ETHIOPIA STEPS REPORT ON RISK FACTORS FOR NON-COMMUNICABLE DISEAES AND PREVALENCE OF SELECTED NCDs

Transcription

1 ETHIOPIA STEPS REPORT ON RISK FACTORS FOR NON-COMMUNICABLE DISEAES AND PREVALENCE OF SELECTED NCDs Ethiopia Public Health Istitute FMOH Ethiopia Public Health Istitute Addis Ababa December 2016 I

2 ETHIOPIA STEPS REPORT ON RISK FACTORS FOR CHRONIC NON- COMMUNICABLE DISEASES AND PREVALENCE OF SELECTED NCDs Ethiopia Public Health Istitute Federal Miistry of Health Ethiopia Public Health Istitute Addis Ababa II

3 December 2016 Table of cotets... i Table of cotets... iii List of figures... iv List of tables... viii Forward... xii Ackowledgemets... xiii Abbreviatios... xiv Executive Summary... xv 1. Itroductio Backgroud Ratioale Objective: Methods ad materials Survey desig: Survey populatio: Sample size determiatio ad samplig procedure: Survey istrumet: Data collectio procedure: Data quality assurace Data maagemet process Weightig of data Data aalysis Ethical clearace Demographic iformatio results Tobacco use ad policy Tobacco use Tobacco policy Alcohol cosumptio Alcohol cosumptio status Diet Fruit ad vegetable cosumptio Dietary salt Oil ad fat cosumptio Physical activity Sedetary life Khat 1 use Violece ad ijury History ad life style advice for selected NCDS History of raised blood pressure III

4 10.3. History of diabetes History of raised cholesterol History of cardiovascular diseases Lifestyle advice Cervical cacer screeig Physical measuremets Blood pressure Heart rate Athropometric measuremets Biochemical measuremets Blood glucose level Total cholesterol HDL cholesterol Fastig triglycerides Salt itake Summary of risk factors Cardiovascular disease (CVD) risk Summary of combied risk factors Factors associated with raised blood pressure ad glucose Recommedatios ad coclusio Coclusio Recommedatio Refereces Aexes Aex 1: Regioal aalysis for selected variables Aex 2. The Master Data book Aex 3: Questioaire Amex 4: SURVEY PERSONNEL List of figures Figure Percetage of smokig status amog all respodets, by sex category, Ethiopia NCD STEPS Figure Smokig status amog all respodets by area of residece, Ethiopia NCD STEPS, Figure Mea amout of tobacco used by daily smokers by type ad sex category, Ethiopia NCD STEPS, Figure Percetage of curret smokers smokig each products by sex category, Ethiopia NCD STEPS, Figure Percetage of curret smokers smokig each products by area of residece, Ethiopia NCD STEPS, Figure Percetage of daily smokers smokig give quatities of maufactured or had-rolled cigarettes per day, by sex category, Ethiopia NCD STEPS, Figure Percetage of daily smokers smokig give quatities of maufactured or had-rolled cigarettes per day by sex category, Ethiopia NCD STEPS, Figure Smokeless tobacco use amog all respodets by area of residece, Ethiopia NCD STEPS, Figure Mea times of smokeless tobacco used by daily smokeless tobacco users per day, by type, Ethiopia NCD STEPS, Figure Percetage of curret user of smokeless tobacco by type ad sex, Ethiopia NCD IV

5 STEPS, Figure Percetage of respodets who oticed iformatio i a ewspaper or magazie about dager of smokig or ecourage to quit, by age ad sex, Ethiopia NCD STEPS, Figure Percetage of respodets who oticed promotio of cigarettes i the past 30 days, by type ad sex, Ethiopia NCD STEPS, Figure 5. 1 Alcohol cosumptio status of all respodets i the past 30 days, by sex, Ethiopia NCD STEPS, Figure 5. 2 Percetage of curret drikers, by sex ad place of residece, Ethiopia NCD STEPS, Figure 5. 3 Frequecy of alcohol cosumptio i the past 12 moths, by sex ad age group, Ethiopia NCD STEPS, Figure 5. 4 Frequecy of alcohol cosumptio i the past 12 moths, by sex ad place of residece, Ethiopia NCD STEPS, Figure 5. 5 Mea umber of drikig occasios i the past 30 days amog curret (past 30 days) drikers, by sex ad age group, Ethiopia NCD STEPS, Figure 5. 6 Mea umber of stadard driks per drikig occasio amog curret (past 30 days) drikers by sex ad age group, Ethiopia NCD STEPS, Figure 5. 7 Proportio of high-, itermediate-, ad lower-volume drikig levels amog all respodets, by place of residece, Ethiopia NCD STEPS, Figure 5. 8 Percetage of lower-volume drikig levels amog all respodets, by sex ad age group, Ethiopia NCD STEPS, Figure 5. 9 Percetage of high-ed, itermediate, ad lower-ed level drikig amog curret (past 30 days) drikers, by age group ad place of residece, Ethiopia NCD STEPS, Figure Percetage of respodets who cosume six or more driks o a sigle occasio at least oce durig the past 30 days, by sex ad age group, Ethiopia NCD STEPS, Figure Frequecy of alcohol cosumptio amog curret (past 30 days) drikers, i the past 7 days, by sex ad age group, Ethiopia NCD STEPS, Figure Frequecy of ot beig able to stop drikig oce started durig i the past 12 moths amog past 12 moth drikers, by sex ad place of residece, Ethiopia NCD STEPS, Figure Percetage of eedig a first drik i the morig to get goig durig the past 12 moths amog the past 12 moth drikers, by sex ad place of residece, Ethiopia NCD STEPS, Figure Percetage of respodets who had family or parter problems due to someoe else s drikig durig i the past 12 moths amog all respodets, by sex ad place of residece, Ethiopia NCD STEPS, Figure 6. 1 Mea umber of day s fruits ad vegetables were cosumed i a typical week, by sex ad place of residece, Ethiopia NCD STEPS, Figure 6. 2 Mea umber of servig of fruits ad vegetables o average per day, by sex ad place of residece, Ethiopia NCD STEPS, Figure 6. 3 Distributio of respodets, by umber of servigs of fruit ad/or vegetables per day, Ethiopia NCD STEPS, Figure 6. 4 Percetage of respodets who always or ofte add salt or salty sauce to their food before eatig or as they are eatig, by age ad sex, Ethiopia NCD STEPS, Figure 6. 5 Percetage of respodets who always or ofte add salt to their food whe cookig or preparig foods at home, by sex ad place of residece, Ethiopia NCD STEPS, Figure 6. 6 Percetage of respodets who always or ofte eat processed foods high i salt, by age V

6 ad sex, Ethiopia NCD STEPS, Figure 6. 7 Percetage of self-reported quatity of salt cosumptio, by sex, Ethiopia NCD STEPS, Figure 6. 8 Percetage of respodets who thik lowerig salt i diet is very, somewhat or ot at all importat, by sex ad place of residece, Ethiopia NCD STEPS, Figure 6. 9 Percetage of respodets who thik cosumig too much salt could cause a serious health problem, by sex ad place of residece, Ethiopia NCD STEPS, Figure Percetage of respodets takig specific actio to cotrol salt itake, by sex, Ethiopia NCD STEPS, Figure Mea umber of meals eate outside the home, by age ad sex, Ethiopia NCD STEPS, Figure Mea umber of meals eate outside the home, by sex ad area of residece, Ethiopia NCD STEPS, Figure 7. 1 Proportio of respodets ot meetig who recommedatios o physical activity for health, by age ad sex, Ethiopia NCD STEPS, Figure 7. 2 Percetage of all respodets classified ito three categories of total physical activity accordig to the recommedatios by age ad area of residece,, Ethiopia NCD STEPS, Figure 7. 3 Mea miutes of total physical activity o average per day, by sex ad place of residece, ethiopia NCD STEPS, Figure 7. 4 Mea miutes of physical activity per day, by type of activity, sex ad place of residece, Ethiopia NCD STEPS, Figure 7. 5 Percetage of work, trasport ad recreatioal activity cotributig to total activity for all respodets, Ethiopia NCD STEPS, Figure 7. 6 Percetage of respodets ot egaged i vigorous physical activity, by age ad sex, Ethiopia NCD STEPS, Figure 8. 1 Percetage of khat chewig status amog respodets by sex ad place of residece, Ethiopia NCD STEPS, Figure 8. 2 Proportio of curret khat chewers i daily basis by sex ad place of residece, Ethiopia NCD STEPS, Figure 8. 3 Proportio of respodets who tried to stop or advised by a doctor /health worker/ to stop khat chewig, by sex ad place of residece, Ethiopia NCD STEPS, Figure 8. 4 Proportios of respodets who faced problems due to someoe else s khat chewig practices, by sex ad place of residece, Ethiopia NCD STEPS, Figure 8. 5 Proportios of curret khat chewer who drik alcohol while usig khat, by age, sex, ad place of residece, Ethiopia NCD STEPS, Figure 9. 1 Proportio of the causes of o-road traffic icidet, by sex ad place of residece, Ethiopia NCD STEPS, Figure 9. 2 Causes of ijury from a violet icidet amog respodets ivolved i a violet icidet by place of residece Ethiopia STEPS survey, Figure 9. 3 Percetage of those receivig violet ijuries i the past 12 moths by relatioship status of differet persos, by place of residece, Ethiopia NCD STEPS, Figure 9. 4 Percetage of those receivig violet ijuries i the past 12 moths by relatioship status of differet persos, by sex, Ethiopia NCD STEPS, Figure 9. 5 Proportio of respodets who experieced sexual abusmet, by sex ad place of residece, Ethiopia NCD STEPS, VI

7 Figure 10.1 Blood pressure measuremet ad diagosis, by sex, Ethiopia NCD STEPS, Figure 10.2 Curretly takig drugs (medicatio) for raised blood pressure prescribed by doctor or health worker amog those diagosed, Ethiopia NCD STEPS, Figure 10.3 Percetage of participats who had see traditioal healer ad curretly takig herbal or traditioal remedy for raised blood pressure, by place of residece, Ethiopia NCD STEPS, Figure 10.4 Blood sugar measuremet ad diagosis, by sex Ethiopia Steps survey, Figure 10.5 Curretly takig ay medicatio or isuli prescribed for diabetes amog those previously diagosed by sex, ad residece area, Ethiopia NCD STEPS, Figure 10.6 Curretly takig isuli prescribed for diabetes amog those previously diagosed by sex, Ethiopia NCD STEPS, Figure 10.7 Total cholesterol measuremet ad diagosis, by sex, Ethiopia NCD STEPS, Figure 10.8 Percetage of respodets havig ever had a heart attack or chest pai from heart disease or a stroke, by age ad sex, Ethiopia NCD STEPS, Figure 10.9 percetage of respodets curretly takig regularly aspiri or/ad statis to prevet or treat heart disease by sex, Ethiopia NCD STEPS, Figure percetage of respodets reportig havig received lifestyle advice from a doctor or health worker durig the past three years, by sex, Ethiopia NCD STEPS, Figure Percetage of wome screeed for cervical cacer by age ad area of residece, Ethiopia NCD STEPS, Figure 11.1 Mea SBP ad DBP (mmhg), by sex ad age, Ethiopia NCD STEPS, Figure 11.2 Percetage of respodets with raised blood pressure, or curretly takig medicatio for raised blood pressure, by sex, Ethiopia NCD STEPS, Figure 11.3 Percetage of respodets with raised blood pressure, excludig those takig medicatio for raised blood pressure, by sex, Ethiopia NCD STEPS, Figure 11.4 Respodets with treated ad/or cotrolled blood pressure amog those with raised blood pressure or curretly takig medicatio, by sex ad area of residece, Ethiopia NCD STEPS, Figure 11.5 Mea BMI (kg/m) by sex ad age group, Ethiopia NCD STEPS, Figure 11.6 Distributio of BMI category by sex, Ethiopia NCD STEPS, Figure 12.1 Mea fastig blood glucose level (mg/dl), by sex ad age group, Ethiopia NCD STEPS, Figure 12.2 Prevalece of IFG, by sex, age group, ad area of residece, Ethiopia NCD STEPS, Figure 12.3 Prevalece of raised blood glucose or curretly takig medicatio for diabetes, by sex age group, ad residece area, Ethiopia NCD STEPS, Figure 12.4 Percetage of respodets with a total cholesterol level of 190 mg/dl ad 240 mmol/l, or curretly takig medicatio for raised cholesterol by sex, Ethiopia NCD STEPS, Figure 12.5 Proportio of populatio with decreased HDL cholesterol, by sex ad age, Ethiopia NCD STEPS, Figure 12.6 Mea fastig triglycerides (mg/dl), by sex, age group, ad area of residece, Ethiopia NCD STEPS, Figure 12.7Percetage of respodets with fastig triglycerides 150 mg/dl, by sex, age group, ad area of residece, Ethiopia NCD STEPS, Figure 12.8 Percetage of respodets with fastig triglycerides 180 mg/dl, by sex, age group, ad area of residece,, Ethiopia NCD STEPS, Figure 13.1 Percetage of eligible idividuals receivig drug therapy ad cousellig to prevet heart attacks ad strokes by sex,, Ethiopia NCD STEPS, Figure 13.2 Summary of combied risk factors, by sex ad age group, Ethiopia NCD STEPS, VII

