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Non-Communicable Disease Prevention


Brief Communication

Non-Communicable Disease Prevention: The Way to Prevent the Rapidly Growing Public Health Problem in Developing World

Abdel Rahim Mutwakel Belal, DPH, FCM

Medical Officer In-Charge (MOIC), Nizwa Healthy Lifestyle Project, Ministry of Health, Sultanate of Oman, Tel: office: +968-25426271, Mobile: +968-92257308, Fax: +968-25426123, E-mail: [email protected], P.O.Box: 503, postal Code: 611, Nizwa, Ad Dakhliyah Region, Sultanate of Oman

Introduction Non-Communicable Diseases (NCDs) represent the major health burden in the industrialized countries and a rapidly growing problem in the developing countries. At the same time NCDs are an area where major health gains can be achieved. Developing countries are experiencing dramatic changes in the health needs of their populations. Although many countries currently face a double burden of infectious diseases and noncommunicable diseases, the latter, including cancer, diabetes and cardiovascular diseases (CVDs), are fast replacing the traditional enemies of infectious diseases and malnutrition as the leading causes of disability and premature death. This trend will continue and by the year 2020, NCDs are expected to account for seven out of every ten deaths in the developing regions, compared with less than half today . Chronic diseases such as cardiovascular, diabetes, cancer, renal, genetic and respiratory conditions are rising dramatically in the Eastern Mediterranean Region. Currently, 45% of the region's disease burden is due to noncommunicable diseases. It is expected that this burden will rise to 60% by the year 2020. The impact of these conditions falls heavily on the region's poor and marginalized populations(1). In many countries of the Eastern Mediterranean Region (EMR), the health aspect of the epidemiological transition is already much further advanced than many health policy-makers


appreciate. Although health officials and the medical profession have a general awareness of the increasing occurrence of NCDs, the problem has, in general, not received the attention it deserves and its extent has not been sufficiently examined. Awareness among the general population of the adverse health consequences of the new behaviour and lifestyles is likewise inadequate. Largely because of the long delay between cause and effect, people tend to misjudge the hazards of these lifestyles(1). Research has already shown that Noncommunicable diseases have their roots in unhealthy lifestyles or adverse physical and social environments. Risk factors like unhealthy nutrition over a prolonged period, smoking, physical inactivity, excessive use of alcohol, and psychological stress are among the major lifestyles issues. While there is firm knowledge on "what should be done?" for the prevention of these diseases, the key question at the present is "How should it be done?"(2). How our existing knowledge of Noncommunicable diseases best be applied for effective prevention in real-life situations? Carefully planned community programmes are an important component of the strategy to help solve this problem. NCDs community-based prevention programs There is a huge gap between the existing medical knowledge and every day situation in the society, results from several obstacles for healthy changes:

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Non-Communicable Disease Prevention cultural, political, economical, psychological, etc. the aim of the community programme is to try to build abridge for people and communities to overcome these obstacles . The background for mass epidemic of NCDs is the unhealthy lifestyles, developed often along with the economic transition. Large proportions of people are at least in some risk. Major reduction in the NCD rates calls for general changes in the NCD-related lifestyles (common risk factors). Since the lifestyles are in a complex way embedded in the community, major changes in lifestyles are possible only, if their determinants in the community changes. Historical development After the main risk factors of non-communicable diseases had been identified in the beginning of the 70's , preventive studies and efforts were gradually started in the developed countries. Epidemiological research to prove causality had progressed from case-control and prospective follow-up studies to preventive trials with one or multiple factors. NCDs prevention programs in developed countries Since the early 1970s, a number of communitybased health intervention projects have started in developed countries. These projects were usually started in the field of cardiovascular disease prevention and emphasized the fact that merely providing risk-reduction measures for clinically high risk people in health services settings would have only have a limited impact on the whole population . The first community-based heart health intervention project was the North Karelia Project which started in 1972 . The very high CVD mortality in Finland in the early 1970s, together with the finding of earlier epidemiological research carried out in Eastern Finland in connection with the Seven Countries Study, was the background on which this project was started .

