MONGOLIAN STEPS SURVEY ON THE PREVALENCE OF NONCOMMUNICABLE DISEASE AND INJURY RISK FACTORS

Transcription

1 MONGOLIAN STEPS SURVEY ON THE PREVALENCE OF NONCOMMUNICABLE DISEASE AND INJURY RISK FACTORS

2 WHO Library Cataloguig i Publicatio Data MONGOLIAN STEPS SURVEY ON THE PREVALENCE OF NONCOMMUNICABLE DISEASE AND INJURY RISK FACTORS Nocommuicable diseases 2. Poverty 3. Developig coutries World Health Orgaizatio 2010 All rights reserved Requests for permissio to reproduce WHO publicatios, i part or i whole, or to traslate them-whether for sale or for ocommercial distributio should be addressed to Publicatios, at the above address (fax: ; permissios@who.it). For WHO Wester Pacific Regioal Publicatios, request for permissio to reproduce should by addressed to Publicatios Office, World Health Orgaizatio, Regioal Office for the Wester Pacific, P.O.Box 2932, 1000, Maila, Philippies, Fax.No.(632) , publicatios@wpro.who.it The desigatios employed ad the presetatio of the material i this publicatios do ot imply the expressio of ay opiio whatsoever o the World Health Orgaizatio cocerig the legal status of ay coutry, territory, city or area or of authorities, or cocerig the delimitatio of its frotiers or boudaries. Dotted lies o maps represet approximate border lies for which there may ot yet be full agreemet. The metio of specific compaies or of certai maufactures products does ot imply that they area edorsed or recommeded by the World Health Orgaizatio i preferece to others of a similar ature that are ot metioed. Errors ad omissios expected, the ames of proprietary products are distiguished by iitial capital letters. The World Health Orgaizatio ca be obtaied from Marketig ad Dissemiatio, World Health Orgaizatio, 20 Aveue Appia, 1211 Geeva 27, Switzerlad (tel: ; fax: ; bookorders@who.it)

3 CONTENT 1. TABLES 4 2. FIGURES 6 3. GLOSSARY 7 4. FOREWORD 8 5. EXECUTIVE SUMMARY 15 CHAPTER 1. RATIONALE 21 o Nocommuicable diseases worldwide ad i Mogolia 22 o Prevalece of commo modifiable risk factors for NCDs 23 o Survey goal, objectives ad importace of the survey 24 CHAPTER 2. SURVEY METHODOLOGY 25 o Survey scope 26 o Survey populatio ad samplig 26 o Traiig of field researchers i survey methodology 28 o Data collectio process 29 o Moitorig of data collectio 34 o Data etry ad cleaig 34 o Weightig of data 34 o Data aalysis 34 Cotet 3 CHAPTER 3. SURVEY RESULTS Demographic idicators Prevalece of commo modifiable risk factors for NCDs 39 o Tobacco use 39 o Alcohol cosumptio 42 o Fruit ad vegetable cosumptio 46 o Physical activity 52 o Body developmet ad physical fitess Prevalece of itermediate risk factors for NCDs 57 o Overweight ad obesity 57 o Prevalece cetral obesity ad body fat 60 o Biochemical risk factors for NCDs 65 o Hypertesio 70 o Diabetes 73 o Breast ad cervical cacer Ijury ad violece 79 o Ijury 79 o Violece Results of comparative study 90 o Treds i prevalece of commo modifiable risk factors for NCDs 90 o Treds i prevalece of itermediate risk factors for NCDs 91 CHAPTER 4. CONCLUSIONS 99 Geeral coclusio 100 REFERENCE 101 ANNEXES 103

4 TABLES Table 4 Table 1. Number of urba ad rural clusters 27 Table 2. Selected clusters ad survey populatio 29 Table 3. Stadard driks guide 30 Table 4. Level of risk associated with alcohol cosumptio, by geder 30 Table 5. Referece values for body fat percet 32 Table 6. Category for fitess test assessmet 33 Table 7. Biochemical idicators (WHO, 2005) 33 Table 8. group ad sex of respodets 36 Table 9. Survey sample (ethicity, settigs) 36 Table 10. Mea umber of years of educatio 37 Table 11. Average aual icome per adult perso (by age) 37 Table 12. Employmet status 38 Table 13. Upaid work ad uemployed (by age ad geder) 38 Table 14. Percetage of curret smokers (by age ad geder) 39 Table 15. Smokig status 39 Table 16. Mea age started smokig 40 Table 17. Alcohol cosumptio status, by age 42 Table 18. Alcohol cosumptio status, by sex 42 Table 19. Mea umber of stadard driks per drikig occasio amog curret (past 30 days) drikers 43 Table 20. Category II, III drikig amog all respodets, by geder 44 Table 21. Category I, II ad III drikig amog curret (past 30 days) drikers, by geder 44 Table 22. Five/four or more driks o a sigle occasio at least oce durig the past 30 days amog total populatio 44 Table 23. Mea umber of days fruit cosumed i a typical week (by geder ad locality) 46 Table 24. Mea umber of servigs of fruit o average per day (by geder ad locality) 46 Table 25. Mea umber of days vegetables cosumed i a typical week (by geder ad locality) 47 Table 26. Mea umber of servigs of vegetables o average per day (by geder ad locality) 47 Table 27. Mea umber of servigs of fruit ad/or vegetables o average per day (by geder ad locality) 48 Table 28. Number of servigs of fruit ad/or vegetables o average per day 49 Table 29. Number of servigs of fruit ad/or vegetables o average per day by locality 49 Table 30. Mea height (cm) 57 Table 31. Mea body weight ad height (by locality) 57 Table 32. Mea BMI (kg/m 2 ), by age ad geder 58 Table 33. Mea BMI (kg/m 2 ), by locality 58 Table 34. BMI classificatios (by geder ad locality) 60 Table 35. Mea waist circumferece (cm), by geder ad age group 60 Table 36. Mea waist circumferece (cm), by locality 61 Table 37. Prevalece of cetral obesity (by age ad geder) 61 Table 38. Prevalece of cetral obesity (by locality) 61 Table 39. Mea body fat (by age ad geder) 62 Table 40. Mea body fat (by locality) 62 Table 41. Proportio of populatio with icreased body fat, by stratum 64 Table 42. Mea total cholesterol (mmol/l) 65

