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Research/Recherche Research/Recherche Distribution and prevalence of major risk factors of noncommunicable diseases in selected countries: the WHO Inter-Health Programme X. Berrios,1 T. Koponen,2 T. Huiguang,3 N. Khaltaev,4 P. Puska,5 & A. Nissinen2 on behalf of the Inter-Health sites6 The Inter-Health Programme was launched in 1986 by WHO, with the collaboration of a coordination centre (National Public Health Institute, Finland) to control and prevent chronic noncommunicable diseases (CNCDs) among adults. Programmes for action were organized based on the concept that most major CNCDs share common risk factors and that those that are lifestyle related are modifiable through efficient interventions using multifactorial strategies involving community participation and behaviour changes carried out at the primary health care level. Twelve countries from all WHO Regions have joined the programme. A baseline survey was undertaken in all countries with a common protocol, following the criteria and methods employed in the MONICA Project. Altogether 36815 men and women aged 35-64 years were included in the present analysis from the following Inter-Health countries: Chile, China, Cyprus, Finland, Lithuanian SSR, Malta, Mauritius, Russian SFSR, United Republic of Tanzania, and USA. In addition to individual country analysis, centralized analysis was carried out at the Finnish National Public Health Institute and the Department of Community Health, Kuopio University, Finland. Reported here are the mean values of blood pressure, body mass index, and serum total cholesterol as well as specific prevalences of smoking, hypertension, obesity, and hypercholesterolaemia. Department of Public Health, Catholic University of Chile, Introduction Santiago, Chile. 2 Department of Community Health and General Practice, Univer- Important demographic changes have taken place in sity of Kuopio, FI-70211 Kuopio, Finland. Requests for reprints recent decades in developing countries. These are should be sent to Professor Nissinen at this address. highlighted by a decrease in fertility rates and an 3 Food Safety Control and Inspection Institute, Tianjing, China. important and steady reduction in infant and mater- 4 Acting Chief, Noncommunicable Diseases, World Health Organi- nal mortality, communicable diseases, and general zation, Geneva, Switzerland. These changes have resulted in an in- 5 Division of Health and Chronic Diseases, National Public Health mortality. Institute, Helsinki, Finland. crease in life expectancy at birth as well as in the 6 Dr V. Grabauskas, Kaunas Medical Academy, Kaunas, Lithua- absolute number and percent of adult populations nia; Dr A. Vassallo, Department of Health, Palazzo Castellania, (1, 15). This process of ageing of the population, Valletta, Malta; Dr C. Komodiki, Department of Medicine and Pub- termed demographic transition, is in progress today, lic Health Services, Ministry of Health, Nicosia, Cyprus; Dr R.G. Oganov, National Centre of Preventive Medicine, Moscow, Rus- although the particular rate varies according to sian Federation; Dr J.W. Farquhar, Stanford Center for Research country (2). in Disease Prevention, Stanford University School of Medicine, In developing countries, health patterns have Palo Alto, CA, USA; Dr Guo Zeyu, Bureau of Public Health, been strongly influenced by these changes: most of Tianjing, China; Dr Chen Chuming, Chinese Academy of Preven- tive Medicine, Beijing, China; Dr H.M. Kitange, Regional Commis- them exhibit a health profile characterized by a sioner's Office, Ministry of Health, Government Regional Hospital, transition from a predominance of mortality from Morogoro, United Republic of Tanzania. infectious and parasitic diseases that are more preva- Reprint No. 5758 lent among younger age groups, to mortality from Bulletin of the World Health Organization, 1997, 75 (2): 99-108 © World Health Organization 1997 99 X. Berrios et al. chronic noncommunicable diseases (CNCDs), more Materials and methods prevalent among the adult and elderly population, with persistence of trauma (3). This transition is pro- ducing a double burden of diseases in developing Study design countries: the emergence of CNCDs when communi- Based on the recommendations contained in the cable infectious diseases have not yet disappeared. core protocol, a quasi-experimental design was used, CNCDs and injuries, also termed lifestyle dis- selecting intervention and reference populations eases (4, 5), are a challenge for public health bodies, (16, 17). The effects of intervention activities were not only in industrialized countries, but also in devel- assessed by examining changes in the status of risk oping countries all over the world. These diseases factors in these two populations before and after