This presentation is based on the various W.H.O. available tools for risk factor surveillance of NCDS.

1. RISK FACTOR SURVEILLANCE
FOR
NON COMMUNICABLE
DISEASES

2. CONTENTS
INTRODUCTION
FROM ETIOLOGY TO RISK FACTORS
NEED FOR SURVEILLANCE
TOOLS FOR NCD SURVEILLANCE
NCD SURVEILLANCE IN INDIA
CONCLUSION

3. PROLOGUE

4. Non Communicable Diseases
(NCDs) are the leading cause
of death globally, and one of
the major health challenges
of the 21st century.

6. FROM ETIOLOGY TO RISK FACTORS
For many diseases the disease agent is still unidentified
• CHD
• Cancer
• Peptic Ulcer
• Mental illness
Where the disease agent is not firmly established, the
aetiology is generally discussed in terms of risk factors

7. Why study Risk
Factors?
• A description of diseases and injuries and the
risk factors that cause them is vital for health
decision-making and planning.
• Most scientific and health resources go towards
treatment. However, understanding the risks to
health is key to preventing disease and injuries
and is cost effective too.

8. FROM HEALTH SURVEYS TO SURVEILLANCE
Research Surveys
Hypothesis-testing
One time
Goes into depth within specific
health issue
Public Health Surveillance
Hypothesis-generating
On-going
Looks at broad trends and
patterns across health issues,
geographic areas

9. TERMINOLOGIES
Survey: Making a single observation to measure and record something.
Surveillance: Making repeated standardised surveys in order that change can be detected. This is quite different to,
but often confused with, monitoring. Surveillance lacks the ‘formulated standards’ that are so important in monitoring.
Surveillance is used to detect change but does not differentiate between acceptable and unacceptable change.
Monitoring: Surveillance undertaken to ensure that formulated standards are being maintained.

10. SURVEILLANCE DEFINITION
On-going, systematic collection, analysis,
interpretation and dissemination of data essential
for health promotion and disease prevention
(CDC 2004)

11. Why is surveillance important ?
• Sizes the problem
• Informs interventions
• Content of advocacy information
• Basis for evaluating impact of policy/practice
• Helps prioritise resources allocation
• Stimulates research

12. TYPES OF SURVEILLANCE – based on data collection
PASSIVE SURVEILLANCE
ACTIVE SURVEILLANCE
Laboratories, physicians, or others regularly report cases of disease or death to the local or state health
department.
Examples:
• A doctor’s office reports 2 cases of measles
• A nursing home reports an unusual number of older patients with unexplained rashes
Local or state health departments initiate the collection of information from laboratories, physicians, health
care providers, or the general population.
Achieves more complete and accurate reporting than passive surveillance
Example: Youth Risk Behavior Surveillance surveys

13. SENTINEL SURVEILLANCE
• A sentinel surveillance system is used when high-quality data are needed about a
particular disease that cannot be obtained through a passive system.
• Selected reporting units, with a high probability of seeing cases of the disease in
question, good laboratory facilities and experienced well-qualified staff, identify and
notify on certain diseases.
• Whereas most passive surveillance systems receive data from as many health
workers or health facilities as possible, a sentinel system deliberately involves only a
limited network of carefully selected reporting sites.

14. NCD Surveillance tools
• NCD global monitoring framework, indicators and targets
• NCD Country Capacity Survey (CCS)
• STEPS (adults)
• GSHS (adolescents)
• Service availability and readiness assessment (SARA)
• Comparable estimates for key risk factors
• Compiling and storing NCD data

15. Monitoring Framework for NCD surveillance
• In May 2013 the 66th World Health Assembly adopted the comprehensive global
monitoring framework (GMF) for the prevention and control of non communicable
diseases.
• The Global Monitoring Framework included a set of indicators capable of
application across regions and country settings to monitor trends and assess
progress made in the implementation of national strategies and
plans on non communicable diseases.