5 Table 43. Total cholesterol 5.0 mmol/l or 190 mg/dl or curretly o medicatio for raised cholesterol 65 Table 44. Percetage with total cholesterol 6.2 mmol/l or 240 mg/dl or curretly o medicatio for raised cholesterol 66 Table 45. Mea fastig triglycerides (mmol/l) 66 Table 46. Percetage of respodets with fastig triglycerides 1.7 mmol/l or 150 mg/dl 66 Table 47. Percetage of respodets with fastig triglycerides 2.0 mmol/l or 180 mg/dl 67 Table 48. Mea blood LDL (mmol/l) cholesterol 67 Table 49. Proportio of populatio with or at risk of icreased blood LDL ( 3.0 mmol/l) 67 Table 50. Proportio of populatio with icreased LDL ( 4.15 mmol/l) 68 Table 51. Mea blood HDL (mmol/l) cholesterol 68 Table 52. Proportio of populatio with decreased LDL (mmol/l) 68 Table 53. Mea blood pressure (by geder ad locality) 70 Table 54. Percetage with SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised blood pressure 70 Table 55. Percetage with SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised blood pressure (by geder ad locality) 71 Table 56. Respodets with treated ad/or cotrolled raised blood pressure 72 Table 57. Mea fastig blood glucose (mmol/l), by age ad geder 73 Table 58. Mea fastig blood glucose (mmol/l), by locality 73 Table 59. Impaired Fastig Glycaemia (by age group) 74 Table 60. Impaired Fastig Glycaemia (by geder ad locality) 74 Table 61. Raised blood glucose or curretly o medicatio for diabetes (by age group) 74 Table 62. Raised blood glucose or curretly o medicatio for diabetes (by geder ad locality) 75 Table 63. Percetage who have had a VIA test ad PAP SMEAR test ( by age ) 76 Table 64. Cervical cacer screeig (by locality) 76 Table 65. Percetage who have had a breast palpatio by health care provider, Percetage who have had a mammogram oly, Performed self breast exam ( by age ) 77 Table 66. Breast cacer screeig (by locality ) 77 Table 67. Self-reported ijuries other tha traffic (by age ad geder) 79 Table 68. Traffic ijury ( by age, geder ad locality) 80 Table 69. Traffic ijuries ( by locality ad risk factors) 81 Table 70. Proportio ot usig seatbelts (by age ad geder) 82 Table 71. Violece agaist wome 85 Table 72. Frequecy of abuse 86 Table 73. Persetage worryig about their persoal ad family security because of someoe s ager 86 Table 74. Percetage beig abused as child 87 Table 5

6 FIGURES Figure 6 Figure 1. Survey frame, selected clusters 26 Figure 2. Multi-stage cluster samplig uits 28 Figure 3. Frequecy of smokig 40 Figure 4. Frequecy of alcohol cosumptio i the past 12 moths 43 Figure 5. Daily servigs of fruits ad vegetables 49 Figure 6. Daily servigs of fruits ad vegetables, by locality 50 Figure 7. Fat itake (by locality) 50 Figure 8. Proportio of populatio egaged i high levels of physical activity, by age ad geder 52 Figure 9. Media duratio of daily vigorous activity (by geder, urba/rural ad type of settig) 54 Figure 10. Physical fitess (by geder) 55 Figure 11. Physical fitess, males (by age group) 55 Figure 12. Physical fitess, by age group 56 Figure 13. Prevalece of overweight ad obesity (by geder) 59 Figure 14. Prevalece of overweight ad obesity, by age ad geder 59 Figure 15. Proportio with icreased body fat cotet, by age ad geder 63 Figure 16. Proportio of populatio with icreased body fat, by age ad geder 63 Figure 17. Respodets with treated ad/or cotrolled raised blood pressure 71 Figure 18. Percetage of respodets who were seriously ijured other tha road 79 traffic crashes8 by age group (N=358) 79 Figure 19. Locatio of accidetal serious ijuries amog respodets seriously ijured, by age group (N=358) 80 Figure 20. Cause of crash amog those respodets ivolved road traffic crash, by age group (N=191) 81 Figure 21. Proportio ot usig seatbelts (by locality ad geder) 82 Figure 22. Prevalece of violece (by age ad geder) 84 Figure 23. Use of weapos i violet act 84 Figure 24. Abusers reported by year-olds 85 Figure 25. Frequecy of child abuse 87 Figure 26. Preferred poit of cotact, by locality 88

7 GLOSSARY BMI BP DM DBP Dept. PHCPIC Dept. SPP Dept. IME IFG MNMRI MOH NRC RPCMB MCA-M MSc NCD PHI SBP PDA WPRO WC GPD - Body Mass Idex - Blood pressure - Diabetes Mellitus - Diastolic Blood Pressure - Departmet of Public Health Care Policy Implemetatio ad Coordiatio of MOH - Departmet of Strategic Policy Plaig of MOH - Departmet of Iformatio, Moitorig ad Evaluatio of MOH - Impaired fastig glucose - Mogolia Natioal Medical Research Istitute - Miistry of Health - Nutritio Research Ceter of Public Health Istitute - Research ad Productio Ceter of Medical Biotechology i Public Health Istitute - Milleium Challege Accout, Mogolia - Master of Health Scieces - No-commuicable diseases - Public Health Istitute - Systolic Blood Pressure - Persoal Digital Assistat: a hadheld PC - Wester Pacific Regioal Office of WHO - Waist Circumferece - Geeral Police Departmet Glossary 7

8 FOREWORD The Natioal NCD Prevetio ad Cotrol Programme was adopted i 2005 by the Govermet of Mogolia ad it is beig implemeted i two phases toward With the techical assistace of the World Health Orgaizatio, the first NCD STEPS survey was coducted i 2005, aimed to establish baselie idicators of the Natioal Programme ad of the NCD surveillace system i Mogolia. Natioal Public Health Istitute of the Miistry of Health has successfully carried out Mogolia STEPS Survey o the Prevalece of Nocommuicable Diseases ad Ijury Risk Factors for the secod time. Foreword 8 The primary objective of the curret survey was to provide up-to-date iformatio for assessig the situatio of NCD risk factors ad ijury amog Mogolia populatio. It was also iteded to furish the ecessary data for moitorig ad evaluatig the implemetatio status of the Natioal Program ad to determie the eeds for MCA Mogolia Health Project ad to cotribute to the further plaig of the ext strategies of the World Health Orgaizatio programme. We believe that the STEPS Mogolia 2009 survey results ot oly geerate key iformatio sources, but will also provide researchers ad all users with comprehesive data ad iformatio o the curret situatio of NCD risk factors, breast ad cervical cacer early detectio status, ad iformatio of ijury ad violece amog the populatio. The sigificace of the survey is to exted NCD risk factor surveillace system i Mogolia ad eable data to be icorporated with WHO NCD Global Ifo Base to obtai iteratioally comparable treds i NCD risk factors amog Mogolia populatio. These valuable iformatio ad facts with evidece provide us to effectively implemet public health policies, programmes, ad projects. We would like to emphasize that the survey was coducted i accordace with iteratioal stadards by meas of the techical assistace of the World Health Orgaizatio, with fiacial assistace from MCA Mogolia Health Project ad effective collaboratio of STEPS Coordiatig Committee i MOH, the Techical Workig members ad experts of all other participatig orgaizatios. MINISTER OF HEALTH S. LAMBAA

