death i 2004 (Table 1). CAUSE OF MORTALITY PERCENTAGE Cerebrovascular Diseases 13.2 Ischemic Heart Disease 11.3 Septicaemia 7.1 Iflueza ad Peumoia 7.0 Cardiac Arrest 5.7 Diseases of the Uriary System 4.2 Coditios Origiatig out of the Periatal Period 3.3 Heart Failure ad Ill-defied Heart Disease 3.1 Maligat Neoplasm of the Prostate 2.4 Pulmoary Heart disease 2.0 Table 1. Leadig Causes of Mortality i St. Kitts ad Nevis 2004 The NCDs which are most frequetly maifested share a set of risk factors that iclude smokig, high blood cholesterol, obesity ad physical iactivity. I 2000, a workplace-based prevalece survey of three hudred ad fifty three (353) adults (aged 25 ad older) doe i St. Kitts, idicated that 25 of me ad more tha 50 of wome were ot sufficietly physically active. It was also oted that about 60 of me ad almost 70 of wome were overweight. Additioally, very high proportios of me (70) ad wome (60) did ot eat adequate fresh fruits ad vegetables o a regular basis. A combiatio of these factors predisposes oe to develop NCDs. This was also reflected i the fidigs of the Exercise Behavioural Survey, doe 12

13 i 2001, where 53.6 of the adult populatio i St. Kitts ad Nevis was foud to have at least oe chroic disease. 1.3 Descriptio of STEPS The World Health Orgaizatio STEPwise approach to chroic disease risk factor surveillace is iteded to provide iformatio o risk factor i the populatio to help cotrol ad prevet the icreasig impact of NCDs. It provides a etry poit for low ad middle icome coutries to get started o chroic disease surveillace activities ad build ad stregthe capacity to coduct surveillace as well as to facilitate the implemetatio of realistic itervetios for chroic disease prevetio ad cotrol. The STEPS methodology is stadardized approach to data collectio of risk factors for chroic disease. It icludes data collectio o risk factors usig a stadardized questioaire, takig of physical measuremets ad blood samples to biochemical aalyses from a radom sample of the populatio. 1.4 Purpose of Study The key premise for implemetig STEPS i St. Kitts & Nevis is to develop ad stregthe the coutry s capacity to better moitor o-commuicable diseases ad their risk factors through cosistet data collectio. The specific objectives are: To develop stadardized tools to eable comparisos over time ad across coutries i the Regio To prevet chroic disease epidemics before they occur To help health services pla ad determie public health priorities To predict future caseloads of chroic diseases ad To provide a baselie for evaluatio of future populatio-wide itervetios 13

14 2. SURVEY METHOD AND OPERATION 2.0 Scope of Study The study was a populatio-based assessmet of the mai risk factors of the priority NCDs i the Federatio ad was carried out amog adults years old from October 2007 to Jauary The WHO STEPwise approach (Fig.1), which provides a framework for surveillace of NCD risk factors ad NCD-specific morbidity ad mortality, was adopted for the survey. For this survey the itet was to iclude Step 1 ad 2 core items, expaded ad optioal items but coduct Step 3 core ad expaded o a subsample of the participats. The respose rate for Step 3 was too low to give sigificat meaig to the survey. The results therefore reflect fidigs for Step 1 ad Step 2 with iformatio o tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, physical measuremet, raised blood pressure, chroic disease history ad family health. Figure 1. The WHO STEPwise Approach to Surveillace of NCDs Data collected from this survey will form the basis for the surveillace of NCDs locally as well as, cotribute to Regioal ad Global databases o NCD risk factors. Exclusio from the survey was permitted if persos (withi the age criterio) were bedridde ad had chroic disabilities. Pregat participats were also excluded from havig hip to waist measuremets doe. Excluded from the survey were also those who qualified but refused to participate ad who coseted but failed to keep appoitmet after 3 visits. 2.1 Samplig ad Sample Size Calculatio St Kitts ad Nevis adopted the STEPS guidelies to calculate the appropriate sample size ad the STEPS methodology to select a atioally represetative sample. The level of cofidece ad the correspodig margi of error used for the sample size calculatios for the survey were 95 ad 0.05, respectively. Due to isufficiet historical iformatio o baselie levels of the idicators, a estimated prevalece of 50 was utilized, as this esures the most coservative sample size. Usig these values ad populatio estimates for each 10-year age group by sex cluster for the combied populatio of St. Kitts ad Nevis (based o the 2001 populatio cesus), sample size 14

15 estimates (Fig 2.) were calculated for each age/sex strata. The total sample size estimate (obtaied by summig across the age/sex strata) was the adjusted for the desig effect ad for the expected o-respose rate. Sice radom samplig was coducted the desig effect for the survey was 1. The expected respose rate for the STEPS survey was 90. Therefore, the total sample size calculated for St. Kitts ad Nevis was 2,903. This total was the proportioately divided betwee St. Kitts ad Nevis, based o the results of the 2001 populatio cesus as follows: St. Kitts: 2,177 ad Nevis: 726. Nevis opted to defer the survey after several weeks of iitiatio. Z E P 1-P SS1 Populatio Cesus 2001 SS2 by AGE/SEX Males Females Males Females Total SS2 Deff SS3 RR Fial SS Fial Sample Size Total St. Kitts Nevis Where: SS1 SS2 SS3 = Total x SS2 x Deff SS4 = SS3 RR Figure 2. Sample Size Calculatios Where: Z P e Strata Deff RR SS Level of Cofidece Baselie Idicator Level Margi of Error Number of age/sex strata Desig Effect Respose Rate Sample size calculatio 15

16 2.2 Ethical Approval I the absece of a Research Ethical Committee, the STEPs survey protocol/proposal was submitted to the Medical Board for St Kitts ad Nevis for cosideratio ad ethical review. The Board approved the implemetatio of the survey with few amedmets. Participats were to be told their results for Steps 2 ad 3 ad advised to see a doctor if tests results were abormally high. 2.3 Staff Recruitmet, Traiig ad Pilot Testig I preparatio for the study twety five (25) persos were recruited ad traied for the fieldwork. They were selected from a cross sectio of persos who had experiece workig i health or participated i previous populatio cesuses ad /or coductig other surveys. The traiig was coducted over four (4) days, September 24-27, 2007, with assistace from the WHO Geeva Steps team ad the CAREC Regioal Office. The traiig sessio icluded itroductio to NCDs, iterview techiques ad detailed itroductio to the data collectio istrumets ad physical measuremet equipmet. The tasks, roles ad resposibilities of the iterviewers were covered durig the first 3 days; followed by pilot testig of the istrumet for Step 1 ad 2 o the fial day. Two persos ad the survey coordiator were also traied for data etry o days 3-4. The residetial area idetified for the pilot testig was chaged because of the perceived high proportio of persos withi the age parameters likely to be at work durig that time. The questioaire was piloted ad field tested o a coveiece sample of 50 public sector workers at the govermet headquarters ad other govermet offices i the tow. Chages were made to several phrases ad phrasig of questios. Traiig for fieldworkers was also carried out a secod time as ew iterviewers were recruited due to the discotiuatio of some who were previously recruited. 2.4 The Istrumet ad Data Collectio The STEPS istrumet was adapted for the survey. Apart from a few deletios as per adjustig to the coutry cotext, the geeric questioaire was used for data collectio. The same questio codes were used. The etire STEPs istrumet was used icludig both the core ad expaded questios. Items that were stadardized related to Questio C5 o ethic groupig Questio C6 o level of educatio groupig Questio C7 o work status over past 12 moths Questio C10 o estimate of aual household icome 2.5 Physical Measuremets: The physical measuremets take were blood pressure, height, weight, hip ad waist circumferece. 16

17 Height - measuremet of the perpedicular distace betwee the top of the head (vertex) ad the bottom of the feet. Head i upright positio ad participat without footwear ad headgear. The height was read i cetimeters to exact poit ad recorded. Weight - a large aalog bathroom scale (Keedy) was used for weight measuremet. The weight was read ad recorded i kilograms but coverted to pouds if the participat wated to kow his weight. Waist measuremet the cross-haded techique was used for measurig waist girth. The circumferece was measured usig tesio measurig tape graduated to 1 mm ad take with light clothig i semiprivate areas or directly over the ski i private areas. The measured circumferece was recorded at the earest 0.1 cm ad take oly oce before recordig. Blood Pressure the measuremets were take usig a OMRON B/P machie (digital automatic blood pressure moitor M4-1). Three measuremets were take for aalysis purposes; recordig the mea of the secod ad third readigs. The right arm was used for this measuremet. If the left arm was used this was oted o the questioaire. The displayed readig of the systolic ad diastolic blood pressure were take ad recorded. If the differece betwee the 1 st ad 2 d readigs was 10mmHg or more, the it was ecessary to obtai a 3 rd readig. Participats were required to rest for three miutes betwee each readig. Large B/P cuffs were made available for arms larger tha 32 cetimeters. 2.6 Method of Data Collectio For the purpose of this study, the selectio of households was made from each eumeratio district (ED) obtaied from the Natioal Plaig ad Statistics Uit of St. Kitts ad Nevis. Usig maps ad addresses of households selected, a startig poit was determied radomly ad thereafter, every selected household, depedig o the umber of households withi the district. The Kish method was used to radomly select oe idividual from eligible persos withi that household to be iterviewed. If o oe was preset i the selected household, a otificatio of visit card was left ad the iterviewer revisited up to 3 times. The perso selected had to be at least 25 years old o their last birthday but ot older tha 64 years old. For logistical purposes, a iterviewer was assiged to selected households withi the parish where she was residet or worked. Data collectio o Steps 1 ad 2 usig the STEPS istrumet was doe by visitig households or a place of the respodet s coveiece. STEP 1 & STEP 2: Iterviewers selected the respodets, coducted iterview for sociodemographic ad behavioral iformatio for STEP 1. Physical measuremets such as height, weight ad blood pressure were collected i STEP 2. Writte istructios re fastig, appoitmet date ad veue for blood test were the give to the participat if selected for STEP 3. STEP 3: the cliical workers (lab techologists), medical ad ursig teams) took blood samples of participat at assiged health cliics or the hospital pathology laboratory. 17

18 Biochemical ivestigatio was doe at the pathology laboratory of the Joseph N. Frace Geeral Hospital. The biochemical aalysis for blood glucose ad lipid profile was coducted usig the stadard routie procedures of wet chemistry. Data collectio started from October 2007 but was impeded by the Christmas holiday ad Carival seaso. Data collectio was stopped at the ed of Jauary Of the 2,177 selected for St. Kitts, a total of 1,501 households were visited i the 9 parishes (clusters) of St Kitts. The sample was proportioately distributed accordig to size ad populatio of parishes. Six hudred ad sevety six (676) households were ot visited. Of the 1501 households, there were 36 refusals (2.4), 5 persos ot eligible (0.3), 7 vacat/ abado houses (0.5), 1 perso was abroad durig survey period (0.07), 7 hard to fid/ ever at home (0.5) ad 2 buildigs were used for purposes other tha residetial (0.1). The umber of respodets for the STEP 3 was too small (N=58) for accurate estimates ad are ot icluded i this report. Overall respose rate was Data Etry ad Aalysis The completed questioaires were checked for completeess o the same day by the data collector ad submitted to the Field Supervisor i batches accordig to household clusters. O receipt, the Field Supervisor couter-checked the data sheets for completeess ad accuracy, packed them ito labelled evelopes which were haded to the data etry persoel. Iterviewers tracked the umber of completed questioaires o a trackig sheet which was submitted with the completed questioaires. Double data etry usig a data etry protocol was doe o computers that had EpiIfo ad Epidata software for double data etry istalled. The database was saved daily i a differet drive as backup so that data would ot be lost. WHO ad CAREC provided assistace with data aalysis ad cleaig. The data were weighted usig populatio weights to adjust for age ad sex differeces betwee the sample ad populatio. Percetages, meas ad correspodig 90 CI were the calculated usig the weighted data. Data aalysis was performed usig EPIINFO STEPS recommeded data aalysis ad reportig tools were used throughout the data aalysis ad reportig process, icludig STEP-developed EPIINFO programmes ad the fact sheet ad data book templates. 2.8 Challeges A umber of challeges affected the overall respose of the survey. At the outset, all of the iterviewers were employed i full time jobs; two (2) of the iterviewers who received traiig abadoed the project ad ew iterviewers had to be traied. Durig the data collectio was halted i 3 clusters which evetually resulted i lower households visited i the rural west. Aother factor affectig the respose rate was the period of the year whe the survey was doe shorter daylight hours commo to the ed ad early moths of the year affected the umber of households visited o a give day. 18