8 List of tables Table 2. 1 Total sample size allocatio by regio, Ethiopia NCD STEPS, Table 2. 2 Compoets of steps survey variables used, Ethiopia NCD STEPS, Table 3. 1 Summary iformatio by age group ad sex of the respodets Ethiopia NCD STEPS, Table 3. 2 Mea umber of years of educatio amog respodets, Ethiopia NCD STEPS, Table 3. 3 Highest level of educatio achieved amog Me survey respodets, Ethiopia NCD STEPS, Table 3. 4 Highest level of educatio achieved amog wome survey respodets, Ethiopia NCD STEPs Survey, Table 3. 5 Highest level of educatio achieved by survey respodets, Ethiopia NCD STEPS, Table 3. 6 Summary results for the ethicity of the respodets, Ethiopia NCD STEPS, Table 3. 7 Marital status of me survey respodets, Ethiopia NCD STEPS, Table 3. 8 Marital status of wome survey respodets, Ethiopia NCD STEPS, Table 3. 9 Marital status of all survey respodets, Ethiopia NCD STEPS, Table Proportio of me respodets i paid employmet ad upaid by age group, Ethiopia NCD STEPS Table Proportio of wome respodets i paid employmet ad upaid by age group, Ethiopia NCD STEPS, Table Proportio of respodets i paid employmet ad upaid by age group, Ethiopia NCD STEPS, Table Proportio of me respodets i upaid work by age group, Ethiopia NCD STEPS, Table Proportio of wome respodets i upaid work by age group, Ethiopia NCD STEPS, Table Proportio of respodets i upaid work by age group, Ethiopia NCD STEPS, Table Mea reported per capita aual icome of respodets i local currecy (Eth Birr), Ethiopia NCD STEPS, Table Household earigs by quitile for those who did t kow their exact per capital aual icome, Ethiopia NCD STEPS, Error! Bookmark ot defied. Table Percetage of curret smokers amog all respodets by age, sex, ad area of residece, Ethiopia NCD STEPS, Table Percetage of Curret daily smokers amog smokers by age, sex, ad area of residece, Ethiopia NCD STEPS, Table Mea age started smokig amog smokers by age group, sex, ad areas of residece, Ethiopia NCD STEPS, Table Mea duratio of smokig amog curret smokers by age, sex, ad areas of residece, Ethiopia NCD STEP, Table Percetage of maufactured cigarette smokers amog curret smokers by age, sex, ad area of residece, Ethiopia NCD STEPS, Table Percetage of Curret smokers who have tried to stop smokig by age, sex, ad area of residece, Ethiopia NCD STEPS, Table Percetage of Curret smokers who have bee advised by doctor to stop smokig by age, sex, ad area of residece, Ethiopia NCD STEPS, Table Percetage of Curret users of smokeless tobacco by age, sex, ad area of residece, VIII

9 Ethiopia NCD STEPS, Table Percetage of former daily smokeless tobacco users amog all respodets, Ethiopia NCD STEPS, Table Percetage of former daily smokeless tobacco users amog all smokers, Ethiopia NCD STEPS, Table Percetage of curret tobacco users (both smokig ad smokeless) amog all respodets, Ethiopia NCD STEPS, Table Percetage of curret daily tobacco users (both smokig ad smokeless) amog all respodets, Ethiopia NCD STEPS, Table Proportio of respodets who were exposed to secod-had smoke i home durig the past 30 days by sex, age group ad area of residece, Ethiopia NCD STEPS, Table Proportio of respodets who were exposed to secod-had smoke i the workplace durig the past 30 days by sex, age ad area of residece, Ethiopia NCD STEPS, Table Percetage of respodets who oticed advertisemets or sigs promotig cigarettes i stores, by age ad sex, Ethiopia NCD STEPS, Table Percetage of curret smokers who oticed health warigs o cigarette packages i the past 30 days, by age, sex ad area of residece, Ethiopia NCD STEPS, Table Percetage of curret smokers who saw health warigs o cigarette packages that thought of quittig i the past 30 days, by age ad sex, Ethiopia NCD STEPS, Table Average price paid for 20 maufactured cigarettes o the last purchase, by age ad sex, Ethiopia NCD STEPS, Table 5. 2 Distributio of curret (past 30 days) alcohol drikers status, by sex ad age,, Ethiopia NCD STEPS, Table 5. 3 Distributio of respodets who stopped drikig due to health reasos by age group, sex ad place of residece, NCD STEPS, Table 5. 4 Mea umber of drikig occasios i the past 30 days amog curret (past 30 days) drikers, by sex, age group ad place of residece, Ethiopia NCD STEPS, Table 5. 5 Mea umber of stadard driks per drikig occasio amog curret (past 30 days) drikers, by sex, age group ad area of residece, Ethiopia NCD STEPS, Table 5. 6 Proportio of high-, itermediate-, ad lower-volume drikig levels amog all respodets, by age group ad place of residece, Ethiopia NCD STEPS, Table 5. 7 Mea umber of times with six or more driks durig a sigle occasio i the past 30 days amog curret drikers, by age, sex ad place of residece, Ethiopia NCD STEPS, Table 5. 8 Mea umber of stadard driks cosumed o average per day i the past 7 days amog curret (past 30 days) drikers, by sex, age group ad place of residece, Ethiopia NCD STEPS, Table 5. 9 Percet cosumptio of urecorded alcohol 1, by sex, age group ad place of residece, Ethiopia NCD STEPS, Table 6. 1 Mea umber of days o which fruits were cosumed i a typical week by age ad sex, Ethiopia NCD STEPS, Table 6. 2 Mea umber of days o which vegetables cosumed i a typical week, by age ad sex, Ethiopia NCD STEPS, Table 6. 3 Mea umber of servigs of fruit o average per day by age ad sex, Ethiopia NCD STEPS, Table 6. 4 Mea umber of servigs of vegetables o average per day, by age ad se, Ethiopia NCD STEPS, IX

10 Table 6. 5 Percetage of all respodets who always or ofte add salt or salty sauce to their food before eatig or as they are eatig, by sex ad place of residece, Ethiopia NCD STEPS, Table 6. 6 Percetage of respodets who always or ofte add salt to their food whe cookig or preparig foods at home, by age ad sex, Ethiopia NCD STEPS, Table 6. 7 Percetage of respodets who always or ofte eat processed foods high i salt, by sex ad area of residece, Ethiopia NCD STEP, Table 6. 8 Percetage of respodets who thik they cosume too much salt or far too much salt, by area of residece ad sex, Ethiopia NCD STEPS, Table 6. 9 Percetage of respodets who thik cosumig too much salt could cause a serious health problem, by age ad sex, Ethiopia NCD STEPS, Table Proportio of households with type of oil or fat most ofte used for meal preparatio i households, Ethiopia NCD STEPS, Table 7. 1 Percetage of respodets ot meetig WHO recommedatios o physical activity for health 1, by sex ad area of residece, Ethiopia NCD STEPS, Table 7. 2 Media miutes of total physical activity o average per day, by sex ad place of residece, Ethiopia NCD STEPS, Table 7. 3 Percetage of respodets ot egaged i vigorous physical activity, by sex ad area of residece, Ethiopia NCD STEPS, Table 7. 4 Mea of miutes spet i sedetary activities o a typical day, by sex ad place of residece, Ethiopia NCD STEPS, Table 7. 5 Medias of miutes spet i sedetary activities o a typical day by sex ad place of residece, Ethiopia Table 8. 1 Mea age of startig khat chewig amog curret khat chewers, by sex, age, ad area of residece, Ethiopia NCD STEPS, Table 8. 2 Proportio Curret khat chewers who have tried to stop chewig by sex, age group, ad place of residece, Ethiopia NCD STEPS, Table 8. 3 Proportio of curret khat chewers who have fried smoker while usig khat, by age, sex, ad area of residece, Ethiopia NCD STEPS, Table 9. 1 Percetage of respodets who ivolved i a road traffic crash durig the past 12 moths, by age, sex, ad place of residece, Ethiopia NCD STEPS, Table 9. 2 Percetage of respodets seriously ijured as a result of road traffic crash amog those ivolved i a road traffic crash, by age, sex, ad place of residece, Ethiopia NCD STEPS, Table 9. 3 Percetage of respodets seriously ijured i a o-road traffic accidet, by sex, age, ad place of residets, Ethiopia NCD STEPS, Table 9. 4 Proportio of respodets seriously ijured from violet icidet, by sex, age, ad area of of residece, Ethiopia NCD STEPS, Table 10.1 Blood pressure measuremet ad diagosis status by age, sex ad area of residece, Ethiopia NCD STEPS, Table 10.2 Blood sugar measuremet ad diagosis by Sex, age group, ad area of residece Ethiopia NCD STEPS, Table 10.3 Total cholesterol measuremet ad diagosis by sex, age group ad area of residece, Ethiopia NCD STEPS, Table 10.4 Curretly takig oral treatmet (medicatio) prescribed for raised total cholesterol amog those previously diagosed y sex, age group ad area of residece, Ethiopia NCD STEPS, Table 10.5 Percetage of wome respodets age years who have ever had a screeig test for X

11 cervical cacer by area of residece ad age, Ethiopia NCD STEPS, Table 11.1 Mea heart rate (beats per miute) by sex, age group ad area of residece, Ethiopia NCD STEPS, Table 11.2 Mea waist-to-hip ratio (excludig pregat wome) by sex, age ad area of residece, Ethiopia NCD STEPS, Table 12.1 Curretly o medicatio for diabetes, by sex, age group, ad area of residece, Ethiopia NCD STEPS, Table 12.2 Mea total cholesterol (mgl/dl), by sex, age, ad area of residece, Ethiopia NCD STEPS, Table 12.3 Mea HDL cholesterol, by sex, age, ad area of residece, Ethiopia NCD STEPS, Table 13.1 Percetage of respodets with a 10-year CVD risk 30 or with existig CVD by sex, age group ad area of residece, Ethiopia NCD STEPS, Table Bi-variate ad multivariate aalyses of demographic ad behavioural risk factors associated with raised blood pressure 1, Ethiopia NCD STEPS, Table Bi-variate ad multivariate aalyses of demographic ad behavioural risk factors associated with raised blood glucose 1, Ethiopia NCD STEPS, XI

12 Forward The global prevalece of chroic o-commuicable diseases is icreasig with greatest burde i developig coutries. No-commuicable diseases (NCDs) are resposible for a high proportio of the death ad disability burde i all coutries. I developig coutries, the burde of disease caused by NCD is icreasig rapidly ad expected to have sigificat ecoomic, social, ad health cosequeces. Prior the preset survey, there was o represetative NCD risk factor survey udertake i Ethiopia. As the tred of NCD burde is icreasig i the health facilities of the coutry, the eed to coduct comprehesive survey was give priority by FMOH. Depedig o the global ad atioal situatios that are related to NCDs, the Ethiopia Federal Miistry of Health has recetly developed a strategic framework that would help for prevetio ad cotrol of chroic ocommuicable diseases. Oe of the objectives of this strategy is geeratig empirical evidece o NCD. I light of this uderstadig, the Ethiopia Public Health Istitute( EPHI) i close collaboratio with health developmet parters has coducted a study aimed to assess risk factors for major o-commuicable diseases (NCDs) ad prevalece of selected NCDs to establish baselie iformatio for policy ad program developmet. Data o prevalece of NCD risk factor is aimed to iform policy makers to desig evidece-based public health itervetios to prevet ad cotrol the epidemics of NCDs. The WHO STEPS survey is a comprehesive study tool to compare with other similar studies doe across the world. Furthermore, it provides baselie data to establish epidemiological surveillace system for NCDs risk factors i the coutry. This is the first atioal represetative populatio based risk factor survey coducted i the Ethiopia. I hope that the fidigs ad recommedatios will be take ito cosideratio by the govermet ad all stakeholders. I would like to take this opportuity to express my gratitude to all who have bee istrumetal i the successful completio of this importat study. Dr. Amha Kebede Director Geeral (EPHI) XII

13 Ackowledgemets The Ethiopia No-Commuicable Diseases (NCDs) steps survey demostrates the combied efforts of the Federal Miistry of Health (FMOH), developmet parters, professioal associatios, ad idividuals without which this report could ot have bee possible. The Ethiopia Public Health Istitute (EPHI) would like to thak the followig idividuals/orgaizatio for their sterlig support ad cotributio: All health developmet parters ad collaborators who have provided support for the successful completio of this survey especially techical ad fiacial support provided by WHO ad assistace i procuremet of reaget from abroad by UNICEF. Members of the Techical Workig Group from respective orgaizatios ad professioal associatios who worked hard i providig techical support by reviewig ad givig feedback o the overall process of the survey. The overall coordiatio ad guidace provided by Health System Research Directorate of EPHI is also highly appreciated. Special thaks also go to the TB ad HIV research directorate team who performed laboratory aalyses for biological samples to make the report a reality. The istitute would like to exted its sicere gratitude to the survey participats who cooperated ad participated i the realizatio of the survey. Last but ot least, EPHI is grateful to all the field staff ivolved i data collectio ad supervisio for the crucial roles played i achievig the survey goal. XIII

14 Abbreviatios AAU BMI BP CI CSA CVD DBP DM EAs EDHS EPHA EPHI EMA FMOH GPAQ IFG HC HDL HMIS HR LDL HPV IRB IFSS MET NCD OR PDA PSU SSU SBP STEPS TWG VIA WHR UNICEF WB WC WHO Addis Ababa Uiversity Body mass idex Blood pressure Cofidece iterval Cetral Statistical Agecy Cardiovascular disease Diastolic blood pressure Diabetes mellitus Eumeratio areas Ethiopia demography ad health survey Ethiopia Public Health Associatio Ethiopia Public Health Istitute Ethiopia Medical Associatio Federal Miistry of Health Geeral Physical Activity Questioaire Impaired fastig glycaemia Hip circumferece High-desity lipoprotei Health maagemet iformatio system Heart rate Low-desity lipoprotei Huma papillomavirus Istitutioal review board Iteret file streamig system Metabolic equivalet Number of respodets No commuicable disease Odds ratio Persoal digital assistat Primary samplig uit Secodary samplig uit Systolic blood pressure WHO STEP-wise approach to surveillace Techical Workig Group Visual ispectio with acetic acid Waist hip ratio Uited Natio Iteratioal Childre Emergecy Fud World Bak Waist circumferece World Health Orgaizatio XIV