9 PARTICIPATING ORGANIZATIONS: Miistry of Health World Health Orgaizatio Milleium Challege Accout Mogolia Health project Public Health Istitute Health Scieces Uiversity Natioal Medical Research Istitute Natioal Cacer Ceter Mogolia State Committee of Physical Culture ad Sports Natioal Traumotology ad Orthopaedic Research Ceter Child Rights Protectio Ceter City Health Authority Regioal Diagostic ad Treatmet Ceters District ad Aimag Health cies Iteratioal Cosultats: Leae Margaret Riley, PhD Head, Surveillace Dept. of Chroic Diseases ad Health Promotio, WHO Melaie Cowa, MPH Techical Officer, Surveillace Dept. of Chroic Diseases ad Health Promotio, WHO Participatig orgaizatios 9 Pricipal Ivestigator, Project leader J.Oyubileg, ScD (Biol), Professor, Academicia Geeral Director, Public Health Istitute STEPS Coordiatig Committee at MOH S.Tugsdelger, MD, MPH, Chairma Director, Dept. Public Health Care Policy Implemetatio & Coordiatio, MOH J.Oyubileg, ScD (Biol), Professor, Academicia Deputy Chairma Geeral Director, Public Health Istitute G.Tsetsegdary, MD, PhD, Secretary Seior officer, Dept. Public Health Care Policy Implemetatio & Coordiatio, MOH B.Burmaa, PhD Seior Officer, Dept. Strategic Policy Plaig, MOH B.Khogolzul, MD Deputy-Director, Dept. Iformatio Moitorig ad Evaluatio, MOH P.Ekhtuya, PhD Deputy Director, Public Health Istitute I.Bolormaa, PhD Scietific Secretary, Public Health Istitute J.Batjargal, MD, PhD Director, Nutritio Research Ceter, Public Health Istitute

10 Participatig orgaizatios 10 Ts.Ekhjargal, ScD (Biol), Academicia Director, Public Health Laboratories, Public Health Istitute D.Otgotuya, MD, MSc Researcher, Nutritio Research Ceter, Public Health Istitute B.Mukhbat, PhD, ScD (Biol) Deputy Director, MCA Mogolia Health Project J.Ekhsaikha, PhD Specialist, MCA Mogolia Health Project J.Tugalag Chairma, Sectio of the Mogolia Physical Educatio ad Sports Authority D.Naratuya, MD, PhD MD, PhD, Health Scieces Uiversity Kh.Altaisaikha, MD, PhD Deputy Presidet, Mogolia Health Scieces Uiversity D.Oyuchimeg, MD Head, Research ad Traiig Uit, Natioal Cacer Research Ceter B.Bayarmaa, MD, MSc Head, Research ad Foreig relatio departmet, Natioal Metal Health Ceter Kh.Nasalmaa, MD Public Health Specialist, Natioal Traumotology ad Orthopaedic Research Ceter S.Ekhtur Head, Departmet of Public Relatio, Natioal Road Traffic cy S.Govid, MPH Public Health Specialist, WHO Coutry Office B.Tsogzolmaa, MSc Programme officer, WHO Coutry Office Sh.Ekhtsetseg, PhD Programme officer, WHO Coutry Office Project team Project coordiator D.Otgotuya, MD, MSc Researcher, Nutritio Research Ceter, Public Health Istitute Survey Team Leaders I.Bolormaa, PhD Scietific Secretary, Public Health Istitute Ts. Ekhjargal, ScD (Biol), Academicia Director, Public Health Laboratories, Public Health Istitut

11 Survey team members J.Tugalag Chairma,Sectio of the Mogolia Physical Educatio ad Sports Authority B. Sodgerel MD, PhD Researcher, Natioal Medical Research Istitute N. Bolormaa MD, MSc Researcher, Nutritio Research Ceter, Public Health Istitute U.Tseredolgor MD, ScD, Researcher, Nutritio Research Ceter, Public Health Istitute T. Erdeezul MD, PhD Lecturer, Health Sciece Uiversity B.Udarmaa, PhD Professioal officer, Natioal Professioal Ispectio cy N.Naratuya, MD, MSc Head of Public Health Maagemet ad Coordiatio Uit, Public Health Istitute S.Tsegmed, MSc Researcher, Hygiee ad Huma Ecology Ceter, Public Health Istitute J.Demberelsure, MSc Researcher, Medical Research ad Traiig Ceter, Public Health Istitute B.Soikhuu, MD Head, Public Health Departmet, City Health Authority B.Davaakhuu Officer, Public Health Departmet, City Health Authority J.Tsogzolmaa, MD, MSc Professioal officer, Natioal Statistical Office D.Erveekhei, MD NCD officer, Regioal Diagostic ad Treatmet Ceter, Khovd aimag Ts Gabat, MD NCD officer, Regioal Diagostic ad Treatmet Ceter, Dorod aimag Ts.Battuvshi, MD Head, Cetral hospital, Orkho aimag Kh. Bakytja Seior Officer, Mogolia Physical Educatio ad Sports Authority Ts. Mart Officer, Health Promotio Divisio, Govermet Implemetatio cy B.Davaadulam. MSc Researcher, Nutritio Research Ceter, Public Health Istitute A.Erdeebat, MD Researcher, Medical Research ad Traiig Ceter, Public Health Istitute Kh.Tseresure, MSc Researcher, Biotechology Research, Traiig ad Productio Ceter, Public Health Istitute Ts.Tseveesure, MSc Researcher, Biotechological Research, Traiig ad Productio Ceter, Public Health Istitute Participatig orgaizatios 11

12 Participatig orgaizatios 12 N. Ekhchimeg Officer, Natioal Ifectious Disease Research Ceter J.Javzadolgor Researcher, Medical Research ad Traiig Ceter, Public Health Istitute D.Odjargal Researcher, Researcher at the Toxicology Ceter, Public Health Istitute M.Oyuchimeg Researcher, Ecology & Hygiee Ceter, Public Health Istitute B. Khishigjargal Officer, Health cy of Sukhbaatar District Sh.Nasalmaa, MD Professioal Officer, Natioal Traumotology ad Orthopaedic Research Ceter O.Altasukh Programmist, Medical Research ad Traiig Ceter, Public Health Istitute B. Dulamsure Researcher, Public Health Laboratory, Public Health Istitute Kh.Madakhtsetse Researcher, Biotechological Research, Traiig ad Productio Ceter, Public Health Istitute L.Lkhagva Officer,, Biotechological Research, Traiig ad Productio Ceter, PHI B.Nyamtsetseg Officer, Health cy of Bayazurkh district D.Khishigbuya, MSc Researcher, Public Health Laboratory, Public Health Istitute Ch.Batkhuu, MD Physicia, State Cliical Hospital II B.Sodomtsere MSc, Public Health Laboratories, Public Health Istitute D.Otgobayar Researcher, Ecology & Hygiee Ceter, Public Health Istitute L.Altatuya Officer, Biotechological Research, Traiig ad Productio Ceter, PHI D.Oyujargal Officer, Public health worker, Bayazurkh District Health Ceter A.Ariuzul Professioal officer, Natioal Cacer Ceter Statistical aalysis team Melaie Cowa, MPH Techical Officer, Surveillace Dept. of Chroic Diseases ad Health Promotio, WHO D.Otgotuya, MD, MSc Researcher, Nutritio Research Ceter, Public Health Istitute

