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NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY PREVALENCE OF NONCOMM

UNICABLE DISEASE RISK FACTORS, 2017

NATIONALHOUSEHOLD HEALTHSURVEY IN TURKEYPREVALENCE OF NONCOMMUNICABLEDISEASE RISK FACTORS2017

Republic of TurkeyMinistry of Health

World Health Organization Regional Office for EuropeUN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark

Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01Email: [email protected]

Website: www.euro.who.int

The WHO Regional Office for EuropeThe World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.

Member StatesAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzechiaDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe former Yugoslav Republic of MacedoniaTurkeyTurkmenistanUkraineUnited KingdomUzbekistan

NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY: PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017


ii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

ABSTRACT

This publication reports the results of the National Household Health Survey – Prevalence of Noncommunicable Disease Risk Factors in Turkey, conducted in 2017 using the WHO-approved STEPwise survey method. The main objectives of the survey were: to determine the prevalence of the most common behavioural and biological risk factors for noncommunicable diseases (NCDs) in the general population aged ≥ 15 years; and to determine differences in the prevalence of risk factors between the sexes, across five age groups and across 12 regions described by level-1 Nomenclature of Territorial Units for Statistics. The risk conditions were grouped into behavioural factors understood as modifiable (tobacco use, harmful alcohol consumption, low consumption of fruits and vegetables, and physical inactivity etc.) and biological factors considered controllable (hypertension, overweight and obesity, high blood sugar and increased total cholesterol etc.). The results obtained in the study show the current prevalence of NCD risk factors among the Turkish population.

In addition to obtaining valuable information on NCD risk factors for people of five different age groups, both sexes and 12 regions, the results of the survey provide a significant input for policy-makers.

Keywords NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL RISK FACTORS TURKEY STEPWISE APPROACH

Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark

Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest).

ISBN 9789289053136

Suggested citation: National Household Health Survey – Prevalence of Noncommunicable Disease Risk Factors in Turkey 2017 (STEPS). Üner S, Balcılar M, Ergüder T editors. World Health Organization Country Office in Turkey, Ankara, 2018.

© World Health Organization 2018

All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

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All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization.

Data source: Ministry of Environment and Urbanization, Republic of Turkey

Map production: WHO Country Office in Turkey

iii

CONT

ENTS

CONTENTS iii

TABLES vi

FIGURES viii

ABBREVIATIONS x

FOREWORD xi

PREFACE xiv

ACKNOWLEDGEMENTS xvi

CONTRIBUTORS xviii

EXECUTIVE SUMMARY xx

1. BACKGROUND OF THE SURVEY 2

1.1. Noncommunicable diseases 2

1.2. Risk factors 3

1.3. NCDs and risk factors in Turkey 4

1.4. STEPwise approach 5

2. SURVEY GOAL AND OBJECTIVES 8

2.1. Survey goal 8

2.2. Survey objectives 8

2.3. Rationale for the survey 8

3. SURVEY METHODOLOGY 10

3.1. Inclusion criteria 10

3.2. Exclusion criteria 10

3.3. Sample size 11

3.4. Effective sample 11

3.5. Sampling frame 11

3.6. Sampling design 11

3.7. Selection of individuals 16

3.8. Survey design 16

3.9. Weighting of the survey 17

3.10. Data collection 19

3.11. Training of the field survey staff 20

3.12. Field work 21

3.13. Data management and consolidation 21

3.14. Measurement and determination of risk factors 21

3.14.1. Step 1 21

3.14.1.1. Tobacco use 21

3.14.1.2.Consumptionofalcohol 21

3.14.1.3.Consumptionoffruitsandvegetables 22

iv National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

CONTENTS

3.14.1.4.Physicalactivity 22

3.14.2. Step 2 22

3.14.2.1.Bloodpressure 23

3.14.2.2. BMI 23

3.14.2.3.Waistandhipcircumference 23

3.14.3. Step 3 24

3.14.3.1.Glycaemia 24

3.14.3.2. HbA1c 24

3.14.3.3.Totalcholesterol 25

3.14.3.4.Triglycerides 25

3.14.3.5.HDLcholesterol 25

3.14.3.6.Urinarysodiumandcreatinine 25

4. SURVEY RESULTS 28

4.1. Sampling and participation 28

4.2. Demographic indicators 28

4.2.1.Ageandsexcharacteristics 29

4.2.2.Maritalstatus 30

4.2.3.Education 32

4.2.4.Employment 36

4.2.5. Income 37

4.3. Tobacco use 39

4.3.1.Conclusions 46

4.4. Alcohol consumption 46


4.5. Use of addictive drugs (substances) 49


4.6. Diet: fruit and vegetable consumption 51


4.7. Dietary salt 53


4.8. Physical activity 55


4.9. History of raised blood pressure 58


4.10. History of diabetes 60


4.11. History of raised total cholesterol 61


4.12. History of CVD 63


v

4.13. Family history of chronic diseases 64


4.14. History of asthma, chronic obstructive pulmonary disease or cancer 65


4.15. Lifestyle advice 67


4.16. Awareness of harm to health from selected risk factors for NCDs 69


4.17. Cancer screening tests 71


4.18. Accidents and injuries 72


4.19. Ambulatory or inpatient care 73


4.20. Ambulatory diagnosis, treatment and home care 74


4.21. Physical measurements 76


4.22. Biochemical measurements 80


4.23. CVD risk 86

4.23.1. Conclusions 88

4.24. Summary of combined risk factors 88


4.25. Health perception 90


CONCLUSION 92

REFERENCES 94

ANNEX 1. FIELD TEAMS BY REGION 98

ANNEX 2. NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY – PREVALENCE OF

NONCOMMUNICABLE DISEASE RISK FACTORS, 2017 FACT SHEET 100

ANNEX 3. WHO STEPS INSTRUMENT FOR NATIONAL HOUSEHOLD HEALTH SURVEY IN

TURKEY: PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017

(SURVEY INFORMATION QUESTIONNAIRE) 107

vi National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

TABLES

Table 1. NUTSregionsinTurkey 12

Table 2. SampleclustersandhouseholdsbyNUTS-1regions 15

Table 3. Distributionofnonrespondinghouseholdnumbersbyclustersand

NUTSregions 17

Table 4. Datafortwo-waysex–agepoststratification 18

Table 5. Datafortwo-waysex-educationpoststratification 18

Table 6. DataforNUTS-1regionpoststratification 19

Table 7. Equipmentandsuppliesusedforthefieldimplementation 19

Table 8. WHOcut-offpointsandriskofmetaboliccomplications 24

Table 9 Overallresponseproportions 28

Table 10. Ageandsexdistributionofrespondents 29

Table 11. NUTS-1distributionofrespondents 30

Table 12. Maritalstatusofrespondentsbysexandagegroup 30

Table 13. MaritalstatusofrespondentsbyNUTS-1regions 31

Table 14. Respondents’highestlevelofeducationbysexandagegroup 33

Table 15. Respondents’levelsofeducationbyNUTS-1regions,bothsexes 34

Table 16. Respondents’meannumberofyearsofeducationbysexandagegroup 34

Table 17. Respondents’meannumberofyearsofeducationbyNUTS-1regions 35

Table 18. Respondents’paidemploymentstatusbysexandagegroup 36

Table 19. Respondents’unpaidemploymentstatusbysexandagegroup 37

Table 20. Respondents’meanannualpercapitahouseholdincomebyNUTS-1regions 38

Table 21. Percentageofcurrentsmokersamongrespondentsbysexandagegroup 39

Table 22. PercentageofcurrentsmokersamongrespondentsbyNUTS-1regions 40

Table 23. Smokingstatusofrespondentsbysexandagegroup 42

Table 24. Meanageatwhichcurrentdailysmokersamongrespondents

startedsmoking,bysexandagegroup 43

Table 25. Meanamountoftobaccousedbydailysmokersbytypeandagegroup 44

Table 26. Currentusersofsmokelesstobaccobysexandagegroup 45

Table 27. Alcoholconsumptionamongrespondentsbysexandagegroup 47

Table 28. Meannumberofepisodesinwhichcurrentdrinkersdrank≥ 6drinkson

asingleoccasionintheprevious30days,bysexandagegroup 48

Table 29. Proportionoftotalrespondentswhodrank≥ 6drinksonasingleoccasion

intheprevious30days,bysexandagegroup 49

Table 30. Respondentswhoneverusedaddictivedrugsbysexandagegroup 50

Table 31. Respondentswhocurrentlyuseaddictivedrugsbysexandagegroup 50

Table 32. Respondentswhotriedaddictivedrugsbysexandagegroup 50

Table 33. Meannumberofdaysinatypicalweekinwhichrespondentsconsumed

fruitbysexandagegroup 51

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Table 34. Meannumberofdaysinatypicalweekinwhichrespondentsconsumed

vegetablesbysexandage 51

Table 35. Meannumberofdaysinatypicalweekinwhichrespondentsofbothsexes

consumedfruitandvegetablesbyNUTS-1regions 52

Table 36. Meannumberofservingsoffruitconsumedperdaybysexandagegroup 52

Table 37. Meannumberofservingsofvegetablesonaverageperdaybysexandagegroup 53

Table 38. Proportionofrespondentsconsumingfewerthanfiveservingsoffruit

and/orvegetablesonaverageperdaybysexandagegroup 53

Table 39 Respondents’useofdietarysaltbysexandagegroup 54

Table 40. Respondents’levelsoftotalphysicalactivityasdefinedbyWHObysex

andagegroup 56

Table 41. Respondents’meanminutesofwork-relatedphysicalactivityonaverage

perdaybysexandagegroup 56

Table 42. Respondents’meanminutesoftransport-relatedphysicalactivityon

averageperdaybysexandagegroup 57

Table 43. Respondents’meanminutesofrecreation-relatedphysicalactivity

onaverageperdaybysexandagegroup 57

Table 44. ProportionsofrespondentsnotmeetingtheWHOrecommendations

onphysicalactivityforhealthbysexandagegroup 58

Table 45. Respondents’activitiestomanagehypertensionbysex 59

Table 46. Respondents’activitiestomanagediabetesbysex 61

Table 47. Respondents’activitiestomanagetotalcholesterolbysex 62

Table 48. Proportionsofrespondentsthatcouldstatetwoormorenegative

healtheffectsofdifferentriskfactors,byagegroup 70

Table 49. Percentagesofrespondentswhohadvisitedahospitalforthetreatment

ofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious

12months,bysexandagegroup 73

Table 50. Proportionofallhypertensivepeoplewithcontrolledbloodpressure

inthepopulation 78

Table 51. ProportionsofrespondentswithmeanHbA1c,bysexandagegroup 82

Table 52. ProportionofrespondentswithraisedHbA1C(≥6.5%)orwhowere

currentlyonmedicationfordiabetes 82

Table 53. Meantotalcholesterol,bysexandagegroup 83

Table 54. Respondents’meanHDLcholesterollevels,bysexandagegroup 84

Table 55. Respondents’meanfastingtriglyceridesbysexandagegroup 85

Table 56. Percentageofrespondentswhohadaten-yearCVDrisk≥ 30%or

alreadyhadCVD,bysexandagegroup 87

Table 57. Proportionofeligiblepersonsreceivingdrugtherapyandcounselingto

preventheartattacksandstrokes 88

Table 58. Healthstatusperceptionofindividuals,byagegroup 91

viii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

FIGURES

Fig. 1. GeographicalbordersofNUTS-1regions 14

Fig. 2. SamplesizesbyNUTS-3provinces 15

Fig. 3. Geographicallocationofsampleclusters 16

Fig. 4. Respondents’levelsofeducationbysex 32

Fig. 5. Respondents’meannumberofyearsofeducationbyNUTSregions 35

Fig. 6. MeanannualpercapitahouseholdincomebyNUTS-1regions 38

Fig. 7. Percentageofcurrentsmokersbysexandagegroup 39

Fig. 8. Prevalenceofdailysmokingamongcurrenttobaccousersbysex

andagegroup 40

Fig. 9. PrevalenceofdailysmokinginrespondentsbyNUTS-1regions 43

Fig. 10. Dailysmokersusingmanufacturedcigarettesbysexandagegroup 44

Fig. 11. Currentsmokerswhohadtriedtoquitduringtheprevious12months 45

Fig. 12. Currentsmokersadvisedbyadoctortostopsmokingintheprevious

12months 46

Fig. 13. Respondents’alcoholconsumptionstatusbyNUTS-1regions 48

Fig. 14. Respondentswhothinkloweringsaltindietisveryimportant 55

Fig. 15. Proportionsofrespondentsnotengaginginavigorous

physicalactivitybysexandagegroup 58

Fig. 16. Bloodpressuremeasurementandhypertension

diagnosisamongrespondentsbysex 59

Fig. 17. Bloodsugarmeasurementanddiabetesdiagnosisamongrespondentsbysex 60

Fig. 18. Percentagesofrespondentswithraisedbloodglucosewhoare

currentlytakingmedicationorinsulin,bysex 61

Fig. 19. Cholesterolmeasurementandraised-cholesterol

diagnosisamongrespondentsbysex 62

Fig. 20. Respondentswhoeverhadaheartattackorchestpainfromheart

disease,orastroke,bysexandagegroup 63

Fig. 21. Percentagesofrespondentswhoarecurrentlytakingaspirinorstatins

regularlytopreventortreatheartdiseasebysex 64

Fig. 22. Typesofdiagnosedchronicdiseaserequiringmedication

forrespondents’parentsorsiblings 65

Fig. 23. Proportionsofrespondentswithanasthmadiagnosis,bysexandagegroup 66

Fig. 24. ProportionsofrespondentswithCOPDdiagnoses,bysexandagegroup 66

Fig. 25. Respondents’perceptionoftheirweightbysex 67

Fig. 26. Percentageofrespondentswhoreceivedlifestyleadvicefromadoctor

orhealthworkerduringtheprevious12monthsbyagegroup 68

Fig. 27. Percentageofrespondentswhocouldnametwoormorenegative

healtheffectsofanyoftheselectedNCDriskfactors 70

Fig. 28. Percentagesofrespondentswhohaveheardthatthecancerscreeningsare

availablefreeinFHCandCEDSTC,bysexandagegroup 71

ix

Fig. 29. Typesofaccidentscausinginjuriessufferedbytherespondentsin

theprevious12months,bysex 72

Fig. 30. Percentagesofrespondentsinjuredasaresultofanaccidentintheprevious

12monthswhoreceivedambulatoryorinpatientcare,byagegroup 73

Fig. 31. Typeandlengthofcarereceivedbyrespondentswhohadvisitedahospitalfor

thetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmainthe

previous12months 74

Fig. 32. Percentagesofrespondentswhohadvisitedhealthpersonnel,bysex 75

Fig. 33. Percentagesofrespondentswhohadvisitedhealthpersonnelwithinthe

previousmonth,byagegroup 75

Fig. 34. Percentagesofrespondentswhohadreceivedmedicalcareathomeinthe

previous12months 76

Fig. 35. Respondents’meanSBPandDBP(mmHg)bysexandagegroup 77

Fig. 36. Percentagesofrespondentswithraisedbloodpressureorcurrentlyon

medicationforraisedbloodpressure,bysex 77

Fig. 37. Percentagesofrespondentswithraisedbloodpressure,excludingthoseon

medicationforraisedbloodpressure,byagegroup 78

Fig. 38. Respondents’meanBMI,bysexandagegroup 79

Fig. 39. DistributionbyBMIcategory,bysex 79

Fig. 40. Meanfastingbloodglucose,bysexandagegroup 80

Fig. 41. Prevalenceofimpairedfastingglycaemiabysexandagegroup 81

Fig. 42. Proportionsofrespondentswhohadraisedbloodglucoseorwere

currentlyonmedicationfordiabetes,bysexandagegroup 81

Fig. 43. PercentageofrespondentswithraisedHbA1c≥ 6.5%,bysexandagegroup 82

Fig. 44. ProportionsofrespondentswithraisedHbA1corraisedbloodglucoseorwere

currentlyonmedication,bysexandagegroup 83

Fig. 45. Percentagesofrespondentswithtotalcholesterollevels≥ 190mg/dlincluding

≥ 240mg/dlorcurrentlyonmedicationforraisedcholesterol,bysex 84

Fig. 46. PercentagesofrespondentswithlowHDLcholesterol,bysexandagegroup

(< 50mg/dlforwomenand< 40mg/dlformen) 85

Fig. 47. Percentagesofrespondentswithfastingtriglycerides

levels≥ 150mg/dland≥ 180mg/dl,bysex 86

Fig. 48. Percentageofrespondentswithaten-yearCVDrisk≥30%oralreadywith

CVDandreceivingdrugtherapyandcounsellingtopreventheartattacks

andstrokes,bysexandagegroup 87

Fig. 49. Summaryofcombinedriskfactorsinrespondents

aged18–69bysexandagegroup 89

Fig. 50. Summaryofallrespondents’combinedriskfactorsbysexandagegroup 89

Fig. 51. Respondents’perceptionsoftheirhealthstatusbysex 90

x National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

ABBREVIATIONS

BMI bodymassindexCEDSTC cancerearlydiagnosisscreeningandtrainingcentres(inTurkey)CHD coronaryheartdiseaseCI confidenceintervalCOPD chronicobstructivepulmonarydiseaseCVD cardiovasculardiseasesDALYs disability-adjustedlife-yearsDBP diastolicbloodpressureFAO FoodandAgricultureOrganizationoftheUnitedNationsFHC familyhealthcentres(inTurkey)GP generalpractitionerHbA1ctest haemoglobinA1corglycatedhaemoglobintestHDLcholesterol high-densitylipoproteincholesterolHPV humanpapillomavirusMET metabolicequivalentsNCDs noncommunicablediseasesNHHST NationalHouseholdHealthSurveyinTurkey– PrevalenceofNoncommunicableDiseaseRiskFactorsNUTS-1 level-1NomenclatureofTerritorialUnitsforStatisticsPCs personalcomputersPSUs primarysamplingunitsSBP systolicbloodpressureSSUs secondarysamplingunitsSTEPS (WHO)STEPwiseapproachtosurveillanceTL TurkishLiraTURKSTAT TurkishStatisticalInstituteWHR waist–hipratio

xi

The prevalence of, and mortality from, noncommunicable diseases (NCDs) have increased in Turkey, as they have around the world, even though life expectancy is rising and the burden of disease is changing. NCDs are the leading cause of death globally and account for a significant share of disability-adjusted life-years; they therefore place a substantial burden on health systems, as well as negatively affecting one’s quality of life.

The majority of NCDs are considered preventable as they are predominantly caused by modifiable risk factors. Current information and experience show that appropriate intervention programmes for societies or individuals can prevent NCDs. Feasible and evidence-based policies, suitable for each country’s infrastructure, are needed for the planning and implementation of intervention programmes.

Leading risks to health, based on one’s lifestyle, such as tobacco use, insufficient physical activity, raised cholesterol, raised blood pressure and alcohol consumption – increase the risk of NCDs. Reducing NCDs requires focusing on reducing their risk factors. Evidence-based public health intervention programmes should be developed at a national level on the basis of the most prevalent risk factors identified. Community-wide representative data is required to plan the activities to be implemented within this framework and to evaluate their effects.

In cooperation with WHO, the Ministry of Health of Turkey therefore conducted the National Household Health Survey – Prevalence of Noncommunicable Disease Risk Factors in Turkey to collect data on prevalent NCDs and respective risk factors based on individual statements and physical and biological measurements. This survey is important because it is countrywide and representative, and provides an opportunity for international comparisons and highlighting needs in the country.

I would like to use this opportunity to extend my gratitude to all who have contributed to this survey, which will provide valuable information for programmes to prevent and control NCDs in our country.

Dr Fahrettin KocaMinister of Health, Republic of Turkey

FOREWORD

xii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

FOREWORD

Noncommunicable diseases (NCDs) are the leading cause of death globally. The growing number of people living with one or more NCDs, as well as the increasing number of premature deaths resulting from them, places a heavy strain on health systems and negatively impacts both economic development and well-being. We can see that efforts to control NCDs do yield results: in the WHO European Region, premature deaths from NCDs clearly declined in 2000–2010. Nonetheless, these conditions still account for nearly 80% of all deaths in the Region. Globally, NCDs represent one of the most pressing challenges to sustainable development in the 21st century. Action to mitigate, prevent and control them will be vital – across all sectors and settings – if the world hopes to achieve the ambitious targets of the Sustainable Development Goals (SDGs).

In accordance with the political declaration on NCD prevention and control adopted by the United Nations General Assembly in 2011, WHO developed its global action plan for NCD prevention and control for 2013–2020. To assess the actions taken to implement this plan, WHO also established a global monitoring framework, which includes nine voluntary targets and 25 indicators on health status, risk factors and health systems’ capacity and response. The action plan and monitoring framework provide a solid basis for all activities to prevent and control NCDs, and it is important for all countries to actively participate in these efforts.

After all, no country is left untouched by the epidemic of chronic diseases, including Turkey. The impact of NCDs in the coming year will be defined by whether and how countries respond to this growing threat to the health and well-being of their people and societies. Turkey is a country that has taken major steps to prevent and control NCDs, to reduce the additional burden on health systems and to provide comprehensive health care for the sick. In 2017, the Ministry of Health endorsed the country’s multisectoral action plan on NCDs for 2017–2025, to improve the health sector’s response to NCDs, to facilitate multisectoral cooperation, to ensure that all institutions implement health policy and to develop a common perspective on the subject. WHO’s nine voluntary global targets for NCD prevention and control were reviewed and adapted to the country context, with the participation of representatives of civil society organizations, academia and the WHO Country Office in Turkey. An additional 25 country-specific indicators were identified and target-specific priority areas were discussed.