15 Executive Summary Itroductio: As the leadig cause of death globally, o-commuicable diseases (NCDs) particularly cardiovascular diseases (CVDs), diabetes, chroic respiratory diseases ad cacer were resposible for 38 millio (68) of the World's 56 millio deaths i Almost three quarters of all NCD deaths (28 millio), ad the majority of premature deaths (82) occur i low-ad middle-icome coutries (LMIC). It is estimated that the cumulative ecoomic losses i LMIC betwee 2011 ad 2025 will be US$7 trillio. This figure exceeds the aual US$ 11.2 billio cost of implemetig a set of high-impact itervetios to reduce NCD burde. No -commuicable diseases have bee a eglected area i may low icome coutries, due to the heavy burde of commuicable diseases, ad other competig priorities. There is scarcity of published studies describig the burde of major o-commuicable disease i sub Sahara Africa. Likewise, except very few studies i some pocket areas, there was o represetative NCD risk factor survey udertake i Ethiopia. As the tred of NCD burde is icreasig i the health facilities of the coutry, the eed to coduct a comprehesive survey has bee give priority by FMOH. The Ethiopia NCD STEPS survey provides baselie data of risk factors for o-commuicable diseases (NCDs). The survey was coducted with the objectives of assessig behavioural ad biological risk factors for major chroic o-commuicable diseases (NCDs) ad prevalece of selected NCDs to establish baselie iformatio for policy ad program developmet. Methods: A commuity based cross sectioal study was coducted i accordace to the WHO a step-wise approach to the surveillace of NCD risk factors. The survey was carried out betwee April ad Jue The data collectio processes icluded three steps - Step 1:This step comprised a questioaire to gather demographic ad behavioural characteristics of the study populatio, Step 2: Physical measuremet was doe to build o the core data i step 1 ad to determie proportio of the study populatio with raised blood pressure, overweight ad obesity, ad Step 3: Biochemical measuremets were udertake to build o the core data i step 1 ad step 2 to measure proportio of the study populatio with diabetes, raised blood glucose ad abormal lipid level. I additio to core ad expaded modules, some optioal modules were icluded i each of the three steps. Data were collected digitally usig persoal digital assistats (PDAs) from which data were trasferred to cetral server usig iteret file streamig system (IFSS) ad exported to Microsoft Excel o persoal computers. Data was cleaed usig SPSS ad Stata ad aalysed usig Epi Ifo versio Descriptive weighted aalysis was doe alog with complex sample aalysis, ad bivariate ad multivariate aalysis was coducted for icreased blood pressure ad icreased blood sugar. Results: Totally, 9,801 study participats age years were ivolved i the survey ad the respose rate was Of the total 9,801 respodets of STEPs survey, about six i te were wome. Regardig educatio level by age, the youger group was more likely educated compared with respodets i the older age group. Of all the respodets 49.4 had o formal educatio, while 28.8 atteded formal educatio with less tha primary level. Majority of the respodets (67.3 ) were curretly married; early 10 were employed; 71 of study participats reported their aual icome less tha 12,000 Birr. The data collected o behavioural XV

16 characteristics showed that about 4.2 of the survey participats were curret smokers (me 7.3, wome 0.4). Amog all curret smokers of both sexes, 82.8 of them smoked tobacco daily. Te percet were exposed to secod-had smoke at home whereas 13 i the workplace. With regard to alcohol cosumptio, early 41 had cosumed alcohol durig the past 30 days prior to the survey. The proportio of me who cosumed alcohol (46.6) was higher tha that of wome (33.5).The average umber of days per week o which fruit ad vegetable cosumed was 0.9 ad 1.5, respectively. More tha iety-eight percet of the populatio cosumed fewer tha five servigs of fruit ad vegetables daily. About six percet of the study populatio did ot meet WHO recommedatios o physical activity for health. Idividuals i rural areas were foud to be more exposed to physical activity tha urba residets. About 16 of respodets were curret khat chewers. Regardig ijury, about 3 of respodets ivolved i a road traffic crash as a passeger, driver, or pedestria durig the past 12 moths precedig the survey. Prevalece of raised blood pressure (SBP > 140 ad/or DBP > 90 mmhg) amog Ethiopia adult populatio was 15.6, with o differece by sex. Six percet of study participats had raised blood glucose ad diabetes. Mea body mass idex (BMI) was 20.4 (20.1 for me ad 20.7 for wome). Few idividuals (6.3) were overweight or obese, with a higher prevalece of overweight i urba residets. The percetage of wome respodets age years that had ever udergoe screeig for cervical cacer was Coclusios ad Recommedatio: Most of the behavioural risk factors, such as tobacco use, alcohol cosumptio, khat cosumptio, were more prevalet amog me compared to wome. Coversely, the biological risk factors, such as obesity, impaired fastig glycaemia, ad raised total cholesterol were more prevalet amog wome tha me. The demographic ad behavioural risk factors such as sex of respodet, age group, area of residece, ot egaged i vigorous physical activity, alcohol cosumptio, ot doig vigorous recreatioal activities, ad addig salt to food had sigificat associatio with raised blood pressure. I additio, the demographic ad behavioural factors (age group, area of residece, alcohol cosumptio, addig salt to food, ot egaged i vigorous physical activity, chewig chat) ad biological risk factors (raised BP or curretly o medicatio) were sigificatly associated (p<0.001) with raised blood glucose. I this survey, 95 of the study populatio were foud with 1-2 NCD risk factors ad a forecast of the disease burde prevailig i urba populatio. Modifyig the lifestyle like avoidig cosumptio of alcohol ad khat limitig salt itake are highly recommeded to decrease the risk of developig raised blood pressure ad blood glucose level. I order to promote itervetios for prevetio ad cotrol of NCDs, reduce the risks associated with it, a comprehesive approach is eeded which will ivolve all sectors icludig Miistries of Health, Educatio, Agriculture, Trade, Youth Wome ad Childre Affair, Sport Commissio, Mass Media, amog others. The attetio of other health developmet parters is also required i the fight agaist NCDs i Ethiopia. Stregtheig the capacity of health facilities is also recommeded to offer the service related to NCDs ad esures that the health system adequately moitors compliace with atioal stadards. Furthermore, strategies of surveillace system for risk factors eed to be established to moitor ad measure chages i NCDs burde over time. XVI

17 1. Itroductio 1.1. Backgroud I coutries across the world, regardless of geographic locatio, size of populatio or stages of social ad ecoomic developmet, o-commuicable diseases (NCDs) are resposible for high proportio of death ad disability. The global prevalece of o-commuicable disease is icreasig, with the greatest burde occurrig i developig coutries, ad it is projected to icrease over the ext decades. This icrease reflects a epidemiological trasitio i developig coutries from commuicable disease to NCDs. As the leadig cause of death globally, NCDs particularly cardiovascular diseases (CVDs), diabetes, chroic respiratory diseases ad cacer were resposible for 38 millio (68) of the World's 56 millio deaths i Almost three quarters of all NCD deaths (28 millio), ad the majority of premature deaths (82) occur i low-ad middle-icome coutries. It is estimated that the cumulative ecoomic losses i low-ad middle-icome coutries betwee 2011 ad 2025 will be US$7 trillio. This figure exceeds the aual US$ 11.2 billio cost of implemetig a set of high-impact itervetios to reduce NCD burde(1). No - commuicable diseases have bee a eglected area i may low icome coutries, due to the heavy burde of commuicable diseases, ad other competig priorities. The prevalece of NCDs is actually risig rapidly ad is projected to cause almost three-quarters as may deaths as commuicable, materal, eoatal, ad utritioal diseases by 2020, ad estimated to exceed as the most commo causes of death by 2030(2). The rapidly icreasig burde of these diseases is affectig poor ad disadvataged populatio disproportioately, cotributig to wideig health gaps betwee ad withi coutries. As ocommuicable diseases are largely prevetable, the umber of premature deaths ca be greatly reduced through proper itervetio programs(3). Existig evidece based studies iform us that the NCDs epidemic ca be reduced by prevetig ad cotrollig the four behavioural risk factors for NCDs: tobacco use, isufficiet physical activity, harmful use of alcohol, ad cosumptio of uhealthy diet. Limited epidemiologic studies idicate that o-commuicable diseases are emergig as a major disease burde i Africa. Cosequetly, developig coutries i Africa are challeged with a double burde of disease from pre-existig commuicable diseases ad the emergig NCD epidemic (4, 5). I sub-sahara Africa, the icreasig NCD burde is compouded by lack of a coheret policy o chroic disease prevetio, cotrol, surveillace, ad research. There is scarcity of published studies describig the burde of major ocommuicable diseases i sub Sahara Africa. Likewise, except very few studies i some pocket areas, quatitative iformatio o the burde of chroic diseases or their risk factors i Ethiopia is very limited. Furthermore, the existig health maagemet iformatio system (HMIS) lacks completeess. Although, there were some small-scale pocket area studies i relatio to some of NCDs ad their risk factors coducted i Ethiopia, the results were ot comprehesive ad atioally represetative. Accordig to EDHS 2011, some of behavioural risk factors (tobacco use, alcohol cosumptio, ad khat chewig) were cosidered i the survey. The fidig showed 7 of me use tobacco products; 45 of wome ad 53 of me reported drikig alcohol at some poit i their lives; 11 of wome 28 of me reported that they have ever chewed khat (6). I oe of the admiistrative zoes of Ethiopia, a populatio-based crosssectioal survey (STEPS) was coducted i Gilgel Gibe, oe of the Ethiopia demographic ad surveillace sites i 2009 ad a radom sample of 4,469 idividuals age years were studied. Overall prevalece of NCDs was 8.9. Prevalece of 3.1 for diabetes, 9.3 for hypertesio, 3.0 for 17

18 cardiovascular diseases, 1.5 for asthma ad 2.7 for metal illess were described(7). A atioal situatio aalysis o NCD was carried out i the coutry i 2009 ad the fidigs depicted lack of completeess of routie iformatio at health facilities. Cosequetly, the aalysis was short of revealig the magitude, patter or tred of chroic diseases reliably. Despite the limitatios i the health maagemet iformatio system (HMIS), chroic diseases such as hypertesio ad diabetes mellitus appear o the list of leadig causes of morbidity ad mortality at hospitals ad regioal health bureaus across the coutry(8). I respose to the above challeges, several efforts were exerted by the Ethiopia govermet to tackle the problem of NCDs. FMOH is respodig with measures that lesse the risk factors that are associated with NCDs. I accordace with the 2011 UN declaratio o NCDs, the FMOH has developed ad lauched the Natioal NCD Prevetio ad Cotrol Strategy. Ethiopia is also a sigatory of the Framework Covetio o Tobacco Cotrol (FCTC) ad followig the proclamatio by the Peoples Represetative of the FDRE o tobacco use, FMOH developed a implemetatio/executio guidelie. As part of the effort to fight cacer, 22,818 wome aged had udergoe cervical cacer screeig; out of whom 2,801(12.3) had sigs of the disease ad 1,348 (5.9) were idetified as full-blow cacer. Furthermore, preparatio to itroduce cacer registry was fialized. A pilot populatio based cacer registry started i Addis Ababa City Admiistratio. The Hawassa UiversityHospital started facility based cacer registry. Various tasks were also performed towards itegratig metal health services with PHCU(9, 10) Ratioale To date, there is o represetative NCD risk factor survey udertake i Ethiopia. As the tred of NCD burde is icreasig i the health facilities of the coutry, the eed to coduct comprehesive survey was give priority by FMOH. Data o prevalece of NCD risk factor will iform policy makers to desig evidece-based public health itervetios to prevet ad cotrol the epidemics of NCDs. The WHO STEPS survey tool was used i the preset survey because it is a comprehesive study tool to compare with other similar studies doe across the world. Furthermore, it provides baselie data to establish epidemiological surveillace system for NCDs risk factors i the coutry Objective: To assess risk factors for major o-commuicable diseases (NCDs) ad prevalece of selected NCDs to establish baselie iformatio for policy ad program developmet. Specific objectives: To assess socio-demographic characteristics i relatio to major o-commuicable disease risk factors To estimate the magitude of behavioural ad biological risk factors for major NCDs To determie the magitude of icreased blood pressure ad glucose i Ethiopia To idetify factors associated with selected NCDs (icreased blood pressure ad glucose) i Ethiopia To provide reliable ad valid iformatio for plaig ad evaluatig public health itervetios. 18