19 3.0 RESULTS The targeted sample size was 2177 from 9 parishes. Data were obtaied from 1433 idividuals i St. Kitts oly; thus, we caot make ifereces from the data to the geeral populatio. The survey results describe what's goig o i the data through simple summaries about the sample ad the measures (e.g. mea, frequecy distributio ad proportios). Further, o exploratio was doe to determie the degree of relatioship betwee ay variables. 3.1 Socio-Demographic The socio-demographic fidigs provide summary iformatio by age ad sex of the respodets, the marital status of the respodets, highest level of educatio achieved by respodets ad employmet status over the previous 12 moths Demographic ad respose iformatio A total of 1,433 persos participated i the survey. The majority of respodets were female comprisig There was a almost equitable distributio of respodets by age group (Fig. 3) except for the years group that comprised oly 12.3 of participats males females both sexes yrs yrs 45-54yrs yrs Figure 3. Age Distributio by Geder Educatio ad Literacy Status A total of 1, 369 persos gave iformatio about the umber of years that they spet i full time study. The mea umber of years of educatio was 11.7 ad varied little by geder. However there was a tred towards decreasig umber of years of educatio with icreasig age. The youger the age group of the participats, the higher was the mea umber of years of schoolig. Respodets years old had up to 10 years of schoolig while those uder 54 years had up to 12 years. Of all the respodets approached, 98.4 idicated that they were able to read ad write, with little variatio by geder. This is cosistet with the fact that 69.0 of participats had completed secodary level schoolig ad 13.8 had pursued higher educatio icludig college ad post graduate studies. Very few respodets (0.4) had recorded o formal schoolig or ot atteded primary school. 19

20 3.1.`3 Ethicity The majority of respodets were of Africa descet (97.2) with small percetages reportig that they were of Spaish (1.1), Asia /Idia (1.0 ) ad white (0.6) Marital Status The majority of participats were sigle (63.8), while just uder a third (26.6) reported beig married. 5.3 of participats were divorced /separated ad 2.0 were widowed Ecoomic ad Employmet Status The majority of respodets were employed with more tha half (61.9) havig ogovermet ad self-employed jobs, while 27.3 had govermet jobs (Fig 4a). Me were more likely to be self-employed ad more wome were uemployed. Of those who were uemployed, a substatial proportio (44.2) idicated they were able to work (Fig 4b). The survey did ot explore the reasos why these idividuals were ot gaifully employed Employed Respodets govermet work o-govt work self-employed upaid work Figure 4a. Employmet Status (N=1435) 0 Uemployed Upaid Work able to work uable to work Retired Home makers Others Figure 4b.Upaid Work/Uemploymet Status (N=154) There was a high o-respose rate for the item o aual household icome. Of those that respoded, 49.6 eared betwee $12, $24, 000; while 18.0 eared $24, 000-$30,000; 22 eared over $30, 000 ad 10.7 made less tha $12,000 aually. 20

21 3.2 NCD RISK FACTORS (STEP 1) Smokig Overall, 8.7 of the survey populatio idicated they curretly smoke tobacco. The distributio of smokig prevalece by age group ad sex (Table 3) revealed that the prevalece of smokig was sigificatly higher amog males (16.2) tha females (1.1). Amog the curret smokers 6.1 smoked daily, while 2.6 declared they did ot smoke daily. Amog me, 11.4 smoked tobacco daily i cotrast to 0.7 of wome who idicated they smoked tobacco daily. The highest proportios of daily smokers for both males (14.1 ) as well as females (1.6 ) were i the age group years. However, there was a substatial declie i the proportios of daily smokers i the older age group of years for both me (8.3 ) ad wome (0.0 ). ad Sex Total Male Fem Male Fem Male Fem Male Fem Male Fem N Curret daily ( ) Curret smokers () Curret No-daily () No smokers () Table 2 - Prevalece of Smokig by Age- group ad Geder The majority of smokers started smokig as teeagers at a average age of 17.2 years ad smoked for a duratio of 13 to 23 years. Data for wome could ot be disaggregated because of small umbers Exposure to Evirometal Tobacco Smoke (ETS) A fair proportio (9.2 ) of the respodets reported they were exposed to evirometal tobacco smoke at home (Fig. 5). O average, 11.2 of me said they were exposed to ETS at home, while 7.2 of the wome reported likewise. Also, withi the age categories, a higher proportio of me idicated they were exposed to ETS at home withi the last week except i the age category where wome outumbered me (12.1:10.7) Male Female Both Sexes exposed Figure 5. Proportio Exposed to ETS at home 21

22 Almost three times as may me (16.6 ) as wome (6.2 ) reported beig exposed to evirometal tobacco smoke at the workplace. O average, 11.5 of the respodets reported they were exposed to ETS at the work place. (Fig. 7) exposed Figure 6. Proportio Exposed to ETS at the workplace Alcohol Cosumptio For the survey, harmful drikig is defied as 60 g. of pure alcohol (6 driks) o average per day for me ad 40 g (4 driks) for wome. A stadard drik cotais approximately 10 g. of pure alcohol. Almost sixty percet (59.4) of the respodets idicated they were ot curretly drikig but drak alcohol i the last 12 moths. Amog wome, 73.6 abstaied i the last 12 moths while 45.4 amog me reported ot drikig alcohol durig the same period. The prevalece (Fig. 7a) of curret drikers (alcohol cosumptio i the past 30 days) was three times higher for males (45.1) tha females (14.3). The prevalece icreased withi each age category for both sexes util the age group where the tred was reversed. Male Female Both Sexes Prevalece( ) Figure 7a. Patter of Curret Alcohol Drikig O average, 24.7 of the respodets reported drikig alcohol o four or more days i the last week. Meawhile, almost four times as may me (29.9 ) as wome (7.8) drak alcohol durig that time period. Of the me who drak alcohol i the last seve days (Fig. 7b), o average more tha a quarter (27.4 ) cosumed five or more driks of alcohol o ay give day, with the highest proportio (33.8 ) i the age category, followed by the age group with driks i 7 days 27.4 Drak 5+ driks o ay day 29.9 Drak 4+ days driks i 7 days 20.1 Drak 4+ driks o ay day 7.8 Drak o 4+ days Figure 7b. Frequecy ad Quatity of Alcoholic Driks Cosumed by Me (i last 7 days) Figure 7c. Frequecy ad Quatity of Alcoholic Driks Cosumed by Wome (i last 7 days) 22

23 Of the wome who drak alcohol i the last seve days, o average just over oe-fifth (20.1) cosumed four or more driks o ay give day(fig.7c), with the highest prevalece (25.5) i the age category, followed by the age group with The fidigs further revealed that o average, 27.4 of me had take alcoholic driks o 5 or more days i the previous week ad 7.8 wome had alcoholic driks o 4 or more days i the same period (Fig.7d) males females both sexes drak o 4 + days males females both sexes Figure 7d. Prevalece of Heavy Drikig 23

24 3.3 Fruit & Vegetable Cosumptio I a typical week the mea umber of days that fruit was cosumed was 3.7 (Fig. 8a), although o a average day, respodets cosumed less tha oe (1) servig of fruit. The mea umber of days per week that vegetables were cosumed was 4.1(Fig. 8b). Similarly the average daily cosumptio of vegetables was low (<1 servig). Fidigs did ot vary by geder or age group with respect to cosumptio of fruits or vegetables. Me Wome Both Sexes Me Wome Both sexes Figure 8a. Average Days Fruits Eate /Week Figure 8b. Average Days Vegetables Eate /Week It was also oted that over a third (35.1) of respodets ate o fruit ad/or vegetables o a average day. Oly 2.7 of persos cosumed 5 servigs of fruits / vegetables per day. The majority of respodets (53.4) cosumed 1-2 servigs of fruit ad /or vegetables o average per day (Fig.8c). o fruit/vegetables 1-2 servigs 3-4 servigs 5 servigs Figure 8c. No of Servigs of Fruit ad/or Vegetables/ day Eatig outside the home I a typical week, almost half (42.1) of the respodets reported that they cosumed 1-2 meals outside the home; while 20.4 ate 3-5 meals away from home. O average me had slightly more meals (2.0) tha wome (1.4) outside of the home i a typical week Type of oil/fat most used for meal preparatio A high proportio of the respodets use fat i meal preparatio; 70.0 used vegetable oil, 11.7 used saturated fats (lard, butter ad margarie) ad 12.0 used uamed fats or oils. Oly 6.4 used o fat. 24

25 3.4 Physical Activity The survey measured physical activity i two ways. A estimate of the mea physical activity (PA) was calculated as MET (metabolic equivalet i miutes) - miutes per week ad respodets physical activity was categorised as low, moderate ad high. The domais ivestigated activity at work, i travel, sports, fitess ad recreatioal/leisure. Amog respodets 38.3 egaged i low levels of PA while 25.5 ad 36.2 egaged i moderate ad high levels respectively (Fig 9a). Levels of total activity varied cosiderably by geder. A higher proportio of males (51.0) egaged i high levels of physical activity. Almost half of the females (48.5) were sedetary ad egaged i low levels of physical activity. As may as 72.2 of the respodets (55.7 males ad 89.0 females), were ot egagig i vigorous physical activity (described as burig 8 time more calories tha it would take to sit quietly). Low Moderate High (=428) (=389) (=405) (=170) (=1392) Figure 9a Percetage Egaged i Physical Activity (both sexes) The media miutes of total physical activity o average per day was 51.4 miutes (Fig.9b). There was marked variatio with geder. Females spet oly 30 miutes o a average day while me spet miutes (1hr 8 mis). The majority of total physical activity was attributable to work (43) while 33.4 was spet i trasport ad just uder a quarter (23.6) was spet i leisure time Me Wome Both Sexes Figure 9b Average Time Spet i Physical Activity (both sexes) 25

26 3.5 Blood Pressure, Diabetes ad Cholesterol History Blood Pressure: Diagosis ad Treatmet The proportio of persos who reported havig ever beig diagosed by a doctor or health worker with hypertesio was The occurrece of diagosed hypertesio was foud to icrease almost liearly with age i both me ad wome, from 7.4 me ad 10.4 wome i the age group years, to 37.5 males ad 53.4 wome i the age group years, respectively. O average, 14.8 of the me ad 24.3 of wome reported havig already bee diagosed as havig hypertesio (Figure 10a). Me (N528) Wome(N900) Both sexes(1428) Figure 10a Proportio of BP Ever Diagosed Figure 10b- Proportio of Raised BP Diagosed (last 12 moths) Of the me ad wome who were diagosed as ever beig hypertesive, 55.6 ad 61.3 were reported havig bee diagosed the previous 12 moths (Fig.10b). Also, 51.1 of the me ad 71.5 of wome who were diagosed as ever beig hypertesive were curretly takig atihypertesive medicatios. Iterestigly, i wome, use of medicatio was higher i the older age group years compared to the youger age group of years with rates of 96.5 compared to 65.1, respectively (Fig 11). Me (96) Wome(238) Both Sexes(334) Figure 11- Proportio Curretly Takig Prescribed BP Medicatio 26

27 3.5.2 Blood Pressure Advice by a Traditioal Healer With regards to seeig a traditioal healer (oe who atted to basic eeds withi their commuities usig plat ad aimal remedies) oe of the me but 2.7 of wome sought advice for their hypertesio i the last 12 moths. Of ote, 4.4 of those who were diagosed with hypertesio were takig herbal remedies for their hypertesio, more so i the older age group tha i the youger age group Blood Pressure Lifestyle Advice More tha half of the respodets were advised by a doctor or health worker to have special diet (62.9), to lose weight (58.1) or to start or do more exercise (56.8) to treat raised blood pressure (Table 3). Few respodets (5.2) were advised to stop smokig. Of ote, these lifestyle advices were ot biased to a particular age group or geder. (Years) Advised to have special diet Advised to start or do more exercise Advised to lose weight Advised to stop smokig Table 3. Proportio that had Lifestyle Advice for BP 3.6 Diabetes History Diabetes: Diagosis ad Treatmet The respodets who reported ever havig bee diagosed with diabetes by a doctor or health worker was 7.6 (4.8 of the me ad 10.4 of wome). Reported diagosis of diabetes was also foud to icrease with age i both me ad wome, from 1.4 ad 3.9 i the age group years, to 18.3 ad 29.8 i the age group years, respectively (Fig.12). 40 Me (N518) Wome(N886) Both Sexes(N1404) Figure 12- Respodets Ever Diagosed with Diabetes Of those already diagosed with diabetes, 58.3 of the respodets reported beig diagosed i the last 12 moths, 29.1 idicated they were curretly takig isuli prescribed by a doctor or health worker ad 60.7 were takig oral drugs prescribed for diabetes. Close to oe third (30.9) of wome were takig isuli prescribed by the doctor or health worker. NB. The umber of male respodets (96) was too small for accurate estimate of medicatio use. 27

28 3.6.2 Diabetes Lifestyle Advice Of the wome already diagosed with diabetes, 100 reported havig had lifestyle advice by a doctor or health worker for diabetes. A large proportio (80.2) was prescribed a special diet, 3.7 were advised to stop smokig, 74 were advised to start or do more exercise ad 62.8 were advised to lose weight (Fig.13). Nb. The umber of me that respoded to havig lifestyle advice was too small for accurate estimates Special Diet To lose weight To stop smokig To start or do more Proportio exercise 74 Figure 13 - Wome Receivig Lifestyle Advice for Diabetes (from Health Worker or Doctor) Of those already diagosed with diabetes, 58.3 of the respodets were diagosed i the last 12 moths, 29.1 idicated they were curretly takig isuli prescribed by a doctor or health worker ad 60.7 were takig oral drugs prescribed for diabetes Traditioal Healer With regards to seeig a traditioal healer, 2.6 sought advice for their diabetes. Of ote, 11.9 of those who were diagosed with diabetes were takig herbal remedies for their diabetes, irrespective of their age group. 28