FOREWORD

xiii

Turkey also hosted the United Nations Interagency Task Force on NCDs in April 2016 and has hosted several missions to assess health systems barriers for better NCDs outcomes. The country implemented a comprehensive analysis of NCDs and their risk factors, using the WHO STEPwise approach to surveillance (STEPS), which focuses on obtaining core data on the established risk factors that determine the major disease burden. I would like to extend my gratitude to the Minister of Health of Turkey, Dr Fahrettin Koca, for the Ministry’s remarkable leadership of and support for these achievements. These actions, along with future activities, will play a pivotal role in helping Turkey face the NCDs epidemic.

The WHO Regional Office for Europe aims to be a partner in fighting NCDs alongside countries of the Region. Establishing a process to monitor and assess the implementation of action to prevent and control NCDs in a country involves a number of challenges related to the availability, comparability and quality of data. Thus, the Regional Office aims to enhance the availability and quality of NCD-related information and to orient health policy in Europe to address the major challenges to health and development, in line with European Health 2020 policy framework and the SDGs.

This report is an important step in setting the baseline for the prevalence of NCDs and their risk factors in Turkey. I hope that this publication will be useful not only in helping decision-makers in Turkey to sustain their commitment but also in saving the lives of citizens at risk of premature mortality from NCDs.

Dr Zsuzsanna Jakab WHORegionalDirectorforEurope

xiv National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

PREFACE

Noncommunicablediseases (NCDs)arethe leadingcauseofdeathat theglobal,regionalandnational levels.NCDskill40millionpeopleeachyear,equivalentto70%ofalldeathsglobally.Eachyear,15millionpeopleaged30–69yearsdiefromanNCD;over80%oftheseprematuredeathsoccurin low- and middle-income countries. NCDs threaten progress towardsthe 2030 Agenda for Sustainable Development, which includes a targetof reducing premature deaths from NCDs by one third by 2030. PovertyiscloselylinkedwithNCDs.TherapidriseinNCDsispredictedtoimpedepoverty reduction initiatives in low-income countries, particularly byincreasinghouseholdcostsassociatedwithhealthcare.

NCD death rates in Turkey are similar to those in the rest of the WHOEuropean Region. NCDs are responsible for 87.5% of all deaths in thecountry. The probability of premature death from one of the fourmajorNCDsforapersonlivinginTurkeywasaroundoneinsix(16.8%)in2015.TheNCDburden isundermining thesocialandeconomicdevelopmentof thecountry.NCDshavesignificantandgrowinghealthandfinancialcosts toindividuals,families,thehealthsystemandtheeconomy.WithoutadequatepreventionofthecommonriskfactorsandearlyidentificationofNCDs,thecostsforTurkishsocietywillincrease.

TorespondtothegrowingburdenofNCDs,headsofstateandgovernmentendorsedtheUnitedNations’PoliticalDeclarationoftheHigh-levelMeetingoftheGeneralAssemblyonthePreventionandControlofNon-communicableDiseases inMay 2011, and theWorldHealthAssembly endorsed theWHOglobalactionplanforNCDpreventionandcontrol2013–2020.

TheGovernmentofTurkeyrecognizedtheimpactofNCDsandreaffirmedits commitment to tackling them and their risk factors. To realize thesecommitments, Turkey published a multisectoral action plan for NCDscoveringtheperiod2017–2025.Inaddition,Turkeydevelopedaninvestmentcase for NCD prevention and control, with contributions from WHO, toprovide evidence that NCDs reduce economic output and to discusspotentialoptionsforresponse,inordertodetermineasetofinterventionsthataremostsuitedtothecountry.

Thedevelopmentandimplementationofhealthpoliciesrequirehigh-qualityanddisaggregateddataatthenational leveltounderstandtheproblems,toinformtheneedforinterventions,todevelopappropriateinterventions

PREFACE

xv

toreducetheburdenofdiseaseandaddresshealthinequalities,andtomonitorprogressinachievingthetargetsset.

Theprimaryobjectiveof thesurvey inTurkey,usingaWHOapproachtosurveillance,wastoevaluatethebaselinesituationofthemainNCDriskfactors,bothbehaviouralandmetabolic/physiological,andtoinformallnationalandinternationalstakeholdersofthesituation.

ThesurveydatawillserveasbaselineinformationfornewNCDpoliciesandastartingpointformonitoringtheprevalenceof riskfactors.Theeffectivenessof interventionstoreducetheburdenofNCDsandtheirrisk factorswillalsobeanalysed.The resultsof thesurveywillenablecomparisonof theprevalenceanddistributionofNCDriskfactorsovertimeandacrosscountries.

ThispublicationreportstheresultsoftheNationalHouseholdHealthSurvey–PrevalenceofNoncommunicableDiseaseRiskFactorsinTurkey,conductedin2017usingtheWHO-approvedSTEPwisesurveymethod(STEPS).The survey’s main objectives were: to determine the prevalence of the most common behavioural andbiologicalriskfactorsforNCDsinthegeneralpopulationaged≥15years;andtodeterminedifferencesintheprevalenceofriskfactorsbetweenthesexes,acrossfiveagegroupsandacross12regionsdescribedbylevel-1NomenclatureofTerritorialUnitsforStatistics.Theriskconditionsweregroupedintomodifiablebehaviouralfactors(tobaccoconsumption,harmfulalcoholconsumption,lowconsumptionoffruitsandvegetables,andphysicalinactivity)andcontrollablebiologicalfactors(hypertension,overweightandobesity,highbloodsugarandincreasedtotalcholesterol).TheresultsobtainedfromthestudyshowthecurrentprevalenceofNCDriskfactorsamongtheTurkishpopulation.

WHOprovides continuouspolicy advice, technical assistanceandcapacity building to theGovernmentofTurkey,aimingtoimprovepopulationhealthandtoreducehealthinequalitiesthroughwhole-of-governmentand-societyapproaches.Inthisway,WHOofferssupporttothecountryinensuringitsengagementintheimplementationatnational levelof theEuropeanstrategyforhealthandwell-being,Health2020,andtheWHOglobalandEuropeanactionplansforNCDpreventionandcontrol.

BoththeGovernmentofTurkeyandWHOareverygratefultotheirpartners:especiallytheInternationalBankfor Reconstruction and Development (World Bank), for the guidance provided under the “Health SystemsStrengtheningandSupportProject”,whichwassignedby theGovernmentofTurkeyand theWorldBank,to providefinancial support to implement thefirst STEPS survey in Turkey; and to other partners at theinternationalandnationallevelswhoprovidedtechnicalassistanceincarryingoutthesurvey.

TheWHOCountryOffice,TurkeyisgratefulfortheexcellentcollaborationwiththeMinistryofHealthofTurkeyandlooksforwardtocontinuedjointworktodisseminateTurkey’sachievementsinothercountries.

Dr Pavel Ursu WHORepresentativeinTurkey

xvi National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

ACKNOWLEDGEMENTS

The members of the “National Household Health Survey in Turkey – Prevalence of Noncommunicable Disease Risk Factors (STEPwise approach to Surveillance (STEPS)” working group would like to express their sincere gratitude to the Ministry of Health of Turkey for the implementation of this survey, and particularly to Emine Alp Meşe, Deputy Health Minister; Eyüp Gümüş, Undersecretary, Elif Güler Kazancı, Deputy Undersecretary; Alper Cihan, Director-General of Health Services; Muhammed Ertuğrul Eğin, Deputy Director-General of Health Services; Oğuzhan Özkan, Head of the Department of Health Research, Directorate-General of Health Services, Tufan Nayır, Adviser to Deputy Health Minister, for their commitment to this report. Special thanks go to Mehmet Rıfat Köse, former Director-General of Health Research of the Ministry of Health, for initiating this process, and continuous commitment to and leadership and guidance throughout the entire STEPS survey process.

The specific contributions of Banu Ayar, Ayşegül Gençoğlu, Abdullah Akünal, Ayşegül Doğan Sönmez at the Department of Health Research, Directorate-General of Health Services, Ministry of Health – in convening the national scientific advisory board, organizing workshops, providing national materials and providing coordination and support in the development of methodology, the survey instrument, sampling, training the research team, data analysis and drafting this STEPS survey report – are particularly acknowledged.

Special thanks to the national scientific advisory board for their valuable contribution to planning, implementing and reviewing the findings of the survey.

This survey was conducted under the overall guidance of Leanne Margaret Riley, Team Leader, Surveillance and Population based-Prevention of Noncommunicable Diseases, WHO headquarters; Pavel Ursu, WHO Representative and Head of the WHO Country Office, Turkey; Gauden Galea, former Director of the Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe and Bente Mikkelsen, Director Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe. Members of the working group also express their sincere gratitude to Enrique Gerardo Loyola Elizondo, Coordinator, Integrated Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe; Lubna Bhatti and Stefan Savin, Department of Surveillance and Population-based Prevention of Noncommunicable Diseases, WHO headquarters; and Toker Ergüder, National Professional Officer, Noncommunicable Diseases and Life-Course, WHO Country Office, Turkey, for their continuous technical support in the development of methodology, the survey instrument, sampling, training the research team and data analysis.

Members of the working group would also like to thank Enis Barış, Practice Manager, Health Nutrition Population; and Ahmet Levent Yener, Senior Human Development Specialist, Health Nutrition Population at the International Bank for Reconstruction and Development (World Bank) for the guidance that they provided under the “Health Systems Strengthening and Support Project” which was signed between Government of the Turkish Republic and the World Bank.

In addition, members of the working group would like to thank the WHO implementing partner, PGlobal Global Advisory and Training Services Inc., for the field implementation of the survey, particularly to Ertan Yülek and Alpaslan Girayalp and all the technical and field

ACKNOWLEDGEMENTS

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teamsfortheirremarkablepartnership,wellasSarpÜner,MehmetBalcılar,UfukYüzüncü,SelçukDinç,AhmetGül,SüzülayHazarandGökhanKoçtürkfortheirtechnicalsupportinthedevelopmentofmethodology,surveyinstrument,sampling,trainingtheresearchteam,dataanalysisanddraftingthisSTEPSsurveyreport.

Thestatisticalanalysis teamcomprised:MehmetBalcılar,SarpÜner,StefanSavin,LubnaBhatti,TokerErgüder,AhmetGül,SüzülayHazarandGökhanKoçtürk;andthereportwasdrafted by Sarp Üner, Mehmet Balcılar, Toker Ergüder, Alpaslan Girayalp , Ufuk Yüzüncü,SelçukDinçandCansuSaraç.

ThanksarealsoextendedGülMenetandSılaSaadetToker for translationand readingoftheTurkishlanguageversionofthisreport,andMehtiAtlıforlayoutandtypesettingofthereport.ThankstoRezinJasimandAyşeÖzlemTorunoğluforprovidingsupportfordraftingofthereport.SpecialthankstoGülMenetformakingthearrangementsforthewholeSTEPSprocess.

Technicalassistance for thesurveyand reportwasprovidedbyWHOandcoordinatedbytheWHORegionalOfficeforEuropeandWHOCountryOffice,Turkeythroughthebiennialcollaborativeagreementcovering2016/2017betweentheMinistryofHealthofTurkeyandWHO.

ThefulllistofexpertswhocontributedtothisreportisgiveninAnnex1.

xviii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

CONTRIBUTORS

Participating organizationsMinistryofHealthoftheRepublicofTurkeyanditsDirectorate-GeneralforHealthResearchTurkishStatisticalInstituteWorldHealthOrganizationWorldBankPGlobalGlobalAdvisoryandTrainingServicesInc.InternationalconsultantsDr Lubna Bhatti, Department of Surveillance and Population-based Prevention ofNoncommunicableDiseases,WHOheadquartersDrEnriqueLoyola,Coordinator,NCDSurveillance,WHORegionalOfficeforEuropeDrLeanneMargaretRiley,TeamLeader,SurveillanceandPopulationbased-PreventionofNoncommunicableDiseasesDr Stefan Savin, Department of Surveillance and Population-based Prevention ofNoncommunicableDiseases,WHOheadquarters

WHO Country Office, TurkeyDrPavelUrsu,WHORepresentativeinTurkeyDrTokerErgüder,NationalProfessionalOfficer,NoncommunicableDiseasesandLife-CourseMsGülMenet,ProgrammeAssistantMsSılaSaadetToker,Interpreter/Translator

Ministry of Health Scientific Advisory CommitteeProfessorDrDenizÇalışkan,PublicHealthDepartment,AnkaraUniversityMedicalFacultyProfessorDrPeyamiCinaz,PaediatricEndocrinologyDepartment,GaziUniversityMedicalFacultyProfessorDrYaseminErten,NephrologyDepartment,GaziUniversityMedicalFacultyProfessorDrBerrinİmgeErgüder,BiochemistryDepartment,AnkaraUniversityMedicalFacultyProfessorDrAhmetKaya,EndocrinologyDepartment,NecmettinErbakanUniversityMedicalFacultyProfessorDrMeralKayıkçıoğlu,CardiologyDepartment,EgeUniversityMedicalFacultyProfessorDrAytekinOğuz,InternalMedicineDepartment,İstanbulMedeniyetUniversityMedicalFacultyProfessorDrSeçilÖzkan,PublicHealthDepartment,GaziUniversityMedicalFacultyProfessorDrNevinŞanlıer,FacultyofHealthSciences,GaziUniversityMedicalFacultySpecialistDrÇiğdemSönmez,PublicHospitalUnionofTurkeyProfessorDrEbruÜnsal,PulmonologyDepartment,YıldırımBeyazıtUniversityMedicalFacultyProfessorDrS.LaleTokgözoğlu,CardiologyDepartment,HacettepeUniversityMedicalFacultyProfessorDrM.TemelYılmaz,EndocrinologyandMetabolismDepartment,İstanbulUniversityMedicalFaculty

Staff of the Ministry of Health of TurkeyDrMehmetRıfatKöse,formerDirectorGeneralofHealthResearchMrOğuzhanÖzkan,HeadofDepartmentofDirectorate-GeneralforHealthServicesSpecialistDrBanuAyar,Directorate-GeneralforHealthServicesDrAyşegülGençoğlu,Directorate-GeneralforHealthServicesMrAbdullahAkünal,Directorate-GeneralforHealthServicesMsAyşegülDoğanSönmez,Directorate-GeneralforHealthServices

CONTRIBUTORS

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Project team (PGlobal Global Advisory and Training Services Inc.)MrAlpaslanGirayalp,ProjectGeneralCoordinator,PGlobalProfessorDrSarpÜner,ProjectManager/TeamLeader,Collaboration,ImplementationandResearchCentreforPreventionofNoncommunicableDiseases,HacettepeUniversityProfessorDrMehmetBalcılar,ProjectChiefConsultant,FacultyofBusinessandEconomics,EasternMediterraneanUniversityDrUfukYüzüncü,ProjectCoordinator,PGlobalMrSelçukDinç,ChiefAnalyst,PGlobalMrMustafaReşitBulut,Analyst,PGlobalMsCansuSaraç,AssistantAnalyst,PGlobalMsGülcanDemirÖzdenk,AssistanttotheTeamLeader,Lecturer,HealthOccupationHighSchool,AhiEvranUniversityAssistantProfessorDrGürcanGünaydın,AssistanttotheTeamLeader,InstituteofCancer,HacettepeUniversityDrM.EminKeleş,AssistanttotheTeamLeader,FacultyofMedicine,HacettepeUniversity

Advisory board (PGlobal Global Advisory and Training Services Inc)ProfessorDrMuratYülek,Consultant,EconomicsandFinance,PGlobalDrErtanYülek,Consultant,OrganizationandPlanning,PGlobalProfessorDrZelihaGünnurDikmen,Consultant,Biochemistry,HacettepeUniversityFacultyofMedicineDrSüleymanCanNumanoğlu,Consultant,PublicHealth,PGlobal

Field survey staff (SeeAnnex1foralistoffieldteamsbyregion.)MrAhmetGül,FieldSurveyGeneralManagerMsSüzülayHazar,FieldCoordinatorMsİlaydaUrvaylioğlu,AssistantFieldCoordinatorMrTolgaÇomak,AssistantFieldCoordinatorMrGökhanKoçtürk,TechnicalCoordinatorMsYeşimUzun,HealthCoordinator

The statistical analysis team ProfessorDrMehmetBalcılar,ProjectChiefConsultant,FacultyofBusinessandEconomics,EasternMediterraneanUniversityProfessorDrSarpÜner,ProjectManager/TeamLeader,Collaboration,ImplementationandResearchCentreforPreventionofNoncommunicableDiseases,HacettepeUniversityDrTokerErgüder,NationalProfessionalOfficer,NoncommunicableDiseasesandLife-CourseMrAhmetGül,FieldSurveyGeneralManagerMsSüzülayHazar,FieldCoordinatorMrGökhanKoçtürk,TechnicalCoordinatorDrStefanSavin,DepartmentofSurveillanceandPopulation-basedPreventionofNoncommunicableDiseases,WHOheadquartersDrLubnaBhatti,DepartmentofSurveillanceandPopulation-basedPreventionofNoncommunicableDiseases,WHOheadquarters

Report drafting team ProfessorDrSarpÜnerProfessorDrMehmetBalcılarAssociateProfessorDrTokerErgüderMrAlpaslanGirayalpDrUfukYüzüncüMrSelçukDinçMsCansuSaraçMsGülMenetMsSılaSaadetToker

xx National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

EXECUTIVE SUMMARY

The National Household Health Survey – Prevalence of Noncommunicable Disease RiskFactorsinTurkeywasorganizedwithfinancialsupportprovidedbytheMinistryofHealthoftheRepublicofTurkeyunderthe“HealthSystemsStrengtheningandSupportProject”loanagreementsignedbetweentheGovernmentoftheTurkishRepublicandInternationalBankforReconstructionandDevelopment(WorldBank).TechnicalassistanceforthesurveywasprovidedbyWHOtotheMinistryofHealthoftheRepublicofTurkeywithinthescopeoftheAgreementsignedon10November2016betweenWHOandtheGovernmentoftheRepublicofTurkey.FieldimplementationoftheNationalHouseholdHealthSurveywasconductedbyPGlobalGlobalAdvisoryandTrainingServicesInc.contractedbyWHOCountryOffice,Turkey.Thefieldsurveyteamsweretrainedon10–14April2017inAnkara(seeAnnex1).Therequisitemedicalequipmentwasdeployedto14logisticalcentresserving79provincesinTurkey,andthefieldsurveyteamsweremobilizedon16–28April2017.Thefirststageofthefieldsurveywasconductedfrom28Aprilto26May.AfterapostponementforRamadan,thesurveywasresumedon3July2017,andcompletedon15September2017,owingtonationalandreligiousholidays,andunforeseencircumstancesthathinderedprogress.

The general goal of the survey was to determine the prevalence of major risk factorsfor noncommunicable diseases using the WHO-approved STEPwise survey method,so as to enable more efficient planning of activities for the prevention and control ofnoncommunicablediseases.

Themainobjectivesofthesurveywere:

todeterminetheprevalenceofthemostcommonbehaviouralandbiologicalriskfactorsfornoncommunicablediseasesinthegeneralpopulationaged≥15years;and

todeterminedifferencesintheprevalenceofriskfactorsbetweenthesexes,acrossfiveagegroupsandacross12regionsdescribedbylevel-1NomenclatureofTerritorialUnitsforStatistics.

Based on multistage cluster sampling methodology for surveillance of noncommunicablediseases,8644subjectswererandomlyselected,toensureequaldistributionoftheparticipantsaccordingtoageandsex,andincludinganestimated20%non-responserate.Atotalof6053subjectsaged≥15yearsparticipatedinthesurveyandtheresponseratewas70.0%.

Ofthetotalnumberofrespondents(N=6053),31.5%reportedbeingcurrentsmokersand29.2%dailysmokers.Mensmokedmorethanwomen(43.4%versus19.7%).Themeanageofstartingsmokingwas18.1yearsforbothsexes(17.2yearsformenand20.2yearsforwomen).Manufacturedcigaretteswereusedbydailysmokersin97.3%ofcases.Themeannumberofcigarettessmokedamongdailysmokerswas15.5.

More than four out of five respondents (83.6%) were lifetime abstainers from alcohol,and 4.3%had abstained for the previous 12months. Only 8.0%of respondents reporteddrinkingalcoholintheprevious30days,andonlyoneinevery20respondents(5.2%)wasanepisodicallyheavydrinker,althoughtheratesofepisodicheavydrinkinginmen(8.7%)wasfourtimesthatinwomen(1.8%).

Fruit and vegetable consumption was in general low: 87.8% of respondents reportedconsumingfewerthanfiveservingsoffruitandvegetablesperday,andthusbeingathigher

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riskfornoncommunicablediseases.Theproportionsweresimilarformen(87.8%)andwomen(87.9%).

