Ahmed et al. BMC Public Health (2019) 19:878 https://doi.org/10.1186/s12889-019-7101-x RESEARCH ARTICLE Open Access The prevalence of selected risk factors for non-communicable diseases in Hargeisa, Somaliland: a cross-sectional study Soheir H. Ahmed1,2*, Haakon E. Meyer2,3, Marte K. Kjøllesdal2, Niki Marjerrison2, Ibrahimu Mdala2, Aung Soe Htet4, Espen Bjertness2 and Ahmed A. Madar2 Abstract Background: Non-communicable diseases (NCDs), particularly cardiovascular diseases, diabetes, respiratory conditions and cancers, are the most common causes of morbidity and mortality globally. Information on the prevalence estimates of NCD risk factors such as smoking, low fruit & vegetable intake, physical inactivity, raised blood pressure, overweight, obesity and abnormal blood lipid are scarce in Somaliland. The aim of this study was to determine the prevalence of these selected risk factors for NCDs among 20–69 year old women and men in Hargeisa, Somaliland. Methods: A cross-sectional study was conducted in five districts of Hargeisa (Somaliland), using the STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) to collect data on demographic and behavioral characteristics and physical measurements (n =1100). The STEPS approach is a standardized method for collecting, analysing and disseminating data on NCD risk factor burden. Fasting blood sugar, serum lipids (total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides) werecollectedinhalfoftheparticipants. Results: The vast majority of participants had ≤1 serving of fruits daily (97.7%) and ≤ 1 serving of vegetables daily (98.2%). The proportion of participants with low physical activity levels was 78.4%. The overall prevalence of high salt intake was 18.5%. The prevalence of smoking and khat chewing among men was 27 and 37% respectively, and negligible among women. In women, the prevalence of hypertension increased from 15% in the age group 20–34 years to 67% in the age group 50–69 years, the prevalence of overweight and obesity (BMI ≥ 25 kg/m2) from 51 to 73%, and the prevalence of diabetes from 3 to 22%. Similar age-trends were seen in men. Conclusion: Most of the selected risk factors for noncommunicable diseases were high and increased by age in both women and men. Overweight and obesity and low physical activity needs intervention in women, while hypertension and low fruit and vegetable consumption needs intervention in both men and women. Somaliland health authorities should develop and/or strengthen health services that can help in treating persons with hypertension and hyperlipidaemia, and prevent a future burden of NCDs resulting from a high prevalence of NCD risk factors. Keywords: STEPs survey, Prevalence, Non-communicable disease risk factors, Somaliland * Correspondence: [email protected] 1College of Medicine & Health Science, University of Hargeisa, Hargeisa, Somaliland 2Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ahmed et al. BMC Public Health (2019) 19:878 Page 2 of 10 Background Methods Epidemiological and demographic transitions are in Study design and sampling progress in low- and middle-income countries [1], A cross-sectional study was carried out in Hargeisa (cap- leading to an increasing burden of non-communicable ital of Somaliland) according to the WHO STEPwise ap- diseases (NCDs). According to the World Health proach to chronic disease risk factor surveillance [18], Organization (WHO), the main types of NCDs are between March and September 2016. The STEPS ap- cardiovascular diseases (CVDs), cancer, chronic pul- proach is a standardized method for collecting, analysing monary obstructive disease (COPD) and diabetes [2]. and disseminating data on NCDs and their risk factors’ These NCDs caused 39.8 million global deaths in burden [18]. We included all three STEPS: STEP (1) 2015 [3]. Nearly three-quarters of all NCDs deaths Questionnaire survey, including the socio-demographic and the majority of premature deaths occur in low- characteristics, behaviours and dietary habits, and his- and middle-income countries and before the age of tory of hypertension and diabetes; STEP (2) Physical 70 years [4]. NCDs such as CVDs are a primary measurements, including anthropometric measurements health concern and a major cause of morbidity and and blood pressure, and STEP (3) A laboratory investiga- mortality worldwide [5]. tion of fasting blood glucose and fasting lipid profiles. Behavioural and metabolic risk factors both contribute The STEPS survey has not been validated among So- significantly to NCDs. They are often interrelated and malis, but it has been pilot tested in the study setting. include unhealthy diet, insufficient