19 2. Methods ad materials 2.1. Survey desig: Accordig to the WHOstep-wise approach to the surveillace of NCD risk factors, a commuity-based cross sectioal study was carried out Survey populatio: The target populatio for this survey icluded all me ad wome age years old who have bee livig at their place of residece for at least six moths. This target populatio icluded all people who cosider Ethiopia to be their primary place of residece. This defiitio icluded those idividuals residig i Ethiopia regardless of their citizeship status..people with the followig characteristics were ot icluded: those who were ot a permaet residet of Ethiopia. those who were istitutioalized-icludig people residig i hospitals, prisos, ursig homes, ad other similar istitutios or residets whose primary resideces are military camps or dormitories. Furthermore, critically ill, metally disabled ad those with some type of physical disability that is ot suitable for physical measuremet were excluded from this study. I geeral, the target populatio of the study icluded idividuals years old ad residig i all geographic areas of the coutry Sample size determiatio ad samplig procedure: A sigle populatio-proportio formula was implemeted to determie the sample size. To adjust for the desig effect, a complex samplig desig effect coefficiet of 1.5 was used to compute the sample size. I order to have a adequate level of precisio for each age-sex estimate ad place of residece, the sample was multiplied by the umber of age-sex ad place of residece groups for which the estimates were reported. Thus, Z-score=1.96; proportio =35.2 (11); margial error=0.04; desig effect =1.5; age-sex estimate ad place of residece - sex estimate =10 groups, ad o-respose rate=20. Thus, 10,260 study participats were to be icluded i the study. I this study, a mix of samplig approach amely stratified, three-stage cluster samplig, simple radom samplig ad Kish method were employed to select the study settigs ad the study participats. The samplig frame was based o the populatio ad housig cesus coducted for Ethiopia i 2007 (CSA, 2008). There are 11 regios icludig the two city admiistratios (Addis Ababa ad Dire Dawa). Each regio is divided ito admiistrative zoes. The two city admiistratios are divided ito sub-cities. The admiistrative zoes i the ie regios ad sub-cities i the two city admiistratios are subdivided ito districts or Woreda. The districts Woredas are also further divided ito Kebele. The kebeles are the smallest admiistrative uits with clear geographic jurisdictio i Ethiopia. Withi Kebeles, there are Eumeratio Areas (EAs) which are delieated by the Cetral Statistical Agecy (CSA) of Ethiopia. Therefore, Eumeratio Areas (EAs) were cosidered as the primary samplig uits for this survey. Accordig to the 2007 populatio ad housig cesus, there were a total of 15,837 Kebeles i Ethiopia i.e. 14,364 i rural ad 1,473 i urba kebeles(12). Takig ito accout the cost of the study ad the level of precisio, 20 households per EA ad oe eligible idividual from each household with a total of 513 EAs were covered atiowide. Stratifyig the samplig desig by place of residece we allocated about 404 EAs for rural ad the remaiig 109 to urba areas (Table 2). 19

20 Table 2. 1 Total sample size allocatio by regio, Ethiopia NCD STEPS, Regios Total EAs Total Sampled EAs Total Sampled House Holds Total Rural Urba Rural Urba Rural Urba Tigray 4,098 1,484 5, Afar Amhara 17,827 3,300 21, , ,640 Oromia 25,264 4,909 30, , ,780 Somali 1, , Beishagul G SNNPR 14,299 2,058 16, , ,040 Gambella Harari Dire dawa Addis Ababa 3,747 3, Total 65,302 16,735 82, ,080 2,180 10,260 As show i the table 2.1 above, the Primary Samplig Uits (PSUs) were the EAs both i rural ad urba settigs. At the first stage, 513 PSUs (404 rural ad 109 urba) were selected with probability proportioate to size. This is followed by a radom selectio of secodary samplig uits (SSUs) per selected PSU i the secod stage. The Secodary Samplig Uits (SSUs) were the households. The total umber of EA i 2007 was 82,037. The Eumeratio areas essetially comprise o average 100 households both i urba ad rural settigs. Twety households were selected from each EA usig systematic samplig. Thus, a total of 10,260 households were selected from the 513 EAs (20 households per EA). The samplig iterval was determied by dividig the total umber of households i the selected EA by 20. Prior to samplig, supervisors ad data collectors visited the selected EAs ad coducted a fresh listig of all households i that EA i cosultatio with local health workers ad ay other active member who have a good uderstadig of the local cotext. I the third stage, eligible idividuals were selected from household usig Kish method. Oly oe eligible participat (a adult age years) i the selected household was erolled i the survey. Usig the Kish method, eligible participats i each household were raked i order of decreasig age, startig with me followed by wome Survey istrumet: The survey was coducted usig the WHO NCD STEPS istrumet versio 3.1. The questioaire cosisted of three STEPS for measurig the NCD risk factors. STEP I icluded questioaires, STEP II icluded physical measuremets ad STEP III icluded biochemical measuremets. Each step cosisted of a umber of core, expaded ad optioal questios. The questioaire was modified with expaded ad optioal questios to suit local eeds. Additioal optioal questios were added to the istrumet because they were deemed locally relevat, Khat chewig, for istace. All the modificatios were doe i accordace with the STEPS maual (WHO steps, 2005). The complete stepwise survey of ocommuicable diseases risk factors is a three-stage process. It starts with gatherig key iformatio o risk factors with a questioaire, the moves to physical measuremets ad the to collectio of blood samples for biochemical aalysis. Biochemical measures iclude fastig total cholesterol, blood glucose; triglycerides ad high-desity lipoproteis were measured usig cardio-check aalyser. 20

21 Step 1: This step comprised of data collectio usig a questioaire. Its purpose was to gather demographic ad behavioural characteristics of the populatio from a represetative sample. Step 2: Physical measuremet. The purpose was to build o the core data i step 1 ad to determie proportio of the study populatio with raised blood pressure, overweight ad obesity. Step 3: Biochemical measuremet: The purpose was to build o the core data i step 1 ad step 2 ad measure proportio of the study populatio with diabetes, raised blood glucose ad abormal lipid level. Table 2. 2 Compoets of steps survey variables used, Ethiopia NCD STEPS, 2015 Steps Core Expaded Optioal Step 1: Behavioural Step 2: Physical measuremet Step 3: Biochemical measuremet Basic demographic iformatio, icludig age, sex, literacy, ad highest level of educatio. Tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity Weight ad height, waist circumferece, blood pressure Fastig blood sugar, total cholesterol, Expaded demographic iformatio icludig years at school, ethicity, marital status, employmet status, household icome Smokeless tobacco use, Past 7 days drikig, Oil ad fat cosumptio, History of blood pressure, treatmet for raised blood pressure, history of raised blood pressure ad diabetes, CVD/cholestrol ad their treatmet Hip circumferece Heart rate HDL-cholesterol ad fastig triglycerides Adopted from the WHO Stepwise survey maual ad WHO recommeded table attached i aex for referece. 21 Tobacco. policy Ijury ad violece Khat cosumptio Urie examiatio (protei ad creatiie ratio) to examie kidey status. Validated questioaires comprisig core ad expaded items as well as optioal modules o violece ad ijury, ad khat use were traslated ito local laguages, amely Amharic, Tigriga ad Oromifa. The questioaire is the traslated back ito Eglish, reviewed by the STEPS TWG member, ad used for the data collectio. Traiig ad pre-test Qualified field data collectors (urses ad laboratory techicias) ad field data supervisors (health officers, medical doctors or urses with Master s Degree ad above) were recruited. Oe week traiig o the STEPS survey was orgaized by the Ethiopia Public Health Istitute (EPHI) i collaboratio with the Miistry of Health ad the WHO Coutry Office i Ethiopia from 2 d 9 th April A total of 75 data collectors ad 27 supervisors atteded the traiig. The traiig of data collectors was coducted by the survey s techical workig group, which had previously bee give geeral traiig (without differetiatio) durig a four-day atioal orietatio semiar, orgaized by EPHI i collaboratio with WHO, from 30 March to 1 st April The focus area of the traiig was o the survey questioaire, physical measuremet, ad blood collectio ad testig, usig persoal digital assistats (PDAs) for data collectio ad data trasfer via iteret file streamig system (IFSS) to cetral server located at EPHI. The traiig also comprised iteractive sessios to itroduce data collectio methods for STEPS 1, 2 ad 3 of the survey. The questioaires were pretested to detect ay possible problems i the flow of the questioaires, gauge the legth of time required for iterviews, as well as ay problems i the traslatios ad problems with PDA. The pre-test for the survey took place from April 7-9, 2015, Adama, Ethiopia. Durig pre-test data collectio, EAs withi Oromia regio which were

22 ot sampled i the mai survey were surveyed for three days to test ad refie the survey istrumets ad the PDA programmes. The pre-test started with the selectio of oe idividual withi the household, accordig to the Kish samplig methodology, ad dissemiatio of iformatio about the survey. Each team admiistered the questioaire, performed physical measuremets, ad laboratory testig. The pretest was aimed at validatig the field data collectors skills i usig the survey questioaire, performig physical measuremets, laboratory testig, usig PDAs ad data trasfer system. After the pre-test, the questioaires ad PDA programmes were fialised for the mai data collectio. EPHI research team lead the traiig ad some of TWG members provided techical support durig the traiig i the area of their expertise Data collectio procedure: The survey data were collected betwee 14 April ad Jue 26, Thirty-five teams were formed to coduct the data collectio. Each team comprised of three people a supervisor ad two data collectors (i.e. oe urse ad oe laboratory techologist), ad each team was provided with a field car. Local field guides (either health extesio worker or a commuity voluteer) were used to reach the selected households. O the day of data collectio, the selected households were visited ad the data collectors gave geeral iformatio verbally o the objectives of the survey. This was followed by selectio of oe study subject from all eligible adults years old i each household usig Kish method Further iformatio was give to the selected participat ad two cosets were requested (oe for STEPS 1 ad 2); after fiishig the data collectio for the first two steps, coset was requested for STEP 3. The collectio of capillary ad veous blood was carried out the day after STEP 1 ad STEP 2 data collectio. Blood was take from the survey participat who fasted at least for 8 hours. The blood collectio was coducted at the earby primary health care facility. STEP 1: Questioaire survey The questioaire was used to collect data o respodet s demographic ad socioecoomic status; tobacco use; alcohol cosumptio; diet, icludig fruit ad vegetable cosumptio, oil ad fat cosumptio, meal cosumptio outside the home, ad dietary salt itake; physical activity; Khat use, violece ad ijury, history of raised blood pressure, diabetes, raised cholesterol ad/or CVDs, lifestyle advice, ad screeig for cervical cacer. Assessig tobacco use Tobacco use was assessed i terms of curret ad previous smokig status, duratio of smokig, quatity of tobacco use, smokeless tobacco use, ad exposure to secod-had smokig. Data collectors used show cards depictig types of commoly used tobacco products. Assessig alcohol cosumptio Alcohol cosumptio was measured usig the cocept of a stadard drik. A stadard drik is ay drik cotaiig about 10g of alcohol. Data collectors used show cards depictig most commoly cosumed alcoholic beverages as stadard driks. Respodets who reported usig alcohol withi the past moth were classified as curret drikers. Three risk categories were used to classify respodets who cosumed alcohol accordig to the average amout of alcohol cosumed per day. Assessig diet 22

23 I order to assess the diet patter of the surveyed populatio, the respodets were asked about frequecy of fruit ad vegetable cosumptio, mea umber of portios of these foods cosumed daily, type of oils ad fat used for meal preparatio, umber of meals eate outside the household per week ad the amout of salt cosumed daily. Cosumptio of fruit ad vegetables was assessed i terms of the umber of servigs, with a servig beig equal to 80g. Show cards were used to collect data o fruit ad vegetable cosumptio o a typical day. Oil ad fat itake was assessed by askig about the type of oil or fat most frequetly used for cookig. Salt cosumptio was assessed by askig about frequecy of additio of salt or a salty sauce to food durig preparatio, or before or while eatig; ad/or frequecy of cosumptio of processed food high i salt. Participats were also asked about their perceptio of the quatity of salt they cosumed ad its lik with health problems, as well as about the importace of reducig salt itake, ad the measures udertake to cotrol it. Assessig physical activity Physical activity was assessed based o itesity, duratio ad frequecy of physical activity at work, i recreatioal settigs ad ivolvig trasportatio (joureys), usig a set of 16 questios. Data were collected o the umber of days, hours ad miutes of physical activity performed at work, ivolvig trasportatio ad i recreatioal settigs for at least 10 miutes or more cotiuously each day. The complex questioaire has the advatage of assessig ot oly the duratio, but also the itesity of physical activity. Show cards were used to depict differet types of physical activity. The total time spet o physical activity per day at work, ivolvig trasport ad i recreatioal activities was measured by usig a cotiuous idicator: the metabolic equivalet (MET) time i miutes per week spet i physical activity. The populatio was classified ito specific groups accordig to their amout of physical activity. METs are commoly used to express the itesity of physical activities, ad are used for the aalysis of Geeral Physical Activity Questioaire (GPAQ) data. MET is the ratio of a perso s workig metabolic rate relative to their restig metabolic rate. Oe MET is defied as the eergy cost of sittig quietly, ad is equivalet to a caloric cosumptio of 1 kcal/kg/hour. For the aalysis of GPAQ data, existig guidelies have bee adapted. It was estimated that, compared with sittig quietly, a perso s caloric cosumptio is four times as high as whe beig moderately active, ad eight times as high as whe beig vigorously active. I order to calculate the categorical idicator for the recommeded amout of physical activity for (good) health, the total time spet carryig out physical activity durig a typical week ad the itesity of the physical activity were take ito accout. Accordig to WHO global recommedatios o physical activity for health, throughout a ormal week adults should do at least the followig amout of exercise (icludig activity for work, as well as durig trasport ad leisure time): 150 miutes of moderate-itesity physical activity; or 75 miutes of vigorous-itesity physical activity; or A equivalet combiatio of moderate- ad vigorous-itesity physical activity achievig at least 600 MET-miutes. For compariso purposes, tables presetig cut-offs from WHO recommedatios(13) were also used durig the data aalysis. The three levels of physical activity suggested i these recommedatios for classifyig populatios are: (1) low, (2) moderate, ad (3) high. 23

