Public Policies and Health Promotion Actions

for the Prevention and Control of Non-

Communicable Diseases (NCDs)

Prof. dr. Mohammad Hakimi, SpOG(K), PhD.

Departemen Obstetri-Ginekologi
Fakultas Kedokteran UGM/RSUP Dr. Sardjito
 Terminology
• Part of the confusion that surrounds chronic
diseases is that they appear under different
names in different contexts.
• Sometimes the term “non-communicable
diseases” is used to make the distinction from
infectious or “communicable” diseases. Yet
several chronic diseases have an infectious
component to their cause, such as cervical
cancer and liver cancer.

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 Terminology
• “Lifestyle-related” diseases is a term
sometimes used to emphasize the
contribution of behavior to the development
of chronic diseases.
• In fact these diseases are heavily influenced
by environmental conditions and are not the
result of individual choices alone; “lifestyles”
are, of course, equally important for
communicable diseases.

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 Terminology
• The term “chronic diseases” is preferred because
it suggests important shared features:
– The chronic disease epidemics take decades to
become fully established – they have their origins at
young ages
– Given their long duration, there are many
opportunities for prevention
– They require a long-term and systematic approach to
treatment
– Health services must integrate the response to these
diseases with the response to acute, infectious
diseases

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 Chronic Diseases
• The main chronic diseases are:
– Cardiovascular diseases, mainly heart disease and
stroke
– Cancer
– Chronic respiratory diseases
– Diabetes

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Global Burden of Non-Communicable
Diseases
• NCDs are the leading cause of death globally,
killing more people than all other causes
combined, i.e., 36 million of a total of 57 million
deaths in 2008, and one quarter of these
occurring before age 60.
• 80 percent of deaths from NCDs occur in
developing countries.
• Currently known cost-effective and feasible
interventions have proven to be effective in
averting much of the human and social impact of
NCDs.

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Global Burden of Non-Communicable
Diseases
• Main NCDs: cardiovascular diseases, cancer,
diabetes, chronic lung disease.
• Main risk factors: diet, smoking, lack of
physical activity, excess use of alcohol
• Associated factors: poverty, economic
transition, rapid urbanization, twenty-first
century lifestyle.
• Poverty predisposes people to increased risk
factors.
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Global Burden of Non-Communicable
Diseases
• Population-wide interventions are cost-
effective and may generate revenues, e.g.:
– increased taxes on alcohol and cigarettes
– regulation of smoking in public locations
– regulation of fat and salt content of manufactured
or processed foods (banning of trans fats)
– food fortification with essential vitamin and
minerals that are insufficiently available in regular
diets for health.

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Global Burden of Non-Communicable
Diseases
• Tobacco control applied in only 10 percent of
world population settings owing to a lack of
political leadership to apply the WHO
Framework Convention on Tobacco Control.
This is due to lack of advocacy and strength of
opposition from vested interests.

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Global Burden of Non-Communicable
Diseases
• Improved health care can reduce many of the
NCDs and delay their most serious effects:
– screening for specific cancers such as cervix,
breast, and colon
– screening and management for hypertension and
diabetes
– immunizations for pneumonia, influenza, rubella,
hepatitis B, and human papillomavirus
– counseling: diet, exercise.

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Chronic Disease Risk Factors

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Chronic Disease Risk Factors

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Chronic Disease Risk Factors

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PURWOREJO DSS
(DEMOGRAPHIC SURVEILLANCE SITE)
1035 km square area
16 sub-districts
709,000 individuals
1 Government & 5 private hospitals
25 primary health centers

14,500 households visited every 6 months

METHODS
Panel Study

Baseline 1st 2nd

Cross Follow Follow
Section Up Up

Quali-
tative
Study
Cross-
sectional
Study
Second
Cross
Section

2001 2002 2003 2004 2005

 WHO Steps WHO STEPS

• The STEPS Instrument

covers three different
levels of "steps" of risk
factor assessment.
Potential #2
These steps are:
• Simple and standardized
1. Questionnaire questions and protocols
• Smoking, alcohol, fruit and vegetable intake,
• Add-on modules
physical activity
2. Physical measurements• Simplicity and adaptability
• Blood pressure, weight,•height,
Within-country trends
waist circumference
3. Biochemical measurements • Between-country comparison
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Trends of smoking behavior
Trends of elevated blood pressure
Trends of overweight and obesity
 Conclusion and implication for future