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After North Karelia Project similar projects were launched in other countries. In USA, Stanford University carried out the so-called Stanford threeCommunity study (1972-75) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score. Subsequently, the National Institutes of Health (NIH) financed three major community-based intervention projects: the Stanford five-City Project (1980-86), showed reductions in smoking, cholesterol, BP, and CHD risk, the Mennesota Heart Heath Program (198088), showed some increases in physical activity in women and reductions in smoking, and the Pawtucket Heart Health Program. Later, projects with various study designs were launched e.g. German Cardiovascular Prevention Study, and the Norsjö Study in Sweden(2) and so on. NCDs programs in the developing countries Although most of the integrated NCDs community programmes have been started in the developed countries, the great increase in the NCDs burden in many developing countries has led to similar activities in these places also. The WHO Interhealth Programme, which was started in 1986, aimed to demonstrate how an integrated programme could be implemented in populations in all regions of the world, at every stage of the demographic and epidemiological transition(2). The core of the programme consisted of interventions aimed at modifying the levels of the major risk factors of NCDs in the community through an integrated community approach to health promotion and maintenance. Chile, China (Beijing and Tianjin), Mauritius, and the United Republic of Tanzania were representing the developing countries, and Finland, Cyprus, and Lithuania, the USA Malta, Russian the Federation, representing

developed countries. In the framework of the Interhealth Programme, special activities were undertaken among school children in Chile and the

Sudanese Journal of Public Health: July 2006, Vol. 1 (3)


Non-Communicable Disease Prevention United Republic






Eastern Mediterranean Regional Office lunched EMAN network also. With the regional development, the Interhealth Programme ended. Elements of the community prevention program The practical framework of the community programme consists of three components: (1) Planning, (2) Intervention or programme implementation, and (3) Evaluation(2). Although they ideally occur in time sequentially, as listed, in many cases these elements take place simultaneously as the project proceeds. Evaluation - Formative summative - Evaluation aims - Feasibility - Effects risk factors disease - Process - Cost - Evaluation study design - Quasi experimental - Reference communities - Population surveys - Disease monitoring - Different research frameworks

community programmes were launched in Mauritus and China . WHO regional networks WHO's European Regional Office launched the CINDI programme (Countrywide Integrated Noncommunicable Diseases Intervention) at the same time when the Global Intrhealth Programme was started. Following CINDI positive experience, the Regional Office for the Americas started a similar network called CARMEN in the 1990s(2). The

Table 1: The major elements in community-based projects Planning Implementation (intervention program) - Community diagnosis - Community-based - Defining of objectives - Target: whole community - Project organization built - Community organization - Preparatory steps - Comprehensive - Combination of different strategies - Diffusion and interaction - Program organization - Community involvement

Community-based NCDs prevention projects in EMR There are successful examples of CommunityBased Prevention Programs in the region, such as Isfahan Healthy Heart Program (IHHP) in Islamic Republic of Iran and Nizwa Healthy Lifestyle Project in Sultanate of Oman. Isfahan Healthy Heart Program (IHHP) is a set of ten community-based a WHO interventional projects for developed by Isfahan Cardiovascular Research Center, collaborating center Cardiovascular disease prevention and control in EMR. These interventional projects have a 3-phase design, lasting a total of 4-5 years. The project is an intervention community-based trial consisting of a number of research studies before and after interventions, a number of cross-sectional surveys prior to interventions to evaluate the existing Sudanese Journal of Public Health: July 2006, Vol. 1 (3)

situation, during intervention and after intervention involving similar samples from the same society. Stage I: 6 months ­ 1 year, stage II: 2-4 years, stage III: one year, Final stage: one year-final analysis(5). Ministry of Health, Sultanate of Oman collaborated with WHO/EMRO to initiate a community based intervention program for prevention noncommunicable diseases. The project established in Nizwa Wilayah, so called Nizwa Healthy Lifestyle Project. The objectives of the project includes mapping of the emerging epidemics of NCDs and to analyze the social, economic, and behavioural determinants of the disease, to reduce the exposure of individuals and populations to the major determinants of NCDs and to prevent the emergence of preventable common risk factors, and to strengthen health care for people with NCDS by supporting effective interventions. The strategy of 232