24 High-level physical activity ivolves a perso reachig ay of the followig criteria: vigorous-itesity activity at least three days per week, achievig at least 1500 MET-miutes per week; or seve or more days of ay combiatio of walkig, moderate- or vigorous-itesity activities achievig a at least 3000 MET-miutes per week. Moderate level physical activity ivolves a perso ot meetig the criteria for the high-level category, but meetig ay of the followig criteria: Three or more days of vigorous-itesity activity of at least 20 miutes per day; orfive or more days of moderate-itesity activity or walkig for at least 30 miutes per day; or Five or more days of ay combiatio of walkig, moderate- or vigorous-itesity activities achievig at least 600 MET-miutes per week. Low level physical activity ivolves a perso ot meetig ay of the above-metioed criteria for the moderate- or high-level categories. History of NCDs ad their risk factors History of diabetes, CVDs, raised blood pressure ad raised cholesterol were assessed by askig whether specific measuremets for these purposes previously performed by a doctor or health worker. Study participats were also asked about ay medicatio take. Lifestyle advice The participats were asked about ay advice give by a doctor or a health worker durig the past three years relatig to reducig commo risk factors for NCDs. Assessig cervical cacer screeig status Cervical cacer screeig status was assessed by askig about whether participats had udergoe visual ispectio with acetic acid (VIA) testig, a Pap smear ad/or huma papilloma virus (HPV) test. STEP 2: Physical measuremets Blood pressure ad heart rate were measured for all survey participats whereas body weight, height, waist circumferece, ad hip circumferece were measured for all survey participats other tha pregat wome. Body weight ad height was measured with the electroic Growth Maagemet Scale. This is a device suitable for measurig a combiatio of factors (body scale with height gauge) with laser. It measures body weight ad height, ad calculates body mass idex (BMI). BMI is a ratio of body weight i kilograms to the square of body height i metres ad was calculated accordig to the formula. BMI calculatio formula BMI = Body weight (kg): Body height/(m 2 ). A BMI 25 idicates that a perso is overweight, while a BMI 30 idicates that a perso is obese. Waist ad hip circumfereces were measured by a o-stretch tape - meter with millimetre precisio. Waist circumferece was measured by placig a tape measure aroud the bare abdome at the midpoit betwee the lower margi of the last palpable rib ad the top of iliac crest of the hip boe. Hip circumferece was measured by placig a tape measuremet aroud the hip at the maximum circumferece over the buttocks or aroud the greater trochater of the femoral boe. The waist hip ratio (WHR) was computed usig measuremets of waist ad hip circumfereces amog all 24

25 respodets, excludig pregat wome. The WHO referece cut-off for WHRs was used to defie obesity at above 0.90 for me ad above 0.86 for wome. Blood pressure ad heart rate measuremets were take three times o the right arm of the survey participats i a sittig positio, usig a Boso-Medicus Uo istrumet with a uiversal cuff ad automatic blood pressure ad heart rate moitor. The mea of three measuremets was take for aalysis. The measuremets were take after the participat had rested for 15 miutes, ad each with three miutes of rest betwee the measuremets (maximum deviatio of cuff pressure measuremet ± 3 mmhg, ad of pulse rate display ± 5). Percetage of raised blood pressure was defied as: Systolic blood pressure (SBP) 140 mmhg ad/or diastolic blood pressure (DBP) 90 mmhg, or curretly takig medicatio for raised blood pressure or hypertesio. The percetage of respodets with treated ad/or cotrolled raised blood pressure amog those with raised blood pressure (SBP 140 ad or DBP 90 mmhg) or curretly takig medicatio for raised blood pressure was categorized as follows: Percet takig medicatio ad SBP <140 mmhg ad DBP <90 mmhg Percet takig medicatio ad SBP 140 mmhg ad/or DBP 90 mmhg Percet ot takig medicatio ad SBP 140 mmhg ad/or DBP 90 mmhg. STEP 3: Laboratory aalysis Laboratory tests were performed for blood glucose, total cholesterol ad HDL cholesterol usig CardioCheck PA Aalyser ad for Triglycerides levels usig Cobas Itegra 400 Plus (Roche Diagostics GmbH, Maheim, Germay) cliical chemistry aalyser. Cocetratios of glucose, total cholesterol ad HDL cholesterol were measured i capillary blood the ext day after STEPS 1 ad 2 of the data collectio. Capillary blood tests were performed for all survey respodets usig a CardioChek PA Aalyser, after fastig. Laboratory test results were assessed ad categorized accordig to the defiitio Data quality assurace Stadard data quality cotrol procedures were implemeted for each critical stage of the study. Quality assurace started at the very begiig durig the desig of the data collectio istrumet ad traslatio to local laguage, traiig field staff ad pre-testig, the physical hadlig of survey istrumets ad data, to the fial data etry ad aalysis. The relevat items of field istrumets were traslated ito local laguages (Amharic, Oromifa ad Tigriga), the traslated back to Eglish to assure cosistecy ad accuracy, ad the pre-tested. The desiged questioaire was tested at the field level with similar cliets at a locatio that has ot bee selected for the actual survey, to esure that there are o errors i the questioaire desig ad that the data collectors ca easily gather the data with the respodets easily uderstadig ad respodig to the questios. Based o the results of the pre-test ad the back traslatio, the questioaires was further reviewed ad fialized. NCD TWG members ad other stakeholders were ivited to atted traiig to provide commets ad alterative perspectives o implemetatio of the research istrumets, cotribute their uique experieces to the study, offer ay particular cosideratios that must be take ito accout, ad iput ay other cotextual experieces ad kowledge that may be useful for the assigmet. To esure that all the field staff are aware of their duties, detailed to-do lists 25

26 were prepared with day to day schedules. Checklist was also prepared for field staff to check their performace agaist the time allocated. Itesive moitorig ad follow-up durig each phase of data collectio was udertake by cetral staff. Durig this time, experieced core research team members techically assisted the field staff ad closely followed the study progress. Furthermore, the moitorig team comprised represetatives from FMOH, EPHA, ad WHO delegatio from WHO HQ ad coutry office were ivolved with the task of moitorig the survey data collectio. The teams carried out moitorig i the field ad provided techical ad logistical support to data collectio teams throughout the data collectio process. Durig field assistace, members of the core research team radomly select 5 of completed households ad recheck them with the resposes of the cliet i the survey ad Kish data, check ID variables ad check that questios are beig properly uderstood ad completed. Correctios ad clarificatios were carefully discussed ad explaied to field staff. The quality of data was further ascertaied durig the data maagemet process. The data maagemet team strictly moitored the field team durig the etire data collectio period. Rages ad ecessary rules for variables were set durig template preparatio, so that ulikely values were rejected. Re-evaluatio ad judgmets o the rejected resposes were made ad appropriate actios were take by the data maagemet team. For Biochemical data all data etry clerks checked their etered data specific to the idetified variables by checkig agaist the form. I additio, the data etry system was programmed i such a way that outlier etries were ot accepted. Fially, all etered data were further visually checked for outliers Data maagemet process The survey data were collected etirely usig PDAs. esteps software was used to desig ad program the data collectio tools i the PDAs. The use of the software ad PDAs to collect the data helped to geerate the fial dataset quickly followig the completio of data collectio. The collected datasets were stored i the device as well as the memory card i rml format. The rml files from the PDAs were trasferred to the supervisors tablet computers via the Widows Mobile Device Cetre. The files were the trasferred to a cetral server located at EPHI via Iteret file streamig system (IFSS) software. IFSS is a applicatio that coects to ad exchages data with the server compoet. Supervisors maaged tablets supported by iteret (EVIDEO) ad ru the IFSS ico (IfssClietPC.exe) located i their desktop to sed all the updated data files to cetral server by eterig their user ame ad password. Fially IFSS automatically perform Automatic packagig ad deliverig file ad Automatic receivig of icomig files. At cetral level, data maagemet activity was performed by creatig two groups of folders o the cetral server ad stored data from 35 teams (group oe 1-17 teams ad group two teams), ad exported data to usable format. The cetral data maagemet team checked the data moitorig sheet to moitor team progress, produced progress report every week o the performace of teams, provided feedback to data collectors, supervisors, ad regioal coordiators. The data were coverted ito Microsoft Excel format. Each survey respodet had a uique idetifier comprised cluster, household umber withi cluster ad idividual ID umber. Next, the survey data were compiled ito a sigle file, ad the accuracy of recordig respodets age ad sex, amog other variables, was established withi a week usig rage ad logic checkig fuctios. Fially, data checkig was also carried out usig the aalysis code provided by WHO HQ, which icludes a code to check the data prior to every aalysis performed. 26

27 2.8. Weightig of data Because the data comprised a sample of the target populatio, it was ecessary to weight the data. Thus, sample weightig ad adjustmets were carried out to correct differeces i the age, sex ad area of residece distributio of the sample versus (vs) the target populatio ad probabilities of selectio. The sample weight for each case i the survey sample accouts for the umber of cases it represets i the samplig frame, based o the sample selectio procedure. The product of the sample weight ad the populatio adjustmet weight ad o-respose weight was used i all weighted aalysis Data aalysis Statistical aalysis of the survey data was performed by data maagemet team of the Ethiopia Public Health Istitute i cosultatio with teams from WHO HQ. Data aalysis was performed usig Epi Ifo versio 3.5.4, usig appropriate methods for the complex sample desig of the survey. The prevalece ad measures of cetral tedecy of NCD risk factors were estimated. Outcome measures (prevalece ad mea variace) ad differeces betwee groups (age, sex ad urba/ rural groups) were calculated with a. Samplig error, which could potetially affect the accuracy of the results of the curret survey, was measured by the stadard error of variables. Margis of error i prevalece ad i measures of cetral tedecy are represeted by umeric values for the lower ad upper limits of a. Results of the survey o the prevalece of NCD risk factors, ad the measures of cetral tedecy ca be cosidered represetative for the target populatio, sice they were adjusted usig populatio, o -respose ad sample weights. Further statistical aalyses were doe by usig chi- squared tests ad logistic regressio models. Chi- squared tests were used whe comparig groups. All factors with a p-value <0.05 i the bivariate aalysis were further etered ito the multivariate model to cotrol for cofoudig effects. Odds ratios (OR) with 95 cofidece itervals (CI) were calculated. Statistical sigificace was accepted at the 5 level (p<0.05) Ethical clearace The project is iteded to collect commuity based primary data across the coutry. Priciples of Ethics were cosidered. Data were collected uliked aoymously, without ay persoal idetifiers. For the purpose of data collectio, iformed coset was obtaied from the study participats before admiisterig the questios/collectig blood sample ad objectives of the study was explaied to the participats by the data collectors. For uder eightee childre (age <18 years) survey participats asset ad coset from their parets or guardias was obtaied. Ethical clearace was obtaied first from the EPHI Istitutioal review board (IRB) the from Natioal research ad Ethics review committee. Furthermore, official letter was produced ad delivered to the respective regioal health bureaus by EPHI durig fieldwork. Physical measuremet was doe by performig measuremets at a separate room ad a area that has bee screeed off from other people withi the household. Idividuals with abormal physical ad biochemical results were referred to the ear-by health facilities for further ivestigatio, diagosis ad follow up. Blood sample was draw by traied health professioal uder stadard cliical procedure. Study participats were idirectly beefited from this study through early idetificatio of risk factors for NCDs for which they were advised ad referred for further cliical follow up. 27

28 3. Demographic iformatio results This sectio briefly describes socio demographic characteristics of survey respodets such as age, sex, educatio, ethicity, occupatio, household icome ad marital status. Out of the 10,260 plaed samples, 10, 029 idividuals were cotacted ad 9801 give coset for step oe makig overall respose rate of Table 3. Prportio of respodets by age group ad sex, Ethiopia NCD STEPS, 2015 Sex Me Wome Both Sex Total The backgroud iformatio of the respodets were used i subsequet sectios for comparig fidigs across differet populatio subgroups. Of the total 9,800 respodets of STEPS survey, more tha half of the respodets which is 5823(59.4 ) were wome. This is cosistet across all age groups though the highest proportio of wome 2518 (63.6 ) beloged to the youger age group (15-29) compared with me respodets 1441 (36.4 ). (Table 3. 1). Table 3. 2 Summary iformatio by age group ad sex of the respodets Ethiopia NCD STEPS, 2015 Me Wome Both Sexes Total With regards to mea umber of years spet i school, all study participats spet a average of 3.8 years with male respodets attaiig 4.5 mea umber of years which is slightly higher tha the female couterparts (3.2). For both sexes, the mea umber of years of educatio cosistetly decrease with age where youger age group were more educated tha the older. The mea umber of years of educatio for the yougest (15-29) ad oldest age group was 5.40 ad 1.28, respectively. Geerally, me respodets were more likely to be educated tha wome respodets across all age groups (tables3.2 ad 3.3). Table 3. 3 Mea umber of years of educatio amog respodets, Ethiopia NCD STEPS, 2015 Me Wome Both Sexes Mea Mea Mea Total

29 Of the total survey respodets, 49.4 had o formal educatio while 28.8 atteded formal educatio with less tha primary level. The percetages of respodets who completed primary, secodary ad college or uiversity completed was 9, 7.0, ad 5.1, respectively. Amog all the respodets, 38.8 of me ad 56.6 of wome had o formal educatio. Amog me respodets, 36.2 atteded less tha primary educatio while the remaiig 10.9, 7.0, ad 6.8 of survey respodets completed primary, secodary ad college/uiversity completed, respectively. Similarly amog wome respodets, 23.7, 9.3, 6.4, ad 3.9 completed less tha primary, primary, secodary ad college/uiversity educatio respectively. Geerally, very small umber (0.1 ) of all respodets completed college or uiversity level educatio. Of which 0.2 were me ad 0.1 were wome. Regardig educatio level by age, the youger group was more likely educated compared with respodets i the older age group. For istace, of all respodets who completed primary educatio 16.3, 6.9, 3.9, ad 3.1 belog to 15-29, 30-44, 45-59, ad age groups, respectively. This is cosistet for all survey respodets across both sexes ad all educatioal levels (Table 3.3). Table 3. 4 Highest level of educatio achieved amog Me survey respodets, Ethiopia NCD STEPS, 2015 Age Group No formal schoolig Less tha primary school Me Primary school completed Secodary school completed College/ Uiversity completed Post graduate degree completed Total Table 3. 5 Highest level of educatio achieved amog wome survey respodets, Ethiopia NCD STEPs Survey, 2015 Age Group No formal schooli g Less tha primary school Wome Primary school completed Secoda ry school completed College/ Uiversity completed Post graduate degree completed Total Table 3. 6 Highest level of educatio achieved by survey respodets, Ethiopia NCD STEPS,

