The magnitude of NCDs is still unknown in Nepal. The ministry of Health and Population, Government of Nepal has not yet formulated policy regarding NCDs in the absence of evidence based finding. The study aims to find out the magnitude of the problem of NCDs in Nepal, thus directing the concerned authorities and at policy level.
Methods
A cross sectional study was performed to find out hospital based prevalence of NCDs, wherein 400 indoor patients of fiscal year 2009 were randomly selected from each of the 31 selected health institutions. It included all tertiary level health institutions of the regional and sub regional hospitals, zonal hospitals, specialized hospitals of cancer and heart diseases and medical colleges. In case of Kathmandu Valley one central hospital, one medical college and one private hospital were randomly selected. Indoor patients, 35 years or older were included in the study. Univariate analysis was carried out using frequencies and percentages.
Results
The study revealed that there were 36.5% of the cases diagnosed with any of the four NCDs (heart diseases, COPD, diabetes and cancer). Breast, cervix and ovarian cancer are the main cancers at national level accounting for 44% of distribution. Majority of the cases were of HTN (47%) followed by CVA, CCF, IHD, RHD and MI. Females and advantaged Janajatis (ethnic group) were found to be having higher proportion of NCDs in their respective groups.
Conclusion
The study was able to reveal that Nepal is also facing the surging burden of non communicable diseases similar to other developing nations of south East Asia. Unless comprehensive and sector wide intervention strategies are planned and implemented effectively, this problem is going to upsurge more.
Sector wise recommendation was provided in the study.
Keywords: Non-communicable diseases, Nepal, Cross-sectional study
Background
Non-communicable diseases (NCDs) refer to diseases or conditions that occur in, or are known to affect,individuals over an extensive period of time and for which there are no known causative agents thatare transmitted from one affected individual to another.[1]The risk factors for many of the NCDs are associated with lifestyle related choicesenvironmental and genetic factors. Tobacco use, harmful use of alcohol, unhealthy diets (high in salt, sugar and fat and low in fruits and vegetables)and physical inactivity are some of the established behavioral risk factors of NCDs.
NCDs have emerged as the major causes of morbidity andmortality worldwide. According to World Health Organization, in 2008, out of 57 million global deaths, 36 million or 63% were due toNCDs, principally cardiovascular diseases or CVDs (17 million deaths, or 48%of NCD deaths), cancers (7.6 million, or 21% of NCD deaths), respiratory diseases, includingasthma and chronic obstructive pulmonary disease (COPD), (4.2 million) and diabetes(1.3 million deaths).[2]These diseases have been the leading cause of death in high-income countriesover the last fifty years, and they are emerging as a leading cause of death in low and middleincome countries. [3]Nearly 80% of NCD deaths occur in low-and middle-income countries and NCDsare the most frequent causes of death in most countries, except in Africa.[2]
Chronic diseases are largerproblem in low-income settings, as double burden of infectious as well as chronic diseases are straining their health services. [4, 5]In South Asia, which has onequarter of the global population but where about halfthe population lives below the poverty line and haslimited access to health care, almost half of the adult burden ofdisease is attributable to NCDs. [6]According to national reports gathered by WHO's South East Asia regional office, of the totaldeaths in South Asia, the proportion attributable to NCDs ranged from about 7% in Nepal to 40% inthe Maldives in 1998. [7] In Sri Lanka the 1999 census report records diabetes prevalence as 8% inrural areas and 12% in urban areas; [8] equivalent current rates for Nepal have been reported as 3% and15% respectively. [9]
In Nepal, prevalence of CHD in eastern region was 5.7% in 2005. Similarly prevalence ofhypertension was 22.7% in Dharan municipality. [10]Various studies have shown that the prevalence ofhypertension in adult population was around 20% in urban population [11]According to the data of 'Sunsari Health Survey' of the year 1993, theprevalence of diabetes and hypertension in Sunsari District, from eastern Nepal, was about 6%and 5.1% respectively in adults. [12] A more recent data from an urban area has shown the prevalenceof diabetes and impaired fasting glucose as 14.2% and 9.1% respectively.[13]
At least 80% of heart disease, stroke, and type 2 diabetes, and 40% of cancer could be avoided through healthy diet, regular physical activity, and avoidance of tobacco use. [14] However, the growing global burden ofNCDs in poor countries and poor population has been neglected by policy makers, majormultilateral and bilateral donor agency and academics [15].Cost effective interventions to reduce chronic disease risks exist, and have worked in manycountries. [14]
Nepal is one of the poorest countries in the world - at 157thposition of Human Development Index. [16]The magnitude ofNCDs is still unknown. The ministry of Health and Population (MoHP), Government of Nepal hasnot yet formulated policy regarding NCDs in the absence of evidence based finding. Thus it isimportant to address the burden of NCDs through research.