13 O.Altasukh Programmist, Research, Traiig ad Iformatio Ceter, PHI S.Tsegmed, MSc Researcher, Hygiee ad Huma Ecology Ceter, Public Health Istitute Report compiled by: D.Otgotuya, MD, MSc Researcher, Nutritio Research Ceter, Public Health Istitute I. Bolormaa, PhD Scietific Secretary, Public Health Istitute P.Ekhtuya, PhD Deputy Director, Public Health Istitute U.Tseredolgor, MD, ScD Researcher, Nutritio Research Ceter, Public Health Istitute J.Tugalag Chairma, Sectio of the Mogolia Physical Educatio ad Sports Authority Participatig orgaizatios Kh. Bakytja Seior officer, Mogolia Physical Educatio ad Sports Authority 13 Ts. Ekhjargal, ScD (Biol), Academicia Director of Public Health Laboratory, Public Health Istitute D. Naratuya, MD, PhD Head, Cardiology Departmet, Medical School, Mogolia Health Scieces Uiversity N.Bolormaa, MD, MSc Researcher, Nutritio Research Ceter, Public Health Istitute D.Oyuchimeg, MD, MSc Head, Research ad Traiig Uit, Natioal Cacer Research Ceter Kh.Altaisaikha, MD, PhD, Professor Deputy Presidet, Mogolia Health Scieces Uiversity J.Erdeezul, MD, PhD Lecturer, Mogolia Health Scieces Uiversity Sh. Nasalmaa, MD Professioal officer, Ijury Rehabilitatio Cliical Ceter B.Badamtsestseg Director, Child Rights Protectio Ceter B.Sukh-Ochir Executive director, Associatio of Professioal Social Workers N. Naratuya, MD, MSc Head, Maagemet ad Coordiatio Uit, Public Health Istitute F Maximillia de Courte, Professor Copehage School of Global Health, Uiversity of Copehage, Demark Cheria Varghese, PhD Techical Officer, Nocommuicable diseases, WPRO, WHO

14 Traslated by: S.Tugsdelger, MD, MPH Director, Public Health Care Policy Implemetatio ad Coordiatio Departmet, MOH Editors: Participatig orgaizatios L.Lkhagva, MD, PhD, DSc, Academicia, Professor Director, Drug Research Istitute G. Tsetsegdary, MD, PhD Seior Officer, Public Health Care Policy Implemetatio ad Coordiatio Departmet, MOH P. Ekhtuya, PhD Deputy Director, Public Health Istitute Note: Ay commets/suggestio related to this survey will be ivaluble i our work ad be appreciated to be cosidered i the future surveys. Therefore, please feel free to sed your commets/ suggestios to the followig address. 14 Address: Public Health Istitute of the Miistry of Health, Peace Aveue-17, Ulaabaatar , pubhealth@magicet.m] jobileg@magicet.m

15 EXECUTIVE SUMMARY The curret Survey o the Prevalece of Nocommuicable Diseases (NCD) ad Ijury Risk Factors was coducted to establish the midterm evaluatio of the Natioal Program o NCD Prevetio ad Cotrol, ad to establish baselie data for a health project fuded by the Milleium Challege Accout (MCA). The cross-sectioal survey used WHO STEPS survey methodology adapted to the coutrys specifics. The goal of the survey was to determie the prevalece of risk factors for NCD ad ijuries usig WHO-approved methods, ad to iform o NCD ad ijury cotrol activities. The survey had the followig objectives: To determie the prevalece of commo modifiable risk factors for NCDs ad major causes of ijuries To determie the prevalece of hypertesio, overweight, obesity, hypercholesterolemia ad hyperglycemia To compare the curret prevalece of NCD risk factors to that idetified i the previous STEPS survey A total of 5,638 radomly selected year-old Mogolia residets of both sexes from 36 soums of 20 aimags ad 6 districts of Ulaabaatar city participated i the survey. The survey data was collected betwee October 8 th ad November 2 d 2009 i selected aimags, ad betwee 10 th ad 25 th of December, 2009 i Ulaabaatar city. Executive summary 15 The survey data was fully collected usig small hadheld computers (PDAs). Because the data was comprised of oly a sample of the target populatio, it was ecessary to weight the data. Thus, sample weightig ad adjustmets to correct the differeces i the age-sex distributio of the sample compared to the target populatio were performed. Data aalysis was coducted usig EPI INFO versio 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, geder ad urba/ rural groups) were calculated with 95 cofidece itervals (). The survey results showed that i Mogolia 27.6 of the populatio smoke whereas 48.0 of me ad 6.9 of wome were curret smokers. The vast majority of smokers (87.9) smoke daily. Nearly oe i two persos (42.9) was exposed to secod-had smokig at home ad over a third (35.6) of the target populatio was exposed at work o at least oe day i the past 7 days, respectively. Curret drikig or cosumptio of alcohol i the past 30 days was reported by 38.6 of all respodets or 49.8 of me ad 27.2 of wome. O a drikig occasio, the curret drikers cosumed 7.7 stadard driks where o average it was 9.2 for me ad 5.1 for wome. The prevalece of bige drikig (more tha 5 driks o oe occasio for me, or more tha 4 driks for wome) was 39.7 i me ad 15.1 i wome, ad was thus more tha twice as commo i males tha females. Average daily servigs of fruits ad vegetables were 1.8, which was 3.2 servigs less tha the WHO recommedatio of the populatio cosumed less tha 5 servigs of fruits ad vegetables daily. Fruit ad vegetable cosumptio i rural areas was sigificatly lower tha i the urba areas. Daily salt itake was 7.3 grams per perso with rural residets usig o average 1.6 more grams of salt compared to their urba couterparts. 7.5 of the populatio were ot meetig the miimum recommedatio for physical activity, which