30 Age Group No formal schooli g Less tha primary school Both Sexes Primary school completed Secoda ry school completed College/ Uiversity completed Post graduate degree completed Total Ethiopia is a atio of diverse ethic groups with uique cultural ad socio ecoomic backgroud relevat to exposure to major NCD risk factors. Of all survey respodets, 28.3 were Oromo, 27.2 were Amhara, 10.8 were Tigre, 6.1 were Somali, 3.5 were Sidama, 3.4 were Afar, 3.2 were Guragie, 2.3 were Wolayta, Hadiya ad Gamo were 1.6 each while the remaiig 12 were from other ethic groups. Table 3. 7 Summary results for the ethicity of the respodets, Ethiopia NCD STEPS, 2015 Age Both Sexes Group (years Orom Amhar Tigr Somali Sidama Afar Guragie Wol Hadi Gamo Other ) o a ay ayta ya ethic group Total Majority of the respodets (67.3 ) were curretly married followed by sigle (17.4 ) ad widowed (6.8 ). Nearly similar proportios (3.9 ad 4.1 ) of respodets were separated ad divorced, respectively. Overall, less tha oe i hudred (0.4 ) respodets were cohabiters. The proportio of curretly married respodets was higher amog me (72.5 ) tha wome (63.8 ). Likewise, the proportio of me who had ever bee married was higher (21.9 ) compared with wome couterparts (14.3 ). O the other had, the umber of wome respodets who were separated, divorced, ad widowed was early two times, four times, ad five times higher tha their me couterparts, respectively(table 3.7, 3.8).. I terms of age, age group has the largest umber 3956 (37.9 ) of ever married idividuals while the largest umber (79.3 ) of curretly married idividuals belog to age group. Wome respodets are more likely to get married (64.1 ) at youger age (15-29) compared with me (48.3 ). Geerally, beig sigle decreases with advacig age while marriage is a predomiat status amog respodets as age icreases (table 3.7, 3.8 ad 3.9). 30

31 Age Group Table 3. 8 Marital status of me survey respodets, Ethiopia NCD STEPS, 2015 N Never married Curretly married Me Separated Divorced Widowed Cohabitig Total Age Group Table 3. 9 Marital status of wome survey respodets, Ethiopia NCD STEPS, 2015 N Never married Curretly married Wome Separated Divorced Widowed Cohabitig Total Age Group Table Marital status of all survey respodets, Ethiopia NCD STEPS, 2015 N Never married Curretly married Both Sexes Separated Divorced Widowed Cohabitig Total Of all survey respodets, early oe i te (9.9) were employed (13.1 me ad 7.8 wome). Amog employed respodets, 5.9 were govermet employed whereas the remaiig 1.0 ad 3 were ogovermetal orgaizatio ad self-employed, respectively. Survey participats of youger age groups were more likely to be employed by govermet istitutios compared to the older age group. This is cosistet across all age groups ad both sexes. More tha 90 (92.3) of wome ad 86.9 of me respodets were egaged i upaid work or uemployed(table 3.10). 31

32 Table Proportio of me respodets i paid employmet ad upaid by age group, Ethiopia NCD STEPS 2015 Employmet status Me Nogovermet Govermet Selfemployed N employee employee Upaid Total Table Proportio of wome respodets i paid employmet ad upaid by age group, Ethiopia NCD STEPS, 2015 Wome Nogovermet Govermet Selfemployed N employee employee Upaid Total Table Proportio of respodets i paid employmet ad upaid by age group, Ethiopia NCD STEPS, 2015 Both Sexes Nogovermet Govermet Selfemployed N employee employee Upaid Total Amog upaid or uemployed respodets, farmers represet the highest proportio (48.1) with 74.0 me ad 31.7 wome. Substatial proportio of those upaid respodets were home makers (27.5) where wome costitute the vast majority (44.7) of home makers compared with me couterparts (0.6). More tha 3 of upaid survey respodets were uemployed of which 2.8 were able to work ad 0.7 uable to work. Amog upaid ad uemployed populatio about oe i te idividuals were studets (11.7 me ad 8.3 wome). 32

33 Table Proportio of me respodets i upaid work by age group, Ethiopia NCD STEPS, 2015 Age Group Private skilled worker Farmer Me Trader Studet Homemaker Retired Uemployed Able to work Total Age Group Not able to work Table Proportio of wome respodets i upaid work by age group, Ethiopia NCD STEPS, 2015 Private skilled worker Farmer Wome Trader Studet Homemaker Retired Uemployed Able to work Total Table Proportio of respodets i upaid work by age group, Ethiopia NCD STEPS, 2015 Age Group Private skilled worker Farmer Both Sexes Trader Studet Homemaker Retired Not able to work Uemployed Able to work Not able to work Total All idividual older tha 18 years i the household were asked about their earigs. Of those who were able to estimate their earig, the mea reported per capita aual icome of respodets was Birr. For idividuals who were ot able to estimate the exact aual icome, quitiles of estimated household earigs was set ad respodets were asked which quitile best fits their icome category. Accordigly, majority (71.1) of survey respodets fall uder first quitile with aual earig of less tha 12,000 Birr. About 17.4 of survey respodets were i the secod quitile with aual earigs of more tha 12,000 ad less tha or equal to 18,000 Birr. Table Mea reported per capita aual icome of respodets i local currecy (Eth Birr), Ethiopia NCD STEPS, 2015 Mea aual per capita icome Mea

34 Estimated household earigs < 12,000 Birr More tha 12,000 18,000 Birr 5.30 More tha 18,000 23,30Bbirr More tha 23,300 30,000Birr More tha 30,000Birr Quitile 1: Quitile 2: Quitile 3: Quitile 4: Quitile 5: Figure 3. 1 Household earigs by quitile for those who did t kow their exact per capital aual icome, Ethiopia NCD STEPS, Tobacco use ad policy 4.1. Tobacco use To assess tobacco use, the survey respodets were iterviewed about their curret smokig status, previous smokig experiece, the age they started smokig, duratio of smokig, the quatity of tobacco smoked daily, use of smokeless tobacco, types of tobacco products used, ad duratio of exposure to secod-had smoke. 5. Over all, about 4 (4.2, : ) of the survey participats were curret smokers (daily, ad o-daily smokers) of all tobacco products. There were more me smokers 7.3 (: ) tha wome 0.4 (: ). There was also a otable icrease i the proportio of smokers i age groups, observed i both me ad wome respodets. There was oly slight differece betwee the percetage of curret smokers i urba ad rural areas, aside from a slightly higher prevalece of smokig amog the rural populatio (4.3, : versus 3.9, : ). Urba residet wome had higher magitude of smokig 0.9, ( : ) tha their rural couterparts 0.3 (: ) ) (Table ). Table Percetage of curret smokers amog all respodets by age, sex, ad area of residece, Ethiopia NCD STEPS,

35 Me Wome Both Sexes Age Group Curret Curret Curret smoker 1 smoker smoker Place of Residece Rural Urba Total Curretly smokig ay tobacco products, such as cigarettes, cigars, or pipes Amog all survey participats, 3.5 (: ) smoke tobacco daily, ad 0.7 (: ) of them were odaily smokers: while 1.8 (: ) were former tobacco smokers, ad 94 (: ) of them ever smoked ay tobacco product before. Me were more likely to use or smoke tobacco daily 6.2 (: ) tha wome 0.2 (: ); ad rural residets were more likely to smoke tobacco daily 3.7 (: ) tha urba residets 2.7 (: ) (Figure ad Figure ) DAILY SMOKER NON-DAILY SMOKER FORMER SMOKER NEVER SMOKER CURRENT SMOKER NON-SMOKER Me Wome Both sex Figure Percetage of smokig status amog all respodets, by sex category, Ethiopia NCD STEPS

36 SMOKING STATUS Rural AMONG Urba ALL Total RESPONDENTS BY AREA OF RESIDENCE Total, Curret smoker Daily smoker, 3.5 Total, Curret smoker No-daily smoker, 0.7 Total, No-smoker Former smoker, 1.8 Total, No-smoker Never smoker, 94 Urba, Curret smoker Daily smoker, 2.7 Urba, Curret smoker No-daily smoker, 1.2 Urba, No-smoker Former smoker, 2.4 Urba, No-smoker Never smoker, 93.7 Rural, Curret smoker Daily smoker, 3.7 Rural, Curret smoker No-daily smoker, 0.6 Rural, No-smoker Former smoker, 1.6 Rural, No-smoker Never smoker, Figure Smokig status amog all respodets by area of residece, Ethiopia NCD STEPS, Amog all curret smokers of both sexes, 82.8 (: ) of them used or smoked tobacco daily. The proportio of daily smokers amog me was 84.2 (: ), which was higher tha that of wome 54.6 (: ), but the age group with the highest prevalece of daily smokers 93.5 (: ) was wome of age years. The percetage of daily smokers for both sexes was higher i rural 85.7 (: ) tha urba residets 69.4 (: ) (Table ). Table Percetage of Curret daily smokers amog smokers by age, sex, ad area of residece, Ethiopia NCD STEPS, Age Group Me Wome Both Sexes Daily smokers Daily smokers 36 Daily smokers Place of Residece Rural Urba Total The survey revealed that, over all, mea age of smokig started amog smokers was 21.0 years (: ). Me were more likely to start smokig earlier tha wome (20.9 years i me versus 22.8 years i wome). There was a differece betwee age groups i terms of the mea age of startig smokig: i

37 me it varied from 17.9 years old i the age group years to 24.4 years old i the age group years. The differece amog wome was much higher, from 19.1(: ) to 40.6 (: ) years i age group ad respectively. Urba residets started smokig at early age 19.3 years (: ) tha rural residets 21.3 years (: ). (Table ). Table Mea age started smokig amog smokers by age group, sex, ad areas of residece, Ethiopia NCD STEPS, Age Group Me Wome Both Sexes Mea age Mea age Mea age Place of Residece Rural Urba Total Mea years of duratio of smokig amog curret smokers for both sexes was 14.4 years (: ) for me, ad 9.9 years for wome. It varies across age groups from 38.9(: ) to 5.9 (: ) years i 60-69, ad age groups respectively. The was a slight differece i mea years of smockig by place of residece with 14.6 years (: ) i rural ad 13.1years (95 CI: ) i urba (Table ). 16.5). Me were more likely to smoke for loger period tha wome, with 14.5 years were (: Table Mea duratio of smokig amog curret smokers by age, sex, ad areas of residece, Ethiopia NCD STEP, Age Me Wome Both Sexes Group Mea Mea Mea duratio duratio duratio Place of Residece Rural Urba Total The vast majority of curret smokers 89.4 (: ) smoked maufactured cigarettes i both sexes. Me were more likely to smoke maufactured cigarettes tha wome with a prevalece of 91.5 (: ); ad 14.1 (: ) urba residets were more likely to smoke maufactured cigarettes tha rural residets 9.8 (: ). While age group of both sexes 37

38 were less likely to smoke maufactured cigarettes tha other age groups. (Table ). Table Percetage of maufactured cigarette smokers amog curret smokers by age, sex, ad area of residece, Ethiopia NCD STEPS, Age Group Maufactured cigarette smoker Me Wome Both Sexes Maufactured cigarette smoker Maufactured cigarette smoker Place of Residece Rural Urba Total Mea umber of maufactured cigarettes smoked was higher i me 7.3 (: ) tha wome 2.4 (: ); While mea umber of gaya used was higher i wome tha me with 2.8 (95 CI: ), ad 0.9 (: ) respectively. (Figure ) Me Wome Both sexes Mea # of maufactured cig. Mea # of hadrolled cig. Mea # of pipes of tobacco Mea # of cigars, gaya Mea # of shisha sessios Mea # of other type of tobacco Figure Mea amout of tobacco used by daily smokers by type ad sex category, Ethiopia NCD STEPS, Overall, amog curret smoker of both sexes, about ie out of te smoked maufactured cigarettes. Me were more likely to smoke maufactured cigarettes tha wome with 90.9 were (: ) ad 48.4 (: ), respectively; while wome were more likely to use shisha tha me with 38.4 (: ), ad 5.9 (: ) (Figure ). Figure shows, amog both 38

39 sexes urba residets were more likely to use shisha tha rural residets, with 20 (: ), ad 4.7 (: ), respectively. Me Wome Both sexes maufactured cig had-rolled cig. pipes of tobacco cigars, gaya shisha other type Figure Percetage of curret smokers smokig each products by sex category, Ethiopia NCD STEPS, Rural Urba Total maufactured cig. had-rolled cig. pipes of tobacco cigars, gaya shisha other type Figure Percetage of curret smokers smokig each products by area of residece, Ethiopia NCD STEPS, Figure presets percetage of daily smokers smokig give quatities of maufactured or hadrolled cigarettes per day. I geeral, about seve out of te daily smokers of both sexes smoked over five ad above cigarettes per day. However,about five out of te wome who are daily smoker smoked less tha five cigarettes per day ad me were more likely to smoke above 10 cigarettes per day tha wome. 39