For this purpose initially hospital based prevalencedata generated from the regional, sub-regional, zonal and specialized centers across the country wastargeted. This study was expected to provide a baseline data on magnitude of the NCDs in Nepal. It aims to find out the magnitude of the problem of NCDs in Nepal, thus directing theconcerned authorities and at policy level.
Methods
It was a cross sectional study to identify thehospital based prevalence of 4 NCDs (cancer, heart diseases, diabetes mellitusand COPD).Thirty one health institutions (central, regional, sub-regional, zonal hospitals, medical colleges andspecialized centers) were selected from the five developmental regions. In Nepal, most of the cases of NCDs are treated in the tertiary level health institutions like central, regional,sub-regional, zonal, specialized hospitals and medical colleges. District level hospitals have fewfacilities for the diagnosis and treatment of NCD cases so they refer these cases to tertiary levelhealth institutions. Taking these issues into account, we selected all the tertiary level health institutions to calculatethe hospital based prevalence of NCDs. All specialized centers (Bhaktapur Cancer Hospital, Bharatpur Cancer Hospital and Sahid Gangalal National Heart Center)were also selected to identify the prevalence of different types of cancer and heart diseases inNepal.In case of Kathmandu valley, three health institutions- one central hospital, onemedical college and one private hospital were randomly selected for this study using lottery method.
This study was conducted over the period of eight months from December 2009 to July 2010. Indoor patients, 35 years or older were included in the study. This study included only the indoor patientsof the selected hospitals because hospitals maintain detailed case records of indoor patients only and theywere easily accessible for the study.
Sample size was calculated on the basis of prevalence (40%) of NCD with12% allowable error (95% CI). The sample size calculated was 384.This figure was rounded so that 400 cases were randomly selected from each selected health institution. During this process, the hospital records were reviewed to obtain the information regarding the total number of indoor cases registered in the year 2009. Then cases were selected using computer generated random numbers (Ms-Excel 2007)until the required sample size of 400 was reached. If the selected case did not fulfill the inclusion criteria, then immediate next number was taken as a case. Details like IPD number, age,sex, ethnicity, address and diagnosis were then obtained.Checklist and data compilation forms were used for this purpose.
The study was approved by the ethical review board of Nepal Health Research Council. Formalpermission was obtained from the concerned authorities of the selected health institutions. Confidentiality was maintained.
Data obtained were coded and entered inMs-Excel 2007. The data base was then exported to SPSS (ver. 11.5) for analysis.Univariate analysis was carried out using frequencies and percentages.
Results
This study was conducted in 31 health institutions (Regional, Sub Regional, Zonal, medical colleges, specialized centers and central hospital) of Nepal for the purpose of identifying the hospital based prevalence of non communicable diseases.
The total number of patient admitted to these hospitals in fiscal year 2009 was 3, 47,261, out of which 11,907 cases were randomly selected. The number of cases selected from the health institutions ranged from 350 - 400.