16 meat early 1 i 10 persos was at icreased risk for physical iactivity. Urba me were 4 times more likely to fall ito the category of low physical activity tha rural me, ad urba wome were twice as likely compared to their rural couterparts. Media duratio of time spet i high or moderate levels of physical activity at work was miutes, durig trasport 30.0 miutes ad i recreatioal settigs 51.4 miutes, respectively. The mea BMI of study populatio was 24.6 kg/m 2 ad it was 24.3 kg/m 2 i me ad 24.9 kg/m 2 i wome, respectively. Accordig to BMI risk assessmet, 39.8 of the populatio was overweight ad 12.5 was obese. Prevalece of overweight ad obesity teded to icrease with age, ad the proportio of overweight or obese wome i all age groups was higher compared to their male couterparts. Prevalece of cetral obesity (Me: WC 90cm ad Wome: WC 80cm) was 29.1 i me ad 55.7 i wome. Executive summary 16 Prevalece of high risk cholesterol category or hypercholesterolemia i the populatio was 25.0 ad prevalece of hypercholesterolemia was 8.5. Prevalece of high risk triglyceride category or hypertriglyceridemia i the populatio was 22.4 with sigificatly higher prevalece i me (29.5) compared to wome (15.4). The proportio of the populatio at risk ad with icreased blood LDL was 42.4 ad 20.2, respectively. The proportio of wome at risk or with decreased blood HDL was 2.7 times higher compared to me. Mea systolic blood pressure (SBP) was mmhg i me ad mmhg i their female couterparts, ad it was sigificatly higher i me tha i wome. Prevalece of hypertesio was Me had sigificatly higher prevalece of hypertesio compared to wome. There was o sigificat differece i the prevalece of hypertesio betwee urba ad rural populatios. Mea fastig blood glucose i the study populatio was 4.7 mmol/l ad there was o differece betwee me ad wome. However, the urba populatio was more likely to have higher mea fastig glucose tha the rural populatio. Prevalece of impaired fastig glycaemia (IFG) was 9.4 i the study populatio ad 11.5 i males, 7.5 i females. Prevalece of diabetes was 6.5 i the study populatio, 8.9 i males, 4.1 i females. Cervical cacer screeig coverage was very low with oly 5.2 of female survey respodets reportig VIA ad Pap smear testig. Wome aged had the highest cervical cacer screeig coverage, which was cosistet with the fact that cervical cacer icidece is highest i this age group. Breast cacer screeig was also isufficiet with 1 i 3 surveyed wome reportig breast self-examiatio, ad oly 3.2 ad 1.7 udergoig cliical breast examiatio ad mammography, respectively.cervical ad breast cacer screeig coverage was similar i urba ad rural settigs. Prevalece of road traffic ijury i the study populatio was 4.0. Oe i four (22.7) traffic ijuries was due to speedig, ad early 1 i 10 (9.1) due to druk drivig. Roughly eight i te drivers ad passegers (83.6) did ot use a seatbelt regularly. Prevalece of violet ijury was 3.5 i the study populatio ad 4.4 i me ad 2.5 i wome. Me more likely to fell victim to iterpersoal violece, which is maily because me teded to use physical force i resolvig coflicts. O the other had, amog those females ivolved i violece icidece, 30.4 reported beig abused by family or itimate parters ad 24.2 were abused by frieds. Of the survey respodets, 62.3 were abused as a child. Results of the comparative study (STEPS 2005 vs. 2009) idicated that the prevalece of smokig i the adult populatio has stayed about the same. Furthermore, wome start smokig o average at a youger age. With regards to alcohol cosumptio, although the percetage drikig alcohol i the past 12 moths has decreased, the frequecy of drikig shows a slight, but ot statistically sigificat, icreasig tred.

17 The comparative aalysis revealed that over the past 4 years the average daily servigs of fruit (0.8 vs. 0.4) ad vegetables (1.6 vs. 1.3) cosumed has decreased sigificatly. At the same time, average daily salt itake decreased. Although there was a icrease i the media time spet i physical activity o average per day (181.4 mis vs mis) ad i the percetage with high level of physical activity (70.4 vs. 81.8), o chages were observed i the percetage of the populatio who were ot fulfillig the miimum recommedatio for physical activity. The mea body mass idex of the adult populatio icreased as well as the prevalece of obesity (by 2.7), ad overweight ad obesity (by 8.3). Mea blood cholesterol ad the percetage with or at risk of icreased total cholesterol were remaied stable. Although the prevalece of hypertesio remaied uchaged, use of medicatio for treatmet of hypertesio ad its resposiveess to ati-hypertesive drugs worseed. Mea fastig blood glucose i the adult populatio ad percetage of people with raised blood glucose or o medicatio for diabetes remaied stable. Accordig to the WHO STEPS methodology, combied exposure of 5 commo risk factors such as curret daily smokers, less tha 5 servigs of fruits & vegetables per day, low level of activity, overweight (BMI 25 kg/m 2 ), raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio) was used to determie populatio risk for NCDs. I coclusio, the summary of combied NCD risk factors demostrates that 1 i 5 (26.4) Mogolia adults ad 1 i 2 (53.8) adults of years of age have three or more commo modifiable NCD risk factors. Twice as may youg me (aged years) tha wome (26.0 vs. 12.4) have 3 or more risk factors. Executive summary 17

18 Mogolia Steps Survey O The Prevalece Of Nocommuicable Disease Ad Ijury Risk Factors-2009 Fact Sheet The STEPS survey of chroic disease risk factors i Mogolia carried out from October to December Mogolia carried out Step 1, Step 2 ad Step 3. Socio demographic ad behavioural iformatio was collected i Step 1. Physical measuremets such as height, weight ad blood pressure were collected i Step 2. Biochemical measuremets were collected to assess blood glucose ad cholesterol levels i Step 3. The STEPS survey i Mogolia was a populatio-based survey of adults aged A multi-stage cluster sample desig was used to produce represetative data for that age rage i Mogolia. A total of 5438 adults participated i the Mogolia STEPS survey. The overall respose rate was 95. A repeat survey is plaed to be coducted i Fact Sheet 18 Step 1 Tobacco Use Results for adults aged years (icl. ) Percetage who curretly smoke tobacco Percetage who curretly smoke tobacco daily For those who smoke tobacco daily Average age started smokig Percetage of daily smokers smokig maufactured cigarettes Mea umber of maufactured cigarettes smoked per day (by smokers of maufactured cigarettes) Step 1 Alcohol Cosumptio Percetage who are lifetime abstaiers Percetage who are past 12 moth abstaiers Percetage who curretly drik (drak alcohol i the past 30 days) Percetage who egage i heavy episodic drikig (me who had 5 or more / wome who had 4 or more driks o ay day i the past 30 days) Step 1 Fruit ad Vegetable Cosumptio (i a typical week) Mea umber of days fruit cosumed Mea umber of servigs of fruit cosumed o average per day Mea umber of days vegetables cosumed Mea umber of servigs of vegetables cosumed o average per day Percetage who ate less tha 5 servigs of fruit ad/or vegetables o average per day Step 1 Physical Activity Percetage with low levels of activity (defied as < 600 MET-miutes per week)* Percetage with high levels of activity (defied as 3000 MET-miutes per week)* Media time spet i physical activity o average per day (miutes) (preseted with iter-quartile rage) Percetage ot egagig i vigorous activity Both Sexes Males Females 27.6 ( ) 24.3 ( ) 19.2 ( ) 84.6 ( ) 8.7 ( ) 34.2 ( ) 7.4 ( ) 38.6 ( ) ( ) 0.4 ( ) 4.8 ( ) 1.4 ( ) 92.3 ( ) 7.5 ( ) 80.8 ( ) ( ) 48.5 ( ) 48.0 ( ) 43.0 ( ) 18.7 ( ) 84.3 ( ) 8.9 ( ) 24.0 ( ) 6.0 ( ) 49.8 ( ) 39.7 ( ) 1.0 ( ) 0.3 ( ) 4.6 ( ) 1.4 ( ) 93.4 ( ) 7.4 ( ) 82.5 ( ) ( ) 42.9 ( ) 6.9 ( ) 5.2 ( ) 23.2 ( ) 86.9 ( ) 7.0 ( ) 44.5 ( ) 8.8 ( ) 27.2 ( ) 15.1 ( ) 1.4 ( ) 0.5 ( ) 4.9 ( ) 1.5 ( ) 91.1 ( ) 7.7 ( ) 78.9 ( ) ( ) 54.2 ( )