40 Me Wome Both sexes Figure Percetage of daily smokers smokig give quatities of maufactured or had-rolled Amog the total umber of curretly smokig respodets, about 52 (: ) had tried to stop smokig i the oe year precedig the survey (52.1 of me (: ), ad 49.4 of wome (: )). I geeral, more urba residets tried to stop smokig tha rural residets, with 58.3 (: ) ad 50.6 (: ) respectively ( Table ). Table Percetage of Curret smokers who have tried to stop smokig by age, sex, ad area of residece, Ethiopia NCD STEPS, Me Wome Both Sexes Age Tried Tried Tried Group to stop to stop to stop smokig smokig smokig Place of Residece Rural Urba Total Table presets curret smokers who have bee advised by doctor to stop smokig. I geeral, 17.2 (: ) of both sexes (with me respodets 17.1 (: ), ad wome respodets 18.5 (: ) who had visited a doctor or other health workers i the 12 moths precedig the survey had bee advised to stop smokig. Survey participats i the age group of both sexes had more visit to a doctor or other health workers g ad had more advice by a doctor or other health worker to stop smokig tha other age groups. Urba residet wome 37.3 (: ) were more advised by a doctor or other health worker to stop smokig tha rural residet wome 0.9 ( <5 Cigs. 5-9 Cigs Cigs Cigs. 25 Cigs

41 CI: ) Table Percetage of curret smokers who were advised by doctors to stop smokig by age, sex, ad area of residece, Ethiopia NCD STEPS, Age Group Advised to stop smokig Me Wome Both Sexes Advised to stop smokig Advised to stop smokig Place of Residece Rural Urba Total I geeral, 0.8 (: ) of survey participats of both sexes curretly used smokeless tobacco. Smokeless tobacco use varies across age group, from 2.4 (: ) i age group to 0.2 (: ) i age group of both sexes. Me respodets were more likely to use smokeless tobacco tha wome respodets, with 1.1 (: ), ad 0.4 (: ), respectively; ad rural residets were more likely to use smokeless tobacco tha urba residets ( Table ) Table Percetage of Curret users of smokeless tobacco by age, sex, ad area of residece, Ethiopia NCD STEPS, Age Group Me Wome Both Sexes Curret users Curret users Curret users Place of Residece Rural Urba Total The survey foud that, overall about 0.8 (: ) of all the respodets of both sexes were curretly usig smokeless tobacco, ragig from 0.6 (: ) of daily usage to 0.2 (: ) of odaily usage. This proportio of curret users (daily ad odaily) of smokeless tobacco was higher i me tha wome (1.1 (: ) versus 0.4 (: )); ad rural residets of both sexes were more likely to use smokeless tobacco tha urba residets with 0.9 (: ), ad 0.1 (: ), respectively. (Figure ad Figure ) 41

42 DAILY USER NON-DAILY USER PAST USER NEVER USED CURRENT USER Me Wome Both sex NON-USER Figure Percetage of daily smokers smokig give quatities of maufactured or hadrolled cigarettes per day by sex category, Ethiopia NCD STEPS, Rural Urba Total Figure Smokeless tobacco use amog all respodets by area of residece, Ethiopia NCD STEPS, The percetage of former daily users of smokeless tobacco products amog all respodets were 0.3 (: ). There were more me users (0.5 : 0.3, 0.7) amog the respodets tha wome (0.1 : 0.0, 0.2) were. There was also a otable icrease i the proportio of smokers i older age groups, observed i both the me ad wome respodets (see table 4.1.9). Furthermore, the percetage of former daily users of all respodets i rural me (0.5) were slightly higher tha urba me (0.1). Similarly, wome smokers were also higher i rural (0.2 ) tha urba (0.0), residece. Table shows, amog all former daily users of all smokeless tobacco, 35.3 of respodets of both sexes were used daily. There were more me daily users (37.2) amog the respodets tha wome (28.7) were. The percetage of me daily users i Rural residece (37.6. ) were greater tha urba (28.6), but i reverse wome daily users were sigificatly higher i urba (80.0) tha rural residece (28.1). Table Percetage of former daily smokeless tobacco users amog all respodets, Ethiopia NCD STEPS,

43 Age Group (Years) Me Wome Both Sexes Former Former daily daily users users Former daily users Place of Residece Rural Urba Total Table Percetage of former daily smokeless tobacco users amog all smokers, Ethiopia NCD STEPS, 2015 Age Group Amog curretly smokeless tobacco users, daily users cosumed o average 1.7 (: ) suff by mouth, 2.2 (: ) suff by ose, 1.1 (: ) chewig tobacco, ad 1.4 (: ) other smokeless products times per day (Figure ). There was differece betwee the mea time of daily smokeless tobacco product users of both sexes i urba ad rural areas, aside from a slightly higher prevalece of users amog the rural populatio of suff by a ose (2.2 to 1), chewig tobacco (1.1 to 0.5) ad other products (1.4 to 0), but for suff by mouth was higher i urba residet (3.0 to 1.6). The mea time proportio of daily tobacco product users was higher i the older age groups of the study populatio. Me Wome Both Sexes Former Former Former daily daily daily users users users Place of Residece Rural Urba Total

44 mea Suff by mouths Suff by ose mea of chawig tobacco other mea Suff by mouths Suff by ose mea of chawig tobacco other mea Suff by mouths Suff by ose Rural Urba Total Me Wome Both sex mea of chawig tobacco other Figure Mea times of smokeless tobacco used by daily smokeless tobacco users per day, by type, Ethiopia NCD STEPS, 2015 More tha fifty percet (53 (: )) of curretly daily smokeless tobacco users cosumed suff by mouth per day. About 1 i 2 persos (50.1, : ) used suff by the ose daily. Approximately thirty-three percet (32.7, : ) also used chewig tobacco ad the rest 11.0 ( ) cosumed other smokeless product. There were more me users tha wome i all of smokeless products of suff by mouth (56.3 versus 41.9), suff by a ose (50.4 versus 49.2), chewig tobacco (34.2 versus 27.2) ad other smokeless tobacco product (12.9 versus 4.6) as show i Figure There was ot sigificat differece i the proportio of smokeless tobacco use i each age group, observed of both the me ad wome respodets. Furthermore, the percetage of daily users of suff by ose, chewig tobacco, ad other smokeless product i rural users (which was 50.8, 33.4, ad 11.4, respectively) were higher tha urba users (32.4, 14.2 ad 0.0, respectively) of both sex, but suff by mouth is higher i urba residets (74.1) tha rural residets (52.2)( Figure 4.10) Suff by Mouth Suff by Nose Chawig Tobacco Other Me Wome Both sex Figure Percetage of curret user of smokeless tobacco by type ad sex, Ethiopia NCD STEPS,

45 The percetage of curret tobacco user (daily ad o-daily smokers) of both smokig ad smokeless products amog all respodets was 4.8 (: ). There were more me tobacco user (8.2) amog the respodets tha wome (0.7). There was also a otable icrease i the proportio of smokers i older age groups, observed i both the me ad wome respodets (Table ). Furthermore, the percetage of curret smokers of all tobacco products i rural me (8.2) was slightly higher tha urba me (7.9). cotrary, wome smokers were higher i urba (0.9 ) tha rural (0.7) residece. Amogst all curret smokers of all tobacco products, 4 of respodets i both sexes were smoked or cosumed either smokig or smokeless tobacco daily. There were more me daily smokers (6.9) amog the respodets tha wome (0.5) were. The percetage of me daily smokers i rural residece (7.1) was slightly higher tha urba (5.7), but daily smokers amog wome were equal i both rural ad urba residets (0.5). (Aex 2). Table Percetage of curret tobacco users (both smokig ad smokeless) amog all respodets, Ethiopia NCD STEPS, Me Wome Both Sexes Age Group Curret N Curret N Curret users users users Place of Residece Rural Urba Total Table Percetage of curret daily tobacco users (both smokig ad smokeless) amog all respodets, Ethiopia NCD STEPS,2015. Me Wome Both Sexes Age Group Daily Daily N N Daily users users users Place of Residece Rural Urba Total More tha oe i te respodets i this survey were exposed to secod-had smoke at home i the 30 days precedig the study. The magitude of secod had smoke was higher i me tha wome (11.4 : 9.3, 13.6) versus (8.9 : 7.3, 10.5) were. 45

46 Table presets, the proportio of exposure to secod-had smoke at workplace was 15.1 for me (: ) ad 12.6 for wome (: ). Geerally, exposure at workplace (12.6) was higher tha at home (10.3), for both sexes. O the other had, the proportio of exposure to secodhad smokig was higher i the youger age groups (30-44) of the study populatio both i home (11.8) ad workplace (14.8), for both sex (Table ). Table Proportio of respodets who were exposed to secod-had smoke i home durig the past 30 days by sex, age group ad area of residece, Ethiopia NCD STEPS,2015. Age Me Wome Both Sexes Group N Exposed Exposed Exposed Place of Residece Rural Urba Total Percetage of respodets exposed secod-had smoke i the home i the past 30 days. Table Proportio of respodets who were exposed to secod-had smoke i the workplace durig the past 30 days by sex, age ad area of residece, Ethiopia NCD STEPS,

47 Age Group Me Wome Both Sexes Exposed Exposed N Exposed Place of Residece Rural Urba Total Percetage of respodets exposed to secod-had smoke i the workplace i the past 30 days Tobacco policy To assess tobacco policy, the survey respodets were asked about tobacco cotrol policy, icludig questios o exposure to the media ad advertisemet, o cigarette promotios, health warigs ad cigarette purchases. About three percet (3.1, : ) of the survey participats reported oticig iformatio o the dagers of smokig cigarettes or that ecourages quittig i the ewspapers or magazies. Approximately eight percet (7.8, : ) reported oticig iformatio about the dagers of smokig cigarettes or that ecourages quittig o televisio. Higher percetage (16.5, 95 CI: ) of the populatio reported oticig iformatio o the dagers of smokig cigarettes or that ecourage quittig o radio (Figure ). There were more me who oticed iformatio about dager of tobacco or ecourage quittig o ay of this media i the survey tha wome respodets. The percetage of respodets who oticed iformatio o the media about the dagers of smokig or ecourage to quit was higher i urba tha rural areas. (Aex 2) oticed ifromatio i Newspaper or Magazie Noticed iformatio o Televisio Noticed iformatio o radio Me Wome Both sex Figure Percetage of respodets who oticed iformatio i a ewspaper or magazie about dager of smokig or ecourage to quit, by age ad sex, Ethiopia NCD STEPS, The percetage of all respodets of both sexes who oticed advertisemet or sigs promotig cigarette i stores was 0.8 (: ). There were more me (1.1) tha wome (0.4) respodets who oticed advertisemet or sigs promotig cigarettes i stores. I additio, the percetage of respodets i both sexes who oticed advertisemet or sigs promotig cigarette i stores was higher i urba (1.6) 47

48 tha rural (0.6). (Table ) Table Percetage of respodets who oticed advertisemets or sigs promotig cigarettes i stores, by age ad sex, Ethiopia NCD STEPS, Me Wome Both Sexes (Years) Place of Residece Rural Urba Total A small proportio of the survey participats i both sexes idicated that they oticed some forms of cigarette promotio. These promotios iclude free sample of cigarettes 0.2 (: ), sale price o cigarettes 0.6 (: ), coupos for cigarettes 0.2 (: ), free gift or special discout 0.2 (: ), clothig or other items with a cigarette brad ame or logo 0.8 (95 CI: ), ad cigarette promotios through the mail was 0.1 (: ). There were relatively more me respodets who oticed cigarette promotio tha wome respodets i ay of the metioed promotio meas(figure ) free samples of cigarettes sale prices o cigarettes coupos for cigarettes free gifts or special discout cigarette brad ame or logo promotios i the mail Me Wome Both sex Figure Percetage of respodets who oticed promotio of cigarettes i the past 30 days, by type ad sex, Ethiopia NCD STEPS, The percetage of curret smokers (daily ad odaily) who oticed health warigs o cigarette package amog all respodets was 26.6 (: ). There were more me curret smokers who oticed health warig messages (27.3) amog the respodets tha wome (10.8). There was also a high proportio of smokers who oticed health warig messages i youger age groups (15-44), observed i both me ad wome respodets (Table ). Furthermore, the percetage of curret smokers (daily ad odaily) who oticed health warigs o cigarette package i urba respodets (48.9) is two folds higher tha rural respodet (21.2). Additioally, me smokers were also higher i urba (53.1) tha rural (21.6) residece, ad similarly, urba residet wome (15.4) were more likely to otice health warigs o cigarette package tha rural residet wome (6.3) were(figure ). Table Percetage of curret smokers who oticed health warigs o cigarette packages i the past 30 days, by age, sex ad area of residece, Ethiopia NCD STEPS,

49 (Years) Me Wome Both Sexes N Place of Residece Rural Urba Total The percetage of curret smokers who oticed health warigs o cigarette package that thought of quittig amog all respodets was 79.5 (: ). There were more me (79.8) amog curret smoker respodets tha wome (58.4) oticed health warig messages that thought of quittig. Moreover, the study also revealed that, rural (82.2) respodets were more likely to otice health warig messages that thought of quittig tha urba (74.5). Additioally, me smokers were also higher i rural (82.7 ) tha urba (74.5) residece; ad cotrarily, wome respodets i urba (75.7) were more likely to otice health warig o cigarette packages that thought of quittig tha rural residece (22.9). (Table ) Table Percetage of curret smokers who saw health warigs o cigarette packages that thought of quittig i the past 30 days, by age ad sex, Ethiopia NCD STEPS, Me Wome Both Sexes Place of Residece Rural Urba Total The cost of a pack of 20 cigarettes varied from low 14.7 birr to highest of 23.4 birr; the mea average price paid for a packet reported by both sexes was 15.3 birr per day. The mea average price paid for a packet of 20 cigarettes reported by wome was higher tha me (21.1 versus 15.0 Birr) were (Table ). Table Average price paid for 20 maufactured cigarettes o the last purchase, by age ad sex, Ethiopia NCD STEPS,