17. Global Monitoring Framework on NCDs
• India is the first country to develop specific national targets and indicators aimed at
reducing the number of global premature deaths from NCDs by 25% by 2025.
• A National Multi-sectoral Action Plan that outlines actions by various sectors to
reduce the burden of NCDs and their risk factors, is being developed and
implemented.
• India will have 9 targets (as per the Global
Action plan) and a tenth target to address
household air pollution —a major health hazard
due to burning of solid biomass fuel and
second-hand smoke.

18. NCD Country Capacity Survey
• To gather information about individual country capacity to respond to NCD prevention and control.
• Assessment focused on current strengths and weaknesses related to:
• NCD infrastructure, policy response, surveillance and health systems response and partnerships and health
promotion.
• 5th wave of surveillance conducted in – previous surveys in 2000, 2005, 2013 and 2015.
• Next wave planned for 2017.
• Generally a high response rate from Member States.
• Periodic monitoring of national progress would
assist countries in identifying gaps in prevention
and control efforts and assist with future planning.

19. STEPS- Adult Risk Factor Surveillance
• The STEPS approach focuses on obtaining core data on the established risk factors that
determine the major disease burden.
• It is sufficiently flexible to allow each country to expand on the core variables and risk
factors, and to incorporate optional modules related to local or regional interests.
• PURPOSE: Designed to help countries build and strengthen their surveillance capacity.

20. STEPS- Adult Risk Factor Surveillance
• The STEPS approach focuses on obtaining core data on the established risk factors that
determine the major disease burden.
• It is sufficiently flexible to allow each country to expand on the core variables and risk
factors, and to incorporate optional modules related to local or regional interests.
• PURPOSE: Designed to help countries build and strengthen their surveillance capacity.

21. STEPS DESIGN
The STEPS Instrument covers three different levels of "steps" of risk factor assessment.
These steps are:
• Questionnaire
• Physical measurements
• Biochemical measurements
Three modules per Step:
• Core
• Expanded
• Optional

22. BASIS OF STEPS
STEPS emphasizes that small amounts of good quality data are more valuable than large amounts of
poor data.
It is based on the following two key premises:
• Collection of standardized data.
• Flexibility for use in a variety of country situations and settings.
POPULATION: The STEPS approach uses a representative sample of the study population. This
allows for results to be generalized to the population.

23. STEPS INSTRUMENT
The STEPS Instrument covers three different levels, or 'Steps', of risk factor
assessment: Step 1, Step 2 and Step 3, as follows:

24. Core, expanded and optional items
Within each Step, there are three
levels of data collection. These
depend on what can realistically
be accomplished (financially,
logistically and in terms of
human resources) in each
country setting.

26. • Targets a nationally representative sample of adults aged 18 – 69.
• STEP 1 (questionnaire) and STEP 2 (physical measures) are conducted in the
household by trained interviewers.
• STEP 3 (biochemical measures) is typically clinic or health centre-based.
• Pocket PCs (PDAs*) are used for data collection: "eSTEPS"
• Repeat survey should be done every 3 - 5 years.
STEPS Methodology

27. From Surveys to Surveillance
• While surveys can be a one off exercise, surveillance involves commitment to data
collection on an on going, repeated basis.
• Repeat surveys are essential to identify trends in the prevalence of risk factors

28. # planning
# in field / data entry
or analysis work
# reporting
completed
Total # active
# trained but
inactive
# with
1 or more
repeats
AFRO 10 18 15 43 (3) 7
AMRO 13 8 1 22 (3) 1
EMRO 2 7 9 18 (1) 7
EURO 1 1 0 2 (0) 0
SEARO 0 2 8 10 (0) 9
WPRO 3 11 11 25 (1) 7
120
Current Status of STEPS

29. STEPS Current Status

30. Global School Based Student Health Survey (GSHS)
Overview & Objectives
• System for surveillance of behavioural risk factors and protective factors in school-aged
children
• Help countries develop priorities, establish programmes, and advocate for resources
• Establish trends in the prevalence of health behaviors and protective factors by country
• Allow countries and international agencies to make comparisons
across countries

31. GSHS: Methods
• Self-administered questionnaire and generic answer sheet
• Targets grades with students aged 13 – 17 years
• Completed by students during one classroom period
• Anonymous and confidential
• 10 Question Modules are available, from which countries can select a minimum of 6:
Alcohol, diet, drugs, hygiene, mental health, physical activity, protective factors, sexual
behaviours, tobacco, violence & injury

32. 106 countries across all six WHO regions have been trained
and 96 have finished GSHS data collection
(including 17 countries with repeat surveys).