29 3.7 Cholesterol Cholesterol Diagosis ad Treatmet O average, 8.8 of the respodets reported havig bee diagosed with raised cholesterol. Fewer me (6.5 ) tha wome (11.1) were diagosed as havig raised cholesterol (Fig. 14a). The prevalece of reported raised cholesterol was foud to icrease with age i both me ad wome, from 1.4 ad 3.9 i the age group years, to 15.3 ad 26.2 i the age group years, respectively Me Wome Both Sexes Figure 14a- Proportio Diagosed as Havig Raised Cholesterol Of those who reported havig bee diagosed with raised cholesterol, 42.4 idicated that they were diagosed i the last 12 moths ad 16.4 of them were takig medicatio. A substatial proportio of the participats with raised cholesterol received advice (Fig 14b) from a doctor or health worker Figure 14b - Proportio Receivig Lifestyle Advice for Raised Cholesterol (from Health Worker or Doctor) 29

30 Of those who reported havig bee diagosed with raised cholesterol, 0.8 sought advice from traditioal healers ad 2.3 had bee takig herbal or traditioal treatmet. NB. The umber of male respodets was too small (<50) to estimate accurately their use of medicatios ad lifestyle advice ad disaggregate by geder. 3.8 Family History of Chroic Disease Coditios The majority of respodets (Table 4) had a family history of diabetes or hypertesio (66.9 ad 72.0, respectively). Almost a third of respodets had a family history of stroke (31.0). Just over a quarter (29.6) had a history of cacer while smaller proportios had a family history of raised cholesterol (21.7) ad early myocardial ifarctio (13.9). Geder Me Wome Both Sexes Age Group (Years) Diabetes or high blood sugar Raised blood pressure Stroke Cacer or Maligat Tumour Raised Cholesterol Early myo cardial ifarctio Table 4. Family History of Chroic Disease Coditios 30

31 3.9 Cacer Kowledge ad Screeig Breast Cacer The survey also provided for optioal items ivestigatig wome s health, as well as history of screeig for prostate ad colo cacers. A high proportio of wome had previously heard of breast cacer(99.4), ad 8.5 were show how to examie their breasts ( Fig. 15a) show how to examie breasts yr ago or less Betwee 1 ad 2 years More tha 2 years ago Never had a breast exam Figure 15a - Proportio Show How to Examie Breasts Figure 15b Last Time Breasts Examied I respose to the timig of the last breast examiatio, most wome (53.9) had 1 year ago but a cosiderable proportio idicated ever havig had oe (13.2) Fig. 15b). The survey further assessed the last time wome had a mammogram ad the proportio that had a mammogram doe because of irregularity see o film of previous testig or examiatio. Amog wome (25-64years old) 81.3 had ever had a mammogram (Fig. 16). Of those that had mammogram, 32.9 had their last mammogram doe because of irregularity i previous mammogram. ever >tha 2 yrs ago 1-2 yrs ago 1 yr ago or less Figure 16- Timig of Last Mammogram by Age Cervical Cacer The survey also ivestigated the proportio of wome that had heard about cervical cacer ad the date of their last pap smear. Of the 892 respodets, 96.1 ( ) had previously heard of this type of cacer. 31

32 Almost half (49.7) had take a pap smear withi the last year but about 11 had ever had a pap smear ad 20.6 more tha 2 years ago. Figure 17 represets the proportio of wome ad timig of the last Pap smear. ever more tha 2 yrs ago 1-2 yrs 1 yr ago Prostate Cacer Screeig Figure 17 - Timig of Last Pap Smear by Age All male respodets were asked about havig a medical examiatio of the rectum. Of a total of 506 males, 15.8 idicated they had a rectal exam; most me were i the years age group (37.5) followed by males i the years old age group (27.1) Colo Cacer Screeig Amog the respodets surveyed, 17.5 had faeces checked for hidde blood. Slightly more males (18.3) tha females (16.6) had this kid of examiatio with the highest proportio (30.6) beig the years old males. Of all the respodets, slightly more me had a colooscopy examiatio tha wome but less tha 5 of them had the test (Fig. 18) respodets (1425) both sexes me wome Figure 18 Proportio that had Colooscopy 32

33 4.0 NCD RISK FACTORS (STEP2 -Physical Measuremets) 4.1 Height, Weight ad BMI Me were o average taller tha wome with a mea height of cm ad cm, respectively. The me ad wome had a mea BMI of 29.2 kg/m 2 ad 31.2 kg/m 2, respectively (Fig. 19a). However, the mea weight for both me ad wome was ot obviously differet, at 84.5 kg ad 83.0 kg, respectively (Fig 19b). kg/m Me Wome Both Sexes kg Me Wome Figure 19a: Average BMI of Respodets Figure19b: Average Weight of Respodets(kg) 4.2 BMI Categories Whe both sexes ad all ages are combied, we fid that 33.5 were overweight, ad 45 were obese, or if we add these values together, 78.5 of the populatio is above the ormal BMI 25 (Fig.20). Oly 0.9 of me ad 1.0 of wome were uderweight ad 24.9 of me ad 16.0 of wome were of ormal weight Uderweight Normal weight Overweight Obese Figure 20- BMI Classificatio of Respodets 33

34 However, 36.2 of me ad 30.6 of wome were overweight, while 37.9 of me (Fig.21a) ad 52.5 of wome were obese (Fig. 21b). Iterestigly, 74.1 of me, ad 83 of wome were at least overweight Uderweight Normal Weight Overweight Obese Liear ( Normal Weight) Figure 21a- BMI Status of Me Uderweight Normal Weight Overweight Obese Liear ( Normal Weight) Figure 21b- BMI Status of Wome Of ote, there is ot much differece i the age group 25-34, but after age 55 more tha 80 of the me were at least overweight. 4.3 Waist Circumferece ad Waist/Hip Ratio Mea Waist Circumferece Waist circumferece is a measure of cetral obesity, which is the type of obesity that predisposes to the chroic o-commuicable diseases. A waist circumferece that is greater tha 94cm (37iches) i males ad 80cm (31.5 iches) i females defies cetral obesity. As show below (Fig. 22a), the mea waist circumferece i me was 94.0 cm, which is below 94 cm, whereas for wome it was 95.1 cm, which is above of 80cm. Also, ote that the mea waist circumferece for wome was already 91.2 cm i the age groups, ad this icreased to 99.9 cm i the age groups. cm Fig 22a Waist Circumferece (cm) of Adults Me Wome

35 4.3.2 Mea Hip Circumferece Aother measure of cetral obesity is the waist/hip ratio. I me, oe is said to be obese if it is above 1 ad i wome if it is above 0.8cm. To calculate this ratio, the hip circumferece was measured ad the mea was foud to be cm i me ad cm i wome (Fig. 22b). cm Me Wome Figure - 22b Hip Circumferece (cm) of Adults Mea Waist/Hip Ratio O average the waist /hip ratio for males was below the 1. There was o variatio i mea waist/hip ratio (0.9) amog me with age differeces. The mea waist/hip ratio for wome icreased with age from 0.8cm i the age groups to 0.9 i the older age groups, with a mea i wome of 0.9, just above the 0.8 cut-off defiitio for cetral obesity. 4.4 Blood Pressure Check Blood pressure is the force that the blood exerts o your arteries as it flow through the body. The systolic blood pressure (top umber)is the measuremet of the pressure exerted o the arteries whe the heart beats. A ideal systolic blood pressure is less tha 120. The diastolic blood pressure (bottom umber) is the measuremet of the pressure exerted by the blood o the arteries whe the heart is at rest. A acceptable diastolic blood pressure is equal to or less tha Mea Systolic Blood Pressure The mea systolic blood pressure (SBP) icreased with age from mmhg i me ad mmhg i wome i the age group, to a mmhg i me ad mmhg i wome, with a mea SBP of mmhg i me ad mmhg i wome (Figure 23a). Mea(mmHg) Me Wome Both Sexes Figure 23a - Mea Systolic Blood Pressure of adults 35

36 4.4.2 Mea Diastolic Blood Pressure (DBP) The mea diastolic blood pressure (DBP) icreased with age from 74.6 mmhg i me ad 73.7 mmhg i wome i the age group, to a 85.1 mmhg i me ad 83.8 mmhg i wome i the 45 to 54 age group, with a mea DBP of 78.9 mmhg i me ad 76.7 mmhg i wome (Figure 23b) Me mmhg Wome Both Sexes Figure 23b - Mea Diastolic Blood Pressure of adults 4.5 Respodets with Raised Blood Pressure Curretly o Medicatio for blood pressure Medicatio use for raised blood pressure icreased with age from 1.6 i me ad 1.9 i wome i the years age group, to 24.6 to 47.8 i the year age group, with a average use of 7.5 i me, ad 15.3 i wome (Figure 24) Me Wome Both Sexes Figure 24- Proportio Curretly o Medicatio for Raised Blood Pressure Stage 1 High blood pressure (SBP 140 ad /or DBP 90), excludig those curretly o medicatio Amog the respodets with raised blood pressure but ot takig atihypertesive medicatios, 26.5 had Stage 1 high blood pressure or readig of SBP 140 ad/or DBP 90 mmhg (Fig 25a). A smaller proportio, 7.8 had Stage 2 high blood pressure or a readig of SBP 160 ad/or DBP

37 Of the same respodets, 33.2 of me ad 19.6 of wome had a Stage 1 high blood pressure (Fig. 25a); while 8.6 of me ad 7.0 of wome had Stage 2 hypertesio. Whe those who were takig atihypertesive medicatios were icluded, 38.2 of me ad 31.9 of wome had a Stage 1 high blood pressure (SBP 140 ad /or DBP 90mmHg) or curretly o medicatio for raised blood pressure (Fig.25b) Me Wome Both Sexes Figure 25a-StFigure 25a - Stage 1 Hypertesio but ot Takig Medicatio Of those with raised blood pressure ad curretly o medicatios 15.5 of me ad 21.2 of wome had Stage 2 hypertesio Me Wome Both Sexes Figure 25b - Stage 1 Hypertesio ad Curretly Takig Medicatios Stage 1 High Blood Pressure or Curretly Takig Medicatios ad Stroke i Family It is iterestig to ote, that 69.9 of me, ad 87.3 of wome who had hypertesio also had a family member who had a stroke, oe of the well recogized complicatios of hypertesio itself (Figure 26). Me Wome Both Sexes Also, 25.7 of me ad 37.7 of wome who had SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised blood pressure had a family member who had high blood pressure. O average 78 of the respodets had a family member who had a stroke ad 31.3 had family members who had high blood pressure Figure 26 - Family Member had Stroke 37

38 4.5.4 Stage 2 High Blood Pressure or Curretly Takig Medicatios ad Family Member had stroke Of those respodets with SBP 160 ad/or DBP 100 mmhg or curretly o medicatio for raised blood pressure hypertesio, 80.2 had a family member who had a stroke ad 36.6 had had high blood pressure. It was further oted, that 67.2 of those me, ad 89.4 of wome also had a family member who had a stroke. Also, 31.8 of me ad 40 of me who had SBP 160 ad/or DBP 100 mmhg or curretly o medicatio for raised blood pressure had a family member who had high blood pressure (Figure 27) Me Wome Both Sexes Figure 27- Family member had High Blood Pressure Heart Rate O average the heart rate for the populatio was 76.5 beats per miute. The mea heart rate per miute for me ad wome was 74.9 ad 77.8, respectively. A few of the respodets, 2.3 of me ad 1.5 of wome had heart rate over 100 beats / mi. 38

39 4.6 Raised Risk Combig lifestyle risk factors with available physical measuremets The survey also provided the percetage of respodets with 0, 1-2 or 3-5 of the factors that placed them at icreased risk for chroic diseases. I geeral, a egligible proportio of the respodets had low risk factor for chroic diseases. About half of them (25 to 64 years) were at icreased risk for NCDs with three or more of the key risk factors (Figure 28) Me Wome Both Sexes with 0 risk factors with 1-2 risk factors with 3-5 risk factors Figure 28 - Proportio with Combied Risk Factors I the youger age group years, oe of the me ad 0.3 of wome had 0 risk factors of me ad 49.9 of wome had 1-2 risk factors, ad 37.0 of me ad 49.7 of wome had 3-5 risk factors. I the older age group years, oe of the me ad 0.3 of wome had 0 risk factors. As expected, more risk factors were commo i the older age group; 34.8 me ad 30.4 of wome had 1-2 risk factors, ad 65.2 of the me ad 69.6 of wome had 3-5 risk factors. 39

