structure to amphetamine and adrenaline (epinephrine). Regular Khat use is associated with a rise in arterial blood pressure and pulse rate, corresponding with levels of cathinone in the plasma. Moreover, regular Khat chewers have gingivitis and loose teeth, but there appears to be no convincing unusual incidence of oral cancer. Among Khat users in Yemen there is, however, a higher incidence of oesophageal cancer compared with gastric cancer. Long term use or abuse can cause insomnia, anorexia, gastric disorders, depression, liver damage and cardiac complications, including myocardial infarction. Manic and delusional behaviour, violence, suicidal depression, hallucinations, paranoia and Khat-induced psychosis have also been reported. On the basis of the scientific data it seems clear that Khat use has negative consequences on the economic development of a country and on the health of societies (Getahun &
Krikorian 1973:374; Balint 2009:608).
1.5 THE WHO STEPS APPROACH
The basis of NCD prevention is the identification of the major common risk factors and their prevention and control. WHO recommends that, where resources are available, data on diseases (for example, heart disease, stroke, cancer) be included in the surveillance process. Such information is also important in assisting health services plan and determine public health priorities. From a primary prevention perspective, surveillance of the major risk factors known to predict disease is an appropriate starting point (Labarthe 1999:75). A well-functioning NCD surveillance system is an integral part of public health. As part of the wider health information system, surveillance provides information for better decision-making in countries. The use of the information determines the data collected and the speed necessary for the information flow within the system. The WHO STEPS document by Bonita, Beaglehole and Kjellström (2001:1022) argues for NCDs surveillance as an essential national public health function. The goal of the WHO global NCDs surveillance strategy is to provide standard methods and tools to enable countries to build and strengthen their capacity to conduct surveillance. The underlying framework is an integrated, systematic approach aimed at sustainable national collection of data on NCDs and their risk factors. This process enables countries to use the collected data for decision-making. The STEPs approach
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is based on the concept that surveillance systems require standardized data collection to ensure comparability over time and across locations. It is also sufficiently flexible to be appropriate in a variety of country situations and settings. The STEPwise approach, therefore, allows for the development of an increasingly comprehensive surveillance system, depending on local needs and resources. While the STEPS approach can be similarly applied to disease-specific mortality and morbidity, the focus of the first STEPS document (Bonita et al 2001:1023) is its implementation for key NCDs risk factors. This is in recognition of the fact that ongoing surveillance of even major diseases such as heart attack and stroke are complex, costly, and difficult to achieve on an ongoing basis.
Similarly, while national registration of deaths is undertaken routinely in many countries, this is not the case in many developing countries. Although there are several non-modifiable risk factors, emphasis of surveillance of factors associated with NCDs is given to those amenable to intervention (Stamler, Stamler, Neaton, Wentworth, Daviglus, Garside, Dyer, Liu & Greenland 1999:2015; Engström, Jerntorp & Pessah-Rasmussen 2001:1101). Surveillance of the eight selected risk factors which reflect a large part of future NCDs burden can provide a measure of the success of interventions.
For example, inappropriate diet and physical inactivity – resulting in high body mass index, raised blood pressure and unfavourable blood lipids – together with tobacco use, explain at least 75% of cardiovascular disease (Magnus & Beaglehole 2001:2659).
Various literatures showed that the burden of NCDs preventable risk factors is increasing in low and middle income countries. The WHO has therefore devised a tool to strengthen the surveillance system of NCDs and the related risk factors in these countries. The tool can also be used as a survey questionnaire by adopting it to the country’s situation (WHO 2005:23). STEPS is a sequential process, starting with gathering information on key risk factors by the use of questionnaires (Step 1), then moving to simple physical measurements (Step 2), and only then recommending the collection of blood samples for biochemical assessment (Step 3).Each STEPS has all three components namely core, expanded and optional. The core component cannot be left out. This approach is flexible based on the country’s situation (WHO 2008:50).
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In conclusion, the fact that studies conducted in Ethiopia to date are very few and majorly concentrating in the capital city Addis Ababa and its surrounding made the availability of the information on NCDs and their risk factors extremely limited. Thus it is believed that this study explores the epidemiology of preventable risk factors of NCDs, knowledge, perceptions, attitudes and behaviours on risk factors and determinants of hypertension among the adults inTigray. This will ultimately help policy makers to focus on NCDs and design strategic plan to address the prevention of these diseases.
Underlying factors Primary risk factors Intermediate risk factors Outcome
Figure 1.1 a conceptual framework of NCDs and the risk factors Globalizati
on and Urbanizati on
Social Factors:
Income/Economi cal,
Environment, cultural factors, Health Care, Policy,
knowledge and perceptions
Physical Inactivity
Reduced intake of Fruits and vegetabl es Misuse of Alcohol
Tobacco use
Khat Chewing
Raised Blood pressure
Overwei ght and Obesity
Raised cholesterol and Triglyceride s
Raised Blood sugar
Chronic Non-communicable Diseases like Cardiovascular Diseases, Diabetes etc.
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Table 1.1 Risk factors common to major NCDs (WHO 2001:10) Risk factors Conditions
CVD* Diabetes Cancer Respiratory conditions**
Smoking ✓ ✓ ✓ ✓ Alcohol ✓ ✓
Nutrition ✓ ✓ ✓ ✓ Physical inactivity ✓ ✓ ✓ ✓ Obesity ✓ ✓ ✓ ✓ Raised blood pressure ✓ ✓
Blood glucose ✓ ✓ ✓ Blood lipids ✓ ✓ ✓
* Heart disease, stroke, hypertension. **Chronic-obstructive pulmonary disease and asthma