Almosthalfoftherespondents(43.6%)didnotmeetWHOrecommendationsonphysicalactivityforhealth,witha significantdifferencebetweenmen (33.1%)andwomen (53.9%).The totalmediantimespentinphysicalactivitywas30.0minutesperday,althoughhigheramongmen(51.4minutes)thanwomen(17.1minutes).Further,81.3%(70.1%ofmalesand92.2%offemales)didnotparticipateinanyeffectivephysicalactivity.Morethantwoinfiverespondentsreportedreceivingadviceonahealthylifestylefromadoctororotherhealthworkerduringtheprevious12months.Inaddition,87.3%ofrespondents(89.1%ofmenand85.5%ofwomen)couldstatetwoormorenegativehealtheffectsofanyoftheselectedriskfactors

Oneinfourofrespondentsaged50–70yearshadhadafaecaloccultbloodtest.Whilemorethanhalfofwomenaged30–65years (54.2%)reportedhavingbeenscreenedforcervicalcancer,threeinfiveofthoseaged40–69yearshadhadamammography.

Asaresultofphysicalmeasurements,themeanbodymassindexrecordedwas26.6kg/m2formenand28.3kg/m2forwomen.Twoineverythreerespondentswereoverweight(bodymassindex≥25kg/m2).Threein10ofrespondents(28.8%)wereobese(bodymassindex≥30kg/m2),andtheproportionofobesewomen(35.9%)was1.6timesthatofmen(21.6%).Meanwaistcircumferencewas87.9cmandhipcircumferencewas102.5forwomen,and91.3cmand98.7cmformen,respectively.

Mean systolic and diastolic blood pressure (including in people taking medication forhypertension)was 123.0mmHg and 78.4mmHg, respectively,with no substantial differencebetweenmenandwomen.Threeoutof10respondentshadhypertensionandwithoutsignificantdifferencesbetweenthesexes.

Mean fasting blood glucose was 97.8 mg/dl (96.2 mg/dl for men and 99.3 mg/dl for women).Accordingtotheresultsofthesurvey,theproportionofrespondentswithimpairedfastingbloodglycaemia (≥ 110mg/dl and< 126mg/dl)was 7.9%and thisproportionwashigheramongmen(8.1%) thanwomen (7.7%).One in 10 respondents (11.1%)haddiabetesor reduced tolerance toglucose(fastingbloodglucose≥126mg/dlortakingantidiabeticmedication),withoutsignificantdifferencesbetweenmenandwomen.TheproportionsofrespondentswithhaemoglobinA1corglycatedhaemoglobin≥6.5%wassimilarformen(11.9%)andwomen(12.2%)andincreasedwithage.

Further,oneinfourrespondents(24.7%)hadaraisedtotalcholesterollevel(≥190mg/dlortakingmedicationforhypercholesterolemia),withtheproportionbeinghigherinwomen(28.5%)thanmen(20.9%).Suboptimallevelsofhigh-densitylipoproteincholesterolwerefoundin55.6%ofmen(<40mg/dl)and49.1%ofwomen(<50mg/dl).Meansaltintakeperdaywashigh:9.9gperday(11.0gperdayformenand8.7gperdayforwomen).

The survey showed that half of the respondents (51.2%) had three ormore risk factors fornoncommunicablediseases,andthisfigureincreasedproportionallywithage.Only1.3%ofthepopulationstudiedhadnoneofthefiveriskfactors.AfactsheetdescribingtheresultsofthesurveycomprisesAnnex2ofthisreport.Annex3presentsthesurveyinstrument.

BACKGROUND OF THE SURVEY

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2 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017

1. BACKGROUND OF THE SURVEY


1.1. Noncommunicable diseases

Chronicconditionsthatarenotcausedbyaninfectiousprocess,arenontransmissible,haveprolongedcourses,arenotresolvedreadilyandforwhichacompletecureismostlynotavailablearecallednoncommunicablediseases.AccordingtoAllenandFeigl,theuseofthetermnoncommunicablefortheworld’sbiggestkillermightcauseconfusion(1)andtheyproposedthetermsociallytransmittedtoreplaceit(2).Despiteseveralattemptstorenamenoncommunicablediseases(NCDs),however,awidelyacceptedalternativetermisnotyetavailable(1).

NCDsusuallyhavecomplexetiology.Severalriskfactorshavebeenimplicatedinthem.Theyusuallyhaveanoncommunicableoriginandalonglatencyperiod.Aprolongedcourseoftheillnessisfrequentlyfollowedby functional impairment or disability.NCDsare oneof themost important health problems today, sincetheyaretheleadingcausesofdeathanddiseaseburdenallaroundtheworld (3).TheglobaltrendinNCDscloselyresemblespandemicsofinfectiousdiseases(4).NCDshaveverydramaticconsequences:theyaffectbothhumanbeingsandthesocioeconomicparametersofsocieties.Theirimpactismoreprominentforlow-andmiddle-incomecountriesandwillevidentlycontinuetogrow.Mortalityduetocardiovasculardiseases(CVD),stomachandcervicalcancerseemstohavedeclinedbetween1980and2012,whilemortalityduetodiabetes,livercancerand(infemales)chronicrespiratorydiseaseandlungcancerincreasedonaverage.Inaddition,high-andlow-incomecountriesshowimportantdifferencesinNCDs.Forinstance,CVDandcancermortalitydeclined inhigh-incomecountries. Inmany low-andmiddle-incomecountries,deathsfromCVDandchronicrespiratorydiseasewererelativelyflat,whilemortalityfrombreastandcoloncancerincreased(5).Nevertheless,NCDsseemtobethemostsignificantpublichealthissueofthe21stcenturyworldwide(6).

TheumbrellaofNCDscoversCVD(48%ofthetotal),cancer (21%),chronicrespiratorydiseases(12%)anddiabetes(3.5%).Thesediseasesareconsideredtobeamongthebiggestkillersintheworld.Morethan36millionpeoplediedfromNCDs(63%ofglobaldeaths)in2008.Approximately14millionpeopledieyoung(at30–70yearsofage)duetoNCDs.Middle-andlow-incomecountriescarrythelargestshareoftheburdenoftheseprematuredeaths.Asresult,NCDshavebeenclaimedtocauseatotaleconomiclossofUS$ 7trillioninfifteenyears (7).Targetingseveralbehavioural riskfactorsforNCDs– includingtobaccouse,unhealthydiet, physical inactivity and the harmful use of alcohol – could preventmany deaths. The annual cost ofimplementingeffectiveinterventionstodecreasetheburdenofNCDsisestimatedtobeaboutUS$ 11.2billion(7). In low-incomecountries,thestrongerconcentrationoncommunicablediseases,maternal/childhealthandothertraditionalhealthconcernsovershadowsfundingforNCDs(8).

NCDswereestimatedtoaccountforover36milliondeathsin2008:63%ofthe57milliondeathsthatoccurredworldwide(9).About80%ofalldeathsfromNCDs(29million)occurredinmiddle-andlow-incomecountries.EventhoughmorbidityandmortalityfromNCDsmostlyoccurinadulthood,exposuretoriskfactorsbeginsearlyinlife.InlinewithresearchdemonstratingthatproperactioncanvastlydecreasetheburdenofNCDs,WHOadoptedanewhealthgoalin2012:toreduceavoidablemortalityfromNCDsby25%by2025(the25by25goal)(10).

During2012,56milliondeathsoccurredworldwide,ofwhich38millionwereduetoNCDs(11).About28millionoftheseNCDdeathsoccurredinmiddle-andlow-incomecountries(12).DeathsduetoNCDshaveincreasedworldwidesince2000.Whilethedeathsfrominfectiousdiseasesareestimatedtodecrease,theannualtotalnumberofdeathsduetoNCDs isestimatedto increaseto52millionby2030 (13).MortalityduetoCVD is

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projectedtorisefrom17.5millionin2012to22.2millionby2030,anddeathsduetocancer,from8.2millionto12.6million.ThefourmajorNCDsaccountforabout82%ofNCDdeaths(13).

PrematuredeathisoneofthebiggestconcernsinevaluatingtheimportanceofNCDsinasociety.Approximately42%ofthepeoplewhodiedfromNCDdeathsin2012werelessthan70yearsold.Mostprematuredeaths(82%)occurinlow-andmiddle-incomecountries.CVD(37%),cancer(27%),chronicrespiratorydiseases(8%)anddiabetes(4%)wereresponsibleforthemajorityofprematureNCDdeaths.

1.2. Risk factors

Alcoholisimplicatedinincreasedriskofcancerofthemouth,oropharynx,nasopharynx,larynx,oesophagus,colon, rectum, liverandfemalebreast (14),aswellasof livercirrhosisandpancreatitis (15,16). Inaddition,alcohol consumption is associatedwith hypertensive disease, atrial fibrillation and haemorrhagic stroke.AccordingtoWHO,48%oftheglobaladultpopulationhasneverconsumedalcoholicbeverages,althoughmiddle-andhigh-incomecountrieshavethehighestalcoholconsumption(17).

Physicalinactivityisoneofthemostimportantriskfactorsformortalityworldwideandisassociatedwith3.2milliondeathsand69.3millionDALYsannually(18).Regularphysicalactivitydecreasestheriskofischaemicheartdisease,stroke,breastandcoloncancer,anddiabetes.Italsoaidsweightcontrolandthepreventionofobesity(19).

ExcessdietaryconsumptionofsodiummaycauseahigherriskofhypertensionandCVD(20,21). Thesourceofsaltinthedietvariesamongcountries.Saltmaybeusedmoreofteninready-mademealsorprocessedfoodsinsomecountries,andinfoodpreparationorconsumptionathomeinothers.Asexpected,highersodiumintake(over3.5gperday)maycauseCVD(22,23).

Tobaccouseisthoughttokillapproximately6millionpeopleeachyear,andsecond-handsmoke,600 000(170 000ofwhomarechildren) (24,25). Inaddition,tobaccousecausesamajoreconomicburden,since itresultsinhighermedicalcostsandlossofproductivity.Thedefinitionoftobaccouseincludesthecurrentuseoftobaccoinbothsmokedandsmokelessforms(26).

Amongadults,theworldwideprevalenceofcurrenttobaccosmokingwasapproximately22%in2012,althoughitdiffersbetweencountriesandishigherinmen(37%)thanwomen(7%)(7).

Highbloodpressureisthoughttoberesponsibleforapproximately9.4milliondeathsand7%ofthediseaseburden in terms of DALYs in 2010 (18). Hypertensionmay cause renal failure, dementia, stroke,myocardialinfarction,cardiacfailureandblindness,whichhaveahugeimpactonhealthsystems(27,28).Severalmodifiablefactorsareimplicatedinhypertension,suchassocioeconomicdeterminants,highfatandsaltconsumption,psychologicalstress,physicalinactivity,overweightorobesity,reducedvegetableorfruitconsumption,alcoholandinadequateaccesstohealthcare.Bothageingandgeneticfactorsareassociatedwithhypertension.

Law,Morris&Wald(29) reportedthatdecreasingsystolicbloodpressureby10mmHgisrelatedtoreductionsof22%incoronaryhearddiseases(CHD)and41%instroke.Similarly,DiCesareetal.(30)showedthatitisalsoassociatedwitha41–46%reductionincardiometabolicmortality.Hypertension,CHD,stroke,diabetes,certaintypesofcancer,obstructivesleepapnoeaandosteoarthritisareassociatedwithobesity.Theidealmedianbodymassindex(BMI)foradultsisacceptedas21–23kg/m2andthetargetedBMIrangeis18.5−24.9kg/m2.OverweightisdefinedashavingaBMI≥ 25kg/m2,whileobesityisconsideredashavingaBMI≥ 30kg/m2.Bothoftheseconditionsmayresultinanincreasedriskforseveralconditions(31).Combined,theycauseabout3.4milliondeathsand93.6millionDALYseachyear(18).Obesityiswellknowntoresultinworsehealthoutcomesandhighermortality.



Globalobesityprevalencehasincreaseddramaticallyoverthelast30years.Womenusuallyhaveagreatertendencytowardsobesitythanmen:11%ofmenand15%ofwomen(≥ 18years)werereportedtobeobesein2014,whilethegeneralprevalencewasabout9%.Morethan5millionadultsintheworldareobese.Inaddition,38%ofmenand40%ofwomen(≥ 18)werereportedtobeoverweightin2014.Overweightisalsoanimportantproblemforchildrenagedunder5years,affectingapproximately42millionofthem.Bothoverweightandobesityareassociatedwithincome,sincetheirprevalenceishigherinbothsexesinhigh-andupper-middle-incomecountries.IntheNetherlandsandSwitzerland,however,obesityprevalenceinchildrenseemstohavebeenstabilized(32,33).

Diabetesisalsoaveryimportantcauseofprematuremortality,withaprevalenceofapproximately9%in2014anddiabetescausesabout1.5milliondeathsand89millionDALYseachyear(7).CVD,kidneyfailure,blindnessand lower-limbamputationareassociatedwithdiabetes (34), and impairedglucose toleranceand fastingglycaemiaareclearlyknowntocarryahigherriskofdiabetesandCVD.Aswithobesity,diabeteshasshowninincreasedglobalprevalenceoverrecentyears,especiallyinlow-andmiddle-incomecountries.Unhealthydiet,physicalinactivity,obesity/overweight,increasedbloodpressure,highcholesterolareamongthemajormodifiableriskfactorsofdiabetes.DiabetesasariskfactorforNCDwasassessedbymeansofbloodglucosemeasurement.Bothobesityanddiabetescanbepreventedbyseveraltypesofinterventionsrelatedtothefoodsectorandthepromotionofphysicalactivityinbothindividualsandpopulations.Similarly,weightlossandroutinephysicalactivitycandecreasetheriskofdiabetes.

1.3. NCDs and risk factors in Turkey

TheissueofNCDsisveryimportantforTurkey,aswellastherestoftheWHOEuropeanRegion.TheWHORegionalOfficeforEuropeestimatedthatthecumulativepercentageofNCD-relateddeathsintheRegionwas86%(35).Of430 459deathsinTurkeyin2000,305 467wereduetoNCDs,andCVDaccountedfor205 457ofthelatter.ThethreemostcommoncausesofdeathfromdiseaseinTurkeyareischaemicheartdisease(22%),cerebrovasculardiseases(15%)andchronicobstructivepulmonarydisease(6%).ThesixthandtenthmostcommoncausesofdeathinTurkeyarehypertensiveheartdiseaseandinflammatoryheartdiseases,respectively(36).

NCDswereestimatedtoberesponsiblefor86%oftotaldeathsinTurkey(37).TheprobabilityofprematuredeathfromthefourmainNCDswasabout18%,and42%ofmalesand13%offemaleswerefoundtobecurrenttobaccosmokers(total:27%)(38,39).Totalalcoholconsumptionpercapitawas1.4Lpurealcoholin2015(12).

PrematuredeathfromNCDswillcontinuetobeamongthemostimportantobstaclestoglobaldevelopmentinthiscentury,includinginTurkey,andtheprematuredeathrateattributedtothefourmainNCDswas303per100 000in2016(40).WHO’sNoncommunicable diseases progress monitor 2017reportedthatNCDsaccountedfor88%ofdeaths(392 000)inTurkey(population:over78million)and17%oftheriskofprematuredeath(41).

TurkeyseemstohavesucceededinsettingnationalNCDtargetsandcollectingmortalitydata,althoughrisk-factorsurveyshavebeenonlypartiallyachieved.Inaddition,thenationalintegratedNCDpolicy,strategyoractionplancouldstillbeimproved.Ontheotherhand,Turkeyhasbeenverysuccessfulintakingmeasuresto reduce the demand for tobacco, including tax increases; large graphic healthwarnings on packaging;bansonadvertising,promotionandsponsorship,campaignswiththemassmedia;andsmoke-freepolicies.Turkeyhasalsotakenactionagainsttheharmfuluseofalcohol,includingadvertisingbansorcomprehensiverestrictions,andincreasedexcisetaxes.Effortstoreduceunhealthydietsincludetheadoptionofpolicieson salt/sodium and saturated and trans fats, and restrictions on food marketing. The country has alsopromotedpubliceducationandawarenesscampaignsonphysicalactivity(41).Theprovisionofdrugtherapyorcounsellingtopreventheartattacksandstrokes,however,hasnotyetbeenachieved.

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1.4. STEPwise approach

ToaddresstheglobalhealthproblemofNCDs,in2013,theWorldHealthAssembly–WHO’sdecision-makingbody – adopted a globalmonitoring framework forNCDs (42),with 25 key indicators to track progress inpreventionandcontrol,andasetofglobalvoluntary targets, linkedto theframework, for: thepreventionandcontrolofNCDsby2025(includingatargettoreduceprematuremortalityfromthefourmainNCDsby25%), themainbehaviouralandmetabolic risk factors,andhealthsystems.Further, the2030Agenda forSustainableDevelopment recognized the importanceofaddressingNCDswith the inclusionofa similarlyambitioustargettoreducethenumberofprematuredeathsfromNCDsbyonethirdby2030(43).

Recognizing a global need for data on key NCD risk factors, WHO initiated the STEPwise approach tosurveillance(STEPS)in2002(44).Itsgoalsaretoguidetheestablishmentofrisk-factor-surveillancesystemsincountriesbyprovidingaframeworkandapproach:

tostrengthentheavailabilityofdatatohelpcountries inform,monitor,andevaluatetheirpoliciesandprogrammes;

tofacilitatethedevelopmentofpopulationprofilesofexposuretoNCDriskfactors; toenablecomparabilityacrosspopulationsandtimeframes;and tobuildhumanandinstitutionalcapacityforNCDsurveillance.

Sinceitsinception,STEPShasarguedthatsmallamountsofgood-qualitydataaremorevaluablethanlargeamountsofpoor-qualitydata.Itsupportsmonitoringafewmodifiableriskfactorsthatreflectalargepartof the futureNCDburdenand thatcan indicate the impactof interventionsconsidered tobeeffective inreducingthe leadingNCDs.BecauseSTEPSalsopromotesthecollectionofdataonanumberofdifferentriskfactors,incontrasttosurveysofsinglefactors,itallowsthecreationofanunderstandingofhowriskfactorsclusterinapopulationandoffersanopportunityforcountriestoestimatethesmallproportionofthepopulationwithhighoverallriskofacardiovascularevent,forreferralforpossibletreatment.

ThesurveillanceofNCDsconsistsofaprocessofpermanentmonitoringofthepopulation’shealthsituation,mainly risk factors for the development of disease and aspects of the social context, in such a way toensurethatinterventionsfocusonandareadjustedtothecharacteristicsofvariouspopulationgroups.Theinformationobtainedcanbeused indecision-makingatthe individualandcollective levels, toreducetherisksofmorbidityandmortality.

Against this backdrop, the study described in this publication provides valuable information onNCD riskfactorsinTurkeyandshouldallowthedifferentactorsofthehealthsystemandthecommunityingeneral,giventhepopulationrepresentativenessoftheresults,clearlytoidentifytheriskfactorsonwhichmeasuresandstrategiesshouldbeformulatedtopreventtheincreaseofnewcasesofCVD,diabetesandcancer.ThestudyusesSTEPStogatherinformationonNCDriskfactorsforthesamplerepresentingTurkeyandits12regions,asdescribedbylevel-1NomenclatureofTerritorialUnitsforStatistics(NUTS-1).

SURVEY GOAL AND OBJECTIVES

2


2. SURVEY GOAL AND OBJECTIVES

2. SURVEY GOAL AND OBJECTIVES

2.1. Survey goal

ThegeneralgoalofthesurveyistodeterminetheprevalenceofmajorriskfactorsforNCDsusingtheWHO-approvedSTEPSsurveymethod(44)byusingtheNationalHouseholdHealthSurveyinTurkey–PrevalenceofNoncommunicableDiseaseRiskFactors(NHHST)toevaluatethebaselinesituationandenablemoreefficientplanningofactivitiesforthepreventionandcontrolofNCDs.

STEPSisasurveillancestrategythatconsistsofasimple,standardizedapproachtocollecting,analysinganddistributinginformationontheriskfactorsthatdeterminethemostcommonNCDs.Itsapplicationseekstohelpbuildandstrengthencountries’capabilitiestoperformsurveillanceoftheseriskfactors.Thismethodis flexible, since it can be adapted to a country or territory’s economic, logistical, human resources andinfrastructurecapacitiesandtoitsinformationneedsfortheconstructionofthebaselineofriskfactorsforNCDs.Atpresent,morethan104WHOMemberStateshaveimplementedthismethod.

TheWHOestablishedeight risk factorsconsidered tobe themost important for inclusion in surveillancestrategies,asvalidmethodologiesareavailablefortheirmeasurementandinviewofthepotentialoftheircontrol to decreasepremature death anddisability. These risk conditionswere grouped into behaviouralfactors understood as modifiable (tobacco use, harmful use of alcohol, low consumption of fruits andvegetables,andphysicalinactivity)andbiologicalfactorsconsideredcontrollable(hypertension,overweightandobesity,highbloodsugarandincreasedtotalcholesterol).

2.2. Survey objectives

TheobjectivesoftheNHHSTare:

● to determine the prevalence of the most common behavioural risk factors for NCDs in the generalpopulationaged≥ 15years,representingbothsexes;

● todeterminetheprevalenceofthemostcommonbehaviouralriskfactorsforNCDsinsamplesrepresentingthepopulationsinthe12NUTS-1regions;

● todeterminetheprevalenceofbiologicalriskfactorsforNCDsinthepopulationaged≥ 15years;and ● todeterminethedifferencesintheprevalenceofriskfactorsbetweenthesexes,areasofresidenceandfiveagegroups.