40 5.0 DISCUSSION of FINDINGS The fidigs of the survey, preset the prevalece of chroic o-commuicable diseases ad their risk factors amog the years old age i St Kitts oly. It is reflective of respodets, represetig the 9 parishes ad icludes males ad females. A eligible adult respodet was radomly selected from each household. Data was collected through face-to-face iterviews after each respodet siged a coset form. The survey provided curret evidece that chroic o commuicable diseases ad related risk factors are critical threats to the health ad wellbeig of the people of St. Kitts. The data highlight behaviours that eed to be targeted i prevetio programmes i order to achieve log term health improvemets ad provides a baselie agaist which these iitiatives ca be evaluated. Tobacco Smokig While smokig is ot a major public health threat give that the majority (91.3) do ot smoke, but there is still a substatial (16.2) proportio of males who curretly smoke tobacco products. It is oteworthy that iitiatio of smokig occurs i the late tees ad the most commo tobacco product used is the maufactured cigarette. These fidigs suggest that strategies to lower the rates of smokig iitiatio durig late adolescece ad to reduce demad for maufactured cigarettes (e.g. advertisig restrictios, icreased excise taxes) are importat to cosider. Smokig cessatio programmes are also eeded to assist persos who wat to chage their behaviour. Alcohol Cosumptio The patters of alcohol cosumptio varied by geder. It is oteworthy that the proportio of abstaiers was higher amog wome (73.4) tha me (45.8). The data also showed that me were more likely tha wome to have bee drikers i the past 30 days (44.7 ad 14.5 respectively) although the percetage of wome who had cosumed alcohol i the past 12 moths was slightly higher tha amog me (12 ad 9.6). Amog curret drikers (cosumptio of alcohol i the past 30 days), levels of harmful drikig (defied 60g as of alcohol per day for me ad 40g for wome) were high amog both sexes (94 ad 92.1 respectively) i cotrast to hazardous drikig that occurred i 4 of males ad 5.5 of females. These fidigs might be explaied by the socio-cultural cotext i which drikig occurs. It is geerally more socially acceptable for me to cosume alcohol tha it is for wome. This cocurs with the higher frequecy of alcohol cosumptio amog me with 13.4 (versus 3.3) drikig daily, 28.7 (versus 7.7) o 1 4 days per week ad 23.2 (versus 60.8) less tha oce per moth. Levels of harmful drikig are cause for cocer ad suggest that strog disicetives are eeded to puish irresposible behaviour such as drivig uder the ifluece of alcohol. The geder differeces i alcohol cosumptio highlight the importace of uderstadig the mechaisms that socialize persos about drikig as well as the geder roles ad idetities that promote high risk drikig as a orm amog males. Oly the ca targeted itervetios be 40

41 devised that are sesitive to ad effective i the curret socio-cultural cotext. There is also a eed for treatmet programmes for persos that egage i problem drikig. Fruit ad Vegetable Itake The majority (97.3) of the respodets i the study reported eatig less tha five servigs of fruit ad vegetables per day. The mea umber of daily servigs of fruit ad or vegetable was 1.6 ad 35.9 of persos ate o fruit or vegetables o a average day. Strategies to be cosidered to icrease the supply of these foods should iclude local cultivatio i home ad commuity gardes as well as govermet subsidies to stimulate the local agricultural sector. This should be coupled with commuity educatio about the importace ad beefits of cosumptio of adequate quatities of fruits ad vegetables. The fact that a cosiderable proportio (42.1) of the respodets ate at least oe meal outside the house presets a opportuity to icrease fruit ad vegetable cosumptio by targetig the proprietors of food hadlig establishmets to icorporate fruits ad vegetables i their meu choices. This would have to be tailored to the idividual establishmets ad take ito accout the cost of implemetig the meu chages, customer prefereces, profiles ad baselie cosumptio. Physical Activity Geder ad age were otable determiats of levels of physical activity. Me were more likely to report high physical activity (51.0) tha wome (21.1). Levels of total physical activity also seemed to declie with age with older persos reportig lower levels of physical activity i each of the three activity strata. Most of the physical activity was related to work ad to a lesser extet to travellig from place to place. The lowest amout of physical activity was reported i the recreatio domai ad probably reflects the priority accorded to leisure as well as the opportuity to participate i orgaized commuity physical activity programmes. While a media of miutes of total physical activity per day was reported for me, oly 30 miutes was recorded for wome. It is recommeded that adults should accumulate 30 miutes or more of moderate physical activity over the course of most, preferably all days of the week. Of ote is that a segmet of the participats, especially wome ad older persos, were ot achievig levels of physical activity that are beeficial to their health. Overweight ad Obesity Levels Data obtaied from the physical measuremets cofirmed a high prevalece of risk factors ad markers for chroic disease i the survey populatio. Cosistet with the fidigs related to physical activity ad utritio, more tha three quarters of the respodets (78.5) were overweight or obese, with the prevalece icreasig with age ad beig slightly higher i females. Waist to hip ratio (WHR) is a measure of cetral adiposity ad is correlated with cardiovascular disease risk. I wome a ratio of less tha 0.80cm is desirable while i me less tha 0.9cm is cosidered healthy. The mea WHR for wome was while it was 0.88 for me idicatig a icreased risk for mortality amog wome. 41

42 The study cofirms that levels of overweight ad obesity are at epidemic proportios that require urget itervetio. Urbaizatio, improvemets i socioecoomic status, better affordability of moder trasportatio, adoptio of eatig habits similar to developed coutries (e.g. icreased cosumptio of fats ad proteis) ad moves towards a sedetary lifestyle all cotribute to the icreasig prevalece of obesity. Give the complexity of these factors, ay attempt to shift the populatio s mea to lower levels must icorporate a itegrated approach that empowers the idividual through educatio about optimal dietary ad physical activity habits but also creates the supportive eviromet through healthy public policies that icrease access to healthy food choices ad safe spaces for physical activity i a variety of settigs. There is also a cultural ad geder dimesio that fuels the epidemic amog wome. Persos of Africa descet appear to be more tolerat of obesity tha other groups. Wome who appear thier eve if their body mass idex is withi ormal limits are perceived as ot havig a healthy weight ad beig less socially desirable to their peers ad male parters. This results i wome who are overweight beig more likely to be satisfied with their body image as well as acceptace ad eve preferece for larger body sizes. This costruct eeds to be explored i further studies i order to devise successful itervetios that address prevailig cultural orms that relate to body size. Raised Blood Pressure /Hypertesio The mea systolic ad diastolic blood pressures i the study were mmhg ad 77.8 mmhg respectively. While this is withi the ormal rage, it is oteworthy that the mea systolic blood pressure amog males was mmhg which ca be cosidered high ormal (i.e. betwee 130 ad 139 mmhg). This suggests that the populatio orm for this parameter eeds to be optimized especially amog males. These geder differeces were also observed i the prevalece of hypertesio. Males had a higher prevalece of both stage I ad stage II hypertesio (33.2 ad 8.6 versus 19.6 ad 7.0 respectively). Despite this observatio, a higher percetage of wome (15.3) as compared to me (7.6) reported receivig medicatio for the treatmet of their hypertesio. This may partially be explaied by cliet treatmet prefereces, cliet compliace ad differetial access to health care services fuelled by cultural orms that ecourage poor health seekig behaviour by males. Give the prevalece of hypertesio, secodary prevetio strategies should iclude itervetios tailored to icrease people s awareess of elevated blood pressure ad to esure that medicatios are take correctly. However it is ulikely that a strategy aimed solely at icreasig levels of awareess ad compliace i treatmet will brig about measurable chages i the blood pressure distributio. As a priority, a broader commuity prevetio strategy might iclude ecouragig the reductio of salt cosumptio as well as explorig policy levers that regulate the salt cotet of commoly cosumed ad locally produced foods (e.g. bread). Combied Risk Factors Populatio risk was assessed i the study. A substatial proportio of the populatio was idetified to be at risk with three to five risk factors. This fidig was eve more magified amog older persos (45 64 years) with just over two thirds (67.4) havig greater tha three 42

43 risk factors. Not surprisigly, the geder disaggregated data showed a greater percetage of wome with 3 factors. This raises cause for cocer rega rdig the future o commuicable disease distributio i the populatio. It also offers the opportuity to implemet programmes to adjust the populatio distributio towards that of a healthier profile. Cacer Kowledge ad Screeig The overwhelmig majority of wome surveyed had heard of breast cacer. Similarly the majority had also bee show how to examie their breasts. Despite this there was a relatively low uptake of screeig services for breast cacer. The majority (66.3) of older wome (55 64 years) had ever had a mammogram. This is cause for cocer give that early diagosis of breast cacer impacts positively o survival. While the survey did ot explore wome s kowledge of breast cacer, it is importat to educate wome about breast cacer ad its risks as well as the beefits of mammography. A icreased role also exists for geeral practitioers ad other health professioals withi a geeral health screeig cotext to ecourage wome to access these services. The majority (96) of wome iterviewed had heard about cervical cacer. A sizeable proportio (10.9) of wome however had ever bee screeed for cervical cacer. Of those who had bee screeed, the majority (76.9) had doe so i the past two years. Older wome (55 64 years) were over represeted amog those who had either bee screeed more tha two years ago or had ever bee screeed. These fidigs suggest that specific itervetios eed to be devised to promote uptake amog older wome who may still be at risk of cervical cacer while maitaiig coverage amog youger wome. The eeds assessmet coducted i idetified a umber of reasos for failure to scree for cervical cacer ad iclude lack of kowledge, lack of time, forgotte appoitmets, fear of the procedure, fear of results ad cost of the test. Ay itervetios must be iformed by the available data ad be sesitive to the cultural ad social cotext. Oly 15.8 of me reported ever beig screeed for prostate cacer with a digital rectal examiatio (DRE). Age was a determiat i the uptake with older me accoutig for just over a third (37.5) of those who had bee screeed. The America Cacer Society recommeds aual screeig begiig at age 50 years. For those at higher risk such as persos with family history, screeig should begi at youger ages. There is a eed to iform me about this disease as well as the beefits ad risk of screeig. It may also be importat to explore the psychosocial costructs that are relevat to iitiatio ad maiteace of screeig amog eligible persos. The uptake for both faecal occult blood testig (17.5) ad colooscopy (3.8) were low. This is a reflectio of the opportuistic ature of screeig ad relatively poor acceptace of the screeig methods especially i the latter case. There is a eed to develop a systematic atioal cacer screeig programme ad educate the public about ratioale ad recommedatios for screeig for various cacers. 43

44 6.0 IMPLICATIONS AND RECOMMENDATIONS The survey data idicate that o-commuicable diseases (NCDs) as well as their risk factors are commo i St Kitts. It is also clear that NCDs such as diabetes, cardiovascular diseases ad cacer are already leadig morbidity ad mortality statistics of St Kitts. However the high level of risk factors observed i the survey ca oly result i more disability ad reduced quality of life if prevetive measures are ot effective. The fidigs also provides a opportuity for a risk approach to NCD surveillace ad cotrol with a shift i emphasis from idividual to commuity health. Overall, more tha 90 of the respodets were foud to have oe or more of the major risk factors for NCDs. The presece of overweight or obese is promiet, may idividuals did ot iclude sufficiet quatities of fruit ad vegetables i the diet ad have low levels of physical activity. There are persos who smoke or are exposed to tobacco smoke mostly at home ad workplaces ad close to oe third of the study populatio drak alcohol regularly. Of great cocer is that 43.4 of the people uder 45 years old have at least three of the risk factors; a idicatio of the high prevalece of the major risk factors amog the productive age group ad a forecast of the disease burde if left uchecked. It is imperative that high priority is give to the review of systems ad executio of actios ecessary for the ogoig surveillace, prevetio ad welless promotio ad cotrol of ocommuicable diseases. Specific recommedatios are: Surveillace Dissemiate ad utilize fidigs of survey to iform NCD plaig ad actios Set up a commuity-based risk factor surveillace system Set up a morbidity ad mortality data collectio ad aalysis system Iclude step 3 of the STEPS survey (biochemical measures) i future surveys to determie the prevalece of diabetes ad dyslipidemias i the coutry for a more complete picture. Coduct further aalyses of the data, such as explorig correlatios betwee educatio/literacy status ad other results or employmet status ad fruit cosumptio or alcohol cosumptio. Prevetio ad welless promotio Desig a atioal media pla to iform the public about NCDs ad their risk factors Brig awareess to the health risks associated with smokig ad beefits of smoke cessatio Employ a itegrated approach risk maagemet for tacklig hypertesio, diabetes ad cardiovascular diseases Stregthe ad support programs prevetig youths from egagig i substace use ad abuse, icludig alcohol. 44

45 Iitiate strategies that ecourage healthy eatig across all age groups by promotig the availability ad cosumptio of more fruits ad vegetables. Create a supportive eviromet that promote weight reductio ad promote physical activity especially durig trasportatio ad leisure. Cotrol Adopt/adapt guidelies ad algorithms for the maagemet of specific major NCDs. Provide basic equipmet to the differet health facilities depedig o the techical level Esure that the health system adequately moitors compliace with atioal stadards for the maagemet of hypertesio, performs moitorig ad treatmet of hypertesio, diabetes ad cardiovascular disease. Explore policy measures for decreasig cosumptio of salt ad fatty foods. 45