33. • The 2007 India (CBSE) GSHS was a school-based survey of students in classes 8, 9,
and 10.
• Measured hygiene; dietary behaviours and overweight; physical activity; tobacco use;
mental health; and protective factors.
• For comparison purposes, only students aged 13-15 years are included in the analyses
for this fact sheet.

34. Service Availability and Readiness
Assessment (SARA)
 A health facility assessment tool designed to assess and monitor service availability and readiness
of the health sector and generate evidence to support planning and managing a health system.
 Designed as a systematic survey to generate a set of tracer indicators of service availability and
readiness, including:
 availability of key human and infrastructure resources;
 availability of basic equipment, basic amenities, essential medicines, and diagnostic capacities; and
 readiness of health facilities to provide basic health-care interventions relating to family planning, child health
services, basic and comprehensive emergency obstetric care, HIV, TB, malaria, and non-communicable
diseases.

36. Comparable estimates for selected NCD Risk
Factors

37. Compiling and storing NCD data

39. NCD SURVEILLANCE INDIA
The growing burden of NCDs represents a major challenge to health development in
India and accurate data are vital to curb the morbidity and mortality due to NCDs.
Two major surveillance studies on NCDs have been conducted in India:
(i) WHO-ICMR NCD risk factor surveillance
(ii)Integrated Disease Surveillance Project (IDSP)

40. WHO-ICMR NCD risk factor surveillance
• Recognizing the lack of a national NCD surveillance system in the country, the
Indian Council of Medical Research (ICMR) planned and coordinated a six-site
pilot study, from 2003 to 2006.
• Ballabgarh and Delhi (North), Chennai (South), Trivandrum (South), Dibrugarh
(East) and Nagpur (Central)
• The WHO STEPwise approach to surveillance of NCDs was adopted.
• The total sample size was 44,537 aged between 15 and 64 years stratified by sex
and 10-year age groups.

41. Key Findings
• Smoking: Smoking was most common among peri-urban/slum men (34.3%) compared to their rural (26.7%) and urban (26.5%) counterparts.
• Alcohol: Alcohol consumption was more prevalent among men. About 33% of urban men, 49.3% of peri-urban/slum men and 40.5% of rural men were
found to be current users of alcohol.
• Physical activity: More than 50% of the urban residents, 41.4% of peri-urban/slum residents and 35% of rural residents had a sedentary lifestyle while
25.4% of rural residents, 14.2% of peri-urban/slum residents and 7.4% of urban residents were involved in vigorous physical activity.
• Fruit consumption: The proportion of subjects who never consumed fruits (in the last week) were 24% in urban, 29% in peri-urban/slum and 41% in rural
area.
• Obesity: Obesity and abdominal obesity were more common in urban residents, followed by peri-urban/slum and lowest among rural residents.
Generalized obesity: Urban (men: 30.7%, women: 38.8%), peri-urban/slum: (men: 16.7%, women: 26.1%) and rural (men: 9.4%, women: 14.1%).
Abdominal obesity: Urban (men: 30.9%, women: 57.8%), peri-urban/slum: (men: 17.9%, women: 41.1%) and rural (men: 12.2%, women: 29.6%).
• Diabetes: Diabetes was diagnosed based on self-reported diabetes diagnosed by a physician. The lowest prevalence of self-reported diabetes was
recorded in rural (3.1%) followed by peri-urban/slum (3.2%) and the highest in urban areas (7.3%).
• Hypertension: The prevalence of hypertension was highest among urban residents (self-reported: 15.1%, newly-diagnosed: 19.3%), followed by peri-
urban/slum (self-reported: 9.9%, newly diagnosed: 20.8%) and rural residents (self-reported: 7.2%, newly diagnosed: 17.4%).