2.3. Rationale for the survey

ManyNCDsmaybereducedthroughmeasurestargetingfourormorerisk factors, includingtobaccouse,physical inactivity, harmful useof alcohol andunhealthydiet. TheMinistryofHealthofTurkeyworked tosetnationaltargetsfor2025basedonthenationalsituation(takingintoaccountthenineglobaltargetsforNCDsandWHO’seffortstocollectdataonoutcomeandprocessindicatorsin2015)andachievethesetargets(takingaccountoftheWHOGlobalNCDActionPlan2013–2020).Further,theMinistryofHealthlaunchedtheNationalMultisectoralActionPlanforNoncommunicableDiseases2017–2025(39).

ThedataontheprevalenceofriskfactorsforNCDsavailablefromprevioussurveysinTurkey,however,werelimitedandfragmented.Nationallyrepresentative,comprehensive,comparableandup-to-datedataonNCDriskfactorsareneededtoevaluatetheeffectivenessofcurrentpublichealthpoliciesandtodevelopfurtherinterventions forNCDpreventionandcontrol.TheWHO-assistedNHHSThasbeen implemented togatherthesedata.Thesurveywasplannedtobecarriedoutintwophases:abaselinestudyconductedin2017andafollow-upphasein2019.Thispublicationdescribesphase1.

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SURVEY METHODOLOGY

3


3. SURVEY METHODOLOGY

3. SURVEY METHODOLOGYTheSTEPSmethodevaluatesriskfactorsthroughtheapplicationoftheSTEPSinstrument,whichallowsthecollectionofdatathrough:

1. aquestionnaire2. physicalmeasures3. biochemicalmeasures.

Eachstepcanbedeepened: theycanbebasic,extendedandoptional. In implementation, theMinistryofHealthfurtherextendedtheSTEPSinstrumentsfornation-specificmeasurements(seeAnnex3).

Step1consistsofevaluationbasedonaquestionnairethat investigatesexposuretofourbehaviouralriskfactors:tobaccoconsumption,harmfulalcoholconsumption,lowconsumptionoffruitsandvegetables,andphysicalinactivity.

Step2considersthephysicalmeasurementofvariablessuchasbloodpressure,height,weight,andwaistandhipcircumferencetoassessexposuretobiologicalriskfactorssuchashighbloodpressure,overweightandobesity.

Step3addsbiochemicalmeasurementsbytakingbloodandurinesamplesforthedetectionofhighlevelsofglycaemia,hypercholesterolemiaandsodiumintake.

DatawerecollectedinApril–September2017,usingtheinstrumentinAnnex3.

NHSSTisacross-sectionalhouseholdsurveythatcollectsinformationthroughanestablishedquestionnaire.Thisinformationisobtainedbyinterviewing,makingaphysicalexaminationofandtakingbiologicalsamplesfromsubjects.Thetargetpopulationconsistsofasampleofpeopleaged≥ 15years, living inhouseholdsrandomlyselectedaccordingtotheWHOprotocol.

Biologicalmeasurementsaremadeonwhole-bloodandurinesamples.Fastingbloodglucose,totalcholesterol,high-density lipoprotein(HDL)cholesterol,triglycerides,haemoglobinA1corglycatedhaemoglobin(HbA1c)test,urinarycreatinine,andurinarysodiumaremeasuredforallrespondentswhoagreedtoparticipateinstep3ofthesurvey.

3.1. Inclusion criteria

Householdmemberswhometthefollowingcriteriawereincludedinthesurvey.Subjects:

● werecitizensoftheRepublicofTurkeyaged≥ 15years; ● gavewritten informed consent to their participation, as demonstrated by the Directorate-General forHealthResearchoftheMinistryofHealthtotheethicscommitteethatapprovedthestudy;and

● hadnodisabilitypreventingthemfromansweringthequestionsoftheinterview.

3.2. Exclusion criteria

Householdmemberswhometatleastoneofthefollowingcriteriawereexcludedfromthestudy:

● anageof0–14years; ● residenceinaninstitution,includingmotels,hotels,hospitals,studenthostels,prisons,etc.; ● lackofstatusasapermanentresidentofTurkey; ● statusasvisitorstothehomeswherethefieldsurveywasperformed;and

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● cognitiveimpairmentatalevelthatwouldhinderthesubjectfromunderstandingthequestionsofsurveyandgivingclearandcorrectanswers.

3.3. Sample size

Forcalculating thesamplesize, theprevalenceofoverweightandobesity (P=53.6%, rounded toP=0.50),identifiedbytheTurkishStatisticalInstitute(TURKSTAT)duringthehealthsurveyof2014,wasused,assuminga95%confidenceinterval(CI)(Z=1.96),a5%acceptablemarginoferror(e),acomplexsamplingdesigneffect(D)coefficientof1.50,andequalrepresentationofthesexesineachagegroup(S)(fiveagegroupsforeachsexoratotalof10groups).Thestudyalsoaimstoobtainregional-levelestimatesfor12NUTS-1regionsinTurkey.Thus,themaximumnumberofdifferentgroupsinthesamplesizewas12.Calculationsresultedinasamplesizeof6915individuals,whichwasfurtherincreasedbyanon-responsefactorof20%(i=0.20)to8644,toaccountfornon-response.Atotalof8644subjectsaged≥ 15yearswasrequiredfollowingtheseassumptions.

3.4. Effective sample

Ofthe8650householdsvisited,16053peopleaged≥ 15yearsparticipatedinthestudy,ofwhom3352alsocompletedstep3(2701peopleoutofthe6053selecteddidnotwanttoparticipate).

The overall non-response rate (including those households whose members were not home or rejectedparticipationatthedoor)correspondsto30%ofthehouseholdsvisitedforsteps1and2and61.22%forstep3.

3.5. Sampling frame

ThesurveyofNCDsriskfactorsisconductednationwide,sothesamplingframeincludedallcitizensinTurkey(2016population:79 814 871).Administratively,Turkeyhas12NUTS-1,26NUTS-2and81NUTS-3regions.Thelevel-3NUTSregionsinTurkeycorrespondto81provinces.Turkeyhad970districtsinNovember2017.Themultistageclustersamplingframecovers865clustersdistributedoverallNUTS-3provinces.ThispublicationpresentsNUTS-1estimates,sothesamplingstrategyconsideredpopulationconcentrationsatthatlevel.TherandomselectionofclustersmayexcludesomeoftheNUTS-3provinces.

3.6. Sampling design

AsperWHOSTEPSrecommendation,amultistageclustersamplingstrategywasused.ThenationalhouseholdaddressframeupdatedinFebruary–August2016wastakenasthebasisofsampling.

(TURKSTATdetermined the 100 primary sampling units (PSUs) using the probability-proportionate-to-sizesamplingmethod.EachPSUcontained10secondarysamplingunits(SSUs).Atstep3,atleast10householdswererandomlyselectedfromeachselectedSSU.Finally,oneeligiblerespondentwasselectedfromthelistofalleligiblerespondentswithinaselectedhousehold,usingtherandomselectionmethodasdescribedintheWHOSTEPsmanual(44).Thesamplesizeforeachstagewas:

1. selectionofPSUs:865clusterswerechosen,eachcontainingapproximately100householdaddresses;2. selectionofSSUs:8644householdswerechosen,with10households(addresses)withineachselected

cluster;3. selectionofindividualsinthefield:afteralleligibleadultsintheselectedhouseholdweredocumented,

oneindividualwasrandomlyselectedbyuseofacomputerprogram.

1 ThesampleoftheTURKSTATincluded8650households,insteadof8644,owingtotheindivisibilityofclusters.



Table1presentsallNUTSregions,andtheirconstituentregionsandprovinces.

Table 1. NUTS regions in Turkey

NUTS-1 (regions) NUTS-2 (subregions) NUTS-3 (provinces)

Istanbul (TR1) Istanbul (TR10) Istanbul (TR100)

WesternMarmara (TR2) Tekirdağ (TR21) Tekirdağ (TR211)

Edirne (TR212)

Kırklareli (TR213)

Balıkesir (TR22) Balıkesir (TR221)

Çanakkale (TR222)

Aegean (TR3) Izmir (TR31) İzmir (TR310)

Aydın (TR32) Aydın (TR321)

Denizli (TR322)

Muğla (TR323)

Manisa (TR33) Manisa (TR331)

Afyonkarahisar (TR332)

Kütahya (TR333)

Uşak (TR334)

EasternMarmara (TR4) Bursa (TR41) Bursa (TR411)

Eskişehir (TR412)

Bilecik (TR413)

Kocaeli (TR42) Kocaeli (TR421)

Sakarya (TR422)

Düzce (TR423)

Bolu (TR424)

Yalova (TR425)

WesternAnatolia (TR5) Ankara (TR51) Ankara (TR510)

Konya (TR52) Konya (TR521)

Karaman (TR522)

Mediterranean (TR6) Antalya (TR61) Antalya (TR611)

Isparta (TR612)

Burdur (TR613)

Adana (TR62) Adana (TR621)

Mersin (TR622)

Hatay (TR63) Hatay (TR631)

Kahramanmaraş (TR632)

Osmaniye (TR633)

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CentralAnatolia (TR7) Kırıkkale (TR71) Kırıkkale (TR711)

Aksaray (TR712)

Niğde (TR713)

Nevşehir (TR714)

Kırşehir (TR715)

Kayseri (TR72) Kayseri (TR721)

Sivas (TR722)

Yozgat (TR723)

WesternBlackSea (TR8) Zonguldak (TR81) Zonguldak (TR811)

Karabük (TR812)

Bartın (TR813)

Kastamonu (TR82) Kastamonu (TR821)

Çankırı (TR822)

Sinop (TR823)

Samsun (TR83) Samsun (TR831)

Tokat (TR832)

Çorum (TR833)

Amasya (TR834)

EasternBlackSea (TR9) Trabzon (TR90) Trabzon (TR901)

Ordu (TR902)

Giresun (TR903)

Rize (TR904)

Artvin (TR905)

Gümüşhane (TR906)

North-eastern Anatolia (TRA)

Erzurum (TRA1) Erzurum (TRA11)

Erzincan (TRA12)

Bayburt (TRA13)

Ağrı (TRA2) Ağrı (TRA21)

Kars (TRA22)

Iğdır (TRA23)

Ardahan (TRA24)

Table 1 (contd)




CentralEastern Anatolia (TRB)

Malatya (TRB1) Malatya (TRB11)

Elazığ (TRB12)

Bingöl (TRB13)

Tunceli (TRB14)

Van (TRB2) Van (TRB21)

Muş (TRB22)

Bitlis (TRB23)

Hakkâri (TRB24)

South-eastern Anatolia (TRC)

Gaziantep (TRC1) Gaziantep (TRC11)

Adıyaman (TRC12)

Kilis (TRC13)

Şanlıurfa (TRC2) Şanlıurfa (TRC21)

Diyarbakır (TRC22)

Mardin (TRC3) Mardin (TRC31)

Batman (TRC32)

Şırnak (TRC33)

Siirt (TRC34)

Fig.1displaysthegeographicalbordersoftheNUTS-1regionsandthe81provincestheycover.

Table 2 presents the number of clusters andnumber of households in eachNUTS-1 regions,while Fig. 2displaysthenumberofhouseholdinthesamplebyNUTS-3provinces.The865clustersarethePSUsofthestudy,whicharedisplayedinFig.3bytheirgeographicalcoordinates.

Fig. 1. Geographical borders of NUTS-1 regions

Source:MinistryofEnvironmentandUrbanization,RepublicofTurkeyandTURKSTAT.

Table 1 (contd)

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Table 2. Sample clusters and households by NUTS-1 regions

NUTS-1 regions Number of clustersNumber of sample

households

TR1 161 1610

TR2 43 430

TR3 129 1290

TR4 88 880

TR5 91 910

TR6 110 1100

TR7 44 440

TR8 53 530

TR9 31 310

TRA 19 190

TRB 32 320

TRC 64 640

Total 865 8650

Fig. 2. Sample sizes by NUTS-3 provinces




Fig. 3. Geographical location of sample clusters


3.7. Selection of individuals

Eachhouseholdwasvisiteduptothreetimes.Ifhouseholdconsentwasobtained,aqualifiedhouseholdmemberwasrandomlyselectedforparticipationinthesurvey.Anappointmentwasmadewiththoseselectedhouseholdmemberswhowerenotavailableduringtheinitialvisitbutcouldbeavailableinthefollowing10days.

3.8. Survey design

The survey was carried out using three consecutive steps, as per WHO STEPS, and considering localnecessitiesandresources.

Step1comprisedtheadministrationofaquestionnaireadaptedfromNHHST,theWHOSTEPSInstrumentforChronicDiseaseRiskFactorSurveillance,theEuropeanHealthExaminationSurvey,andWorldBankHealthSystemStrengtheningandSupportProjectDevelopment indicatorsselectedbytheMinistryofHealthandadditional questions recommended by the Ministry’s Directorate-General for Health Research. Face-to-face interviewswereheld,using thequestionnaire tocollectdemographicandbehavioural information ina household setting, including informationon tobaccouse, alcohol consumption, diet (including fruit andvegetable consumption, oil and fat consumption, meal consumption outside the home and dietary salt),physicalactivity,historyofhighbloodpressureand/orraisedcholesterol,historyofdiabetesandCVD,lifestylecounselling,cancerscreeningandaccesstohealthcare.

Step2comprisedaseriesofphysicalmeasurementsofoverweightandobesityusingspecifictestsanddevices(bodyweightandheight,waistandhipcircumference),bloodpressureandheartrate.Duringthehouseholdvisits,bloodpressureandheartrateweremeasuredontwoseparateoccasions,onthejointrequestofWHOandtheDirectorate-GeneralforHealthResearchoftheMinistryofHealth.Thefirstmeasurementwasmadeduringstep2andthesecond,duringthesubsequentvisittoeachhouseholdforstep3(fastingmeasures).

Step3compriseda seriesofbiochemicalmeasurements incapillaryblood,usingdrychemicalmethods,andinurine.Measurementsincludedbloodglucose,totalcholesterol,HDLcholesterol,triglycerides,HbA1Candurinarysodiumandcreatinine.Participantscollectednon-fastingurinesamplesincontainersthattheyputintozip-closableplasticbags.SamplesweresentforanalysistotheCentralLaboratoryoftheHacettepeUniversityFacultyofMedicine,Ankara,Turkey.

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3.9. Weighting of the survey

Becausethedatacoveredasampleofthetargetpopulation,theyhadtobeweighted.Thus,sampleweightingwascarriedouttocorrectdifferencesintheage,sex,areaofresidencedistribution(NUTS-1region),educationlevel of the sample versus the targetpopulationandprobabilitiesof selection.Thesampleweight foreachcaseinthesurveysampleaccountedforthenumberofcasesitrepresentedinthesamplingframe,basedonthesampleselectionprocedure.TURKSTATprovided thefirst-stagesampleweights,basedon the inclusionprobabilitiesofthecluster-levelPSUs,andtheinclusionprobabilitiesoftheSSUs.Thethirdcomponentofthesamplingweightwastheinclusionprobabilityofahouseholdmember,whichwasobtainedfromthehouseholdinformationrecords.TheproductofthethreeinclusionprobabilitiesforPSUs,SSUsandhouseholdmemberswasinvertedtoobtainthebaseweights.

Thesecondweightwas thenon-responseweight,whichwasobtainedfromthe interviewtracking forms.Investigators first adjusted inclusion probabilities at the cluster level for non-coverage, as some of theaddresses included in the sample did not exist because ofminor differences between actual addressesand the address-based population count of TURKSTAT. The non-responding households in each clusterwereobtained from the interview tracking forms. Table 3 presents thenumberof clusters by numberofnon-respondinghouseholdsforeachNUTSregion.Therewasatotalof2422non-responsesin865clusters.Therewereanadditional175non-coveredaddresses,leavingatotalof6053respondinghouseholdsoutof8650householdaddresses in thesample.2Thenoncoverageandnonresponseadjustmentswereavailableattheclusterleveland,thus,investigatorswereabletocalculatenonresponseweightsandadjustthemfornoncoverageattheclusterlevel.Theproductofthesampleweightsandnonresponsegavethebaseweights,whichwerefurtheradjustedwithpoststratificationtoaccountfordifferencesinthesex–age,sex–educationandNUTS-1proportionsfromthoseintheactualpopulation.Thenonresponseratesvariedacrossthestepsofthestudy,sodifferentnonresponseweightswerecalculatedforsteps1and2,andstep3.

Table 3. Distribution of nonresponding household numbers by clusters and NUTS regions

NUTS-1 regionsNumber of non-responding households in each cluster

0 1 2 3 4 5 6 7 8 9 10

TR1 12 15 22 27 19 20 10 15 9 7 5

TR2 8 8 8 7 5 6 1 0 0 0 0

TR3 22 19 24 19 16 13 8 6 2 0 0

TR4 23 18 26 14 5 1 0 1 0 0 0

TR5 15 21 15 16 16 5 0 1 2 0 0

TR6 19 11 16 18 14 9 10 11 1 0 1

TR7 13 10 5 6 2 2 1 3 1 1 0

TR8 13 15 6 7 5 1 3 2 0 0 1

TR9 16 7 2 0 2 0 1 1 0 1 1

TRA 9 3 2 0 2 3 0 0 0 0 0

TRB 12 5 7 2 2 1 1 1 0 0 1

TRC 22 3 3 7 7 3 5 2 2 2 8

Total 184 135 136 123 95 64 40 43 17 11 17

Total non-responses 0 135 272 369 380 320 240 301 136 99 170

2 TURKSTATprovided8650householdsinthesampleinsteadofthe8644planned,becauseitcouldnotadjustthenumberofhouseholdstobesamplesineachcluster.



Thethirdweight(populationweight,alsoknownaspoststratification)wasusedforanydiscrepancythatmayexistbetweenthesampleandthepopulation.Byadjustingtheseweights,thesurveysamplewasessentiallyforcedtoresemblethepopulation,thusenablinginferencetotheentirepopulation,notjustthesample.Toobtainthepoststratificationweights,thesex–age,sex–educationandNUTS-1distributionofthepopulationwas taken from the 2016 estimates based on TURKSTAT’s 2015 address-based population count. As theresponseratesvariedacrosssteps1and2,andstep3,poststratificationneededtobedoneseparatelyforthem.

Table 4 presents the proportions used for two-way sex–age poststratification. It presents samplepercentages forbothsteps 1 and2, andstep3by sexandagegroups, aswell as thepopulationanalogytaken fromTURKSTAT.Analogously, Table 5 presents the sample andTURKSTATproportions for two-waypoststratificationofsex–educationlevel.Finally,Table6presentstheNUTS-regionssampleandpopulationproportionsusedforpoststratificationtomatchtheregionalpopulationdistribution.Tomatchthesampleproportions, investigators used the raking (otherwise known as iterative proportional fitting, sample-balancing, or raking ratio estimation)method (45) for adjusting the samplingweights of the sample databasedonknownpopulationcharacteristicsgiveninTables4–6.

Table 4. Data for two-way sex–age poststratification

Age group (years)

Men Women

Sample steps 1 and 2 (%)

Sample step 3 (%)

TURKSTAT (%)


Sample step 3 (%)

TURKSTAT(%)

15–29 8.21 7.43 16.12 11.12 9.46 15.47

30–44 10.77 9.87 15.28 17.35 15.72 15.00

45–59 10.61 10.44 10.92 16.09 16.71 10.79

60–69 6.29 6.77 4.55 7.65 8.56 4.90

≥ 70 4.56 5.61 2.93 7.35 9.43 4.03

Table 5. Data for two-way sex-education poststratification

Education level

Men Women


Sample step 3 (%)

TURKSTAT (%)


Sample step 3 (%)

TURKSTAT (%)

Illiterate or literate but no formal schooling

3.92 5.16 2.18 22.88 22.08 13.92

Primary school completed

13.79 14.26 10.23 16.24 13.63 21.43

Secondary, vocational secondary or high school completed

15.96 14.77 28.43 5.86 5.16 7.36

College, faculty, master’s or doctorate completed

6.77 5.94 9.00 22.88 22.08 13.92

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Table 6. Data for NUTS-1 region poststratification

NUTS-1 regionsSample steps 1 and

2 (%)Sample step 3

(%)TURKSTAT

(%)

TR1 14.59 8.11 18.74

TR2 5.42 3.73 4.67

TR3 14.85 15.87 13.59

TR4 11.99 5.52 9.89

TR5 11.23 14.17 9.90

TR6 12.06 14.80 12.55

TR7 5.60 7.70 4.97

TR8 6.66 7.70 6.03

TR9 4.20 6.09 3.53

TRA 2.63 3.52 2.59

TRB 4.25 4.62 4.44

TRC 6.53 8.17 9.10

3.10. Data collection

Total of thirty teams, each of which comprising two-person, collected the survey data, using e-STEPtabletsoftware,andthedatawerestored inacentralizedserver.Theteamsalsorecordedonthetabletsthe geographical coordinates of each household visited. Each survey team included a health specialistwhoperformedphysicalandbiochemicalmeasurements.Whentheyfoundnobodyathome,teamsvisitedhouseholdsuptothreetimes.Theyobtainedtheconsentoftheselectedparticipantforallthreestepsofthesurvey.Theteamswereequippedwithportabledevicesthatallowedthemtoperformallphysicalandbiochemicalmeasurements,andtheygaveacopyoftheresultsofthebiochemicalmeasurementstoeachparticipant.Thedatacollection tookplace fromApril toSeptember2017.Thefield implementationof thesurveyusedthemedicalequipmentandsupplieslistedinTable7.