46 GLOSSARY OF TERMS USED AND REFERENCES 1. WHO World Health Orgaizatio 2. STEPS the WHO STEPwise approach to surveillace 3. No-commuicable diseases (NCDs) diseases or coditios that are ot ifectious 4. Chroic diseases - diseases that are log-lastig or recurret 5. BMI Body mass idex 6. SBP Systolic blood pressure 7. DBP diastolic blood pressure 8. CHD coroary heart disease 9. CVD cardiovascular disease Refereces 1. Epi Ifo. [computer program] Versio 6. Atlata, GA: Ceters for Disease Cotrol ad Prevetio Global Ifobase se: World Health Orgaizatio (WHO). (2002) STEPS : Framework for Surveillace. WHO STEPwise Approach to Surveillace of No-commuicable Disease. (STEPS) World Health Orgaizatio. 5. World Health Orgaizatio (2005). WHO STEPS Surveillace Maual: The WHO STEPwise approach to the chroic disease risk factor surveillace. Geeva, WHO 6. World Health Orgaizatio. (2005) Prevetig chroic diseases: A vital ivestmet. Geeva, WHO 7. World Health Orgaizatio (2003). Diet Nutritio ad the Prevetio of Chroic Diseases. Geeva, WHO 8. WHO (2005) The SuRF Report 2 Surveillace of Chroic Disease Risk Factors: Coutry level data ad Comparable Estimates. Geeva, WHO 46

47 APPENDICES 47

48 Appedix A The STEPwise Approach Chroic Disease Risk Factor Survey St Kitts ad Nevis 2007 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace

49 Participat Id Number STEPS Istrumet For Chroic Disease Risk Factor Surveillace St. Kitts ad Nevis 2007 Survey Iformatio Locatio ad Date Respose Code 1 District code 2 Ceter/Village ame 3 Ceter/Village code 4 Iterviewer Idetificatio I1 I2 I3 I4 5 Date of completio of the istrumet dd mm year I5 Participat Id Number Coset, Iterview Laguage ad Name Respose Code 6 Coset has bee read out to participat. Yes 1 No 2 If NO, read Coset 7 Coset has bee obtaied (verbal or writte) Yes 1 No 2 If NO, END I6 I7 8 Iterview Laguage Eglish 1 I8 Spaish 2 [Add others] 3 [Add others] 4 9 Time of iterview (24 hour clock) : hours miutes I9 10 Last ame I10 11 First ame I11 Additioal Iformatio that may be helpful 12 Cotact phoe umber where posible I12 13 Specify whose phoe Work 1 Home 2 Neighbour 3 Other 4 I13 14 Address I14 The iformatio i I6 to I14 should be kept separate from the documet, sice it cotais cofidetial iformatio. St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace

50 Participat Id Number Step 1 Demographic iformatio CORE: Demographic iformatio Questio Respose Code 15 Sex ((Record Male/Female as observed)) 16 What is your date of birth? Do ot kow Male 1 Female 2 17 How old are you? Years 18 I total, how may years have you spet at school or i full-time study (excludig pre-school)? If kow, go to C4 Day Moth Year C1 C2 C3 Years C4 EXPANDED: Demographic Iformatio Respose Code 19 What is your ethiic/racial backgroud? Black/Africa Spaish Asia White Refused 20 What is your marital status? Sigle Married 21 What is the highest level of educatio you have completed? Livig together Widow/Widower 4 Separated / Divorced 5 No formal educatio 1 Primary school icomplete 2 Primary school completed 3 Secodary school completed 4 High school completed 5 C5 C5a C6 College/uiversity completed 6 Post graduate degree 7 Refused 8 22 Ca you read ad write? Yes No 1 2 C6a 23 Which of the followig best describes your mai work status over the last 12 moths? (USE SHOWCARD) Govermet employee 1 No-govermet employee 2 Self-employed 3 No paid 4 Studet 5 Home maker 6 Retired 7 Uemployed (able to work) 8 Uemployed (uable to work) 9 Refused 88 C7 24 How may people older tha 18 years, icludig yourself, live i your household? Number of people C8 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 2

51 Participat Id Number 25 Takig the past year, ca you tell me what the average earigs of the household have bee? (RECORD ONLY ONE, NOT ALL 3 26 If you do t kow the amout, ca you give a estimate of the aual household icome if I read some optios to you? Is it (READ OPTIONS) Per week Go to T1 C9a Per moth Go to T1 C9b Per year Go to T1 C9c Refused 8 C9d $12,000 1 More tha $12, 000 $18,000 2 More tha $18,00 $24,000 3 More tha $24,000 $30,000 4 More tha $30,000 5 Do ot kow 7 Refused 8 C10 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 3

52 Participat Id Number Step 1 Behavioral measuremets CORE: Tobacco use Now I am goig to ask you some questios about various health behaviours. This icludes thigs like smokig, drikig alcohol, eatig fruits ad vegetables ad physical activity. Let's start with tobacco. Questio Respose Code 27 Do you curretly smoke ay tobacco products, such as cigarettes, cigars or pipes? 28 If Yes, Do you curretly smoke tobacco products daily? 29 How old were you whe you first started smokig daily? 30 Do you remember how log ago it was? (RECORD ONLY 1, NOT ALL 3) Do t remember O average, how may of the followig do you smoke each day? (RECORD FOR EACH TYPE) Age Yes 1 No 2 If No, go to T6 Yes 1 Do't remember 777 I Years Or i moths Or i weeks Maufactured cigarettes Had-rolled cigarettes No 2 If No, go to T6 If kow, go to T5a If kow go to T5a If kow go to T5a T1 T2 T3 T4a T4b T4c T5a T5b Pipes full of tobacco T5c Do t remember 777 Cigars, cheroots, cigarillos T5d Other If other go to T5 T5e Other (please specify): T5other EXPANDED: Tobacco use Questio Respose Code 32 I the past, did you ever smoke daily? yes 1 33 If Yes, How old were you whe stopped smokig daily? Age Do't remember 777 No 2 If No, go to T9 If kow go to T9 T6 T7 34 How log ago did you stop smokig daily? (RECORD ONLY 1, NOT ALL 3) Do t remember 777 Years ago If kow go to T9 T8a Or Moths ago If kow go to T9 T8b Or Weeks before T8c 35 Do you curretly use ay smokeless tobacco such as [suff, chewig tobacco, betel]? 36 If Yes, Do you curretly use smokeless tobacco products daily? Yes 1 No 2 If o, go to T12 Yes 1 No 2 If o, go to T12 T9 T10 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 4

53 Participat Id Number EXPANDED: Tobacco use, cotd. 37 O average, how may times a day do you use Suff, by mouth l Suff, by ose l (RECORD FOR EACH TYPE) Do't kow I the past, did you ever use smokeless tobacco such as [suff, chewig tobacco, or betel ] daily? 39 I the last 7 days, how may days did someoe i the house smoke whe you were preset? 40 Durig the last 7 days, how may days did someoe smoke i closed areas i your workplace (i the buildig, i a work area or a specific office) whe you were preset? Chewig tobacco Betel, quid Other If yes, go to T11other T11a T11b T11c T11d T11e Other (please specify) T11other Yes 1 No 2 0 day days days days 4 7 days 5 0 day 1-2 days 1 2 T12 T13 T days 5-6 days 7 days You do ot work i a closed area Do t kow 6 7 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 5

54 Participat Id Number CORE: Alcohol cosumptio The ext questios ask about the cosumptio of alcohol. Questios Respose Code 41 Have you cosumed alcohol (such as beer, wie, spirits, fermeted cider or stout withi the past 12 moths? (USE SHOW CARDS OR SHOW EXAMPLES) 42 I the past 12 moths, how frequetly have you had at least oe drik? (READ RESPONSES or SHOW CARDS) Yes 1 No Daily days per week days per week days per moth 4 Less tha oce a moth 5 2 If No go to D1 A1 A2 43 Whe you drik alcohol, o average, how may driks do you have durig oe day? (READ RESPONSES SHOW CARDS) Number Do't Kow 77 A3 44 Have you cosumed alcohol (such as beer, wie, spirits, fermeted cider or [add other local examples] withi the past 30 days? (USE SHOW CARDS OR SHOW EXAMPLES) Yes 1 No 2 If o go to A6 45 Durig each of the past 7 days, how may stadard Moday A5a driks of ay alcoholic drik did you have each day? Tuesday A5b (RECORD FOR EACH DAY Wedesday A5c USE SHOWCARD) Thursday A5d Friday A5e If o driks record 00. Do t kow 77 Saturday A5f Suday A5g EXPANDED: Alcohol cosumptio Questios Respose Code 46 I the past 12 moths, what was the largest umber of driks you had o a sigle occasio, coutig all types of stadard driks together? 47 For me oly: I the past 12 moths, o how may days did you have five or more stadard driks i a sigle day? Largest Number A6 Number of Days A7 A4 48 For wome oly: I the past 12 moths, o how may days did you have four or more stadard driks i a sigle day? 49 I the last 30 days, how may days o a average did you cosume alcoholic beverages? Number of Days A8 A9 Days Do t remember/not sure Do t wat to respod St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 6

55 Participat Id Number 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. Questios Respose Code 50 I a typical week, o how may days do you eat fruit? Number of days (USE SHOWCARD) If oe go to D3 D1 Do ot kow How may servigs of fruit do you eat o oe of those days? (USE SHOWCARD) 52 I a typical week, o how may days do you eat vegetables? (USE SHOWCARD) 53 How may servigs of vegetables do you eat o oe of those days? EXPANDED: (USE SHOWCARD) Diet 54 What type of oil or fat is most ofte used for meal preparatio i your household? (USE SHOWCARD SELECT ONLY ONE) 55 I a typical week how may meals do you eat outside the house? Number of servigs Do ot kow 77 Number of days Do ot kow 77 Number of servigs Do ot kow 77 Vegetable oil 1 Lard or suet 2 Butter 3 Margarie 4 Noe i particular 6 If oe go to D5 Other 5 If other, go to D5 other Noe used 7 Do ot kow 77 D2 D3 D4 D5 Other D5other Number D6 Do ot kow 77 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 7

56 CORE: Physical Activity Participat Id Number 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. I aswerig the followig questios 'vigorousitesity 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. Questios Respose Code Activity at work 56 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 work] for at least 10 miutes cotiuously? [INSERT EXAMPLES] (USE SHOWCARD) Yes 1 No 2 If No, go to P 4 P1 57 I a typical week, o how may days do you do vigorousitesity activities as part of your work? Number of days P2 58 How much time do you sped doig vigorous-itesity activities at work o a typical day? 59 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 miutes cotiuously? [INSERT EXAMPLES] (USE SHOWCARD) Hours : miutes : hrs mis Yes 1 No 2 If No, go to P7 P3 (a-b) P4 60 I a typical week, o how may days do you do moderateitesity activities as part of your work? 61 How much time do you sped doig moderate-itesity activities at work o a typical day? Travel to ad from places Number of days P5 Hours : miutes : hrs mis 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. [isert other examples if eeded] P6 (a-b) 62 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 63 I a typical week, o how may days do you walk or bicycle for at least 10 miutes cotiuously to get to ad from places? 64 How much time do you sped walkig or bicyclig for travel o a typical day? Hours : miutes : Hrs mis 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). 65 Do you do ay vigorous-itesity sports, fitess or recreatioal (leisure) activities that cause large icreases i breathig or Yes 1 heart rate like [ruig or football, ] for at least 10 miutes cotiuously? [INSERT EXAMPLES] (USE SHOWCARD) No 2 If No, go to P 13 Number of days P8 P9 (a-b) P10 66 I a typical week, o how may days do you do vigorousitesity sports, fitess or recreatioal (leisure) activities? 67 How much time do you sped doig vigorous-itesity sports, fitess or recreatioal activities o a typical day? Number of days P11 Hours : miutes : hrs mis P12 (a-b) St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 8

57 Participat Id Number CORE: Physical Activity (Recreatioal activities) cotiued. Questios Respose Code 68 Do you do ay moderate-itesity sports, fitess or recreatioal (leisure) activities that causes a small icrease i breathig or heart rate such as brisk walkig,(cyclig, swimmig, volleyball)for at least 10 miutes cotiuously? [INSERT EXAMPLES] (USE SHOWCARD) Yes 1 No 2 If No, go to P 16 P13 69 I a typical week, o how may days do you do moderate-itesity sports, fitess or recreatioal (leisure) activities? 70 How much time do you sped doig moderate-itesity sports, fitess or recreatioal (leisure) activities o a typical day? Sedetary behaviour Number of days Hours : miutes : hrs mis The followig questio is about sittig or recliig at work, at home, gettig to ad from places, or with frieds icludig time spet [sittig at a desk, sittig with frieds, travellig i car, bus, trai, readig, playig cards or watchig televisio], but do ot iclude time spet sleepig. [INSERT EXAMPLES] (USE SHOWCARD) 71 How much time do you usually sped sittig or recliig o a typical day? EXPANDED: History of raised Blood Pressure Hours : miutes : hrs mis Questios Respose Code 72 Have you ever had your blood pressure measured by a Yes health professioal? No 2 If No, go to H 6a H1a 73 Have you bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? Yes 1 No 2 1 If No, go to H 6a H2a 74 If yes Yes 1 Were you told i the last 12 moths? No 2 H2b 75 Are you curretly receivig ay of the followig treatmets/advice for high blood pressure prescribed by a doctor or other health worker? Drugs (medicatio) that you have take i the last 2 weeks Yes No 1 2 Special prescribed diet Yes 1 No 2 Advice or treatmet to lose weight Yes 1 No 2 Advice or treatmet to stop smokig Yes 1 No 2 Advice to start or do more exercise Yes 1 No 2 76 Durig the past 12 moths have you see a traditioal Yes 1 healer for raised blood pressure or hypertesio? No 2 77 Are you curretly takig ay herbal or traditioal remedy for your raised blood pressure? Yes 1 No 2 P14 P15 (a-b) P16 (a-b) H3a H3b H3c H3d H3e H4 H5 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 9