42. Integrated Disease Surveillance Project
NCD – Risk Factor Survey
• The Government of India through the Ministry of Health and Family Welfare (MOHFW) initiated a
decentralized, state based Integrated Disease Surveillance Project (IDSP) in the country with the
assistance of the World Bank in the year 2004.
• The component of non communicable disease surveillance planned periodic community based surveys
of population aged 15-64 to provide data on the risk factors at state level enabling states to develop
strategies and activities to prevent and control the non-communicable diseases.

43. OBJECTIVES AND METHODOLOGY
The specific objectives of the survey were to:
• Assess the prevalence of NCD risk factors in different strata of population in the states.
• Establish a baseline database of NCD risk factors needed to monitor trends in population
health behavior and risk factors for chronic diseases over a period of time in the states; and
provide evidence for evolving strategies and interventions for identified risk factors in the
community to reduce the burden of Non-Communicable Diseases in the population.
• WHO STEPS methodology for NCD Risk Factor Surveillance has been
adopted for the survey.

44. KEY
FINDINGS
The phase I (2007-08) of the survey covered seven states namely Andhra
Pradesh, Kerala, Madhya Pradesh, Maharashtra, Mizoram, Tamil Nadu and
Uttarakhand. • Current daily smokers
• Current smokeless tobacco users
• Respondents consumed alcohol in last 12 months
• Respondents consumed less than five servings of
fruits & vegetables (%) per day
• Type of oil consumption among the households for
cooking (%)
• Mean time spent on physical activity per day (minutes)
• Stage I & II hypertension (%)
• History of raised blood sugar (%)
• Overweight respondents
Overall, NCD risk factors were prevalent across all the socio-economic and demographic categories of
population in phase I states. The results generated through this survey would certainly focus on major
issues in bringing changes or initiate various programs related to control of non communicable diseases.

45. CONCLUSION
• Non-communicable diseases (NCDs) are reaching epidemic proportions worldwide
and in India.
• NCD risk factor surveillance is quite challenging, as the NCDs are chronic diseases
and have prolonged exposure to risk factors and clinical manifestations
• Surveillance of NCD risk factors are therefore needed as they could help in policy
planning and implementation of preventive measures.
• Remember - The risk factors of today are diseases of tomorrow

46. REFERENCES
• Deepa, M., Pradeepa, R., Anjana, R., & Mohan, V. (2011). Noncommunicable diseases risk factor surveillance:
experience and challenge from India. Indian journal of community medicine : official publication of Indian Association of
Preventive & Social Medicine, 36(Suppl 1), S50-6.
• World Health Organization. Global school-based student health survey: India (CBSE) 2007 fact sheet.
• Anand K, Shah B, Yadav K, Singh R, Mathur P, Paul E, Kapoor SK. Are the urban poor vulnerable to non-communicable
diseases? A survey of risk factors for non-communicable diseases in urban slums of Faridabad. National Medical
Journal of India. 2007 Jan 1;20(3):115.
• Riley, L., Guthold, R., Cowan, M., Savin, S., Bhatti, L., Armstrong, T. and Bonita, R., 2016. The World Health
Organization STEPwise approach to noncommunicable disease risk-factor surveillance: methods, challenges, and
opportunities. American journal of public health, 106(1), pp.74-78.
.

47. • World Health Organization. Assessing national capacity for the prevention and control of
noncommunicable diseases: report of the 2017 global survey.
• Mishra US, Rajan SI, Joe W, Mehdi A. Surveillance of chronic diseases: challenges and strategies for
India.
• World Health Organization. Noncommunicable diseases country profiles 2014.
• World Health Organization (WHO). Noncommunicable diseases global monitoring framework 2013.
Geneva: WHO. 2013

48. THANK YOU
“The risk factors of today are diseases of tomorrow”