19 Results for adults aged years (icl. ) Both Sexes Males Females Step 2 Physical Measuremets Mea body mass idex - BMI (kg/m 2 ) Percetage who are overweight (BMI 25 kg/m 2 ) Percetage who are obese (BMI 30 kg/m 2 ) 24.6 ( ) 39.8 ( ) 12.5 ( ) Average waist circumferece (cm) -- Mea systolic blood pressure - SBP (mmhg), icludig those curretly o medicatio for raised BP Mea diastolic blood pressure - DBP (mmhg), icludig those curretly o medicatio for raised BP ( ) 78.9 ( ) 24.3 ( ) 37.0 ( ) 11.1 ( ) 83.2 ( ) ( ) 79.6 ( ) 24.9 ( ) 42.7 ( ) 14.1 ( ) 82.6 ( ) ( ) 78.1 ( ) Percetage with raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP) 27.3 ( ) 31.4 ( ) 23.2 ( ) Percetage with raised BP (SBP 140 ad/or DBP 90 mmhg) who are ot curretly o medicatio for raised BP Step 3 Biochemical Measuremet Mea fastig blood glucose, icludig those curretly o medicatio for raised blood glucose (mmol/l) 61.1 ( ) 4.7 ( ) 71.9 ( ) 4.8 ( ) 46.0 ( ) 4.7 ( ) Fact Sheet Percetage with impaired fastig glycaemia as defied below: (capillary whole blood value 5.6 mmol/l (100 mg/dl) ad <6.1 mmol/l (110 mg/dl)) 9.4 ( ) 11.5 ( ) 7.5 ( ) 19 Percetage with raised fastig blood glucose as defied below or curretly o medicatio for raised blood glucose (capillary whole blood value 6.1 mmol/l (110 mg/dl)) 6.5 ( ) 8.9 ( ) 4.1 ( ) Mea total blood cholesterol, icludig those curretly o medicatio for raised cholesterol (mmol/l) 4.4 ( ) 4.5 ( ) 4.2 ( ) Percetage with raised total cholesterol ( 5.0 mmol/l or 190 mg/dl or curretly o medicatio for raised cholesterol) 25.0 ( ) 27.4 ( ) 22.5 ( ) Summary of combied risk factors curret daily smokers less tha 5 servigs of fruits & vegetables per day low level of activity overweight (BMI 25 kg/m 2 ) raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP) Percetage with oe of the above risk factors 3.0 ( ) 1.9 ( ) 4.0 ( ) Percetage with three or more of the above risk factors, aged 15 to 44 years 19.4 ( ) 26.0 ( ) 12.4 ( ) Percetage with three or more of the above risk factors, aged 45 to 64 years 53.8 ( ) 61.4 ( ) 46.1 ( ) Percetage with three or more of the above risk factors, aged 15 to 64 years 26.4 ( ) 33.1 ( ) 19.4 ( )

20

21 CHAPTER I RATIONALE 21

22 Nocommuicable diseases worldwide Accordig to the World Health Orgaizatio (WHO) ocommuicable diseases (NCDs) such as cardiovascular diseases (CVDs), diabetes, chroic pulmoary diseases ad cacers accouted for 60 percet of populatio mortality globally ad 80 percet of mortality i low ad middle icome coutries i 2008 [3]. The WHO estimates that mortality due to smokig could icrease twice i low ad middle icome coutries by 2030, reachig 6.8 millio deaths, if o effective prevetive measures are take. Similarly, cacer mortality could icrease from 7.4 millio deaths i 2004 to 11.8 i Chapter I. Ratioale However, the experiece of a umber of coutries demostrates that NCDs ca be preveted effectively. There is a growig scietific evidece that if we succeed i cotrollig commo modifiable risk factors leadig to NCDs, we ca prevet some 80 of cardiovascular disease, 90 of type II diabetes as well as 1/3 of cacers [9]. Nocommuicable diseases i Mogolia Mogolia has bee udergoig a epidemiological trasitio sice 1990s. As a result, diseases related to lifestyle ad health behavior, such as cardiovascular diseases, diabetes, cacer ad ijuries are growig steadily ad have become the leadig causes of populatio mortality. I 2008 the followig diseases were the leadig causes of death i Mogolia: Diseases of circulatory system per 10,000 populatio Neoplasms per 10,000 populatio Ijury, poisoig ad certai other cosequeces of exteral causes per 10,000 populatio Diseases of digestive system per 10,000 populatio Periatal coditios per 10,000 populatio. Diseases of circulatory system are the leadig cause of populatio morbidity ad mortality, ad were accouted for every third death i Accordig to official health statistics, mortality due to the diseases of circulatory system is ad per 10,000 males ad females, respectively [1]. Cervical cacer is the secod most commo cacer diagosed i wome i Mogolia. Betwee 2000 ad 2008 the prevalece of cervical cacer icreased from 38.8 to 68.4, the icidece from 6.6 to 15.5, ad mortality from 3.4 to 4.0 per 100,000. Util recetly, breast cacer was rare i Mogolia. However, its icidece is growig steadily, ad curretly it is the sixth most commo cacer. Betwee 2000 ad 2008 the prevalece of breast cacer rose from 12.5 to 20.6, the icidece from 2.5 to 3.6, ad mortality from 0.8 to 1.3 per 100,000. Ijury More tha 5 millio people aually or 16,000 people daily lose their lives due to ijuries worldwide. Thousads more are disabled. Ijury mortality has icreased dramatically i recet years i Mogolia. It was the fifth leadig cause of populatio mortality i 1990, ad has rise to the third positio sice The mai causes of ijury mortality are traffic ijuries, suicide, homicide ad other ijuries, which accout for 19.7, 16.3, 10.4 ad 46.9 percet of mortality, respectively[13]. Violece Studies have bee coducted that looked ito the forms, prevalece ad cosequeces of geder-