Table 7. Equipment and supplies used for the field implementation

Equipment Usage area Pieces

SiemensDCAVantageInstrument HbA1C 33

CardioChekPAAnalyzer Glucose,triglycerides 33

OmronM7IntelliIT Bloodpressure 33

SECAStadiometer Height 33

SECAelectronicflatscale Weight 813

SECAgirth-measuringtape Girth 201

EquipmentCarryingSafetyCase Medicalequipmentandkitscarryingcase 66

SampleshipmentbagShipmentofurinetothelaboratoryforanalysis(sodiumandcreatinine)

300

CDMVITvacuumurinetube Vacuumurinetube 10 000

CDMVIBsterileurineglass Sterileurineglass 10 000



Equipment Usage area Pieces

Lancet Bloodsample/hygiene 10 000

Gloves Bloodsample/hygiene 10 000

Alcoholicwipes Bloodsample/hygiene 10 000

Capillarytube(40ml) Bloodsample 10 000

Capillarytube(15ml) Bloodsample 10 000

Cardioglucosekit Bloodsample(glucose) 10 000

CardiotriplepanelBloodsample(measurementofcholesterol,HDLcholesterol,triglyceridevalues)

10 000

SiemensDCA2000HBA1CReagentKit(ECCN;EAR99/AL:N)

HbA1C 10 000

Forthesupplementaryrequirementsforthefieldsurvey,speciallydesignedsafetycasestotransport theinstrumentsforbiochemicalmeasurementwasmanufactured,aswellasbagstotransporttheinstrumentsanddevicesforphysicalmeasurement (seeTable7).Speciallydesignedcaseswereusedtotransporttheurinesamplesincoldchain,viaspecialcourierservicesfromdifferentpointsofthefieldsurveytotheCentralLaboratoryofHacettepeUniversityFacultyofMedicine.

3.11. Training of the field survey staff

The field teams received theoretical and practical training and carried out their functions following theguidelinesoftheSTEPSmanual(44)andthespecificationsofthemanualsfortheequipmentusedtomeasureglycaemiaandcholesterol.Theteams(78fieldsurveypersonnelfrom15regionallogisticcentres,representing79provincesinTurkeydesignatedbyTURKSTATbasedon12NUTS-1regions)receivedfourdaysoftraining(10–14April 2017) inAnkara to foster their skills in communication and their knowledgeof techniques forthe development of interviews, equipment management and physical and biochemical measurements.Thetraineescomprised31interviewers/data-collectionspecialists,32healthprofessionalsand15regionalsupervisorsandcoordinatorstoconductthenationwidefieldsurveys.

Thetrainingwasconducted,underthesupervisionofthefieldteamcoordinator,bytheprogrammeleader,members of project team and representatives of themanufacturers of the equipment used tomeasurebloodglucose,glycaemia,cholesterolandHbA1c.RepresentativesoftheWHOCountryOffice,TurkeyandtheDirectorate-GeneralforHealthResearchoftheMinistryofHealthalsotookpart.

Thetrainingprogrammeforthefirsttwodaysfocusedontwomaingroups:data-collectionpersonnelandhealthprofessionals.Expertstrainedthefirstgroupinthecomprehensiveuseofthetablets,withspeciallydesignedsoftware,inadministeringthequestionnairesduringhouseholdvisits,whiledoctorsandtrainersfromsupplierfirmstrainedthesecondgroupintechniquesforintakinganthropometricmeasurements.Thegroupswerejointlyfamiliarizedwiththeproceduretobefollowedbeforeandduringthehouseholdvisits.

ThelasttwodaysoftrainingweredevotedtopilotfieldsurveyinthreedifferentregionsinAnkara(Mamak,AltındağandKeçiören):makingvisits to randomlyselectedhouseholdswhere the traineesbothcollecteddataandmadephysicalandbiochemicalmeasurementsundertheclosesupervisionofexperts.Anevaluationmeetingwasorganizedontheclosingdayofthetrainingprogrammetoelaborateontheresultsofthepilotfieldsurvey,thenecessaryclarificationsweremadeandtheprecautionsweretaken.

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3.12. Field work

Afterthetraining,theorganizationoftheNHHSTwasfinalizedsothatitcouldbeconductedin79provinces,encompassingurbanandruralareas,andcoordinated,controlledandsupervisedfromtotalof15logisticalcentresinTurkey.Allnecessarylegalproceduresandformalitieswerecompletedfortheemploymentoftotalof30fieldsurveyteamsand15regionalsupervisorsandcoordinators.

Eachteamwasfurnishedwithseparatesurveyguidesforthedatacollectorsandthehealthstaff,andallformstobeusedduringhouseholdvisitsand/ortobepresentedtothelocalauthoritiesuponrequest.Allnecessaryofficialcorrespondenceandprocedures,aswellasthedeploymentofthemajorityofmedicalequipmentandmaterialsfromtheheadquartersinAnkara,werecompletedandthefieldsurveywasinitiatedasof21April2017.

Thefieldandzonecoordinatorssystematicallysupervisedthefieldwork,accordingtoguidelinesgivenintheSTEPSmanual(44),mainlytoensurethereliabilityofthedatacollected.Tocompletethefieldoperation,thesurveycoordinatorsvisitedandsurveyedthehousingunits,andsubsequentlyfocusedonthefinalreportofthefieldoperation.

The work of control and supervision of the surveys carried out by the field coordinator and the zonecoordinatorswasconductedsystematicallyinordertoensurethereliabilityofthedatacollection.

3.13. Data management and consolidation

Tofacilitatethecollectionandmanagementofdataandreducethetimeofapplicationofthesurvey,eSTEPSsoftwaredevelopedbyWHOforthecollectionoftheSTEPSinstrumentwasinstalledontabletpersonalcomputers(PCs).Theinterviewerstypedintothetabletsalltheinformationobtainedfromtheparticipants,andthedatawereuploadedtoacentralizeddatabaseonaserver,attheendofeachcollectiondayoraftereachsurveywascompleted.Thecoordinatorscontinuouslymonitoredtheuploading.Thecentraldatabasewasconsolidatedandthequalityofthedatawasvalidatedaccordingtocriteriaincludinginconsistency,jumperrors,absenceofdata,surplusdataandinvaliddata.Thevalidateddatabasefortheanalysisprocesswasgeneratedinthisway.

3.14. Measurement and determination of risk factors

ThemeasurementoftheriskfactorswascarriedoutfollowingalltheguidelinesandrecommendationsoftheSTEPSmethod(44).

3.14.1. Step 1

ThroughtheapplicationoftheSTEPSquestionnaire,thefieldimplementation teamsinvestigatedexposuretofourbehaviouralriskfactors:tobaccoconsumption,alcoholconsumption,lowconsumptionoffruitsandvegetables,andphysicalinactivity.

3.14.1.1. Tobacco use

Currentanddailyconsumption,theageofonsetofdailyconsumption,timeofcessationofdailyconsumptionandexposuretosecond-handsmokeinthehomeandotherspaceswereinvestigated.

3.14.1.2. Consumption of alcohol

Theconsumptionofalcoholisestablishedaccordingtoperiodicity(inthepreviousyearandmonth)andthenumberofdrinksconsumed.Theparticipantswereclassifiedas:



● non-orexdrinker:absenceofalcoholicbeveragesduringtheprevious12months; ● allrespondentsdrinkingatahighlevel:≥ 60gpurealcoholonaverageperoccasionamongmenand≥ 40gamongwomen;

● allrespondentsdrinkingatanintermediatelevel:40–59.9 gpurealcoholonaverageperoccasionamongmenand20–39.9 gpurealcoholamongwomen;and

● allrespondentsdrinkingata lower level:< 40 gpurealcoholonaverageperoccasionamongmenand< 20 gpurealcoholamongwomen)(44).

3.14.1.3. Consumption of fruits and vegetables

Teamsaskedparticipantsabouttheirconsumptionoffruitsandvegetablesinatypicalweek(numberofdaysofconsumptionanddailyportionsconsumed).Toestablishriskbehaviour,theytookaccountofthecurrentrecommendationofdailyconsumptionofatleastfiveservingsoffruitsorvegetables(44).

3.14.1.4. Physical activity

TheSTEPSquestionsonphysicalactivitywereadaptedfromtheWHOGlobalPhysicalActivityQuestionnaire,version2,whichassessesbehaviourinthreedomains:atwork(whichincludespaidandunpaidwork,inandoutsidethehome),fortransportandduringleisuretime.Toestablishthetotalandthelevelofphysicalactivityof each participant,metabolic equivalents (METs) perminutewere calculated for oneweek; for this, theweeklyminutesofvigorousphysicalactivityweremultipliedby8METsandtheminutesofmoderatephysicalactivityanddisplacements,by4METs.(Bydefinition,themovementsareconsideredasmoderate-intensityphysicalactivity.)Thephysicalactivityofthesurveyedpopulationwasdescribedusingcontinuousindicators(MET-minutesperweekandminutesperweek)andcategoryindicatorsusingthefollowingcut-offpointstoestablishthelevelofphysicalactivity(44).

Participants’physicalactivitywassaidtobehighiftheymetoneofthefollowingcriteria:

● vigorous-intensityactivityforatleastthreedays,reachingaminimumof1500MET-minutesperweek;or ● ≥ 7daysofphysicalactivityinanydomainandintensity,reachingaminimumof3000MET-minutesperweek.

Participants’physicalactivitywassaidtobemoderateiftheydidnotmeetthecriteriaforthehighlevel,butmetanyofthefollowingthreecriteria:

● vigorous-intensityphysicalactivityfor≥ 3daysforatleast20minutesaday; ● moderate-intensityphysicalactivityfor≥ 5daysforatleast30minutesaday;or ● physicalactivityofanyintensityanddomainfor≥ 5days,reachingaminimumof600MET-minutesperweek.

Participants’ physical activity was said to be low if they did notmeet the criteria stated for the high ormoderatelevels.

3.14.2. Step 2

Physicalmeasurementsofbloodpressure,height,weight,andwaistandhipcircumferenceweremadetoevaluatetheexposuretobiologicalriskfactors:hypertension,overweightandobesity.

23

3.14.2.1. Blood pressure

Bloodpressure(BP)wasmeasuredthreetimes,with15minutes’restafterthefirstmeasurementandthree

minutesbetweenthesecondandthird.ToestablishthealterationoftheBP,thefollowingcut-offpointswere

takenintoaccount:

● high:systolicbloodpressure(SBP)≥ 140mmHgordiastolicbloodpressure(DBP)≥ 90mmHg;and

● veryhigh:SBP≥ 160mmHgorDBP≥ 100mmHg.

Teamsalsoinquiredaboutanyhistoryofhypertensiondiagnosismadebyadoctororotherhealthprofessional

To establish the total prevalence of hypertension, teams took account of the figure for high BP and the

reportedcurrentuseofdrugsforthecontrolofarterialhypertension(questionaskedtotheparticipantswith

abackgroundreportofdiagnosis).Inaddition,theydeterminedtheprevalenceofhighBPwithandwithout

antihypertensivetreatment,andnormalbloodpressurewithantihypertensivetreatment.

3.14.2.2. BMI

ThecalculationofBMIisbasedonmeasurementsofheightandweightinthesurveypopulation.Theheight

measurementismadewithacrylicheight2 mlong,fixedwithadhesivetapeonsurfacesperpendicularto

thefloor,suchaswallsordoors,askingtheparticipanttostandwithoutshoes,withhisorherbodytouching

thestadiometer.Forthemeasurementofweight,anelectronicscalewasused,placedonaflat,horizontal

andfirmsurfacesuchasthefloor;theparticipantshadtostandinfrontofthescalescreen,atthecentre

ofthescalesurface,standingwiththeheelstogether,thearmsatthesidesandchinparalleltothefloor.

Beforethemeasurement,theteamverifiedthattheparticipantwasnotwearingexcessclothes,soasnotto

overestimatetheweight.

Withtheheightandweightaverages,teamscalculatedparticipants’BMI,classifyingthemusingthefollowing

categories(44):

Category BMI (kg/m2)

Underweight < 18.5

Normalweight 18.5–24.9

Overweight 25–29.9

Obesity > 30

3.14.2.3. Waist and hip circumference

For the measurement of the waist and hip circumference, the participant remained standing, with feet

togetherandhandsoneachsideofthebody.A6-mmwidefibreglassretractabletapemeasure,graduated

incentimetres,wasplaceddirectlyontheparticipant’sskinatthemidpointbetweenthelastribandtheiliac

cresttomeasurethecircumferenceofthewaistandinthemostprominentpartofthewaist.

Thecut-offpointsgiveninTable8wereusedinthemeasurementofwaistcircumferencetoestablishthe

prevalence of waist obesity and to classify the risk of CVD andmetabolic alterations related to obesity,

accordingtowaistmeasurement,bysex.



Table 8. WHO cut-off points and risk of metabolic complications

IndicatorCut-off points (cm)

Risk of metabolic complicationsMen Women

Waistcircumference > 94 > 80 Increased

Waistcircumference > 102 > 88 Substantiallyincreased

Waist–hipratio ≥ 0.90 ≥ 0.85 Substantiallyincreased

3.14.3. Step 3

Step3oftheSTEPSsurveyincludedurineandbloodtesting.Duetofastingrequirementsforglucoseandtriglyceridesmeasurements,bloodtestingwasdoneinthemorningofthedayaftersteps1and2weredone.Participantswereaskedtofastfor24hoursbeforebloodsamplesweretaken.Fastingvenouscapillarybloodsamplesweretakentoassessbloodglucose,HbA1c, triglycerideandcholesterol levelsanddeterminethepresenceofhyperglycaemiaandhypercholesterolemia.Thesebiochemicalmeasurementswereperformedby drymethod using the devices listed in Table 7, including automated instruments for the biochemicalsamplingbydrymethodrecommendedbyWHO(44)forthisstudy.Thebiochemicalmeasurementsinstep3includedthefollowing:

● glucose ● cholesterol ● triglycerides ● HDLcholesterol ● HbA1c ● urinarysodiumandurinarycreatinine

DuringtheSTEPS3implementation,measurementofBPwasrepeatedthreetimes,with15minutes’restafterthefirstmeasurementandthreeminutesbetweenthesecondandthird.

3.14.3.1. Glycaemia

Todeterminetheprevalenceofraisedbloodglucose,theteamstookintoaccountthevalueofthefastingbloodglucoseor thecurrentconsumptionof insulinorothermedications tocontroldiabetes (aquestionaskedofparticipantswhoreportedahistoryofdiagnosisofdiabetesbyahealthprofessional).Inaddition,theprevalenceofhighbloodsugarwithandwithouttreatment,andnormalglycaemiawithtreatment,wasdetermined.Thefollowingcut-offpointswereusedfordetectingglycaemia(44):

● impairedfastingglycaemia:plasmavenousvalue≥ 110mg/dland< 126mg/dl;and ● raisedfastingbloodglucose:plasmavenousvalue≥ 126mg/dlorcurrentlyonmedicationforraisedbloodglucose.

3.14.3.2. HbA1c

TheNHHSTalsoincludedmeasurementofHbA1cinstep3ofthesurvey.Thefollowingcut-offpointwasusedfordiagnosingglycaemia:

● raisedfastingbloodglucose:HbA1c≥ 6.5%.

25

ThestudyalsocombinedfastingbloodglucoseandHbA1candusedthefollowingcut-off:raisedfastingbloodglucose:

● fastingplasmavenousglucose≥ 126mg/dlorHbA1c≥ 6.5%orcurrentlyonmedicationforraisedbloodglucose.

3.14.3.3. Total cholesterol

Todeterminetheprevalenceofhypercholesterolemia,thetotalfastingcholesterolvalueorthecurrentuseofmedicationsorspecialdiet forcontrolwasconsidered,basedonaquestionaskedtoparticipantswhoreportedadiagnosisofhypercholesterolemiabyahealthprofessional.Thecut-offpointsestablishedintheSTEPSmanual(44)wereusedtoclassifytotalcholesterollevels,usingthedrymethod:

● raisedtotalcholesterol:≥ 190mg/dlorcurrentlyonmedicationforraisedcholesterol.

3.14.3.4. Triglycerides

FastingtriglycerideswerealsomeasuredfollowingtherecommendedprocedureinSTEPSandusingthecut-offrecommendedbyWHO(44):

● raisedtriglycerides:fastingtriglycerides≥ 180mg/dl.

3.14.3.5. HDL cholesterol

Toexaminelow-cholesterolprevalenceinthestudypopulation,theteamsmeasuredHDLcholesterolinSTEPS3usingthecut-offpointrecommendedbyWHO(44):

● suboptimalHDLcholesterol:HDL< 40mg/dlformenand< 50mg/dlforwomen.

3.14.3.6. Urinary sodium and creatinine

Urinary sodium and creatinine were measured to determine population levels of high salt intake, a riskfactormainly forhypertensionandCVD.Urinesamplesweresent to theCentralLaboratoryofHacettepeUniversityFacultyofMedicineinAnkaraincoldchain.Thesampleswereanalysedbylaboratorytechnicians,who recorded the resultsona tabletPCanduploaded them to thedatabaseon theserver, tohaveeachparticipant’sdatacomplete.Theidentificationnumberofeachparticipantplayedacrucialrolehere,sinceitwasthevariableusedformatchingthedata.

LevelsofsodiumandcreatinineinspoturinesamplesareusedinSTEPStoestimatepopulation24-hoursaltintake,usingthefollowingformulas(providedbytheWHORegionalOfficeforEurope):

● estimated 24-hour sodium intake for males: [39.58 + (0.45*urinary sodium (mmol/L)] – [3.09*urinarycreatinine(mmol/L)*88.4/1000)+(4.16*BMI)+(0.22*age)];and

● estimated 24-hour sodium intake for females: [17.02+ (0.33*urinary sodium (mmol/L)] – [2.44*urinarycreatinine(mmol/L)*88.4/1000)+(2.42*BMI)+(2.34*age)–(0.03*age)].

The24-hour sodiumvalues inmmolaredividedby 17.1 inorder togetgramsof salt.Asmentioned,WHOrecommendsanintakeof< 5gsaltor< 2gsodiumperpersonperday.

SURVEY RESULTS

4


4. SURVEY RESULTS

4. SURVEY RESULTSTheforemostobjectiveofthestudyistoassesstheriskfactorsforNCDsinthepopulationofTurkeyusingtheSTEPSapproach.Inadditiontoinformationusedtoassesstheriskfactorsandtheprevalenceofseveralhealth characteristics, the study also collected information onmajor demographic characteristics of therespondents,astherecanbestronglinksbetweenthem.Theearliersectionsofthischapterpresentsomeinformation on the demographic characteristics of the study population in Turkey and the later sectionspresentresultsontherespondentsbehaviouralandbiologicalriskfactorsforNCDs.Allresultspresentedinthisreportarebasedonweighteddata,exceptsomedemographicsampleinformation.

4.1. Sampling and participation

Asmentioned,8650householdswereselectedin865clusters(55clusterswithvillagestatusand810withnon-villagestatus)composedof10participantsineachcluster,withatotalof6555peopleeligibleforselectionasparticipants.Ofthese,6053(92.3%)weresurveyed,withanaverageageof46.8yearsandmarginoferrorof±0.45.AsTable9shows,outof8650households,6053selectedhouseholdmembersparticipatedinsteps1and2ofthestudy,while3352ofthesealsoparticipatedinstep3.Theoverallparticipationratewas70.0%forsteps1and2and38.6%forstep3.Outof8650householdsvisited,householdmemberswereawayfromhomeorrejectedparticipationatthedoorin2095.Thefieldteamswereabletoobtaininformationandselectamember toparticipate in the study from6555households.After the successful selectionof aneligiblehouseholdmember,502rejectedparticipationinsteps1and2and3253rejectedparticipationinstep3(seeTable9).

Table 9. Overall response proportions

Age group (years)

Men Women Both sexes

Eligible Responded Eligible Responded Eligible Responded

N N % N N % N N %

15–29 539 497 92.2 730 673 92.2 1269 1170 92.2

30–44 729 652 89.4 1146 1050 91.6 1875 1702 90.8

45–59 703 642 91.3 1045 974 93.2 1748 1616 92.4

60–69 397 381 96.0 484 463 95.7 881 844 95.8

≥ 70 307 276 89.9 475 445 93.7 782 721 92.2

Total 2675 2448 91.5 3880 3605 92.9 6555 6053 92.3

4.2. Demographic indicators

Thesurveycollected informationondemographic indicatorssuchas theage,sex,education,occupation,householdincomeandmaritalstatusofrespondents.

The6053respondentswereaged≥ 15yearsandcamefrom79provincesinTurkeycollectedinto12NUTS-1regions(seeTable1).Thissubsectionpresentssomedemographicindicatorsofthestudypopulationbyageandsex.TheNUTS-1demographicindicatorsarealsogivenincaseswherethesamplecharacteristicsvarysignificantlyacrossregions.

29

4.2.1. Age and sex characteristics

Table10givestheweightedandunweighteddistributionsofthe6053samplerespondentsbyagegroupandsex, indicating thatmenmadeup40.4%andwomen, 59.6%.3 As the survey respondentswere limited topeopleaged≥ 15years, thesample’sage–sexdistribution isnotrepresentativeofthewholepopulationofTurkey.Theweightedage–sexdistributioninTable10representsactualpopulationdistributionaccordingtoTURKSTAT’s2016populationestimates.Onlytheageandsexcharacteristicsoftheunweightedsamplearediscussedinthissection,becauseweightedfiguresreportedinTables10and11exactlymatchTURKSTAT’s2016populationestimates,owingtothepoststratificationbytwo-waysexandagedistribution.