Non-Communicable Disease Prevention the project based on targeting the three common risk factors for NCDs namely; physical inactivity, unhealthy dietary habits, and tobacco use . Non-communicable disease risk factors situation in Sudan Data on the disease burden of NCDs in Sudan is scarce and deficient, but the trend of transition of disease pattern from predominantly communicable diseases to non-communicable diseases has been remarkably noted throughout the world. Sudan is not an exception of the international trend. Same factors and conditions apply to its situation. Additional factors further complicate the situation in the country i.e. armed and political conflicts, scarce resources and poor capacity for future foreseeing and strategic planning. Regionally increases in sedentarization, accompanied with increased poverty rates and high rates of illiteracy, modified people's lifestyle due to urban expansion and globalization influence, has led to the current shift of disease pattern in EMR(7). Factors such as increased rates of smoking, obesity in addition to increasing injuries due to traffic accidents and violence are pushing more to the imbalance. As an indicator of this shift, DM represents the ninth cause of hospital admission in the Sudan, contributing by 1.9 percent. The number of patients has doubled between 1997 and 2000, with a crude prevalence of 3.4 percent (men 3.5 %, women 3.4 %) and average attributed death of 5.9 percent in the same period. The highest crude prevalence is in the northern part (5.5 %) and the lowest in the western desert­like parts (1.9%). The highest prevalence is demonstrated in Danagla tribe (8.3 %). Another example is that cancer incidence rates have significantly increased to become one of the major killer diseases (second in 2002), with a percentage of 34.5 and 14.3 percent for breast and cervical cancers respectively. The same is believed

5. 4. 3. 2.



regarding cardiovascular diseases, mental illnesses and accidents, as hospital data shows an increase in the numbers of cases although no adequate information is available. Tobacco use, on its part, is contributing to the transition as showed in a recent assessment: 25 percent of Sudanese men, 2 percent of women and 20 percent of school students use different types of tobacco(8). It is high time to address this growing public health problem in Sudan. WHO Stepwise surveillance tools provide good opportunity to collect data about the risk factors of NCDs. According to the resources available the country can use step one and tow only to collect this base line data and formulate community-based interventions. Also CommunityBased Initiatives (CBIs) such as Basic Development Needs Programme (BDN) is an acid to build a pilot Community-Based Prevention project for non-communicable disease in Sudan. References

1. Ala'din Alwan. Noncommunicable diseases: a major challenge to public health in the Region. Eastern Mediterranean Health Journal. 1997;3(1):6-16. Aulikki Nissinen, Ximena Berrios, and Pekka Puska. Community-based Noncommunicable disease interventions: lessons from developed countries to developing ones. Bulletin of the World Health Organization. 2001; 79 (10). Pekka Puska. Lessons learnt from Community-based Noncommunicable experiences in disease developed interventions: countries. WHO

consultation on future strategies for the prevention and control of Noncommunicable diseases. Geneva, 27-30 September 1999. Pekka Puska. Successful prevention of noncommunicable diseases: 25 year experiences with North Karelia Project in Finland. Public Health Medicine 2002;4(1):5-7 Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control.

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Non-Communicable Disease Prevention

Design, methods and initial experience. N. SarrafZadegan et al. Acta Cardiologica. 2003;58:4. 6. Nizwa Healthy Lifestyle Project, Directorate 8. General of Health Services in Ad Dakhliyah Region, Ministry of Health, Oman. Strategic intervention plan. 2003. 7.


WHO regional office for the eastern Mediterranean region. Promoting healthy lifestyles. EM/RC50/5. 2003 August. Federal ministry of Health, Sudan. 25 years strategic plan for the health sector. 2003

Sudanese Journal of Public Health: July 2006, Vol. 1 (3)



Sudanese Journal of Public Health

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