Proportion of NCDs at the National level
Altogether 11,907 cases were selected from the 31 health institutions including specialized centres. Among them 36.5% (4,343) werecases of NCDs. (Figure 1)
Proportion of various NCDs at the National level
The proportion of heart diseases was higher than other NCDs. Out of the total (4343) NCD cases, heart diseases constituted 38%. COPD was the second leading disease (33%) where as diabetes and cancer was10% and 19% respectively. (Figure 2)
Distribution of NCDs by age groups
Majority of the patients were from 35-50 years followed by 51-65 years. Proportion of NCD cases was found to be higher in the age group > 80 years and followed by 66-80 years.(Table 1)
Distribution of various NCDs among age groups
Proportion of CVD and cancer was found to be higher in the age group 35-50 years. Similarly, COPD and DM were found to be higher in age group above 80 years and 51-65 years respectively. (Table 2)
Distribution of NCDs by ethnic groups
Ethnicity of cases was classified in seven groups according to the government classification of ethnicity. Most of the patients were from upper caste groups followed by disadvantage Janajati population while very few were from religious minorities. The proportion of relatively advantagedJanajati suffering from NCDs was higher than other ethnic groups.(Table 3)
Distribution of various NCDs among ethnic groups
The proportion of relatively advantaged Janajati was found to be suffering more from heart diseases, diabetes and cancer (22.33%, 5.16% and 14.73% respectively) while dalit suffered more from COPD which was reported 16.97 %.( Table 4)
Distribution of NCDs by sex
Among the total sample population female population was higher than male population. Similarly proportion of female was found to be suffering more from NCDs in comparison to male. (Table 5)
It was found that among different NCDs, there were more males suffering from heart diseases and COPD than female and females suffered more from DM and cancer than male. (Table 6)
Distribution of NCDs by developmental regions
Most of the study population was from Central Development Region followed by western Development Region whereas comparatively few from Far Western Development Region. Similarly proportion of NCDs was found to be higher in CDR and WDR. (Table 7)
Distribution of various NCDs among developmental regions
The study revealed that people from WDR were found to suffer more from heart diseases and DM which account for 44.93% and 11.25% respectively. Similarly people from FWDR and MWDR were found to be suffering more from COPD (55.5 % and 50.5%) and EDR from cancer (31.46%). (Table 8)
Discussion
Our study revealed that, out of the 3,294 NCD cases, majority of the cases (43%) had COPD and 40% had heart diseases followed by DM (12%) and Cancer (4%). The reason behind such a high proportion of COPD cases could be due to the use of traditional cooking stoves and combustion of solid biomass fuels (animal dung, crop residue, and wood) which are the main sources of indoor air pollution. The consumption of non filtered cigarettes could be another reason for the high prevalence of COPD. According to the WHO report on Non Communicable Diseases in South East Asia Region, according to the hospital based study COPD is leading NCD followed by CVD, cancer and diabetes in Nepal [17].
Most of the patients suffering from non communicable diseases in this study belonged to the age group 35-65 years.It is obvious from most of the reports that this age group suffered more from NCDs and hence the inclusion criteria was involving individuals >35 years. The report released by Mauritius on Non Communicable Diseases indicated the most commonly affected age group as 25-74 years[18]. It seems the productive age group are mostly affected and have indirect impact on productivity and economic growth of the country as a whole. The ethnic distribution of the disease showed higher proportion of advantaged Janajati (52.34% out of the total advantaged Janajati cases) to be suffering from NCDs. Female population (52.47%) was found to be higher in proportion of NCDs [19]. Among the developmental regions of Nepal, Central Development region (CDR) has almost half of the total cases of NCDs. This might have been influenced by the fact that most sophisticated hospitals are in Kathmandu (which lies in CDR) and which compels most of the people to seek health care from the hospitals of Kathmandu.
The study revealed that breast, cervix and ovarian cancer are the main cancers at national level accounting for 44% of distribution which suggests that the female is more vulnerable to these cancers. A hospital based retrospective study conducted in two hospitals namely Bhaktapur Cancer Care Center and Om Hospital and Research Center had also reported similar trends. It was observed that female (56.4 %) had more number of cases of cancer than male and accounted for about 43.5% of the total cases of malignancy. Top five malignancies included: breast (17.31%), lung (17.03%), NHL (Non-Hodzkin's Lymphoma) (8.38%), stomach (7.54%) and ovarian (7.54%) cancers respectively. It was found that stomach and lung cancer is the most common cancer that occurs in digestive and respiratory system respectively, NHL in the lymphatic system and breast cancer in female reproductive system [20]. Higher prevalence of hypertension (47%) followed by CVA, CCF, IHD, RHD and MI is similar as that of WHO report in Non Communicable Diseases in South East Asia Region which has showed the highest number of cases of rheumatic heart disease followed by stroke and IHD in Nepal[21].
A number of studies conducted in India have shown a significant association with a low intake of fruits and vegetables and the risk of non communicable diseases. It has been estimated that 2.7 million lives could be potentially saved if the consumption of fruits and vegetables were sufficiently increased[22].