FromtheresultsgiveninTable10,theagedistributionofthesamplerespondentsforthefivegroups–15–29,30–44,45–59,60–69and≥ 70years–are19.3%,28.1%,26.7%,13.9%and11.9%,respectively.Basedonthiscategorization,47.4%oftherespondentswereinthegroupaged15–44,and40.6%inthegroupaged45–69.Thoseintheoldestagegroupmakeup11.9%oftherespondents.

Table11showsthedistributionoftherespondentsbyNUTS-1regions:14.6%forTR1,5.4%forTR2,14.9%forTR3,12.0%forTR4,11.2%forTR5,12.1%forTR6,5.6%forTR7,6.7%forTR8,4.2%forTR9,2.6%forTRA,4.2%forTRBand6.5%forTRC.Accordingtothe2016censuscountbyTURKSTAT,thedistributionoftheTurkishpopulationbyNUTS-1regionswas18.7%forTR1,4.7%forTR2,13.6%forTR3,9.9%forTR4,9.9%forTR5,12.6%forTR6,5.0%forTR7,6.0%forTR8,3.5%forTR9,2.6%forTRA,4.4%forTRBand9.1%forTRC.

AccordingtotheresultsgiveninTable10andTable11,womenwereoversampledandmenundersampled.Similarly, there was minor over- and undersampling by NUTS-1 regions, which were accounted for byappropriatesample,populationandnon-response (cluster-level)weighting,appliedusingcomplexsampledesign.

Table 10. Age and sex distribution of respondents

Age group (years)


NWeighted cases (%)

Unweighted cases (%)

NWeighted cases (%)


NWeighted cases (%)


15–29 497 51.0 42.5 673 49.0 57.5 1170 31.6 19.3

30–44 652 50.5 38.3 1050 49.5 61.7 1702 30.3 28.1

45–59 642 50.3 39.7 974 49.7 60.3 1616 21.7 26.7

60–69 381 48.1 45.1 463 51.9 54.9 844 9.5 13.9

≥ 70 276 42.2 38.3 445 57.8 61.7 721 7.0 11.9

Total 2448 49.8 40.4 3605 50.2 59.6 6053 100.0 100.0

Note. The weighted results exactly match TURKSTAT’s 2016 population estimate, owing to post-stratification by two-way sex–age and NUTS-1 population distribution.

3 Thissectiondiscussesonlytheageandsexcharacteristicsoftheunweightedsample,becausetheweightedresultsreportedinTables10and11exactlymatchTURKSTAT’s2016populationestimate,owingtopost-stratificationbytwo-waysex–ageandNUTS-1populationdistribution.


4. SURVEY RESULTS

Table 11. NUTS-1 distribution of respondents

NUTS-1 regions

Respondents

NWeighted cases

(%)Unweighted cases

(%)

TR1 883 18.7 14.6

TR2 328 4.7 5.4

TR3 899 13.6 14.9

TR4 726 9.9 12.0

TR5 680 9.9 11.2

TR6 730 12.6 12.1

TR7 339 5.0 5.6

TR8 403 6.0 6.7

TR9 254 3.5 4.2

TRA 159 2.6 2.6

TRB 257 4.4 4.2

TRC 395 9.1 6.5

Total 6053 100.0 100.0

Note. The weighted results exactly match TURKSTAT’s 2016 population estimate, owing to post-stratification by two-way sex–age and NUTS-1 population distribution.

4.2.2. Marital status

Table 12presents the results for themarital statusof respondentsbyagegroupandsex.More thanhalf(65.9%)statedthat theywerecurrentlymarried (65.9%ofmenand66.0%ofwomen);27.0%weresingle;1.8%,divorced;andtheremaining5.3%,widowed.Maritalstatusvariedwithage,withthepredominanceofmarriagetoapartnerstartingfromtheageof30andthestatusofasingleperson,inthoseaged15–29years.

Thepercentageofsinglewomen(22.4%)waslowerthanthatofsinglemen(31.7%),andmorepeoplewerewidowedthandivorced.Thepercentageofwidowsaged≥ 70years(39.2%)wasalmost10timesthatinthegroupaged45–59(4.0%),showingthefeminizationofoldageorexcessmalemortality.

Table 12. Marital status of respondents by sex and age group

SexAge group (years)

N

Marital status

Single (%)

Currently married (%)

Divorced (%)

Widowed (%)

Men

15–29 497 83.2 16.7 – 0.1

30–44 652 12.1 86.7 1.1 0.2

45–59 642 3.6 93.5 1.9 1.1

60–69 381 2.0 92.0 1.4 4.6

≥ 70 276 0.8 84.2 0.3 14.8

Total 2448 31.7 65.9 0.9 1.6

31


N

Marital status

Single (%)

Currently married (%)

Divorced (%)

Widowed (%)

Women

15–29 673 62.3 36.4 1.2 0.1

30–44 1050 6.6 88.8 3.7 0.9

45–59 974 4.4 84.1 4.4 7.0

60–69 463 1.9 69.5 2.5 26.1

≥ 70 445 1.0 41.6 0.4 57.0

Total 3605 22.4 66.0 2.7 8.9

Both sexes

15–29 1170 73.0 26.3 0.6 0.1

30–44 1702 9.4 87.7 2.4 0.5

45–59 1616 4.0 88.8 3.1 4.0

60–69 844 1.9 80.3 2.0 15.7

≥ 70 721 0.9 59.6 0.3 39.2

Total 6053 27.0 65.9 1.8 5.3

Table13displaysasignificantvariationacrossNUTS-1regionsforallclassesofmaritalstatus.TheproportionofthosenevermarriedwaslowestinTR3(20.2%)andhighestinTRC(38.4%).Thepercentageofcurrentlymarried respondents was highest in TR8 (70.5%) and lowest in TRC (59.3%). The proportion of divorcedrespondents was highest in TR3 (3.8%) and lowest in TR9 and TRA (0.1%). The percentage of widowedrespondentswaslowestinTRC(1.7%)andhighestinTRA(8.4%).

Table 13. Marital status of respondents by NUTS-1 regions

NUTS-1 regions

Both sexes

NSingle

(%)Currently married

(%)Divorced

(%)Widowed

(%)

TR1 883 28.6 65.2 1.7 4.5

TR2 328 23.5 67.4 2.6 6.5

TR3 899 20.2 68.0 3.8 8.0

TR4 726 27.2 66.2 1.6 5.0

TR5 680 27.6 65.2 1.9 5.3

TR6 730 24.1 69.1 2.5 4.3

TR7 339 28.6 63.7 0.6 7.1

TR8 403 20.7 70.5 1.6 7.2

TR9 254 30.5 64.1 0.1 5.3

TRA 159 21.9 69.5 0.1 8.4

TRB 257 34.7 62.1 0.3 2.9

TRC 395 38.4 59.3 0.5 1.7

Total 6053 27.0 65.9 1.8 5.3

Table 12 (contd)


4. SURVEY RESULTS

4.2.3. Education

Educationalattainment4 isgivenbysex inFig.4.Amongthefemalerespondents,24.5%were illiterateorhad no formal schooling, 38.4% had primary-level schooling; 27.3%, secondary or vocational secondaryschooling; and 9.8%, a college education. The corresponding percentages formales were: 9.7%, 34.1%,39.5%and16.7%,respectively.

Fig. 4. Respondents’ levels of education by sex

1

Fig. 1. Respondents’ levels of education by sex

9.7

34.1

39.5

16.7

24.5

38.4

27.3

9.8

18.5

36.7

32.2

12.6

0

5

10

15

20

25

30

35

40

45

Illiterate or literate but noformal schooling

Primary school completed Secondary, vocationalsecondary/high school

completed

College, faculty, master's ordoctorate completed

Perc

enta

ge


Table 14 shows that 18.5% of the respondents were illiterate or had no formal schooling, 36.7% of allrespondents had primary-school education; 32.2%, secondary or vocational secondary education; and12.6%, college education. Theproportion of respondentswith no education increasedwith age, and thathigherlevelsofeducationwerefoundinyoungeragegroups.Theseresultsareperfectlycompatiblewiththeaverageyearsofeducationcompleted,whichisexaminedlater(seeTable16).

Table 15 shows the highest level of educational attainment by NUTS-1 regions, with significant variationbetweenregionsineducationalattainmentatall levels.TRAhadthehighestrateof illiteracyornoformalschooling(39.6%),followedbyTRB(33.1%)andTRC(31.6%).ThelowestsuchrateswerefoundinTR4(11.4%),TR5(12.1%)andTR1 (10.1%).Theregionswiththehighestpercentagesofhigh-schooleducationwereTRC(40.8%), TR4 (37.1%) and TR5 (36.3%) while those with the lowest such percentages were TRA (22.0%),followedbyTR3(26.9%)andTR8(28.3%).

Table16andTable17showtheaverageyearsofeducationofthesurveyrespondentsbysexandagegroup,andNUTS-1regions,respectively.Themeannumberofyearsofeducationwaslow(9.1years)fortheoverallstudysample,as55.2%oftherespondentshadaneducationlevelbelowsecondaryschool.Theaverageyearsofeducationdifferedgreatlybybothsexandage.Thegroupwiththehighestnumberofaverageyearsofeducationwasthataged15–29years.Asmentioned,theaverageyearsofeducationdecreasedproportionallywithage.

4 Thissectiondiscussesonlyhighestlevelofeducationalattainmentoftheunweightedsample,becausetheweightedresultsreportedinTables14and15exactlymatchTURKSTAT’s2016populationestimates,owingtopost-stratificationbytwo-waysex–education,age–sexandNUTS-1populationdistribution.

33

Tabl

e 14

. Re

spon

dent

s’ h

ighe

st le

vel o

f edu

catio

n by

sex

and

age

gro

up

Sex

Age

grou

p (y

ears

)N

Illite

rate

or l

itera

te b

ut n

o fo

rmal

sch

oolin

g (%

)Pr

imar

y sc

hool

co

mpl

eted

(%)

Seco

ndar

y, v

ocat

iona

l se

cond

ary,

or h

igh

scho

ol

com

plet

ed (%

)

Colle

ge, f

acul

ty, m

aste

r’s o

r do

ctor

ate

com

plet

ed (%

)

Wei

ghte

d ca

ses

Unw

eigh

ted

case

sW

eigh

ted

case

sUn

wei

ghte

d ca

ses

Wei

ghte

d ca

ses

Unw

eigh

ted

case

sW

eigh

ted

case

sUn

wei

ghte

d ca

ses

Men

15–2

949

70.

81.4

4.1

4.8

75.4

68.2

19.7

25.6

30–4

465

22.

02.

619

.328

.459

.147

.519

.621

.5

45–5

964

24.

37.

331

.346

.646

.131

.818

.314

.3

60–6

938

19.

715

.043

.953

.034

.822

.611.

79.

4

≥ 70

276

28.5

39.5

41.1

45.3

20.8

9.8

9.6

5.4

Tota

l24

484.

49.

720

.534

.157

.039

.518

.116

.7

Wom

en15

–29

673

2.1

4.9

5.2

8.5

70.7

64.9

22.0

21.7

30–4

410

506.

79.

935

.347

.441

.129

.616

.913

.0

45–5

997

415

.120

.545

.255

.229

.018

.510

.75.

7

60–6

946

339

.249

.537

.138

.719

.29.

34.

62.

6

≥ 70

445

64.0

71.0

28.1

25.4

6.7

2.7

1.10.

9

Tota

l36

0514

.924

.527

.738

.442

.727

.314

.79.

8

Both

sex

es15

–29

1170

1.43.

44.

76.

973

.166

.320

.823

.3

30–4

417

024.

37.

127

.240

.150

.236

.518

.316

.3

45–5

916

169.

715

.338

.251

.837

.623

.814

.59.

2

60–6

984

425

.033

.940

.445

.126

.715

.38.

05.

7

≥ 70

721

49.0

58.9

33.6

33.0

12.7

5.4

4.7

2.6

Tota

l60

539.

618

.524

.236

.749

.932

.216

.412

.6

Note

. The

wei

ghte

d re

sults

repo

rted

exa

ctly

mat

ch T

URKS

TAT’s

201

6 po

pula

tion

estim

ates

, ow

ing

to p

ost-

stra

tifica

tion

by tw

o-w

ay s

ex–e

duca

tion,

age

–sex

and

NUT

S-1 p

opul

atio

n di

strib

utio

n.


4. SURVEY RESULTS

Respondents aged 15–29 received 11.3mean yearsof education, in contrast to thefigures for thegroupsaged30–44(9.6years),45–59(8.1years),60–69(6.0years)and≥ 70(3.9years).Similarlytothepatternforagegroups,theaverageyearsofeducationdifferedsignificantlybetweenthesexes:9.9yearsformenand8.2yearsforwomen(anaveragedifferenceof1.7years).

TheaverageyearsofeducationbyNUTS-1regionsshowninTable17andFig.5parallelthegeneraltrendsinTable15.TheaverageyearsofeducationwerehighestinTR5(9.9years)andlowestinTR8(8.3years).

Table 15. Respondents’ levels of education by NUTS-1 regions, both sexes

NUTS-1 regions

N

Illiterate or literate but no formal schooling (%)

Primary school completed (%)

Secondary, vocational secondary, or high

school completed (%)

College, faculty, master’s or doctorate

completed (%)

Weighted cases

Unweighted cases

Weighted cases

Unweighted cases

Weighted cases

Unweighted cases

Weighted cases

Unweighted cases

TR1 883 6.0 10.1 28.0 43.3 46.2 31.3 19.8 15.4

TR2 328 6.9 12.2 34.3 50.6 46.3 28.4 12.5 8.8

TR3 899 9.7 16.4 29.0 42.8 41.8 26.9 19.5 13.9

TR4 726 5.1 11.4 23.4 39.0 56.4 37.1 15.1 12.5

TR5 680 5.7 12.1 23.2 33.1 50.3 36.3 20.9 18.5

TR6 730 8.4 19.0 22.0 36.3 56.9 34.4 12.8 10.3

TR7 339 11.5 26.0 23.3 35.1 51.4 28.6 13.7 10.3

TR8 403 15.1 31.5 23.8 33.3 48.5 28.3 12.5 6.9

TR9 254 10.6 20.1 19.6 27.2 45.4 34.3 24.4 18.5

TRA 159 26.7 39.6 17.5 24.5 39.5 22.0 16.3 13.8

TRB 257 16.9 33.1 17.5 24.9 48.4 30.0 17.3 12.1

TRC 395 16.0 31.6 16.0 22.5 59.5 40.8 8.4 5.1

Total 6053 9.6 18.5 24.2 36.7 49.9 32.2 16.4 12.6

Note. The weighted results reported in the table exactly match TURKSTAT’s 2016 population estimates due to the post-stratification by two-way sex–age and NUTS-1 population distribution.

Table 16. Respondents’ mean number of years of education by sex and age group

Age group (years)


N Mean 95% CI N Mean (95% CI) N Mean (95% CI)

15–29 497 11.4 11.2–11.7 673 11.2 11.0–11.5 1170 11.3 11.2–11.5

30–44 652 10.3 10.0–10.7 1050 8.8 8.4–9.2 1702 9.6 9.3–9.8

45–59 642 9.3 8.9–9.7 974 6.8 6.3–7.3 1616 8.1 7.7–8.4

60–69 381 7.5 7.0–7.9 463 4.6 4.0–5.2 844 6.0 5.6–6.4

≥ 70 276 5.7 5.0–6.4 445 2.5 2.1–3.0 721 3.9 3.4–4.3

Total 2448 9.9 9.7–10.1 3605 8.2 8.0–8.4 6053 9.1 8.9–9.2

35

Table 17. Respondents’ mean number of years of education by NUTS-1 regions

NUTS-1 regions

Respondents (N)Years

Mean 95% CI

TR1 883 9.7 9.3–10.1

TR2 328 8.4 7.7–9.2

TR3 899 8.8 8.3–9.3

TR4 726 9.4 9.0–9.8

TR5 680 9.9 9.3–10.5

TR6 730 8.9 8.5–9.3

TR7 339 8.8 8.1–9.6

TR8 403 8.1 7.2–8.9

TR9 254 9.5 8.7–10.3

TRA 159 8.3 6.7–9.9

TRB 257 8.6 7.6–9.5

TRC 395 8.5 7.7–9.2

Total 6053 9.1 8.9–9.2

Fig.5showsthegeographicdistributionoftheaveragenumberofyearsofeducation,whichwaslowestinthewesternBlackSearegion,followedbycentralAnatolia,easternTurkeyandsouth-easternTurkey.ThehighestnumberofyearsofeducationwasobservedintheeasternBlackSearegion,theMarmararegionandwesternAnatolia.

Fig. 5. Respondents’ mean number of years of education by NUTS regions



4. SURVEY RESULTS

4.2.4. Employment

Table18presentsthedistributionofrespondentsbypaid-employmentstatus,whileTable19presentsthedistributionofunpaidandunemployedrespondents.Ineachtable,theresultsarebrokendownbyagegroupandsex.ThegroupsdescribedinTable18andTable19aremutuallyexclusive.

During the year of the survey, the main paid employment of the respondents was employment outsidethegovernment (nongovernmental –23.5%), followedbyemploymentby thegovernment (6.0%)andself-employment (5.7%) (Table 18). Table 18 shows that 64.9% of the respondents were doing unpaid work.Occupationalstatusdifferedsignificantlyaccordingtosex,ageandareaofresidence.Intermsofpaidwork,themajorityofmen(38.9%)andwomen(8.1%)werenongovernmentalemployees.

Amongmendoingpaidwork,nongovernmentalemploymentisfollowedbyself-employmentandgovernmental(10.2%and8.6%,respectively).Thiswasobservedformeninallagegroups(Table18).

Whenunemploymentisconsidered,ratesofpeopleunemployedandabletoworkwerehigherintheyoungeragegroups:13.3%forthegroupaged15–29;7.8%forthoseaged30–44,4.2%forthoseaged45–59and2.6%forthoseaged60–69.Alargefractionofthewomenwerehomemakers(Table19).

Table 18. Respondents’ paid employment status by sex and age group


N

Employment status (%)

Government employee

Nongovernment employee

Self-employedUnpaid including

retired

Men 15–29 496 3.6 34.6 3.8 58.0

30–44 651 13.5 62.5 18.0 6.0

45–59 642 13.8 35.0 12.1 39.1

60–69 381 2.4 7.6 7.5 82.5

≥ 70 275 – 2.9 1.0 96.1

Total 2445 8.6 38.9 10.2 42.4

Women 15–29 672 3.7 11.1 0.6 84.6

30–44 1049 5.5 12.2 2.0 80.3

45–59 973 2.7 4.8 1.9 90.6

60–69 461 0.4 0.1 – 99.5

≥ 70 445 – 0.2 – 99.8

Total 3600 3.4 8.1 1.2 87.3

Both sexes 15–29 1168 3.7 23.1 2.2 71.0

30–44 1700 9.5 37.6 10.1 42.8

45–59 1615 8.3 20.0 7.1 64.7

60–69 842 1.4 3.7 3.6 91.3

≥ 70 720 – 1.3 0.4 98.2

Total 6045 6.0 23.5 5.7 64.9

When the sexes are compared, the percentage doing paidworkwas higher inmen (57.6%) thanwomen(12.7%),aswas thepercentage thatwasunemployedbutable towork (15.0% inmenand4.1%inwomen),againbecausethemajorityofwomenhadhomemakerstatus.

37

Table 19. Respondents’ unpaid employment status by sex and age group


N

Unpaid employment status (%) Unemployed (%)

Unpaid employee

StudentHome-maker

RetiredAble to

workNot able to work

Men 15–29 258 0.2 79.6 – 0.1 19.2 0.9

30–44 41 3.2 1.9 14.1 7.0 64.9 8.9

45–59 282 0.2 – 0.6 84.0 11.7 3.6

60–69 317 0.6 – 1.1 89.7 5.3 3.3

≥ 70 262 0.3 – 0.9 88.9 2.5 7.5

Total 1160 0.4 35.2 1.1 45.3 15.0 3.1

Women 15–29 568 – 49.1 41.5 0.1 9.2 –

30–44 860 – 0.9 95.0 0.5 3.4 0.2

45–59 899 0.2 0.2 87.5 11.1 0.9 0.1

60–69 459 – – 78.8 20.3 0.5 0.4

≥ 70 444 0.4 – 74.9 19.6 1.5 3.6

Total 3230 0.1 15.0 73.7 6.7 4.1 0.4

Both sexes 15–29 826 0.1 61.8 24.3 0.1 13.3 0.4

30–44 901 0.2 1.0 89.3 1.0 7.8 0.8

45–59 1181 0.2 0.1 61.1 33.3 4.2 1.1

60–69 776 0.2 – 45.0 50.5 2.6 1.7

≥ 70 706 0.4 – 44.4 48.1 1.9 5.2

Total 4390 0.2 21.6 50.1 19.2 7.6 1.3

4.2.5. Income

The average incomeof a household provides information on its capacities tomeet themembers’ needs,particularlyforfood.Theaverageannualpercapitaincomewascalculatedastotalannualhouseholdincomedividedbythenumberofmembersofworkingage(≥ 18years).Themajorityofhouseholds(4097or67.7%)reportedtheirapproximateincome.