23 based violece, child abuse ad violece agaist the elderly i Mogolia. These studies demostrate that 1 i every 3 wome experiece some form of violece, 1 i every 10 wome is battered, 1 i every 5 families has abusive relatios, half of all childre are abused, ad 1 i every 4 elderly is a victim of family violece. A umber of victims of family violece with moderate to severe ijuries registered with a foresic medicie uit has icreased 2.5 times over the last few years [12]. Prevalece of commo modifiable risk factors for NCDs Accordig to the Mogolia STEPS Survey o the Prevalece of NCD Risk Factors (2005) 24.2 percet of the populatio were daily smokers, ad almost three quarters (72.5) of the respodets cosumed less tha 5 servigs of fruits ad vegetables daily. The prevalece of people who egaged i low levels of physical activity was 23.1 percet or oe i five. The survey idicated that 31.6 of the populatio were overweight or obese (21.8 overweight ad 9.8 obese). The prevalece of high blood pressure was 28.1 percet ad the prevalece of diabetes was 8.2. The curret survey was udertake to idetify the prevalece of risk factors for NCDs ad ijuries, to iform the evaluatio of the Natioal Program o NCD Prevetio ad Cotrol, ad to establish baselie data for a health project fuded by the Milleium Challege Accout (MCA). 23 Chapter I. Ratioale

24 SURVEY GOAL The goal of the survey was to determie the prevalece of risk factors for NCDs ad ijuries usig WHO-approved methods, ad to iform o NCD ad ijury cotrol activities. SURVEY OBJECTIVES To determie the prevalece of commo modifiable risk factors for NCDs ad major causes of ijuries; 24 Chapter I. Ratioale To determie the prevalece of hypertesio, overweight, obesity, hypercholesterolemia ad hyperglycemia, ad To compare the curret prevalece of NCD risk factors to that idetified i the previous STEPS survey. SCIENTIFIC NOVELTY AND IMPORTANCE OF THE SURVEY The survey will iform the evaluatio of the Natioal Program o NCD Prevetio ad Cotrol, ad will establish baselie data for a health project fuded by the Milleium Challege Accout (MCA). The use of iteratioally validated survey methods adapted to the coutry specifics will cotribute to the developmet of health research ad will eable iteratioal comparisos. The survey uses WHO STEPS survey methodology, ad advaced software, laboratory tests ad statistical aalysis methods, which will geerate reliable iformatio for policymakig ad program plaig.

25 CHAPTER II SURVEY METHODOLOGY 25

26 1. Survey scope The curret Survey o the Prevalece of NCD ad Ijury Risk Factors is coducted to iform the mid-term evaluatio of the Natioal Program o NCD Prevetio ad Cotrol, ad to establish baselie data for a health project fuded by the Milleium Challege Accout. The survey used WHO STEPS survey methodology adapted to the coutry specifics, ad was coducted i the followig three steps. 26 Chapter II. Survey methodology 1. STEP 1: Questioaire survey iformatio o smokig, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, ad history of hypertesio, diabetes, screeig for cervical ad breast cacer, ijuries ad violece, ad their causes was collected by usig a questioaire. 2. STEP 2: Physiological measuremets overweight ad obesity (body weight ad height, waist ad hip circumferece, ad body fat), blood pressure, ad physical fitess were measured usig specific tests ad devices. 3. STEP 3: Laboratory aalysis blood glucose, cholesterol ad triglycerides were measured i peripheral (capillary) blood at data collectio sites usig dry chemical methods, while LDL ad HDL were measured i blood serum usig wet chemical methods. 2. Survey populatio ad samplig A total of 5,438 radomly selected year-old Mogolia residets of both sexes from 36 soums of 20 aimags ad 24 khoroos of 6 districts of Ulaabaatar city participated i the survey(figure 1). All participats completed STEPS 1 ad 2 of the survey except pregat wome, persos with disabilities ad bedridde patiets, for whom physiological measuremets were ot performed. Every third perso aged radomly selected ito the study completed STEP 3 or biochemical testig. Respose rate of the survey was 95 i both STEP1, 2 ad STEP3. Figure 1. Survey frame, selected cluster

27 For calculatig the survey sample size, the prevalece of overweight ad obesity (P=32.6) idetified durig the previous (2005) roud of STEP survey was used, assumig 95 cofidece iterval (Z=1.96), 5 acceptable margi of error, complex samplig desig effect coefficiet of 1.5, ad equal represetatio of geders i each age group (5 age groups for each geder or a total of 10 groups). This gave a sample size of 4,840 persos, which was further icreased by 15 (5,694) to accout for cotigecies such as o-respose or recordig error (Formula 1). Sample size calculatio formula: 1. =Z 2 P(1-P) e (1-0.3) = = x desig effect x age-geder factor = x 1.5 x 10 = / probability of o-respose = 4840 / 0.85 = 5694 The survey was desiged to cover all geographical areas of Mogolia, ad a four-stage cluster samplig process was carried out to radomly select participats from the target populatio. Give the urba vs. rural differeces i lifestyle ad disease status, the target populatio was stratified ito urba ad rural areas ad the sample was draw proportioally from each based o the target populatio i each area. Thus, out of the 60 total clusters selected, 28 were urba ad 32 were rural. Ulaabaatar city, Darkha-Uul ad Orkho aimags represeted urba areas, while the rest of aimags ad soums represeted rural areas (Table 1). 27 Chapter II. Survey methodology Table 1. Number of urba ad rural clusters Settig Target populatio As of total populatio Survey populatio Number of clusters Urba Rural Total Niety-five participats were selected from each cluster. I the urba areas, khoroos were selected, the family groups, the households. I rural areas, soums were selected, the baghs the households How this selectio was proceeded is explaied i the followig paragraph (Figure 2). A total of 28 khoroos were selected from a list of all khoroos (=173) i the urba area usig probability proportioal to size samplig, where the size was 25.5 of the total target populatio of 851,062 persos aged years old. From each selected khoroo, three of the family groups were selected usig probability proportioal to its total umber of households. Withi each of the three family groups, 95 households were selected usig simple radom samplig from updated household registries.