58 Participat Id Number EXPANDED: History of Diabetes Questios Respose Code 78 Have you ever had your blood sugar measured by a Yes 1 health professioal? No 2 If No, go to L1a H6a 79 Have you ever bee told by a doctor or other health Yes 1 worker that you have diabetes? No 2 If No, go to L1a H7a 80 If yes Yes 1 Were you told i the last 12 moths? No 2 H7b 81 Are you curretly receivig ay of the followig treatmets/advice for diabetes prescribed by a doctor or other health worker? Isuli Yes 1 Oral drug (medicatio) that you have take i the last 2 weeks s No 2 Yes 1 No 2 Special prescribed diet Yes 1 No 2 Advice or treatmet to lose weight Yes 1 No 2 Advice or treatmet to stop smokig Yes 1 No 2 Advice to start or do more exercise Yes 1 82 Durig the past 12 moths have you see a traditioal healer for diabetes? 83 Are you curretly takig ay herbal or traditioal remedy for your diabetes? EXPANDED: History of raised total cholesterol No 2 Yes 1 No 2 Yes 1 No 2 H8a H8b H8c H8d H8e H8f H9 H10 Questios Respose Code 84 Have you ever had your cholesterol measured by a Yes 1 health professioal? No 2 If No, go to F1a L1a 85 Have you ever bee told by a doctor or other health Yes 1 worker that you have raised cholesterol? No 2 If No, go to F1a L2a 86 If yes Yes 1 Were you told i the last 12 moths? No 2 L2b 87 Are you curretly receivig ay of the followig treatmets/advice for raised cholesterol prescribed by a doctor or other health worker? Oral treatmet (medicatio) take i the last 2 weeks Yes 1 No 2 Special prescribed diet Yes 1 No 2 Advice or treatmet to lose weight Yes 1 No 2 Advice or treatmet to stop smokig Yes 1 No 2 Advice to start or do more exercise Yes 1 88 Durig the past 12 moths have you see a traditioal healer for raised cholesterol? 89 Are you curretly takig ay herbal or traditioal remedy for your raised cholesterol? No 2 Yes 1 No 2 Yes 1 No 2 L3a L3b L3c L3d L3e L4 L5 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 10

59 Participat Id Number EXPANDED: Family history Questios Respose Code 90 Have some of your family members bee diagosed with the followig diseases? Diabetes or blood sugar Yes 1 No 2 Raised Blood pressure Yes 1 No 2 Stroke Yes 1 No 2 Cacer or maligat tumor Yes 1 No 2 Raised Cholesterol Yes 1 No 2 Early Myocardial Ifarctio Yes 1 No 2 F1a F1b F1c F1d F1e F1f Step 1 Optioal modules Sectio: Wome Health Respose Code 91 Have you heard about breast cacer? Yes 1 No 2 92 Have you bee show how to examie your breasts? Yes 1 No 2 93 Whe was the last time you had a examiatio of your breasts? 94 A mammogram is a x-ray of each breast to check for the possibility of a breast cacer. Whe was the last time you had a mammogram? 95 The mammograms are doe as routie examiatios, but are sometimes carried out after a visit to the physicia or a health professioal due to some irregularity. Was the last mammogram carried out for that reaso? 1 year or less 1 Betwee 1 ad 2 years 2 More tha 2 years 3 Never 4 Do ot remember 7 1 year or less 1 Betwee 1 ad 2 years 2 More tha 2 years 3 Never 4 If Never, go to W6 Do ot remember 7 Yes 1 No 2 96 Have you heard about cervical cacer? Yes 1 W1 W2 W3 W4 W5 No 2 W6 97 Pap test or a cytological test is a exam to detect cervical cacer. Whe was the last time you had a Pap test? 1 year or less 1 Betwee 1 ad 2 years 2 More tha 2 years 3 Never 4 Do ot remember 7 W7 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 11

60 Participat Id Number Cacer screeig Respose Code 98 A medical exam of the rectum is a exam i which a physicia or health professioal carries out with gloves i order to explore the prostate of the patiet ad look at the size, shape or hardess. Have you ever had this kid of examiatio? 99 A examiatio of hidde blood i feces is a examiatio used to kow if there is blood i the feces. Have you ever had this kid of examiatio? 100 A colooscopy is a medical examiatio i which a tube is itroduced i the rectum to be able to visualize the itestie i order to kow if there are alteratios or problems. Have you ever had this kid of examiatio? Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 R1 R2 R3 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 12

61 Participat Id Number Step 2 Physical Measuremets CORE: Height ad Weight Respose Code 101 Iterviewer ID M1 102 Device IDs for height ad weight Height M2a Weight M2b 103 Height I Cetimeters (cm). M3 104 Weight I Kilograms (kg) If too large for scale, code (For wome) Are you pregat? Yes 1 If Yes, go to M8 No 2 CORE: Waist 106 Device ID for waist 107 Waist circumferece CORE: Blood pressure 108 Iterviewer ID I cetimeters (cm). 109 Device ID for blood pressure M9 110 Cuff size used Small 1 Medium 2 M10 Large Readig 1 Systolic (mmhg) M11a M4 M5 M6 M7 M8 Diastolic (mmhg)) M11b 112 Readig 2 Sistólica ( mmhg) M12a 113 Diastólica (mmhg) M12b Readig 3 Systolic (mmhg) M13a 114 Durig the past two weeks, have you bee treated for raised blood pressure with drugs (medicatio) prescribed by a doctor or other health worker? EXPANDED: 115 Hip circumferece ad Heart rate Diastolic (mmhg) M13b Yes 1 No 2 Hip circumferece I cetimeters (cm). M Heart Rate (Record if automatic blood pressure device is used) Readig 1 Beat per miute M16a Readig 2 Beat per miute M16b Readig 3 Beat per miute M16c M14 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 13

62 Participat Id Number Step 3 Biochemical measuremets CORE: Blood glucose Respose Code 117 Durig the last 12 hours have you had aythig to eat or drik, other tha water? 118 Techicia ID Yes 1 No 2 B1 B2 119 Device ID 120 Time of day blood specime take (24 hour clock) Hours : miutes 121 Fastig Blood glucose mmol/l : hrs mis. B3 B4 B5 CORE: Blood lipids 122 Device ID 123 Total cholesterol mmol/l. B6 B7 EXPANDED: Triglycerides ad HDL Cholesterol 124 Triglycerides mmol/l. B8 125 HDL Cholesterol mmol/l. B9 St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 14

63 Participat Id Number St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 15

64 Participat Id Number St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace 16

65 TYPICAL PHYSICAL ACTIVITIES For use with This show card relates to: WORK RELATED PHYSICAL ACTIVITY MODERATE Itesity Activities Makes you breathe somewhat harder tha ormal VIGOROUS Itesity Activities Makes you breathe much harder tha ormal Step Sectio Items Step 1, core physical activity P P1 to P15 LEISURE /SPARE TIME RELATED PHYSICAL ACTIVITY MODERATE VIGOROUS Itesity Activities Itesity Activities Makes you breathe somewhat Makes you breathe much harder harder tha ormal tha ormal Examples: - Cleaig (vacuumig, moppig, scrubbig, sweepig, iroig) - Washig (by had) - Gardeig - Milkig cows - Platig ad harvestig crops - Diggig dry soil - Weavig - Woodwork (chisellig, sawig, softwood) - Mixig cemet (with shovel) - Labourig (pushig loaded wheelbarrow, operatig jackhammer) - Walkig with load o head - Tedig aimals Examples: - Forestry (cuttig, choppig, carryig wood) - Sawig hardwood - Ploughig - Cuttig crops (sugar cae, baaas) - Gardeig (with pick axe) - Labourig (shovellig sad) -Loadig furiture (stoves, fridge) -Istructig sports aerobics - Sortig postal parcels (fast pace) - Cyclig rickshaw drivig Examples: - Cyclig - Joggig - Dacig - Horseracig - Tai chi - Yoga - Pilates - Low-impact aerobics - Cricket Example: - Basketball - Football - Teis - High-impact aerobics - Beach volleyball - Dacig (soca, ballroom, salsa etc) - Fast swimmig St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace

66 Diet (Typical Fruit ad Vegetables ad Servig Sizes) For use with This show card relates to: Step Sectio Items Step 1, core diet D D1 to D4 VEGETABLES are cosidered to be: 1 Servig = Examples Raw gree leafy vegetables 1 cup Other vegetables, cooked or chopped raw ½ cup Spiach, salad, etc. Tomatoes, carrots, pumpki, cor, Chiese cabbage, fresh beas, oio, etc. Vegetable juice ½ cup FRUIT Is cosidered to be: Apple, baaa, orage, guava, star fruit, 1 Servig = Examples 1 medium size piece Chopped, cooked, caed fruit ½ cup Fruit juice ½ cup Juice from fruit, ot artificially flavoured 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). WHO Recommedatio The World Health Orgaizatio recommeds at least: 400 grams of vegetables ad fruits per day, or Five servigs of 80 grams each. Note: Tubers such as potatoes ad cassava, however, are ot icluded i this recommedatio. St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace

67 ALCOHOL CONSUMPTION Show Card For use with This show card relates to: Step Sectio Items Step 1, core alcohol cosumptio A A1 to A5 1 stadard bottle 1 sigle measure 1 medium size 1 measure of regular beer of spirits glass of wie apetitif (285ml) (30 ml)e.g. (120 ml) e.g. (60ml) e.g. guiess scotch dry wie sherry stout vodka sweet wie cocktails gi red wie martii bourbo white wie campari St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace

68 List of Tobacco Products For use with This show card relates to: Step Sectio Items Step 1, core tobacco use T T1 to T8 Cigarettes Cigarellos Cigars Cheroots Chuttas Bidis Goza / Hookah

69 List of Tobacco Products For use with This show card relates to: Step Sectio Items Step 1, core tobacco use T T1 to T8 Cigarettes Cigarellos Cigars Cheroots Chuttas Bidis Goza / Hookah

70 List of Work Status For use with This show card relates to: Step Sectio Items Step 1, core demographic iformatio C C7 Work Status Govermet employees No-Govermet employee Self-employed Descriptio A idividual who is hired by the govermet office or agecy ad paid a salary. This icludes employees of: Govermet Miistries (public sector workers, civil servats) State (Police, Defece Force, etc) Semi-autoomous istitutios (such as social security, SSMC, Port Authority, Solid Waste Co, istitutios) that are owed by the govermet. Istitutios like religious schools (if paid by the govermet). A idividual who is hired to work ad is paid a salary or wages. This icludes ay employees ot workig for the govermet. A idividual who produces goods for sale or ears a icome through provisio of services to differet people or firms. The idividual works aloe or with itermittet assistace from others, but does ot employ ayoe for a paid wage or salary o a regular basis. No-paid - subsistece farmig etc Studet Homemaker (household chores) Retired Uemployed - uable to work A idividual who speds sigificat amout of time workig for a voluteer orgaizatio, family busiess, family farm or other similar activity without pay. A idividual whose primary activity is egagig i studies at elemetary, secodary, uiversity or techical schools. A idividual whose primary activity is i carryig out household tasks without beig paid. A idividual who has eared icome durig some period i the workforce or as a employer ad who is o loger workig due to age. A idividual who caot work because of his/her health status. St. Kitts ad Nevis STEPwise approach to chroic disease risk factor surveillace

71 Appedix C The STEPwise Approach to Chroic Disease ad Risk Factor Survey Implemetatio Pla for St. Kitts ad Nevis 2007 St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 1