are, however, preventable, and premature deaths the intervention. For this purpose, baseline and can be avoided if efficient interventions are made on terminal cross-sectional prevalence surveys were the risk factors associated with them through the employed. promotion of healthy lifestyles. Decades of research have provided the experience and the knowledge to reduce considerably their burden (6-10), and the Study population role of serum total cholesterol, hypertension, and The study population consisted of people living in an smoking in their development was established in the intervention (experimental) and in a reference (con- 1960s and 1970s (11, 12). trol) area, both of which fulfilled specially defined As a result, in 1986 WHO initiated a global pro- characteristics (18). This article covers 10 of the 12 ject for developing countries based on an integrated Inter-Health countries. programme approach (5, 13, 14), i.e. diseases with Local study populations were selected randomly common risk factors should be approached using a from entire populations using the MONICA Project common strategy of health promotion and provision recommendations (18). The sampling frame con- of preventive health services. The outcome was the sisted of individuals of both sexes aged 35-64 years, establishment of the WHO Inter-Health Pro- ensuring that at least 200 people were represented in gramme, whose aim was to demonstrate how such each 10-year age group. The characteristics of the integrated programmes could be implemented in study populations in the various participating coun- populations in all regions of the world, at every stage ties are shown in Table 1. of the demographic and epidemiological transition Since this article primarily reports the status of (15). The core of the programme consists of inter- risk factors in the Inter-Health countries, but does ventions aimed at modifying the levels of the major not evaluate the intervention activities, samples risk factors of CNCDs in the community through an from intervention and reference populations, when integrated, community-oriented approach to health available, were combined for the analysis. The size of promotion and maintenance (5, 13, 14, 16, 17). samples range from 959 in Stanford, CA, USA, to Table 1: Characteristics of the study populations, by programme area, year, and sex Men Women Response Country Centre Period (n) (n) Total rate(%) Group 1 Finland North Karelia, Kuopio 1982 2123 2230 4353 87.1 Lithuanian SSR Kaunas 1983-85 728 735 1463 69.2 Malta Malta 1985 630 672 1 302 64.3 Cyprus Nicosia 1989-90 458 540 998 78.9 Russian SFSR Moscow 1984-85 1940 1889 3829 72.4 USA Stanford 1979-80 435 524 959 68 Group 2 Chile Santiago 1987-88 185 336 521 87.2 China Beijing 1989 2723 3046 5769 89.2 China Tianjing 1989 5771 5877 11648 92 Mauritius Port Louis 1987 1402 1 562 2964 86.2 United Republic of Tanzania Morogoro, Kilimanjaro 1987-88 1368 1 641 3009 89 100 WHO Bulletin OMS. Vol 75 1997 WHO Inter-Health Programme 11 648 in Tianjing, China. The response rate varied (SBP) ¢160mmHg (:21.26kPa) and/or diastolic from 64.3% in Malta to 92% in Tianjing, China blood pressure (DBP) :95mmHg (:12.7kPa). (Table 1). Serum lipids. Total serum cholesterol was the mini- mum obligatory parameter to be measured. The Data collection and survey methods guidelines for processing samples followed the In the developed countries (Finland, Lithuanian MONICA Project recommendations (18). Fresh SSR, Malta, Russian SFSR, and USA) the data were blood samples were used for total cholesterol collected over the period 1979-85, but in Cyprus determinations at local sites. The samples were pro- over the period 1989-90, while in the developing cessed within 24 hours of being collected. Aliquots countries (Chile, China, Mauritius, and United Re- were also separated and sent to reference laborato- public of Tanzania) the corresponding period was ries for external quality control. 1987-89. The following risk factors were covered: smoking, alcohol intake, blood pressure, serum Data processing and statistical analysis lipids, obesity, physical inactivity, diet, and environ- mental risk factors. Information on educational, The data were analysed at the Department of Com- level, occupation, socioeconomic status, vital statis- munity Health and General Practice, University tics, social support, availability of health services and of Kuopio, Finland, using the SPSS/PC+ statistical morbidity data were also collected. Criteria for sur- package. Absolute and relative frequency distribu- vey procedures and techniques were based on those tions of the variables selected for the analysis were used in the WHO MONICA Project (18). Because obtained. Ages were adjusted using the new stan- this methodology has been extensively described dard world
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