Bridging health promotion intervention policy with behavioral risk factor surveillance in Thailand The 7 th World Alliance for Risk Factor Surveillance (WARFS) Global Conference Toronto, Ontario, Canada, 16-19 October 2011 Public Health Ontario 20 October 2011, 11.00-12.30 Supawan Manosoontorn, PhD, MPH, BSc Center of Behavioral Risk Factor Surveillance Bureau of Non-communicable Disease Ministry of Public Health, Thailand 1
Presentation topics Behavioral Risk Factor Surveillance System in Thailand Lifestyle diseases and behavioral risk factors that informs healthy lifestyle policy 2
Thailand: Country background, 2011 Area 513,115 sq.km Population 65.4 m. Thai 62.1 m. (M: 32.1 m./ F: 33.3 m.) Non-Thai 3.3 m. Pop: (Urban 45.7% : Rural 54.3%) Province 76 + BKK Life expectancy at birth Male 69.5 yr : Female 76.3 yr Total Health Exp of GDP 3.5%(1994) 4%(2008) 3
Behavioral Risk Factor Surveillance System in Thailand Public health surveillance system Population-based point in time survey Individual interview survey Focus on behavioral risk factor of CVD, DM and injury and intervention policy Three-year round continuous survey Inform CVD/DM/injury behavioral risk factor of Thai population in terms of province, region, and nation BRFSS users: decision makers, program managers, population 4
Conceptual framework of BRFSS Figure 4 Example of Major Selected Non-Communicable Disease (NCD) Risk Factors and Determinants Non-modifiable Risk Factors Age Sex Genes Behavioural Risk Factors Tobacco Diet Alcohol Physical Activity Intermediate Risk Factors Hypertension Blood lipids Obesity / Overweight Diabetes Endpoints Coronary heart disease Stroke Peripheral vascular disease Several cancers COPD/em physema Socio-economic, Cultural & Environmental Conditions Source: World Health Organization (WHO) 5
Sampling frame Stratified two-stage cluster sampling, 2010 Urban Province Rural Electing area Finite population vs Nonfinite population Village Individual sample Age M F 15-54 24 24 55-74 12 12 Total 36 36 72 samples/1 cluster 864 samples/12 clusters Complex sampling design Stratified two-stage cluster sampling, 2010 Sampling frame designed by Dr.Gun Cerngrungroj and Dr.Yongyuth Chaiyapong Individual sample Age M F 15-54 24 24 55-74 12 12 Total 36 36 72 samples/1 cluster 864 samples/12 clusters 1,728 samples/province (75 provinces + BKK = 131,328 samples) Complex analysis/multilevel analysis, using SAS software for estimation 6
Components of Thai BRFSS Part 1 Socioeconomic status Part 2 General health status Part 3 Accessibility to health services Part 4 Overweight and obesity Part 5 Fruit and vegetable intake Part 6 Physical activity Part 7 Alcohol consumption Part 8 Tobacco consumption Part 9 Cardiovascular screening Part 10 Hypertension and self management Part 11 Diabetes and self management Part 12 Chronic diseases Part 13 Cervical cancer screening Part 14 HIV/AIDS examination Part 15 Knowledge of CVD/DM Prevention Part 16 Road traffic and injury 7
Lessons learned in implementing Thai BRFSS Need for strong political back up Develop culture and values to use Thai BRFSS as evidence base to target intervention and inform policy Involvement of all levels of the data chain in determining what data is needed and how it will be used 8
Nearly 80% of the 36 million global NCD deaths were in lowand lower middle-income countries, 2008 In low- and lower middle-income countries, 29% of NCD deaths occur among people under the age of 60, compared to 13% in high-income countries. Nearly half (48%) of all NCD deaths in low- and middle-income countries are under the age of 70 years, compared with 26% in high-income countries. Source : The Global status report on non-communicable diseases 2010, WHO 2011 Regional Office for South-East Asia, WHO 9
22% of the global NCD deaths occur in the South-East Asian Region, 2008 55% of all deaths in the Region are due to NCDs more than deaths from communicable diseases, maternal and child health issues, nutritional deficiencies and injuries put together. 8 million people die of NCDs each year in the Region; 2.7 million are below the age of 60 years. Source : The Global status report on non-communicable diseases 2010, WHO 2011 Regional Office for South-East Asia, WHO 10
Proportion of NCD, CD and injury to total deaths 45 40 35 30 25 20 15 NCD CD Injurry 10 5 0 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990 1991-1995 1996-2000 Source : Nawarat Petcharoen. Adult Mortality of Cardiovascular Disease in Thailand 11
Number of DALY / million, Thailand 2.6 CD 1.3 2.0 NCD 5.6 6.4 7.1 1999 2004 2009 Injury 1.3 1.4 1.3 0.0 2.0 4.0 6.0 8.0 Male Female CD 0.8 1.2 1.6 CD 0.5 1.0 0.8 NCD 2.9 3.4 3.7 1999 2004 2009 NCD 2.6 3.0 3.4 1999 2004 2009 Injury 1.0 1.1 1.0 Injury 0.3 0.3 0.3 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Source : Burden of disease in Thailand 2009, BOD working group 12
Burden (DALY) by broad disease groups, 2009, Thailand Proportion of total Proportion by sex male female 56% 53% 55% 62% 77% 62% 37% 41% 62% 38% 67% 44% 47% 45% 38% 23% 38% 63% 59% 38% 62% 33% total Cardiovascular diseases Cancer Mental disorders Unintentional injuries Infectious diseases Diabetes Sense disorders Chronic respiratory disea Musculo-skeletal disease Digestive disorders Source : Burden of disease in Thailand 2009, BOD working group 13