50 Me Wome Both Sexes Mea Mea Mea (birr) (birr) (birr) Place of Residece Rural Urba Total The cofidece iterval of average price paid for 20 maufactured cigarettes o the last purchase for wome ad both sex respodets is ot calculated due to the presece of higher differece o the values, so that the extreme values affected the calculatio of the iterval estimatio of the average price paid for 20 maufactured cigarettes Coclusios 1. About four percet of the survey participats were curret smokers (daily ad o-daily smokers) of all tobacco products that have smoke or ca be smoked, puttig them at high risk for NCDs. There were more me smokers 7.3 amog the survey respodets tha wome Curret tobacco use (smoke ad o-smoke ) was Amog all survey participats, 3.5 of them smoke daily. The share of daily smokers amog me (6.2) was higher tha wome (0.2). 4. Over all, mea age to start smokig started amog smokers is 21.0 years. Me were more likely to start smokig earlier tha wome were (mea age = 20.9 years i me versus 22.8 years i wome). 5. Maufactured cigarettes were the most commoly used tobacco product (used by 89.4 of the study populatio). Me daily smokers smoked more cigarettes (7.3 cigarettes) tha wome (2.4 cigarettes) did. 6. Oe i te idividuals (10.3) were exposed to secod-had smoke at home, ad oe i eight i the workplace (12.6), with more me (26.5) exposed tha wome (18.6), which cosiderably icreases the risk of NCDs amog exposed idividuals. 7. I Ethiopia, a quarter of the populatio (26.6) oticed health warigs o cigarette package ad four i five idividuals (79.5) of these populatio reported thought about quittig after readig the warig labels. 8. The cost of a pack of 20 cigarettes varied from low 15.2 birr to higher of birr; the mea average price paid for a packet reported by both sexes was 22.8 per day. 50

51 5. Alcohol cosumptio 5.1. Alcohol cosumptio status The 2015 Ethiopia NCD steps survey studied the alcohol cosumptio patters, frequecy of alcohol drikig ad risks associated with alcohol cosumptio accordig to sex, age ad place of residece of the survey respodets. Amog all respodets, i the age group years, early 41 (: ) cosumed alcohol durig the past 30 days prior to the survey time. The proportio of me who cosumed alcohol for the past 30 days (46.6, : ) was more likely higher tha that of wome (33.5, : ) (Figure 5.1). Both Sexes Wome Me Curret driker (past 30 days) Drak i past 12 moths, ot curret Past 12 moths abstaier Lifetime abstaier Figure 5. 1 Alcohol cosumptio status of all respodets i the past 30 days, by sex, Ethiopia NCD STEPS, Figure 5.1show a slight decrease i alcohol cosumptio i Ethiopia i compariso with the EDHS 2011 results that reported a prevalece of 53 amog me ad 45 amog wome. Although the EDHS aalysed differet age groups (15 49 age group for wome ad age group for me), the lower prevalece of alcohol cosumptio i the yougest age group supports the coclusio that a positive tred is emergig i terms of a reductio i alcohol use. 51

52 Percetage Table 5. 1 Distributio of curret (past 30 days) alcohol drikers status, by sex ad age,, Ethiopia NCD STEPS, Me Wome Both sexes (Years) Total Amog urba residets of both sexes i the age group years, almost half (47.1), ad from rural residets 39.1 had cosumed alcohol i the past 30 days. This patter is also cosistet with the result from EDHS 2011 which was 61 ad 51 of me i urba ad rural dwellers were cosumers of alcohol, respectively. Moreover, EDHS 2011 revealed that 50 of wome i urba ad 43 of wome i rural area ever cosumed alcohol (6) Rural Urba Total 40.7 Me Wome Both sexes Figure 5. 2 Percetage of curret drikers, by sex ad place of residece, Ethiopia NCD STEPS, The survey revealed that, amog ever drikers, but ot i the last 12 moths, 28.5 (: ) had stopped drikig due to health reasos. Moreover, 30.3 (: ) of me, ad 26.5 (: ) of wome had stopped cosumig alcohol due to health reasos. Amog the respodets who ever drak alcohol, the proportio of rural residets who stopped drikig due to health reasos for both sexes were more likely higher (28.9; 95CI: ) tha urba residets, which is 26.9 (: ). 52

53 15-29 Years Years Years Years Years Table 5. 2 Distributio of respodets who stopped drikig due to health reasos by age group, sex ad place of residece, NCD STEPS, Age Group Stoppig due to health reasos () Me Wome Both Sexes Stoppig due to health reasos () Stoppig due to health reasos () Place of Residece Rural Urba Total About 9 of me ad 3.5 of wome who cosumed alcohol i the last 12 moths drak alcohol every day. The proportio of all the past 12 moths cosumers who drak alcohol daily costituted 4.1; those who cosumed alcohol o 5 6 days per week costituted 3.7; ad those who drak 3-4 days per week, 1-2 days per week, ad 1 3 days per moth costituted 10.3, 34.4, ad 23.8,respectively. The rest of the respodets (23.7) reported cosumig alcohol oce per moth or less ofte. I the age group years, it was observed that the proportio of daily drikers were more likely higher tha other age groups. Both sexes Wome Me Both sexes Wome Me Both sexes Wome Me Both sexes Wome Me Both sexes Wome Me Percetage Daily 5-6 days/ week 3-4 days/ week 1-2 days/ week 1-3 days/ moth < oce a moth 53

54 Figure 5. 3 Frequecy of alcohol cosumptio i the past 12 moths, by sex ad age group, Ethiopia NCD STEPS, Amog me respodets, who are livig i urba areas ad cosumed alcohol daily were a bit higher tha rural residets; 10.8 ad 8.2, respectively. While, the proportio of wome respodets who cosumed alcohol i a daily bases were similar i urba ad rural areas (3.5). From me respodets, the proportio of rural residets who cosumed alcohol 5-6 days per week, 3-4 days per week, ad 1-2 days per week were foud to be higher tha those of urba dwellers, 6.7 versus 3.2, 15.8 versus 9.7, ad 37.7 versus 33.5, respectively. Likewise, the proportio of wome respodets who are livig i rural areas cosumed alcohol 5-6 days per week, 3-4 days per week, ad 1-2 days per week were more likely higher tha urba residets. Figure 5. 4 reveals that wome respodets who had cosumed alcohol less tha oce a moth were more likely higher tha those of me respodets were Rural Urba Total Rural Urba Total Rural Urba Total Figure 5. 4 Frequecy of alcohol cosumptio i the past 12 moths, by sex ad place of residece, Ethiopia NCD STEPS, The alcohol cosumptio patter was further aalysed by explaiig the frequecy of drikig i the past 30 days, ad the mea umber of stadard driks per drikig occasio. I the past 30 days curret alcohol drikers of both sexes had cosumed alcohol o average o 5.5 occasios (: ), with me showig to 6.3 occasios ad wome 4.3 occasios. For both sexes, the mea umber of drikig occasios was foud to be higher amog rural populatios, at 5.9 occasios (: ) tha amog urba residets, at 4.2 occasios (: ). The highest mea umbers of drikig occasios i the past 30 days amog curret drikers of both sexes were observed i the age groups ad years. (See Table 5. 3). Me Wome Both sexes Daily 5-6 days/ week 3-4 days/ week 1-2 days/ week 1-3 days/ moth < oce a moth 54

55 Mea umber of drikig occasios Years Years Years Years Total Figure 5. 5 Mea umber of drikig occasios i the past 30 days amog curret (past 30 days) drikers, by sex ad age group, Ethiopia NCD STEPS, Table 5. 3 Mea umber of drikig occasios i the past 30 days amog curret (past 30 days) drikers, by sex, age group ad place of residece, Ethiopia NCD STEPS, Me Wome Both Sexes Me Wome Both Sexes Mea 1 N Mea Mea Place of Residece Rural Urba Total The cofidece iterval of mea umber of drikig occasios for me respodets is ot calculated due to the presece of high geographical variatios, so that the extreme values affected the calculatio of the iterval estimatio of the mea umber of drikig occasios Curret drikers of respodets cosumed o average 3.5 stadard driks per drikig occasio (: ), with me cosumig 4.3 stadard driks ad wome cosumig 2.3 stadard driks. I all age groups, me cosumed almost two times more per drikig occasio tha wome (Figure 5. 6). The umber of stadard driks per occasio were higher amog the rural populatio at 3.7 driks as opposed to 3.1 driks for urba residets. (Table 5. 4). 55

56 Mea umber of stadard driks Years Years Years Years Total Me Wome Both Sexes Figure 5. 6 Mea umber of stadard driks per drikig occasio amog curret (past 30 days) drikers by sex ad age group, Ethiopia NCD STEPS, Table 5. 4 Mea umber of stadard driks per drikig occasio amog curret (past 30 days) drikers, by sex, age group ad area of residece, Ethiopia NCD STEPS, Me Wome Both Sexes Mea 2 Mea Mea Place of Residece Rural Urba Total The cofidece iterval of mea umber of stadard driks per drikig occasio for me respodets is ot calculated due to the presece of high geographical variatios, so that the extreme values affected the calculatio of the iterval estimatio of the mea umber of stadard driks The risk associated with alcohol cosumptio was assessed i curret (past 30 days) drikers based o the average amout of alcohol cosumed per drikig occasio i the past 30 days. The result revealed that a higher proportio of urba area respodets had a lower level risk (45.2) tha rural area respodets (36.3). Figure 5. 8 shows that 38 of all curret drikers (: ) had a low risk associated with alcohol cosumptio; 43.1 of me (: ) ad 32 of wome (: ). I additio, 1.8 of me (: ) ad 1 of wome (: ) had a medium risk, while 1 of me (: ) ad 0.1 of wome (: ) had a high risk. (Table 5.5 ad Fig.5.7). 56

57 Percetage High-ed level Itermediate level Lower-ed level Rural Urba Total Figure 5. 7 Proportio of high-, itermediate-, ad lower-volume drikig levels amog all respodets, by place of residece, Ethiopia NCD STEPS, 2015 Table 5. 5 Proportio of high-, itermediate-, ad lower-volume drikig levels amog all respodets, by age group ad place of residece, Ethiopia NCD STEPS, Age Group (Years) Highed level 1 Itermedi ate level 2 Lowered level Place of Residece Rural Urba Total Drikig at high-ed level is defied as drikig 60g of alcohol o average per occasio amog me ad 40g of alcohol o average per occasio amog wome 2 Drikig at itermediate level is defied as drikig g of alcohol o average per occasio amog me ad g of alcohol o average per occasio amog wome 3 Drikig at lower-ed level is defied as drikig <40g of alcohol o average per occasio amog me ad <20g of alcohol o average per occasio amog wome 57

58 Percetage Percetage years years years years Rural Urba Total Me <40g Wome <20g Both Sexes lower-ed level Figure 5. 8 Percetage of lower-volume drikig levels amog all respodets, by sex ad age group, Ethiopia NCD STEPS, years years years years Rural Urba Total High-ed Itermediate Lower-ed Figure 5. 9 Percetage of high-ed, itermediate, ad lower-ed level drikig amog curret (past 30 days) drikers, by age group ad place of residece, Ethiopia NCD STEPS, Amog the survey respodets, oe i eight idividuals cosumed six or more driks o a sigle occasio at least oce durig the past 30 days, with a sigificat differece betwee me ad wome. A total of 20.5 of me (: ), ad 2.7 of wome (: ) reported havig cosumed six or more driks at least oce durig the last 30 days. The proportio of people reportig this experiece is almost similar i the rural ad urba residets for both me ad wome. The mea umber of time with six ad more driks per drikig occasio was foud to 1.1 for both sexes i the past 30 days. Me experieced this patter 1.6 times while wome oly 0.2 times. 58

59 Percetage years years years years Total Me Wome Both Sexes Figure Percetage of respodets who cosume six or more driks o a sigle occasio at least oce durig the past 30 days, by sex ad age group, Ethiopia NCD STEPS, Table 5. 6 Mea umber of times with six or more driks durig a sigle occasio i the past 30 days amog curret drikers, by age, sex ad place of residece, Ethiopia NCD STEPS, Age Group Me Wome Both Sexes Mea Mea 95 CI 3 umber of umber of times times Mea umber of times Rural Urba Total The cofidece iterval of mea umber of stadard driks per drikig occasio for me respodets is ot calculated due to the presece of high geographical variatios, so that the extreme values affected the calculatio of the iterval estimatio of the mea umber of stadard driks About 11 (: ) of me, ad 6 (: ) of wome drak alcohol every day i the past 7 days amog curret (past 30 days) drikers. The proportio of all respodets who drak daily costituted 9; those who cosumed alcohol o 5-6 days per week costituted early14; those who drak 3-4 times per week costituted 26; ad those who cosumed 1-2 days per week costituted 37. The rest of respodets (14) did ot cosume alcohol i the past 7 days. The survey results attested to a higher prevalece of daily drikers i urba areas. The proportio of daily drikers i urba 11 (: ) was slightly higher tha rural residets 9 (: ). I cotrary to this fidig, EDHS 2011 revealed that higher percet of rural me (57 of rural versus 39.5 of urba) age group15-59 years ad wome (55 of rural versus 27.7 of urba) age group15-49 years drak six ad more i the past 30 days compared to urba me ad wome respectively (6). 59