Our study revealed that heart diseases is more likely to occur in those who have habitual consumption of saturated oils where as American Journal of Clinical Nutrition states that diets rich in vegetables and use of mustard oil could contribute to the lower risk of IHD among Indians[23]. Similarly, in a study done in IHD showed that a maximum number of the respondents (63.8%) used refined vegetable oil for cooking followed by mustard oil usage by 21% which contain significant level of poly unsaturated fatty acids shown to be protective against coronary artery disease [24].
Hence, the findings observed in the present study point toward an urgent need of developing strong community-based intervention programs to address the increasing burden of these diseases.
Conclusion
This cross sectional study was carried out to estimate the hospital based prevalence of non communicable diseases. It was able to reveal the evidence of problem of NCD Nepal is facing.
This hospital based cross sectional study revealed that there were 36.5% of the cases diagnosed with any of the four NCDs (heart diseases, COPD, diabetes and cancer) in the fiscal year 2065/66. Breast, cervix and ovarian cancer are the main cancers at national level accounting for 44% of distribution. Majority of the cases were of HTN (47%) followed by CVA, CCF, IHD, RHD and MI. It reflects that Nepal is also facing the surging burden of non communicable diseases similar to other developing nations of south East Asia.
In conclusion, the magnitude of non communicable disease is substantial in Nepal and is regarded as a public health problem. Although evidence for the pandemic of non communicable chronic diseases is irrefutable, as also seen in this study, there is a paucity of program to detect, manage and prevent these diseases in Nepal. The governmental, non-governmental and community based organizations are still fighting to tackle the burden of infectious diseases. Unless urgent and specific focus on preventing, treating and control of NCDs are targeted, the burden of the NCDs will be unbearable to the poor nation like Nepal. This study had provided a background data on NCD and the concern organizations should focus and contribute in the prevention, control and reduction of NCDs burden and its risk factors.
Recommendations
Given the complex causality of NCDs, its prevention requires an integrated action across a range of sectors at local, regional and national levels. Each individual sector can perform a specific role to contribute from their level. Health care and public health must play a fundamental role in providing care and support for the patients but also in applying the unique public health models to prevent the associated risk of NCDs.
Recording and Reporting System
Poor recording system was observed in most of the hospitals. There was no uniform format to record the patient's details. Various characteristics of the patients such as caste, address and even diagnosis were not clearly written on record book in many hospitals' inpatient register due to which, it became difficult to get the information concerning patient and the diagnosis.
Some of the medical colleges and government hospitals used computer based software to record the patients' data, but the software and format differ from hospital to hospital. So there is an immense need of uniform recording and reporting format and if possible the data should be maintained in an electronic version. Data based system should be established to centralize the data and to properly maintain the data at different level of health system.
Ministry of Health and Population
Ministry of Health could develop priority based infrastructures and modules to prevent and control the NCDs at different stages. It should develop a national level policy and plan of action for good planning and implementing the collaborative action between the health sector and other donor agencies to emphasize on clinical as well as preventive measures for the control of NCDs.
Capacity building programs to the medical personnel like in service training should be provided to update the knowledge and to promote the skills.
Most of the health institutions especially in rural part of the country, lack efficient and new technology along with the expert manpower due to which the patients are forced to move to the urban areas for quality health care. Ministry should establish non communicable disease center at each development region so that people of rural area also can enjoy the quality health services.
It should establish the surveillance system of NCDs as like other disease surveillance or need to establish the integrated surveillance system. There is important role of surveillance for NCDs inthe Region which can prompt the countries to establish sustainable databases forNCDs and their risk factors. This would greatly facilitate in policy development and planning for NCD prevention and control.
Advocacy campaigns such as awareness raising programs, street dramas, concerts should be conducted for the general people on how to prevent from the risk of developing NCDs. The Involvement of the public figures at the local and national media in these events can boost the impact.
Population level
Health is an individual issue and initiation from an individual level should be done to be free from NCDs. NCDs result from genetic, behavioral and environmental factors and the interactions between them.
At the population level, a high prevalence of risk factors at community level can be reduced by developing healthy life style which includes healthy dietary intake (less intake of fried, oily, junk food), regular physical activity, low intake of salt, caloric balance, psychological stress etc. Alcoholic and smoking habit are the associated detrimental factors that are responsible for different types NCDs so such habits should be restrained. Children should be encouraged to amend the healthy life styles and behaviors to promote health in order to reduce the burden of NCDs in the next generation.