72 Executive Summary The disease burde caused by chroic diseases is icreasig rapidly ad has sigificat social, ecoomical ad health cosequeces. Globally, chroic o-commuicable diseases (NCDs) are resposible for 60 of all deaths. Additioally, i the Caribbea, the four leadig causes of deaths (51) i 2000 were chroic NCDs. Chroic NCDs also rak amog the mai causes of morbidity ad mortality i St. Kitts ad Nevis. A chroic disease survey of workers doe i St. Kitts i 2000 idicated that 25 of me ad more tha 50 of wome were ot sufficietly physically active. It was also oted that about 60 of me ad almost 70 of wome were overweight. Additioally, very high proportios of me (70) ad wome (60) did ot eat adequate fresh fruits ad vegetables o a regular basis. I a later study, the 2001 Diet ad Exercise Behaviour Survey, 53.6 of the adult populatio i the Federatio, had at least 1 chroic disease. This situatio is serious cosiderig that at least 80 of all heart disease, stroke ad diabetes are prevetable. The key to cotrollig the global epidemics of chroic diseases is primary prevetio based o the comprehesive populatio-wide programmes. The aim is to avert these epidemics wherever possible ad to cotrol them as quickly as possible where they are already preset. The World Health Orgaizatio supports the implemetatio of the STEPwise approach (STEPS) to the surveillace of chroic diseases risk factor ad chroic disease specific morbidity ad mortality. Goal: To develop ad stregthe the coutry s capacity to better moitor ocommuicable diseases ad their risk factors though cosistet data collectio. Objectives To develop stadardized tools to eable comparisos over time ad across coutries To prevet chroic disease epidemics before they occur To help health services pla ad determie public health priorities To predict future caseloads of chroic diseases ad To moitor ad evaluate populatio wide itervetios The STEPS survey provides a etry poit for surveillace activities. Followig a sequetial process, key iformatio is gathered about behavioral ad biological risk factors across the populatio. A total of 2903 adult males ad females, aged 25 to 64 years will be ivited to participate i the survey. The optimal recommeded time frame for coductig a STEPS survey of chroic disease risk factors is approximately 6-8 moths. Data collectio will be doe durig October to December Resources for the completio of the research project are extesive. A comprehesive budget, estimated aroud EC$62, is required to sufficietly cover related expeses. The WHO STEPS team ad the CAREC will provide global coordiatio ad techical assistace for the implemetatio of the STEPS surveillace. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 1

73 Protocol for the WHO STEPwise Approach to Chroic Disease Risk Factor Surveillace Itroductio Chroic o-commuicable diseases are resposible for 60 of all deaths globally. I developig coutries, the disease burde caused by chroic diseases is icreasig rapidly ad will have sigificat social, ecoomical ad health cosequeces. The mai chroic diseases attributable to commo risk factors are heart diseases, stroke, chroic respiratory diseases ad diabetes. There are some commo prevetable risk factors which uderlie most chroic diseases. They are the leadig causes of death ad disability burde i all coutries irrespective of their ecoomic status. The modifiable risk factors, which are lifestyle-related, iclude tobacco use, harmful alcohol cosumptio, low fruit ad vegetable cosumptio ad physical iactivity; while the major biological risk factors are overweight ad obesity, raised blood pressure, raised blood sugar ad raised cholesterol. Together, these major risk factors accout for 80 of deaths from heart disease ad stroke. A chroic disease survey of workers doe i St. Kitts i 2000 idicated that 25 of me ad more tha 50 of wome were ot sufficietly physically active. It was also oted that about 60 of me ad almost 70 of wome were overweight. Additioally, very high proportios of me (70) ad wome (60) did ot eat adequate fresh fruits ad vegetables o a regular basis. I a later study, the 2001 Diet ad Exercise Behaviour Survey, 53.6 of the adult populatio had at least 1 chroic disease. The key to cotrollig the global epidemics of chroic diseases is primary prevetio based o the comprehesive populatio-wide programmes. The aim is to avert these epidemics wherever possible ad to cotrol them as quickly as possible where they are already preset. The basis therefore, for the prevetio of chroic diseases is the idetificatio of major risk factors ad their prevetio ad cotrol. Goal To develop ad stregthe the coutry s capacity to better moitor o-commuicable diseases ad their risk factors though cosistet data collectio. Objectives To develop stadardized tools to eable comparisos over time ad across coutries To prevet chroic disease epidemics before they occur To help health services pla ad determie public health priorities To predict future caseloads of chroic diseases ad To moitor ad evaluate populatio wide itervetios St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 2

74 Scope I 2005, the World Health Orgaizatio recommeded a STEPWise approach (STEPS) to the surveillace of chroic diseases risk factors ad chroic disease specific morbidity ad mortality. The tool used to collect data ad measure chroic disease risk factors is called the STEPS Istrumet or 'steps' of risk factor assessmet. STEPS, a household survey uses a sequetial process of gatherig iformatio about behavioral ad biological risk factors across the populatio: Step1, Step 2 ad Step 3 with Core, Expaded ad Optioal items. STEPS surveillace starts with gatherig key iformatio with a questioaire, ad the moves to simple physical measuremets, followed by more complex collectio of blood samples for biochemical aalysis. For this survey, the itet is to iclude core ad expaded items from Steps 1, 2 ad 3, but will coduct Step 3 o a simple radom subsample of the participats. The subsample will be draw from 25 of the sample size, stratified by sex ad te year age groups. Populatio ad Sample Size The WHO/PAHO/CAREC is providig support with the sample calculatio ad the Miistry of Plaig ad Statistical Departmet i St. Kitts ad Nevis will assist with the sample selectio. As is typical, the level of cofidece ad the correspodig margi of error used for the sample size calculatios for the survey were 95 ad 0.05, respectively. Due to isufficiet historical iformatio o baselie levels of the idicators, ad estimated prevalece of 50 was utilized. This is the most coservative estimate as it assumes a highly variable populatio ad ecourages accurate prevalece estimates for all idicators from the survey results. Usig these values ad populatio estimates for each 10-year age group by sex clusters for the combied populatio of St. Kitts ad Nevis (based o the 2001 populatio cesus), sample size estimates were calculated for each age /sex strata. This ecourages accurate reportig of the survey results to each of these levels for the etire populatio. The total sample size estimate (obtaied by summig across the age/sex strata) was the adjusted for the desig effect ad for the expected o-respose rate. Sice radom samplig will be coducted the desig effect for the survey is 1 ad based o previous surveys, the expected respose rate for the STEPS survey is 90. Therefore, the total sample size calculated for this survey is 2, 903 (appedix 3 for detailed calculatios) This total was the proportioately divided betwee St. Kitts ad Nevis, based o the results of the 2001 populatio cesus as follows: St. Kitts: 2,177 ad Nevis: 726. For the purpose of this survey, radom selectios will be made based o available household listigs. The selectio of households will be made from each eumeratio district (ED). A startig poit will be determied radomly ad thereafter, every selected household, depedig o the umber of households withi the ED. The Kish method will be used to select oe idividual from eligible persos withi that household to be iterviewed. If o oe is preset i the selected household, a otificatio of visit card will St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 3

75 be left ad the iterviewer will revisit. The iterviewer the moves o to the ext house o the list i the origial order. The perso selected for iterview must be at least 25 years o the last birthday but ot older tha 64 years old. Exclusio from the study is acceptable oly if persos (withi the age criterio) are bedridde ad have chroic disabilities. Pregat participats will be excluded from havig hip to waist measuremet doe. Data collectio will be doe over a period of eight to tes weeks - October to December Iterviewers will meet participats at home i the eveigs ad o weekeds. However, the collectio of blood samples will be doe i a cliic settig at morigs while participats are fastig. The survey is expected to be completed i six to eight moths. This timeframe is based o ideal evirometal cosideratios ad huma resource capacity for the STEPS project. Resources Huma Resources The survey team comprises of all those ivolved i the data collectio, maagemet ad aalysis processes. The WHO Geeva Steps team ad the CAREC (Regioal Office) will provide guidace ad techical support for the STEPS surveillace. There are several etities ivolved i STEPS with roles ad resposibilities at differet levels. STEPS Site Coordiator (STEPS Coord) - Key perso resposible for plaig ad implemetig STEPS ad sits o the Implemetatio /Coordiatig Committee. Coordiatig/Implemetatio Committee for Surveillace (CCS)-resposible for overseeig the practical ad logistic issues relatig to the overall implemetatio of the STEPS. Data Collectio Team - udertakes a core fuctio i STEPS ad icludes all those who have bee recruited to collect the survey data, amely o Data collectio Supervisor o Iterviewers o Cliical health professioals Data Maagemet Team- comprises those who have bee recruited to eter, check, clea, correct ad aalyze the data gathered by the survey team. A team leader or supervisor may be the STEPS Site Coordiator or the STEPS data aalyst. Statistical Adviser- plays a key role i the sample ad data maagemet process. The statistical adviser may be part of the coordiatig committee or the aalysis team. WHO Geeva STEPS team ad the focal poit from the CAREC will provide support ad advise with this role i the absece of a statistical adviser i coutry. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 4

76 Data Aalysis team icludes persos that will udertake the descriptive ad statistical aalysis of the data gathered usig the STEPS istrumet. The team will work closely with site coordiator, data maagemet team ad statistical adviser to produce results for STEPS reports. Equipmet ad Supplies The followig geeral office equipmet ad supplies will be required for the STEPS coordiatio ad data etry office: Photocopier At lest 1 computer with iteret Shelvig coectio Filig cabiet or boxes Office statioery supplies (pes, Telephoe paper, evelopes, staples etc) Priter Blak CDs USB flash stick For Step 1 ad Step 2 the followig geeral supplies will be required i sufficiet quatity for the whole survey: STEPS Istrumet District ad area maps Questio by questio guide Household lists Show cards Adult portable height legth Coset forms measurig devices Participat iformatio form Weighig scales Iterview trackig form Costat tesio tape measure Field log books to record each data Digital automatic blood pressure collectio team s daily activities moitors (small, medium ad large Clipboards cuffs) Pes, pecils, ID cards A cliic settig is preferred for takig blood samples for the biochemical measuremets required i Step3. The followig supplies ad equipmet will be required: Touriquets Vacutaiers Needles ad syriges Exam gloves Sharps disposal cotaiers Cotto balls Iput from Iteratioal ad Regioal Orgaizatios Vacutaier eedle holders Ice chests (ice) storage Access to trasportatio (for trasfer of specimes) The WHO STEPS team ad the CAREC will provide global coordiatio for the implemetatio of the STEPS surveillace. Techical assistace, computer software ad utilities ad materials will be made available for the traiig of workers, data aalysis ad reportig. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 5

77 STEPS Actio Pla The optimal recommeded time frame for coductig a STEPS survey of chroic disease risk factors is approximately 6-8 moths. This timeframe is based o seasoal cosideratios ad the Federatio s ability to secod staff to the STEPS project for its duratio. A chart of the mai tasks with estimated timelie is provided. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 6

78 Actio Pla for Implemetig STEPS Risk Factor Survey Compoet Activity Duratio Timelie Establishmet o Set up coordiatig committee o Idetify survey coordiator o Idetify scope of STEPS survey o Develop implemetatio Plaig ad pla Scopig o Desig ad select sample frame o Adapt STEPS istrumet o Apply for ethical approval o Pilot test o Commuicatio strategy (meetigs, prit ad electroic media) 4 weeks Jauary February weeks February - March weeks 2-3 weeks 1day 2-4 weeks 1-2 weeks March-April 2007 July 2007 July 2007 September 2007 Recruitmet ad Traiig o Recruit staff 2-3 weeks August 2007 o Procure equipmet ad 4-6 weeks July- August 2007 supplies o Traiig of iterviewers 1 week September 2007 Data Collectio o Approach selected households o Coduct survey 8-10 weeks October December 2007 Data Etry o Eter data (1 st & 2 d ) key etry o Clea ad check data o Merge databases Data Aalysis o Coduct prelimiary data aalyses Reportig ad Dissemiatig Results o o o o Coduct descriptive ad comparative aalyses Produce prelimiary reports Produce Fact Sheet Produce Coutry Report 6-8 weeks November 2007 Jauary weeks 3-5 weeks February 2008 February March weeks March 2008 St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 7

79 Commuicatio Strategy ad Dissemiatio of Results Geeral iformatio about the survey will be provided to the public via the ewspapers, local radio ad televisio statios ad the govermet iformatio service. Additioally, households ivolved i the survey will be specifically otified through towhall/commuity meetigs, house to-house visits by ursig assistats ad by letters. Relevat govermet bodies ad ay sposorig or iterest groups will receive iformatio from the Miistry of Health through the usual official chaels. O completio of the survey, the fidigs ad highlights of the issues that will be covered i the comprehesive report will be dissemiated to key stakeholders, the media ad STEPS team. The methods of commuicatio will iclude the prit ad electroic mass media, ewsletters, brochures ad verbal presetatios. Budget Before pursuig with the research project, it is relevat to ascertai that the budget sufficietly covers related expeses, persoel, maiteace ad miscellaeous costs aticipated. The budget, which follows, comprehesively outlies what fiacial resources eeded for the implemetatio of the STEPS survey. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 8