• On-going epidemiological transition

within a rural population in Purworejo
District
• Existing vicious cycle between
socioeconomic conditions and chronic
disease risk factors
• Necessary to understand local context of
risk factors to design culturally
appropriate intervention initiatives
Cardiovascular Disease in Women
• Both women and their healthcare providers
have traditionally considered cardiovascular
disease and CHD as a male problem.
• Where did this misperception arise?
Cardiovascular Disease in Women
• Heart disease is the leading cause of death for
women both in most of the industrialized
world.
• Whereas cardiovascular deaths in men have
declined, the number of cardiovascular deaths
in women remains unchanged or is increasing.
Cardiovascular Disease in Women
• The onset of clinical manifestations of coronary
heart disease (CHD) in women lags behind men
by about 10 years and by as much as 20 years for
more ominous events such as myocardial
infarction and sudden cardiac death.
• Despite this age disparity in coronary events for
women, with the aging of the population and
with elderly women outnumbering elderly men,
more women than men have died of
cardiovascular disease.
• The sex gap in mortality continues to widen.
Historical Perspective
• For many years, the
medical community has
viewed women’s health
with a bikini approach,
focusing essentially on
the breast and
reproductive system.
• The rest of the woman
was virtually ignored in
considerations of
women’s health.
(Wenger, 2004).
 Indirect Maternal Death
Deaths resulting from previous existing
diseases or disease that develops during
pregnancy and which was not due to
direct obstetric causes, but was
aggravated by the physiological effects of
pregnancy

Cardiac disease, Diabetes, Hypertension

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Indirect causes of maternal death
• Comprehensive analyses of the causes of
maternal mortality have been published by
WHO and the Institute for Health Metrics and
Evaluation.
• These analyses strikingly show the increasing
importance of indirect causes of maternal
death.
 Causes of maternal deaths

Indirect causes 3,20%

7,90%

27,50%

27,10%

9,60%

10,70%
14,00%

Abortion Embolism Hemorrhage

Hypertension Sepsis Other direct causes
Indirect causes
(Say et al., 2014)
 Indirect causes of deaths

5,50%
7,20% HIV-related

Pre-existing medical
conditions
Other indirect causes

14,80%

Pre-existing medical conditions

(Say et al., 2014)

 Causes of maternal death
Mean proportion (left) and total number (right) of maternal deaths due to
different causes in 1990 and 2013. Error bars show 95% uncertainty intervals.

(Kassebaum et al., 2014)

Indirect causes of maternal death
• The greater relative importance of indirect
causes could be a result of successful
addressing of direct complications of
pregnancy and childbirth, and of a change in
risk factors and disease patterns.
• Storm et al. (2014) conclude that indirect
causes of maternal deaths cannot be ignored
and that efforts should be focused on their
reduction.
 Natural history of disease
Onset of Usual time of
symptoms diagnosis
Exposure

Pathologic
changes

Stage of Stage of Stage of Stage of

susceptibility subclinical clinical recovery,
disease disease disability or
death

PRIMARY SECONDARY TERTIARY

PREVENTION PREVENTION PREVENTION
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Hanson & Gluckman, 2011.
 Health Promotion
• Health promotion is the process of enabling
people to increase control over, and to
improve, their health.
• It moves beyond a focus on individual
behaviour towards a wide range of social and
environmental interventions.

World Health Organization

37
Stepwise Approach for Prevention

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 References
• Hanson M and Gluckman P. Developmental origins of noncommunicable
disease: population and public health implications. Am J Clin Nutr
2011;94(suppl):1754S–8S.
• Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and
national levels and causes of maternal mortality during 1990–2013: a
systematic analysis for the Global Burden of Disease Study 2013. Institute for
Health Metrics and Evaluation. Lancet 2014;384(9947):980-1004.
• Labarthe DR. Epidemiology and Prevention of Cardiovascular Diseases: A
Global Challenge, Second Edition. Sudbury, MA: Jones and Bartlett
Publishers, 2011.
• Mosca L, Banka CL, Benjamin EJ et al. Evidence-Based Guidelines for
Cardiovascular Disease Prevention in Women: 2007 Update. 2007;JACC
49:1230-50.
• Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO
systematic analysis. Lancet Glob Health 2014;2:e323–33.
• Storm F, Agampodi S, Eddleston M, et al. Indirect causes of maternal death.
Lancet Glob Health 2014;2:e566.
• Tulchinsky TH, Varavikova EA. The New Pubic Health, Third Edition. Chapter 5.
Non-Communicable Diseases and Conditions. Amsterdam: Elsevier, 2014.
• Wenger NK. You’ve Come a Long Way, Baby. Cardiovascular Health and
Disease in Women Problems and Prospects. Circulation 2004;109:558-560.
“The Blue Marble”—an international symbol of peace and healing—photographed by
Astronauts, Eugene Cernan, Ronald Evans, and Jack Schmitt, December 7, 1972;