Table20showshouseholds’meanpercapitaannual income.Meanannualpercapitahousehold incomeisthecombinedannualincomedividedbythenumberofhouseholdmembersage≥ 18years.Themeanannualincomereported,irrespectiveofthenumberofpeopleemployedperhousehold,is14 992.30TurkishLira(TL).AverageannualincomepercapitavariedsignificantlyacrosstheNUTS-1regions.Themeanannualpercapitaincomeinthehighest-incomeregion(TR8)is2.5timesthatinthelowest-incomeregion(TRA).TheregionswiththehighestincomewereTR8,TR5,TR1andTR9,andthosewiththelowestwereTRC,TR6,TR2andTRA.


4. SURVEY RESULTS

Table 20. Respondents’ mean annual per capita household income by NUTS-1 regions

NUTS-1 regionsHouseholds

N Mean income (TL)

TR1 561 17 953.2

TR2 227 10 025.8

TR3 319 12 956.6

TR4 494 14 171.4

TR5 625 20 435.0

TR6 592 10 051.6

TR7 300 13 564.6

TR8 331 22 098.5

TR9 136 17 139.2

TRA 88 8 994.7

TRB 181 10 697.5

TRC 243 10 632.5

Total 4097 14 992.3

Note. Mean annual per capita household income is the combined annual income divided by the number of household members aged ≥ 18 years. Cases are unweighted.

Fig.6showsthesignificantvariationinmeanannualpercapitaincomeacrossregions:incomewashighestinthewesternAnatoliaregion,followedbythewesternBlackSeaandIstanbulregions,andthelowestincomewasobservedinthesouth-easternandnorth-westernregions.

Fig. 6. Mean annual per capita household income by NUTS-1 regions


39

4.3. Tobacco use

Tobaccoisusedinseveralforms,suchascigarette,cigarsandbidis,aswellasinpipesandhookahs.Theworldwide prevalence of current tobacco smoking among adults was approximately 22% in 2012. Theprevalenceoftobaccosmokingdiffersamongcountries.Men(37%)tendtosmokemorethanwomen(7%)(7).

AccordingtotheresultsgiveninTable21,theprevalenceofcurrenttobaccoconsumptionwas31.5%.Smokingprevalencewassignificantlyhigherinmen(43.4%)thanwomen(19.7%),withthedifferencebeingsignificantataP-value< 1%(P<0.01).

Theprevalenceof tobaccouse isveryclose to theprevalenceofsmoking,and31.6%of the respondentscurrentlyused(smokedorsmokeless)tobacco(males43.6%andfemales19.7%).

Inthetotalpopulation,currentsmokingstatusvariedamongagegroups(seeFig.7),peakinginthegroupaged30–44.Althoughprevalencewashigher inmen thanwomenacrossall agegroups, smokingpeakedat54.0%formenand29.3%forwomen.Prevalencefellalmostexponentiallyafterage44andreachedtheminimumintheoldestgroup.

Table 21. Percentage of current smokers among respondents by sex and age group

Age group (years)


NCurrent

smoker (%)95% CI N

Current smoker (%)

95% CI NCurrent

smoker (%)95% CI

15–29 497 44.6 39.6–49.6 673 15.9 12.4–19.4 1170 30.6 27.2–33.9

30–44 652 54.0 49.3–58.6 1050 29.3 25.2–33.5 1702 41.8 38.6–45.0

45–59 642 42.4 37.4–47.4 974 22.4 17.8–27.0 1616 32.4 29.1–35.7

60–69 381 26.3 20.9–31.7 463 9.3 5.0–13.5 844 17.5 14.0–20.9

≥ 70 276 12.2 6.4–18.0 445 3.7 1.1–6.3 721 7.3 4.4–10.2

Total 2448 43.4 40.8–46.0 3605 19.7 17.6–21.8 6053 31.5 29.7–33.3

Fig. 7. Percentage of current smokers by sex and age group

2


Fig. 3. Prevalence of daily smoking among current tobacco users by sex and age group

44.6

54.0

42.4

26.3

12.2

15.9

29.3

22.4

9.3

3.7

30.6

41.8

32.4

17.5

7.3

0

10

20

30

40

50

60

15–29 30–44 45–59 60–69 ≥70

Perc

enta

ge


91.0 93

.6

94.6 98

.8

76.6

92.9

87.9 93

.3

94.5 98

.1

94.5

92.5

90.2 93

.5

94.5 98

.6

81.9

92.8

0

20

40

60

80

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge



4. SURVEY RESULTS

Table22showsthattheprevalenceofcurrentsmokingvariedacrossNUTS-1regions,eventhoughnoneofthedifferenceswerestatisticallysignificantatthe5%level.Nevertheless,thehighestrateswerefoundinTR4,TR2,TR5andlowestinTRC,TR8andTRB.

Table 22. Percentage of current smokers among respondents by NUTS-1 regions

NUTS-1 regions

Respondents

NCurrent smokers

(%)95% CI

TR1 883 30.8 26.1–35.4

TR2 328 37.2 29.7–44.8

TR3 899 31.7 27.6–35.8

TR4 726 37.5 31.9–43.2

TR5 680 36.5 31.2–41.7

TR6 730 28.7 23.6–33.7

TR7 339 29.0 20.8–37.3

TR8 403 26.9 18.8–35.0

TR9 254 32.4 24.0–40.9

TRA 159 33.7 24.3–43.1

TRB 257 28.3 20.2–36.3

TRC 395 26.8 19.9–33.7

Total 6053 31.5 29.7–33.3

Fig.8showsrespondents’smokingstatusbysexandagegroup:92.8%ofcurrenttobaccouserssmokeddaily,withsimilarbehaviourinbothsexes(92.9%inmenand92.5%inwomen).


2



44.6

54.0

42.4

26.3

12.2

15.9

29.3

22.4

9.3

3.7

30.6

41.8

32.4

17.5

7.3

0

10

20

30

40

50

60

15–29 30–44 45–59 60–69 ≥70

Perc

enta

ge


91.0 93

.6

94.6 98

.8

76.6

92.9

87.9 93

.3

94.5 98

.1

94.5

92.5

90.2 93

.5

94.5 98

.6

81.9

92.8

0

20

40

60

80

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


41

Consequently,theprevalenceofdailyconsumptionis29.2%(Table23).Similarlytocurrentsmoking,dailysmokinginmenwasmorethantwicethatinwomen(40.4%and18.2%,respectively,P<0.01).Dailysmokingpeakedinthegroupaged30–44(39.1%)anddecreasedafterwardsto30.7%forpeopleaged45–59,17.2%forpeopleaged60–69,and6.0%inthoseaged≥ 70(P<0.01);thedifferenceinprevalencebetweenthegroupsaged30–44and≥ 70wasparticularlygreatinwomen(7.8times).

Table23also shows theproportionsof currentnon-usersof tobaccowhowere former smokers: 10.7%of thewholestudypopulation,althoughthisratewashigherformen(14.8%)thanwomen(6.6%).Therewasasignificantdifferenceacrossagegroupsformen,butnotforwomen.

Aswithcurrentsmoking,dailysmokingshowednostatisticallysignificantdifferencebetweenNUTS-1 regions,althoughtheprevalencewashighestinTR4,TR2andTR5andlowestinTRC,TR8andTR7(Fig.9).Theregionswiththe lowestratesarepredominantlyrural.Theregionswiththehighestandlowestsmokingrates(TR4andTRC,respectively)showadifferenceof11.8percentagepoints.


4. SURVEY RESULTS

Tabl

e 23

. Sm

okin

g st

atus

of r

espo

nden

ts b

y se

x an

d ag

e gr

oup

Sex

Age

grou

p (y

ears

)N

Curr

ent s

mok

ers

(%)

Nons

mok

ers

(%)

Daily

sm

oker

s95

% C

INo

ndai

ly95

% C

IFo

rmer

sm

oker

s95

% C

INe

ver s

mok

er95

% C

I

Men

15–2

949

740

.635.7–45.5

4.0

2.0–6.1

4.7

1.9–7.5

50.7

45.2–56.1

30–4

465

250

.545.8–55.3

3.4

1.8–5.1

10.5

7.9–13.2

35.5

31.0–40.0

45–5

964

240

.135.2–45.0

2.3

0.9–3.7

20.0

16.0–24.1

37.6

32.8–42.4

60–6

938

126

.020.6–31.4

0.3

0.0–1.0

33.1

27.2–38.9

40.6

34.3–46.9

≥ 70

276

9.4

4.2–14.5

2.9

0.2–5.5

45.3

37.9–52.8

42.4

35.4–49.5

Tota

l24

4840

.437

.8–4

2.9

3.1

2.2–

4.0

14.8

13.1–

16.5

41.8

39.0

–44.

5

Wom

en15

–29

673

14.0

10.6–17.4

1.90.8–3.1

4.3

2.4–6.2

79.7

75.9–83.6

30–4

410

5027

.423.3–31.5

2.0

1.0–2.9

6.4

4.4–8.4

64.3

60.1–68.5

45–5

997

421

.116.6–25.7

1.20.2–2.3

9.3

6.2–12.3

68.3

63.4–73.2

60–6

946

39.

14.8–13.3

0.2

0.0–0.5

8.0

5.0–11.0

82.7

77.8–87.7

≥ 70

445

3.5

1.0–6.1

0.2

0.0–0.6

7.5

4.0–11.1

88.7

84.4–93.0

Tota

l36

0518

.216

.1–20

.31.5

0.9–

2.0

6.6

5.5–

7.8

73.7

71.4

–75.

9

Both

se

xes

15–2

9117

027

.624.4–30.8

3.0

1.8–4.2

4.5

2.8–6.2

64.9

61.2–68.6

30–4

417

0239

.135.8–42.3

2.7

1.7–3.7

8.5

6.8–10.2

49.8

46.6–53.0

45–5

916

1630

.727.4–33.9

1.80.9–2.6

14.7

12.1–17.2

52.9

49.5–56.2

60–6

984

417

.213.7–20.7

0.2

0.0–0.6

20.1

16.7–23.4

62.5

58.2–66.7

≥ 70

721

6.0

3.4–8.6

1.30.2–2.5

23.5

19.2–27.7

69.2

64.6–73.8

Tota

l60

5329

.227

.5–3

1.02.

31.7

–2.8

10.7

9.7–

11.8

57.8

55.9

–59.

7

43

Fig. 9. Prevalence of daily smoking in respondents by NUTS-1 regions

3

Fig. 4. Prevalence of daily smoking in respondents by NUTs-1 regions

Fig. 5. Daily smokers using manufactured cigarettes by sex and age group

29.7

35.3

28.8

35.9

33.5

26.225.8

25.1

30.2

26.9 26.7

24.1

29.2

20

22

24

26

28

30

32

34

36

38

TR1 TR2 TR3 TR4 TR5 TR6 TR7 TR8 TR9 TRA TRB TRC TOTAL

Perc

enta

ge

98.8

97.7

95.2

96.4

90.0

97.3

94.8

98.9

96.9

93.9

100.

0

97.297

.8 98.1

95.8

95.7

93.1

97.3

85

90

95

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


Table24showsthemeanageatwhichcurrentdailysmokersamongtherespondentsstartedtosmoke.Themeanageofonsetofdailytobaccosmokingwas18.1years(95%CI:17.8–18.5%)forbothsexes,andtherewasastatisticallysignificantdifferenceofthreeyearsbetweenmenandwomen(P<0.05).Theonsetoftobaccosmokingrosewithage,withyoungerrespondentsstartingtosmokeearlierinlifealsovariesbetweenagegroups:itwasloweramongyoungerparticipants,goingfrom16.3yearsamongparticipantsaged15–29yearsto23.0yearsamongtheparticipantsaged≥ 70(P<0.05fordifferenceacrossallagegroups),behaviourthatwasobservedinbothsexes,butmoremarkedinwomen.

Table 24. Mean age at which current daily smokers among respondents started smoking, by sex and age group

Age group (years)


NMean

(years)95% CI N

Mean (years)

95% CI NMean

(years)95% CI

15–29 204 15.8 15.5–16.2 99 18.0 17.1–18.8 303 16.3 16.0–16.7

30–44 319 17.6 17.0–18.1 263 20.1 18.8–21.4 582 18.5 17.9–19.0

45–59 262 18.2 17.4–18.9 176 21.2 20.0–22.4 438 19.2 18.5–19.9

60–69 99 18.1 16.8–19.5 32 23.5 19.7–27.2 131 19.6 18.2–21.0

≥ 70 23 18.5 16.6–20.3 9 31.6 24.6–38.5 32 23.0 19.4–26.7

Total 907 17.2 16.9–17.5 579 20.2 19.5–20.9 1486 18.1 17.8–18.5

The age of onset of daily tobacco consumption showed statistically significant differences betweenNUTS-1regions,althoughnotallregionsdifferedstatisticallyinapairwisecomparison.Nevertheless,theageofonsetwaslowestintheTRCandTR2(16.7and17.4years,respectively)andhighestinTR5andTR4(18.7and18.8,respectively).


4. SURVEY RESULTS

Fig. 10givesthepercentagesofdailysmokersusingmanufacturedcigarettes:97.3%ofalldailysmokers,97.2%forwomenand97.3%formen.Theuseofmanufacturedcigarettesdecreasedwithage,althoughthedifferenceswerenotstatisticallysignificantatthe5%level.


3

Fig. 4. Prevalence of daily smoking in respondents by NUTs-1 regions


29.7

35.3

28.8

35.9

33.5

26.225.8

25.1

30.2

26.9 26.7

24.1

29.2

20

22

24

26

28

30

32

34

36

38

TR1 TR2 TR3 TR4 TR5 TR6 TR7 TR8 TR9 TRA TRB TRC TOTAL

Perc

enta

ge

98.8

97.7

95.2

96.4

90.0

97.3

94.8

98.9

96.9

93.9

100.

0

97.297

.8 98.1

95.8

95.7

93.1

97.3

85

90

95

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


Table25showsthatdailysmokersamongtherespondentsusedanaveragenumberof15.5manufacturedtobacco cigarettes per day,withmen usingmore thanwomen (16.8 and 12.7, respectively,P < 0.05). Thenumberofmanufacturedcigarettesconsumeddailyincreasedwithage,from14.8forthoseaged15–29yearsto15.2forthoseaged≥ 70(Table25),abehaviourthat ismainlyobservedinwomen.Womenconsumedahigheraveragenumber(5.9cigarettes)betweentheagesof15–29and≥ 70.

Table 25. Mean amount of tobacco used by daily smokers by type and age group

Age group (years)

Manufactured cigarettes Hand-rolled cigarettes Pipes of tobacco

NMean

no.95% CI N

Mean no.

95% CI N Mean

no.95% CI

15–29 308 14.8 13.6–16.0 289 1.0 0.4–1.7 290 0.0 0.0–0.0

30–44 582 15.8 14.6–16.9 541 0.6 0.3–0.9 542 0.0 0.0–0.0

45–59 434 16.0 14.5–17.6 406 1.7 1.0–2.5 408 0.0 0.0–0.0

60–69 132 15.5 13.0–18.0 127 2.1 0.9–3.4 128 0.0 0.0–0.1

≥70 32 15.2 12.5–17.9 31 1.5 0.0–3.4 33 0.0 –

Total 1488 15.5 14.8–16.2 1394 1.1 0.8–1.4 1401 0.0 0.0–0.0

Table26presentsthelowratesofsmokeless-tobaccouseinTurkey:0.3%forbothsexes,0.6%formenand0.1%forwomen.Ratesformenwerehighestinthegroupsaged30–44and45–59;therateforwomenwashighestinthegroupaged60–69.

45

Table 26. Current users of smokeless tobacco by sex and age group

Age group (years)


NCurrent

users (%)95% CI N

Current users (%)

95% CI NCurrent

users (%)95% CI

15–29 497 0.2 0.0–0.5 673 0.2 0.0–0.5 1170 0.2 0.0–0.4

30–44 652 1.4 0.2–2.6 1050 – – 1702 0.7 0.1–1.3

45–59 642 0.4 0.0–0.9 974 – – 1616 0.2 0.0–0.5

60–69 381 – – 463 0.6 0.0–1.7 844 0.3 0.0–0.9

≥ 70 276 – – 445 – – 721 – –

Total 2448 0.6 0.1–1.0 3605 0.1 0.0–0.3 6053 0.3 0.1–0.6

Fig.11showsthepercentagesofcurrentsmokersinthestudypopulationwhohadtriedtostopsmokingduringprevious12monthsbysexandagegroup:27.4%forbothsexes,althoughtheratewashigherformen(29.4%)thanwomen(23.0%).Whilethepercentageofcurrentsmokerswhohadtriedtoquitvariedacrossagegroupsforbothmenandwomen,itwashighestformenaged60–69(40.0%)andforwomenaged15–29(26.9%).

Fig.12presentstheproportionsofcurrentsmokerswhosedoctorshadadvisedthemtostopsmokingintheprevious12months;theproportionwasmuchlowerformen(21.2%)thanwomen(24.7%)andvariedacrossagegroups.

Fig. 11. Current smokers who had tried to quit during the previous 12 months

4


Fig. 7. Current smokers advised by a doctor to stop smoking in the previous 12 months

26.3

30.8

28.8

40.0

34.2

29.4

26.8

22.9

21.2

18.3

9.1

23.0

26.4 28

.0

26.2

34.1

26.8 27.4

0

5

10

15

20

25

30

35

40

45

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

Men Woman Both sexes

11.9

22.0 25

.3

45.1

44.3

21.2

14.2

27.0

27.1

39.5

39.6

24.7

12.5

23.8 26

.0

43.5

42.9

22.3

0

5

10

15

20

25

30

35

40

45

50

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge



4. SURVEY RESULTS


4



26.3

30.8

28.8

40.0

34.2

29.4

26.8

22.9

21.2

18.3

9.1

23.0

26.4 28

.0

26.2

34.1

26.8 27.4

0

5

10

15

20

25

30

35

40

45

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


11.9

22.0 25

.3

45.1

44.3

21.2

14.2

27.0

27.1

39.5

39.6

24.7

12.5

23.8 26

.0

43.5

42.9

22.3

0

5

10

15

20

25

30

35

40

45

50

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


4.3.1. Conclusions

Someofthemostimportantresultsontobaccousebyrespondentsincludedthefollowing:

● 31.6%currentlyused(smokedorsmokeless)tobacco(males:43.6%,andfemales:19.7%); ● 31.5%currentlysmokedtobacco(males:43.4%,andfemales:19.7%); ● 29.2%currentlysmokedtobaccodaily(males:40.4%,andfemales:18.2%),andtheyhadstartedsmoking,onaverage,attheageof18.1years(males:17.2,andfemales:20.2);

● 97.3%dailysmokersusedmanufacturedcigarettes(males:97.3%,andfemales:97.2%); ● usersofmanufacturedcigarettessmokedameannumberof15.5perday(males:16.8,andfemales:12.7); ● 0.3%ofrespondentscurrentlyusedsmokelesstobacco(males:0.6%,andfemales:0.1%); ● amongthestudygroup,10.7%wereformersmokers(males:14.8%,andfemales:6.6%)and57.8%hadneversmoked(males:41.8%,andfemales:73.7%).2.3%werenondailysmokers(males:3.1%,andfemales:1.5%);

● thepercentageofcurrentsmokerswhotriedtostopsmokinginprevious12monthswas27.4%(males:29.4%,andfemales:23.0%);

● thepercentageofcurrentsmokersadvisedbyahealthcareprovidertostopsmokingintheprevious12monthswas22.3%(males:21.2%,andfemales:24.7%).

4.4. Alcohol consumption

Alcoholuseisrelatedtoseveraleffectsonhealth,suchasincreasedriskofcancer,strokeandcirrhosis;andmortalityanddisabilityresultingfromaccidents,injuries,assault,violence,homicideandsuicide(46).Alcoholconsumptionwasestimatedtoaccountfor5.9%(3.3million)ofalldeathsgloballyand5.1%ofDALYsin2012.In2010,alcoholconsumptionworldwidewasestimatedtobe6.2Lpurealcoholperpersonaged≥ 15years.TheharmfuluseofalcoholiscloselyassociatedwithNCDs.AccordingtoWHO,alcoholconsumptioninTurkeyin2010wasapproximatelyonethirdofthatintheworld.BothinTurkeyandintheworld,alcoholconsumptionishigheramongmenthanwomen (47).Someactionhasbeentakenagainsttheharmfuluseofalcohol inTurkey,includingadvertisingbansorcomprehensiverestrictions,andincreasedexcisetaxes(27).

47

Table 27 presents the findings for alcohol consumption by respondents, by sex and age group. Of allrespondents,4.1%reportedhavingconsumedalcohol in the12monthsbeforethesurvey.Theprevalenceofalcoholdrunkinthe30daysbeforethesurveywas8.0%forthesurveypopulationgroup,buthigher inmenthanwomen(13.1%and3.0%,respectively,P < 0.05).Italsovariedwithage,beingaround9.7%inthoseunder30yearsofageand1.7%inthoseaged≥ 70.Forbothmenandwomenrespondents,theprevalenceofalcoholconsumptionintheprevious30daysdeclinedwithage.Table27alsoindicatesthat83.6%ofthestudypopulationwerelifetimeabstainers,withahigherrateinwomen(92.7%)thanmen(74.4%),and4.3%ofthepopulationhadabstainedintheprevious12months,withahigherrateformen(6.5%)thanwomen(2.1%).