physical activity, Before the inception of the study, two study teams smoking, excessive use of alcohol, raised blood pressure, were selected and underwent three days of training be- overweight and obesity, and abnormal blood lipid levels fore the study implementation. A pilot study was con- [6, 7]. Raised blood pressure, dyslipidaemia and smoking ducted in 20 households and it did not lead to any account for the majority cause of heart attack and modification of the questionnaire or measurement pro- strokes [8, 9]. Further, sociodemographic factors such as cedures (weight, height, waist and hip circumference age, gender and education have been associated with in- and blood pressure). The selection criteria were women creased NCDs risk [10]. and men aged 20–69 years. Exclusion criteria were con- Somaliland (formerly North Somalia) has a population firmed pregnancy or those diagnosed with terminal or estimated at 4.5 million people, of which approximately incapacitating illnesses. 53% resides in urban areas [11]. Health indicators for Due to the lack of data on the prevalence of the se- Somaliland are among the worst in Sub-Saharan Africa lected risk factors on the population under study, the (SSA), with key issues being related to poor governance sample size was calculated using the diabetes prevalence and inadequate financial resources [12]. Data about of 4% [19]. There is no population registry in NCDs and their risk factors in this region are scarce. We Somaliland, and the only available registry is the number have previously reported that the prevalence of over- of households. Each household has a unique number. weight and obesity was significantly higher among Hargeisa city composes of five major districts, of which Somalis in Oslo, Norway compared to Hargeisa, each district is further subdivided into four main subdis- Somaliland [13], and according to the Ministry of Health tricts. The sample design for the survey was two-stage of Somaliland, unhealthy lifestyle, including physical in- cluster sampling and the 20 subdistricts were the pri- activity, smoking and chewing khat, has led to an in- mary sampling unit (PSU) (first stage). Out of the twenty crease in NCDs [14]. Urbanization has been identified as PSUs, ten were randomly selected and at the second a root cause of the increasing prevalence of NCDs and stage, 1100 households were randomly selected from the their risk factors in sub-Saharan Africa [15]. In Hargeisa, ten subdistricts based on the probability proportionate the urban society might have adopted a new sedentary to size (PPS) in each subdistrict. lifestyle and the return of the diaspora might bring nega- In each selected household, all eligible individuals aged tive aspects of Western lifestyles, increasing the popula- 20–69 years living in the house were listed in a Kish grid tion’s risk of NCDs [14]. Insight into the prevalence of [20]. The Kish method addresses the selection of gender selected risk factors for NCDs in Somaliland is import- and different age groups in the sample. Men and women ant, as the country is currently undergoing rapid were listed in order of decreasing age and given a rank urbanization and epidemiological transitions [16, 17]. A number. If the selected person rejected participation, the rise in NCDs and their risk factors will add a high bur- next person on the Kish grid was selected until there den to an already pressed health system due to infec- was one person from each household participating in tious diseases. The aim of the present study is to the study. If there was nobody at home on the day of the determine the prevalence of selected risk factors for study, a notification letter was left at the door, and we NCDs among 20–69 year old women and men in returned the next day until we had a participant from Hargeisa, Somaliland. each house. None of the randomly selected households Ahmed et al. BMC Public Health (2019) 19:878 Page 3 of 10 were empty or refused to participate in the study and we NS-EN ISO 15189 TEST 209. The inter-assay coefficients included one person from each of the randomly selected of variation were 1.3% (TC), 1.6% (LDL-cholesterol), 1.8% 1100 households. A total of 195 eligible men were se- (HDL-cholesterol), and 3.8% (TG). Total cholesterol, lected. However, 50 men either refused or could not LDL-cholesterol, HDL-cholesterol, and TG were mea- meet after several contacts, resulting in 74.3% (145/195) sured using an enzymatic method (ADVIA 2400 Siemens) of the invited men to be included in the study. Among . women only three refused to participate, which means 99.7% (955/958) of those invited then participated.