28 Figure 2. Multi-stage cluster samplig uits 28 Chapter II. Survey methodology Primary uit Secodary uit Tertiary uit Fial uit For the rural area, 32 of the soums were selected from a list of all soums (=324) usig probability proportioal to size samplig, where the size was 23.1 of the total target populatio of 919,417 persos aged years old. From each selected soum, 2 baghs were selected usig probability proportioal to its total umber of households. Withi each selected baghs, 95 of the households were selected usig simple radom samplig from updated household registries (Table 2). From each selected household i urba ad rural areas, oly oe perso aged years was selected usig Kish Method as the last step. Data collectio period. The survey data was collected betwee October 8 th ad November 2 d i aimags, ad betwee 10 th ad 25 th of December, 2009 i Ulaabaatar city. Traiig of field researchers i survey methodology. A semiar o the STEPS Survey o the Prevalece of NCD ad Ijury Risk Factors was coducted by the Public Health Istitute i collaboratio with the Miistry of Health, WHO ad MCA-supported Health Project o 15 th September, The semiar was atteded by more tha 50 stakeholders icludig Ms. Leae Riley, STEPS Team Leader, WHO HQ, members of the survey coordiatig committee, represetatives from health research, traiig, service ad sports orgaizatios, iteratioal doors ad civil society.

29 Table 2. Selected clusters ad survey populatio Urba Cities/Aimags Number of Clusters Proportio of participats aged years (N, ) Ulaabaatar (40.0) Darkha (3.3) Erdeet (3.5) Total (46.8) A traiig of 50 atioal researchers was coducted by the survey techical workig group i collaboratio with the WHO experts o September 16-21, O the first two days the traiees were exposed to the methods of samplig ad obtaiig iformed coset from selected survey respodets. The core of the traiig was focused o a survey questioaire ad skills to use Persoal Digital Assistats (PDAs) for data etry. The last two days of the traiig cosisted of iteractive sessios to itroduce data collectio methods for Steps 1, 2 ad 3 of the survey. Dorod Dudgobi Zavkha (3.4) 82 (1.5) 188 (3.5) Pilot test. The traied field researchers carried out a pre-testig comprised of all three steps of the survey i two districts of Ulaabaatar city. Over 80 people participated i the pretestig. The pre-testig started with the data Uvurkhagai (3.3) Umugobi (2.8) collectio team leaders selectig family groups, Sukhbaatar Selege Tuv (1.7) 177 (3.3) 178 (3.3) households ad idividuals accordig to the samplig methodology, ad dissemiatig iformatio about the survey to selected Uvs (3.4) idividuals i collaboratio with family practitioers ad urses. There were eight Khovd (3.4) data collectio teams with 5 researchers each. Khuvsgul (5.1) Each team collected questioaire data from Khetii Gobi-Altai Total (1.7) 95 (1.7) 2892 (53.2) ad performed physiological measuremets o 9-10 idividuals, ad performed laboratory aalysis o 3-4 idividuals. The pre-testig was aimed at validatig the field researchers skills i usig survey questioaires, performig physiological measuremets ad laboratory tests, ad usig PDAs. Based o the fidigs of the pre-testig, hads-o traiig o physiological measuremets was repeated. After re-traiig, all researchers uderwet testig i practical skills. Rural Arkhagai (5.2) Baya-Ulgii 1 95 (1.7) Bayakhogor (3.5) Bulga (3.3) Dorogobi 1 77 (1.4) 29 Chapter II. Survey methodology Data collectio process Validated questioaires of WHO STEPS Survey o the Prevalece of NCD Risk Factors ad Commuity Survey o Ijuries ad Violece were traslated ito Mogolia, adapted to coutry specifics, back traslated ito Eglish, reviewed ad approved by iteratioal ad atioal cosultats, ad used for the survey data collectio. STEP 1: Questioaire survey The questioaire was used to collect data o respodet s socio-ecoomic status, tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, ad history of hypertesio, diabetes, screeig for cervical ad breast cacer, ad ijuries ad violece, ad their causes. Assessig alcohol cosumptio: Alcohol cosumptio was assessed usig the cocept of stadard driks. A stadard drik is ay drik cotaiig 10 grams of pure alcohol (Table 3).

30 Researchers used a poster ad a guide showig a table with stadard driks depictig 5 types of commoly cosumed alcoholic beverages. Table 3. Stadard driks guide 30 Chapter II. Survey methodology Alcoholic beverages Amout cotet Pure alcohol amout Stadard driks Vodka 1 glass / 50 ml / 40 Alc/Vol 20 g 2 Wie 1 glass / 100 ml / 12.5 Alc/Vol 12.5 g 1.3 Beer 1 bottle / ca 330 ml / 4-5 Alc/Vol 15 g 1.5 Home brewed alcohol 1 cup / 100 ml / 15 Alc/Vol 15 g 1.5 Mare s milk 1 cup / 250 ml / 5 Alc/Vol 12.5 g 1.3 I the curret survey respodets reportig alcohol use withi the past 1 moth were classified as curret drikers. Three risk categories were used to classify respodets who cosumed alcohol depedig o the average amout of alcohol cosumed per day. These categories are defied i the table below (Table 4). Table 4. Level of risk associated with alcohol cosumptio, by geder Uits are i amout of alcohol cosumed o average per day Geder, cotet of pure alcohol Category I Category II Category III Male <40 g g >60 g Female <20 g g >40 g Bige drikig was defied as cosumig o oe occasio 5 or more stadard driks for males ad 4 or more stadard driks for females. Assessig fruit ad vegetable cosumptio: I order to assess the diet patter of the surveyed populatio, the respodets were asked about frequecy of fruit ad vegetable cosumptio, type of oil used i food, ad amout of salt cosumed daily. Cosumptio of fruits ad vegetables was assessed i terms of umber of servigs, ad a servig was equal to 80 g. I order to facilitate data collectio, showcards were produced cotaiig 52 photo images of servigs of 21 differet ames of fruits belogig to 14 fruit groups, 19 differet ames of vegetables belogig to 11 vegetable groups (excludig potato), 11 differet ames of oil ad fats belogig to 6 groups, ad 2 types of salt. The showcards were used to collect data o fruit ad vegetable cosumptio o a typical day. I additio, a poster with fruit ad vegetable servig guide was used. Salt cosumptio was assessed by askig for how may days a pack of 500 grams of salt is used i a household, ad estimatig average daily salt itake by dividig 500 g by a umber of days ad a umber of members i a household. Fat ad oil itake was assessed by askig about a type of oil most frequetly used for cookig. Assessig physical activity: Physical activity was assessed based o itesity, duratio ad frequecy of physical activity at work, i recreatioal settigs ad durig trasportatio usig a complex set of 16 questios. Data o the umber of days, hours ad miutes of physical activity performed at work, trasport ad recreatioal settigs for at least 10 miutes per day were collected. The complex questioaire has a advatage of assessig ot oly the duratio, but also the itesity of physical activity. The media time of total physical activity per day spet for work, trasport ad recreatioal activities was measured by usig the stadard metabolic equivalet time, or MET. This uit is used to estimate