80 Name of Item 1. ALLOWANCES 1.1. Data maagemet team Budget for Implemetig STEPS Risk Factor Survey Amout Justificatio EC$ Icetive for 2 field $50 per week (maximum 8 weeks) ad 2 officers for data maagemet ( ie to check, clea ad correct data gathered) 1.2. Iterviewers (field work) 1.3. Cliical data collectors (field work) 1.4. Data etry clerks Total Allowaces 2. TRAVEL SUBSISTENCE 2.1 Boat Trasport from Nevis 2.2 Subsistece for travelers i St. Kitts 2.3 Subsistece for travelers i Nevis Total Travellig Subsistece 3. PRINTING AND REPRODUCTION 3.1 Pritig ad duplicatig 3.2 Photocopyig, Photography & Bluepritig Total Pritig Cost 4. TRAINING & MEETINGS 4.1 Traiig of field staff 4.2 Reportig Writig Retreat 4.3 Meetigs of Coordiatig Committee Total Cost Traiig & Meetigs 23, , $31, $9, $ , $8, Icetive for 22 $8. 00 per household (based o 2,903 participats) (must be completed questioaire ad measurig of BP, height ad weight) Icetive for 10 cliical data collectors- max of 726 per/participat (glucose ad lipid profile = oe specime) Icetive for data 1.00 per questioaire (based o 2, 903 questioaires) 2 clerks Eight (8) persos to atted traiig i St. Kitts retur fare@ $42/perso/day for 5 days To travel withi St. $6/day x 12 persos (max of 8 weeks ) - public tras To travel withi $10/day x 4 persos (maximum of 8 weeks) To travel withi St. Kitts ad $300 x 6 persos private trasportatio To purchase ik for priter Cost for photocopier toer ( for photocopyig 3000 questioaires, 16 field mauals, participat coset forms ad other statioery ecessary to carry out study) To purchase refreshmets@ $39./perso/day for 5-day traiig workshop i St. Kitts for research teams To use UWI Cetre as $ x 4 To purchase refreshmet for Core Team members whe coductig report writig retreat. (2 ½ - day sessios) Govermet facilities to be utilized as veue. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 9

81 Name of Item 5. STATIONERY 5.1 Office Supplies & Statioery Total Statioery Costs 6. CLINICAL DATA COLLECTION 6.1 Supplies for BP ad athropometric measuremets 6.2 Supplies for biochemical measuremets 6.3 Trasportatio of samples to lab Amout EC$ $3, $4, $2, $1, $ Justificatio To purchase statioery ad related supplies for the study ad traiig. Copy $115/pk x 6 Compositio $5 x 20 Electric pecil sharpeer Pecils $15/pk x10 $10.50 x 10 Small sharpeers@ $2. x 12 x 12 Brief x 24 For purchasig cliical data collectio devices: 12 OMRON digital BP each 12 $ measurig $ To procure supplies for the collectio of blood samples (726 specimes) Vacutaier eedle holders x 2 Vacutaier grey tubes x5 Disposable touriquet (latex) x 2 Exam gloves 138/case To coduct biochemical aalysis (glucose, lipid profile) Trasportig samples by lad (3 days /wk x$8.00@ $13 /g/m) Trasportig samples by boat (3 days /wk x $10 Total Cliical Data Collectio & Equipmet cost $8, GRAND TOTAL FOR SURVEY :$62, St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 10

82 APPENDIX 1 Overview of Persoel Required for STEPS Key Role Core Resposibilities Officer(s) No STEPS Site Coordiator (STEPS Coord) Coordiatig Committee for Surveillace (CCS) Data Collectio Team Key player i STEPS plaig ad implemetatio Sits o ad reports to Chairperso of Coordiatig Committee Drafts ad overseas progress of the implemetatio pla Supervises data collectio &data maagemet teams Develops parterships & cotributes to health commuicatio activities Prepare future STEPS surveys Support the STEPS site coordiator Act as a advocacy ad maagemet body Oversees the overall implemetatio of STEPS Assists i traslatig the data ito policy ad programmes Esures the log term sustaiability of STEPS surveillace Participates i traiig of field staff Obtais lists of the selected sample & maps of ED Obtais ecessary supplies ad equipmet Supervises iterview processes ad record daily activities Seds progress reports to STEPS Coord Provides completed istrumets to data etry staff. Esures quality of data -Miistry appoited -Uiversity Rep -Public Health Specialist -Epidemiologist -Statisticia -Iterist -Health Educator -Lab Maager -DMO -NCD Coordiator Field Supervisor (St. Kitts ad Nevis) 2 Iterviews participats i household settigs Takes physical measuremets Iterviewers (St. Kits ad Nevis) Check for appropriate participat coset Take blood samples from participat & record results for Step 3 Label samples ad record participat ID umbers Cliical health professioal Data Maagemet Team Esure proper sample is selected Drawig the survey sample Applyig weights to survey data Providig statistical advice durig the aalysis ad reportig process Logs receipt of completed istrumets Files paper copies of istrumet Eters survey data Checks, cleas ad corrects data gathered Idetify errors ad resolvig problems with supervisor Statistical Adviser 1 Data etry Data maagemet support staff 2 2 St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 11

83 Persoel Required for STEPS (cot d) Key Role Core Resposibilities Officer(s) No Data Maagemet Team (cot d) Supervisig ad/or coductig variable checks o etered data Importig dataset, creatig database, ad guardiaship Geeratig derived variables Udertakig exploratory data aalysis Udertakig descriptive aalyses Udertakig additioal aalyses if eeded Calculatig weights for estimatio Producig tables ad graphs for reports Assistig i report preparatio Data aalyst 1 St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 12

84 APPENDIX 2 STEPS Istrumet STEP Descriptio Purpose WHO Recommedatio 1 To obtai iformatio o A affordable optio which provides basic demographic ad - sociodemographics All coutries should udertake the core items of behavioural iformatio usig a - tobacco use Step 1. questioaire. - alcohol cosumptio - fruit ad vegetable cosumptio 2 3 Collectio of simple physical measuremets i the household settig. Also affordable ad ca be doe at the same time as Step 1 Takig blood samples for biochemical measuremets i a cliic settig - physical activity To build o the core data i Step 1 ad determie the proportio of adults that : - Are overweight ad obese - Have raised blood pressure To detect the prevalece of diabetes or raised blood glucose ad raised cholesterol. Most coutries should udertake the core items of Step 2 If ot viable to survey all participats due to costs, a useful optio is to coduct tests o a sub-sample of the participats. St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 13

85 Appedix 3 Populatio Estimates: AGE GROUP Sample Size Calculatios: ST. KITTS AND NEVIS 2001 Populatio Cesus MALES FEMALES TOTAL TOTAL Z e P 1-P SS1 Populatio Cesus 2001 SS2 by AGE/SEX Males Females Males Females Fial Sample Size Total SS2 Deff SS3 RR Fial SS Total St. Kitts Nevis Where: SS1 SS2 Where: Z P e Strata Deff RR SS Level of Cofidece Baselie Idicator Level Margi of Error Number of age/sex strata Desig Effect Respose Rate Sample size calculatio SS3 = SS2 x Deff SS4 = SS3 RR St. Kitts ad Nevis STEPwise Approach to chroic disease risk factor surveillace 14

86 ST. KITTS AND NEVIS - SAMPLE SIZE CALCULATIONS RR=85 Populatio Cesus 2001 SS2 by AGE/SEX Fial Sample Size Z e P 1-P SS1 Males Females Males Females Total SS2 Deff SS3 RR SS4 Total St. Kitts Nevis Sarah Quesel: Recommeded RR=90 Populatio Cesus 2001 SS2 by AGE/SEX Fial Sample Size Z e P 1-P SS1 Males Females Males Females Total SS2 Deff SS3 RR SS4 Total St. Kitts Nevis RR=95 Populatio Cesus 2001 SS2 by AGE/SEX Fial Sample Size Z e P 1-P SS1 Males Females Males Females Total SS2 Deff SS3 RR SS4 Total St. Kitts Nevis Z Level of Cofidece Proportios P Baselie Idicator Level St. Kitts: 75 (=15681/21046 x 100) e Margi of Error Nevis: 25 (=5365/21046 x 100) StrataNumber of age/sex strata Deff Desig Effect RR Respose Rate pop Cesus 2001 CAREC August,

87 CAREC August, 2007

88 Appedix D St Kitts STEPS Survey 2008 Fact Sheet The STEPS survey of chroic disease risk factors i St. Kitts was carried out from October 2007 to Jauary St. Kitts carried out Step 1 ad Step 2. Socio demographic ad behavioral iformatio was collected i Step 1. Physical measuremets such as height, weight ad blood pressure were collected i Step 2. The STEPS survey i St. Kitts, was a populatio-based survey of adults aged A stratified radom samplig sample desig was used to produce represetative data for that age rage i St. Kitts. A total of 1443 adults participated i the St. Kitts STEPS survey. The overall respose rate was A repeat survey is plaed for 2011 if fuds permit. Results for adults aged years (icl. ) Both Sexes Males Females Step 1 Tobacco Use Percetage who curretly smoke tobacco 8.7 ( ) 16.2 ( ) 1.1 ( ) Percetage who curretly smoke tobacco daily 6.0 ( ) 11.4 ( ) 0.7 ( ) For those who smoke tobacco daily Average age started smokig Percetage smokig maufactured cigarettes Mea umber of maufactured cigarettes smoked per day (by smokers of maufactured cigarettes) Percetage exposed to smoke at home o 1 or more days per week Percetage exposed to smoke at workplace o 1 or more days per week Step 1 Alcohol Cosumptio Percetage of abstaiers (who did ot drik alcohol i the last year ) Percetage of curret drikers (who drak alcohol i the past 30 days) For those who drak alcohol i the last 30 days 17.2 ( ) 51.8 ( ) 6.3 ( ) 9.2 ( ) 11.5 ( ) 10.8 ( ) 29.8 ( ) 16.9 ( ) * 50.9 ( ) * 6.4 ( ) * 11.2 ( ) 16.6 ( ) 9.5 ( ) 45.1 ( ) 7.2 ( ) 6.2 ( ) 12.1 ( ) 14.3 ( ) Percetage who drak alcohol o 4 or more days i the last week 24.7 ( ) 29.9 ( ) 7.8 ( ) Percetage of wome who had 4 or more driks o ay day i the last week 20.7 ( ) Percetage of me who had 5 or more driks o ay day i the last week 20.1 ( ) Step 1 Fruit ad Vegetable Cosumptio (i a typical week) Mea umber of days fruit cosumed 3.7 ( ) 3.5 ( ) 3.9 ( ) Mea umber of servigs of fruit cosumed per day 0.8 ( ) 0.7 ( ) 0.8 ( ) Mea umber of days vegetables cosumed 4.1 ( ) 4.0 ( ) 4.2 ( ) Mea umber of servigs of vegetables cosumed per day 0.8 ( ) 0.8 ( ) 0.8 ( ) Percetage who ate less tha 5 of combied servigs of fruit & vegetables per day 97.3 ( ) 97.6 ( ) 97.0 ( ) Step 1 Physical Activity Percetage with low levels of activity (defied as <600 METmiutes/week) 38.3 ( ) 28.3 ( ) 48.5 ( ) Percetage with high levels of activity (defied as 3000 METmiutes/week) 36.2 ( ) 51.0 ( ) 21.1 ( ) Media time spet i physical activity per day (miutes) (preseted with Iter-quartile rage) 51.4 ( ) ( ) 30.0 ( ) Percetage ot egagig i vigorous physical activity 72.2 ( ) 55.7 ( ) 89.0 ( ) St. Kitts STEPS chroic disease risk factor surveillace fact sheet

89 Step 2 St. Kitts STEPS Survey 2008 Fact Sheet Results for adults aged years (icl. ) Both Sexes Males Physical Measuremets Mea body mass idex - BMI (kg/m 2 ) Percetage who are overweight or obese (BMI 25 kg/m 2 ) Percetage who are obese (BMI 30 kg/m 2 ) Average waist circumferece (cm) Mea systolic blood pressure - SBP (mmhg), excludig those curretly o medicatio for raised BP Mea diastolic blood pressure - DBP (mmhg), excludig those curretly o medicatio for raised BP Percetage with raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP) Percetage with raised BP (SBP 160 ad/or DBP 100 mmhg or curretly o medicatio for raised BP) Summary of combied risk factors curret daily smokers less tha 5 servigs of fruits & vegetables per day low level of activity (<600 MET -miutes) Percetage with low risk (i.e. oe of the risk factors icluded above) 30.2 ( ) 78.5 ( ) 45.0 ( ) ( ) 77.8 ( ) 35.0 ( ) 18.4 ( ) 29.2 ( ) 74.1 ( ) 37.9 ( ) 94.0 ( ) ( ) 78.9 ( ) 38.2 ( ) 15.5 ( ) 31.2 ( ) 83.0 ( ) 52.5 ( ) 95.1 ( ) Fem ales ( ) 76.7 ( ) 31.9 ( ) 21.2 ( ) overweight or obese (BMI 25 kg/m 2 ) raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP) 0.1 ( ) 0.0 ( ) 0.3 ( ) Percetage with raised risk (at least three of the risk factors icluded above), aged 25 to 44 years old 43.4 ( ) 37.0 ( ) 49.7 ( ) * Percetage with raised risk (at least three of the risk factors icluded above), aged 45 to 64 years old Number of respodets too small for accurate estimate 67.4 ( ) 65.2 ( ) 69.6 ( ) For additioal iformatio, please cotact the STEPS Focal Poit: Ms E. Petriella Edwards Health Promotio Uit, Miistry of Health, St. Kitts skcc_prevetio@yahoo.com Tel: St. Kitts STEPS chroic disease risk factor surveillace fact sheet