Top ten DALY by specific disease and gender, 2009, Thailand DALY Male Female Rank Disease DALY ('000) % % DALY ('000) Disease 1 Traffic accidents 476 8.8 8.6 363 Diabetes Alcohol 2 Dependence/harmful use 451 8.3 8.1 341 Stroke 3 Stroke 359 6.6 7.3 309 Depression 4 HIV/AIDS 267 4.9 4.0 170 Ischaemic heart disease 5 Liver cancer 251 4.6 3.5 149 Osteoarthritis 6 Ischaemic heart disease 236 4.3 3.5 147 HIV/AIDS 7 Diabetes 207 3.8 2.8 120 Traffic accidents 8 Depression 165 3.0 2.8 118 Anaemia 9 Cirrhosis 164 3.0 2.6 108 Liver cancer 10 COPD 159 2.9 2.5 106 Dementia All causes 5436 100 100 4231 All causes Source : Burden of disease in Thailand 2009, BOD working group 14
DALY attributable to risk factors by age and gender, 2009, Thailand WSH = Water Sanitation Health Source : Burden of disease in Thailand 2009, BOD working group 15
National policies and plan in response to lifestyle diseases epidemic Mortality / 100,000, caused by lifestyle diseases HT DM IHD Stroke 35 30 25 20 15 10 5 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010,2011 Diseases Specific Vertical Program Vertical program: Reorientation to Risks focused 1.Health Service Reoriented: Comprehensive risk screening communication & management Standardized & Proactive Screening & communication and behavior modification Promotion for Healthy Diet, PA & Stress Coping, Tobacco & Alcohol Reduction 2. Health system reform and support Diseases Management National Policy: Tobacco Control, Injury Control, Diet & PA, Alcohol Control for Health Public Policy Healthy Thailand Thailand Healthy Lifestyle Strategic Plan (draft) 2007-2010 9 th national Health Development Plan 2001-2006 10 th national Health Development Plan 2007-2011 National Overweight and Obesity Management Strategic Plan(2010-2014) Applied from Jureeporn Kongprasert Thailand Healthy Lifestyle Strategic Plan (B.E.2011-2020) National Food Safety Strategic Plan (B.E.2011-2020)
Trend of morbidity/100,000 from lifestyle disease and key health promotion intervention policy with behavioral risk factor surveillance in Thailand Morbidity 100,000, caused by lifestyle diseases HT DM IHD Stroke 1400 1200 1000 800 600 400 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Unhealthy lifestyle and screeninh service, impacted on lifestyle diseases 90 80 70 60 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 H_drink Sm oke Low F&V NoExc Overw eight HT Scr DM Scr Launch HT/DM/CA Screening and Nonpharmacologic care Improve quality of DM care Input awareness and screening of CVD Improve standard of HT/DM/CA screening Start CBI for comprehensive risk reduction Push HT/DM awareness and start national exercise campaign
Impact of health intervention policy on HT/DM in Thailand DM Prevalence 6.9 % DM Prevalence 6.9 % Awareness 43.6% 29.2% HT Prevalence 22.0 % Awareness 30.4% 36.7 % FPG< 140mg/dL NHES 2005 NHES 2005 NHES 2009 NHES 2009 Awareness 69.8% 54.% HT Prevalence 21.4 % Awareness 49.7% 50.6 % BP <140/90 mmhg) 1970 1990 2010 2030 M F M F M F M F 18
Thailand Healthy Lifestyle Strategic Plan 2011-2020 Ultimate goal People, community, society and country have immunity and capacity to prevent health threat from lifestyle diseases Main goals on 3 major areas 5 Important lifestyle diseases 1] Diabetes 2] Hypertension 3] Heart disease 4] Stroke disease 5] Cancer 5 Aspects 1] Incidence 2] Complication 3] Disability 4] Mortality 5] Expense 3 Components (Sufficiently healthy lifestyle) 1] Balanced diet 2] Adequate physical exercise 3] Suitable emotional management 18 primary indicators (6) Short-term:1-3 yrs. [2011-2013] Involvement of stakeholders / awareness and lifestyle management /capacity building of surveillance, prevention & control / reduce sweet, salt, fat, smoke, alcohol (8) Medium-term:5 yrs. [2011-2015] Decrease overweight, obesity / increase exercise / decrease cholesterol / decrease metabolic syndrome / stress management / decrease disease complication (4) Long-term:10 yrs. [2011-2020] Decrease mortality and slow down prevalence from lifestyle disease / decrease health expenditure Strategy Healthy public policy Social mobilization & public communication Community building Surveillance & care system Capacity building
Lesson learned and unique initiatives for CVD / DM control in Thailand (2007-2010) Input HT / DM as risk management for secondary prevention Establishment of health promoting hospital- subdistrict level with diet and physical activity change clinic Comprehensive community-based intervention in local setting (villages) strategic route map as a tool Community managed Health Fund Application of Thai traditional medicine in NCD prevention & control Formulate provincial and district multi-sectoral committee for NCD prevention and control Strengthening surveillance-prevention-control management system at provincial level 20
Key challenges Increase in supply of healthy food and products, subsidies for health foods Law enforcement on control of unhealthy food & beverages Arrangement of environment to encourage and increase physical activities Design cities and towns to promote health Promote and improve self-management & health literacy Address NCD-related issues as human development among stakeholders in all levels How to make NCD as health for all policies Multi-sectoral collaboration / cooperation Strengthening the health care system to proactive prevention and control 21
Sukhothai Historical Park The Grand Palace Sawasdee ka The Southern Sea Thailand the land of smile 22