Fig.13presentsrespondents’alcoholconsumptionstatusbyNUTS-1regions.ThepercentagesofabstainerswerelowestinTR3,TR6andTR5regions,astatisticallysignificantdifferencewithTR6atthe5%significancelevel (P < 0.05), and highest in TR7, TRB and TRC, although no statistically significant differences wereobserved.

Table 27. Alcohol consumption among respondents by sex and age group


N

Current drinker

(past 30 days)

Drank in previous 12 months, not

currently

Abstainer (previous 12

months)

Lifetime

abstainer

% 95% CI % 95% CI % 95% CI % 95% CI

Men 15–29 497 15.0 11.2–18.8 6.4 3.8–8.9 2.8 1.2–4.5 75.8 71.4–80.3

30–44 652 12.9 9.6–16.2 7.1 5.0–9.2 6.9 4.6–9.2 73.1 69.0–77.2

45–59 642 15.0 11.4–18.6 4.8 2.5–7.2 6.6 4.4–8.8 73.6 69.2–77.9

60–69 381 8.5 4.8–12.2 4.6 2.0–7.2 13.5 9.1–17.9 73.4 67.6–79.2

≥ 70 276 4.0 1.0–7.1 4.7 0.0–9.9 12.8 8.2–17.5 78.4 71.7–85.1

Total 2448 13.1 11.2–15.0 6.0 4.8–7.2 6.5 5.3–7.6 74.4 72.0–76.8

Women 15–29 673 4.2 2.2–6.1 2.9 1.2–4.5 1.3 0.5–2.2 91.6 89.0–94.3

30–44 1050 3.5 1.7–5.3 2.7 1.1–4.3 3.4 1.4–5.4 90.4 87.4–93.4

45–59 974 2.2 0.9–3.5 2.3 0.9–3.6 1.9 0.8–3.0 93.6 91.5–95.7

60–69 463 2.2 0.0–5.5 – – 0.9 0.1–1.7 96.9 93.5–100.0

≥ 70 445 – – – – 2.3 0.1–4.5 97.7 95.5–99.9

Total 3605 3.0 2.1–4.0 2.2 1.4–2.9 2.1 1.4–2.9 92.7 91.3–94.1

Both sexes

15–29 1170 9.7 7.5–11.9 4.6 3.1–6.2 2.1 1.1–3.0 83.6 80.8–86.3

30–44 1702 8.2 6.3–10.1 4.9 3.6–6.3 5.2 3.6–6.7 81.7 79.1–84.3

45–59 1616 8.6 6.6–10.7 3.6 2.0–5.1 4.3 3.0–5.5 83.5 80.9–86.2

60–69 844 5.2 2.8–7.7 2.2 1.0–3.5 7.0 4.7–9.2 85.6 82.2–89.0

≥ 70 721 1.7 0.4–3.0 2.0 0.0–4.2 6.7 4.0–9.4 89.6 86.1–93.1

Total 6053 8.0 7.0–9.1 4.1 3.3–4.8 4.3 3.6–5.0 83.6 82.1–85.1


4. SURVEY RESULTS

Fig. 13. Respondents’ alcohol consumption status by NUTS-1 regions

5

Fig. 8. Respondents’ alcohol consumption status by NUTS-1 regions

3.0

4.0

8.8

5.2

4.1

5.3

1.

0

4.0

1.3

2.8

1.2

1.0

4.1

1.8

1.2

11.8

5.1

4.7

4.3

0

.9

2.2

2.5

4.7

2.6

2.8

4.3

87.6

83.9

64.2

83.4

82.8

80.0

96.3

85.2

88.7

91.2

94.0

93.1

83.6

0 10 20 30 40 50 60 70 80 90 100

TR1

TR2

TR3

TR4

TR5

TR6

TR7

TR8

TR9

TRA

TRB

TRC

TOTAL

Percentage

Current drinker (past 30 days) Drank in past 12 months

Past 12 months abstainer Lifetime abstainer

7.5

10.9

15.2

6.3

8.4

10.4

1.8

8.6

7.5

1.4

2.2

3.1

8.0

Table28givesthemeannumberoftimesthatcurrentdrinkershaddrunk≥ 6standartdrinksinasingledrinkingoccasionintheprevious30days:3.6onaverage,withalowernumberformenthanwomen(3.4and4.4,respectively,P<0.05).Amongthosewhoconsumed≥ 6drinksonasingleoccasioninthepreviousmonth,themajorityhad3.0times(thegroupaged45–59).

Table 28. Mean number of episodes in which current drinkers drank ≥ 6 drinks on a single occasion in the previous 30 days, by sex and age group

Age group (years)


NMean

number95% CI

(number)N

Mean number

95% CI (number)

NMean

number95% CI

(number)

15–29 67 3.6 1.7–5.5 20 3.8 0.5–7.2 87 3.6 2.0–5.3

30–44 68 3.7 2.0–5.4 24 1.8 1.1–2.6 92 3.3 1.9–4.7

45–59 84 3.2 2.2–4.2 16 1.6 1.1–2.2 100 3.0 2.1–3.9

60–69 23 2.7 0.7–4.8 2 27.3 20.2–34.3 25 7.6 0.0–16.1

≥ 70 7 1.8 0.6–3.0 – – – 7 1.8 0.6–3.0

Total 249 3.4 2.6–4.3 62 4.4 0.7–8.1 311 3.6 2.6–4.6

49

Table29presentsthepercentageofrespondentswhohaddrunk≥ 6drinksonasingleoccasionintheprevious30days:anexcessiveconsumptionlevelforbothmenandwomen.Ingeneral,theprevalenceofexcessivealcoholconsumptionwas5.2%,withastatisticallysignificantdifferencebetweenmenandwomen:8.7%and1.8%,respectively(P<0.05).Theprevalenceofexcessivealcoholconsumptioningeneraldeclinedwithageinbothmenandwomen(exceptinthegroupaged45–59),butmorepronouncedlyinmen.

Table 29. Proportion of total respondents who drank ≥ 6 drinks on a single occasion in the previous 30 days, by sex and age group

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

15–29 497 10.2 6.8–13.7 673 2.1 0.8–3.5 1170 6.3 4.3–8.2

30–44 652 8.6 5.7–11.4 1050 2.3 0.6–4.0 1702 5.5 3.8–7.1

45–59 642 9.9 6.9–12.9 974 1.6 0.4–2.8 1616 5.8 4.1–7.5

60–69 381 4.5 1.9–7.0 463 1.6 0.0–4.8 844 3.0 1.0–5.0

≥ 70 276 2.5 0.4–4.5 445 – – 721 1.0 0.2–1.9

Total 2448 8.7 7.0–10.3 3605 1.8 1.0–2.6 6053 5.2 4.3–6.2

4.4.1. Conclusions

Someofthemostimportantresultsonalcoholusebyrespondentsincludedthefollowing:

● 83.6%werelifetimeabstainers(males:74.4%,andfemales:92.7%); ● 4.3%hadabstainedintheprevious12months(males:6.5%,andfemales:2.1%); ● 8.0%werecurrentdrinkers(haddrunkalcoholintheprevious30days)(males:13.1%andfemales:3.0%);and

● 5.2%hadengagedinheavyepisodicdrinking(≥ 6drinksonanyoccasionintheprevious30days)(males:8.7%,andfemales:1.8%).

4.5. Use of addictive drugs (substances)

Psychoactivesubstancesareamajorcauseof threats to thehealthandeconomyofboth individualsandsocieties (48).Onein20adults(aged15–64years)aroundtheworldwasestimatedtohaveusedatleastoneillegaldrugin2010(49).Inadditiontooverdoses,asignificantproportionofdrug-relateddeathsisduetotheindirecteffectsofintoxication,whichresultinCVD,liverandmentaldisorders(50).InTurkey,itwasestimatedthattherewere0.2–0.5casesper1000ofhigh-riskopioiduse,andthat0.1%and0.7%ofadults(aged15–64)hadeverusedamphetaminesormarijuana,respectively,by2011(51).

Table30showsthat97.0%ofthestudypopulationreportedneverusingaddictivedrugsduringtheirlives:98.6%ofwomenand95.5%ofmen.Whilemenreportedlowerlevelsofneverusingdrugsinallagegroups,thedifferencewassmallerinthetwooldestgroups(thoseaged60–69and≥ 70).Menandwomenshowedsimilarpatterns:thepercentagesofthosewhohadneverusedaddictivedrugstendedtorisewithage.


4. SURVEY RESULTS

Table 30. Respondents who never used addictive drugs by sex and age group

Age group (years)


NNever used (%)

95% CI NNever used (%)

95% CI NNever used (%)

95% CI

15–29 497 92.9 88.5–97.3 673 97.8 96.3–99.3 1170 95.3 92.9–97.7

30–44 652 96.5 94.8–98.2 1050 98.7 97.8–99.6 1702 97.6 96.6–98.6

45–59 642 96.7 94.8–98.6 974 99.4 98.8–99.9 1616 98.0 97.0–99.0

60–69 381 96.9 94.6–99.2 463 98.6 97.3–99.8 844 97.8 96.5–99.0

≥ 70 276 98.1 96.7–99.6 445 98.8 97.7–99.9 721 98.5 97.6–99.4

Total 2448 95.5 93.9–97.1 3605 98.6 98.0–99.1 6053 97.0 96.2–97.9

Table31showsthat0.5%oftherespondentscurrentlyusedaddictivedrugs,althoughsuchusewashigherinmen(0.9%,)thanwomen(0.2%).Prevalencewashigherintheyoungeragegroupsandgraduallydecreasedwithage.

Astothosewhohadtriedaddictivedrugsatsometimeinthepast(Table32),theaverageformenwas2.6%;andtheyoungestagegroupreportedthehighestproportion(4.4%).Amongwomen,0.9%hadtriedaddictivedrugsinthepast,withthehighestproportionalsointheyoungestagegroups(1.9%).

Table 31. Respondents who currently use addictive drugs by sex and age group

Age group (years)


NCurrently using (%)

95% CI NCurrently using (%)

95% CI NCurrently using (%)

95% CI

15–29 497 1.5 0.3–2.6 673 – – 1170 0.7 0.1–1.3

30–44 652 1.0 0.0–2.0 1050 0.3 0.1–0.6 1702 0.7 0.1–1.2

45–59 642 0.2 0.0–0.6 974 0.4 0.0–0.9 1616 0.3 0.0–0.6

60–69 381 0.2 0.0–0.6 463 0.3 0.0–0.6 844 0.2 0.0–0.5

≥ 70 276 0.2 0.0–0.5 445 0.2 0.0–0.6 721 0.2 0.0–0.6

Total 2448 0.9 0.4–1.4 3605 0.2 0.1–0.4 6053 0.5 0.3–0.8

Table 32. Respondents who tried addictive drugs by sex and age group

Age group (years)


N Tried (%) 95% CI N Tried (%) 95% CI N Tried (%) 95% CI

15–29 497 4.4 0.2–8.7 673 1.9 0.5–3.3 1170 3.2 0.9–5.5

30–44 652 0.9 0.3–1.5 1050 0.5 0.1–0.8 1702 0.7 0.3–1.0

45–59 642 2.8 0.9–4.7 974 0.1 0.0–0.2 1616 1.4 0.5–2.4

60–69 381 2.0 0.3–3.8 463 1.2 0.0–2.4 844 1.6 0.5–2.7

≥ 70 276 1.0 0.0–2.2 445 1.0 0.0–1.9 721 1.0 0.2–1.7

Total 2448 2.6 1.1–4.0 3605 0.9 0.5–1.4 6053 1.7 1.0–2.5

51

4.5.1. Conclusions

Someofthemostimportantresultsondrugusebyrespondentsincludedthefollowing:

● 97.0%reportedneverhavingusedaddictivedrugs(males:95.5%,andfemales:98.6%); ● 0.5%currentlyusedaddictivedrugs(males:0.9%,andfemales:0.2%); ● 1.7%hadtriedaddictivedrugs(males:2.6%,andfemales:0.9%).

4.6. Diet: fruit and vegetable consumption

AhigherriskofCVDisstronglyassociatedwithincreaseddietaryintakeoftransfats,saturatedfatsandsalt,andalowintakeoffruits,vegetablesandfish(7,12,28).Nearly16millionDALYs(1.0%ofthetotal)and1.7milliondeaths(2.8%ofthetotal)aroundtheworldarelinkedwithlowfruitandvegetableconsumption.

Onaverage,respondentswerefoundtohaveeatenfruiton4.6daysinatypicalweek;thisvaluewasslightlyhigherinwomen(4.8days)thanmen(4.5days).Themeanwaslowerinthetwoyoungestagegroups,forbothmenandwomen(Table33).

Themeannumberofdaysinatypicalweekonwhichthegeneralpopulationofrespondentsatevegetableswas5.1(Table34);aswiththemeanforfruitconsumption,thisvaluewasslightlyhigherinwomen(5.2days)thanmen(4.9days).Vegetableconsumptionwaslowerinthetwoyoungestagegroupsandhigherinthetwooldest.

Table 33. Mean number of days in a typical week in which respondents consumed fruit by sex and age group

Age group (years)


NMean (days)

95% CI (days)

NMean (days)

95% CI (days)

NMean (days)

95% CI (days)

15–29 474 4.1 3.9–4.3 645 4.6 4.4–4.8 1119 4.3 4.2–4.5

30–44 629 4.2 4.0–4.4 1026 4.6 4.4–4.8 1655 4.4 4.2–4.5

45–59 618 4.8 4.6–5.1 939 5.0 4.9–5.2 1557 4.9 4.8–5.1

60–69 371 5.5 5.3–5.8 452 5.2 5.0–5.4 823 5.4 5.2–5.5

≥ 70 268 5.3 5.0–5.7 434 5.0 4.7–5.2 702 5.1 4.9–5.3

Total 2360 4.5 4.4–4.6 3496 4.8 4.7–4.9 5856 4.6 4.5–4.7

Table 34. Mean number of days in a typical week in which respondents consumed vegetables by sex and age

Age group (years)


NMean (days)

95% CI (days)

NMean (days)

95% CI (days)

NMean (days)

95% CI (days)

15–29 459 4.6 4.4–4.9 629 4.9 4.7–5.1 1088 4.8 4.6–4.9

30–44 622 5.0 4.8–5.2 1023 5.2 5.1–5.4 1645 5.1 5.0–5.2

45–59 614 5.0 4.8–5.2 942 5.4 5.3–5.6 1556 5.2 5.1–5.4

60–69 371 5.2 5.0–5.5 452 5.5 5.3–5.7 823 5.4 5.2–5.5

≥ 70 264 5.6 5.3–5.9 430 5.2 4.9–5.4 694 5.3 5.1–5.5

Total 2330 4.9 4.8–5.1 3476 5.2 5.1–5.3 5806 5.1 5.0–5.2

Table35showsthemeannumberofdaysoffruitandvegetableconsumptioninatypicalweekbyNUTS-1


4. SURVEY RESULTS

regions.TRC(south-easternAnatolia)hadthelowestfruitconsumptionandTR7(centralAnatolia),thelowestvegetableconsumption. Incontrast,averagevegetableconsumptionwashighest inTR9andaveragefruitconsumptionwashighestinTR6.

Table 35. Mean number of days in a typical week in which respondents of both sexes consumed fruit and vegetables by NUTS-1 regions

NUTS-1 regions

Fruit consumption Vegetable consumption

Respondents (N)

Mean (days)

95% CI (days)

Respondents (N)

Mean (days)

95% CI (days)

TR1 852 4.6 4.4–4.8 853 4.8 4.6–5.0

TR2 324 4.1 3.7–4.5 326 4.8 4.3–5.3

TR3 895 5.0 4.7–5.2 897 5.2 5.0–5.4

TR4 724 4.8 4.6–5.0 725 4.4 4.1–4.8

TR5 680 4.4 4.2–4.6 680 5.3 5.1–5.5

TR6 728 5.1 4.8–5.3 723 5.6 5.4–5.9

TR7 313 4.4 4.0–4.7 311 3.8 3.4–4.3

TR8 400 4.7 4.3–5.0 403 5.5 5.2–5.8

TR9 252 4.4 4.0–4.8 253 6.1 5.8–6.3

TRA 157 4.9 4.4–5.5 158 5.6 5.2–6.0

TRB 242 4.8 4.6–5.1 241 5.6 5.1–6.0

TRC 289 3.8 3.4–4.3 236 4.8 4.5–5.2

Total 5856 4.6 4.5–4.7 5806 5.1 5.0–5.2

Table 36 andTable 37present the averagenumbersof servingsof fruits and vegetables, respectively, thatrespondentsconsumedonatypicaldayoftheweek.Averagefruitconsumptionwasslightlyhigherinmenthanwomen,andinbothmenandwomeninthetwooldestagegroups(Table36).Table36presentsthemeannumberofservingsoffruitsconsumedperdaybysexandagegroup:1.4forbothsexes,1.5forwomenand1.4formen.

Table 36. Mean number of servings of fruit consumed per day by sex and age group

Agegroup (years)


N Mean (servings)

95% CI (servings)

N Mean (servings)

95% CI (servings)

N Mean (servings)

95% CI (servings)

15–29 460 1.3 1.1–1.6 635 1.4 1.2–1.6 1095 1.3 1.2–1.5

30–44 622 1.3 1.1–1.4 1021 1.3 1.2–1.5 1643 1.3 1.2–1.4

45–59 614 1.5 1.3–1.7 935 1.6 1.4–1.9 1549 1.6 1.4–1.8

60–69 370 1.8 1.5–2.0 449 1.6 1.4–1.9 819 1.7 1.5–1.9

≥ 70 268 2.0 1.5–2.5 430 1.5 1.1–1.9 698 1.7 1.4–2.0

Total 2334 1.4 1.3–1.5 3470 1.5 1.3–1.6 5804 1.4 1.3–1.5

Table37presentsthemeannumberofservingsofvegetablesonaverageperdaybysexandagegroups:1.7forbothsexes,1.7forwomenand1.6formen,withnostatisticaldifferenceacrossthesexes.Thereisalsonostatisticaldifferenceacrosstheagegroupsintermsofmeannumberofservingsofvegetablesonaverageperday.

53

Table 37. Mean number of servings of vegetables on average per day by sex and age group

Age group (years)


NMean

(servings)95% CI

(servings)N

Mean (servings)

95% CI (servings)

NMean

(servings)95% CI

(servings)

15–29 458 1.6 1.3–1.9 627 1.6 1.3–1.9 1085 1.6 1.3–1.8

30–44 619 1.5 1.3–1.7 1019 1.7 1.5–2.0 1638 1.6 1.4–1.8

45–59 612 1.6 1.2–2.0 942 1.8 1.5–2.1 1554 1.7 1.4–2.0

60–69 369 1.5 1.1–1.8 449 2.0 1.6–2.4 818 1.7 1.5–2.0

≥ 70 263 2.1 1.5–2.8 428 1.8 1.2–2.3 691 1.9 1.5–2.3

Total 2321 1.6 1.4–1.8 3465 1.7 1.6–1.9 5786 1.7 1.5–1.8

Table38showsthat87.8%oftheproportionofthestudypopulationconsumedfewerthanfiveservingsoffruitand/orvegetablesonaverageperday.Thisproportionwashigherinthetwoyoungestagegroups,andhighestforbothmenandwomeninthegroupaged30–44years.Thus,87.8%oftherespondentsdidnotreachtherecommendeddailyconsumptionofatleastfiveservingsoffruitsorvegetables.Thisbehaviourdidnotshowstatisticallysignificantdifferencesbysex,agegroup,areaorregionofresidence(seeTable38).

Table 38. Proportion of respondents consuming fewer than five servings of fruit and/or vegetables on average per day by sex and age group

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

15–29 464 89.3 85.4–93.2 639 89.3 86.2–92.4 1103 89.3 86.7–92.0

30–44 627 89.4 86.7–92.1 1028 89.4 87.0–91.9 1655 89.4 87.5–91.3

45–59 619 87.6 83.8–91.4 947 87.0 84.1–89.9 1566 87.3 84.7–89.9

60–69 372 83.3 78.3–88.2 452 82.8 78.5–87.1 824 83.0 79.7–86.3

≥ 70 268 79.1 72.8–85.4 432 85.5 80.3–90.6 700 82.7 78.7–86.8

Total 2350 87.8 85.8–89.8 3498 87.9 86.3–89.5 5848 87.8 86.4–89.3

4.6.1. Conclusions

Someofthemostimportantresultsonrespondents’fruitandvegetableconsumptionincludedthefollowing:

● themeannumberofdayswhenfruitswereconsumedinatypicalweekwas4.6(males:4.5,andfemales:4.8); ● themeannumberofservingsoffruitconsumedonaverageperdaywas1.4(males:1.4,andfemales:1.5); ● themeannumberofdayswhenvegetableswereconsumed ina typicalweekwas5.1 (males:4.9,andfemales:5.2);

● themeannumberofservingsofvegetablesconsumedonaverageperdaywas1.7(males:1.6,andfemales:1.7);

● 87.8%ofrespondentsatefewerthanfiveservingsoffruitand/orvegetablesonaverageperday(males:87.8%,andfemales:87.9%).

4.7. Dietary salt

Table 39presents the respondents’ salt-consumptionhabits by sex and agegroup.Whenboth sexes areconsidered,morethanonefourthofthestudypopulation (28.1%)alwaysoroftenaddedsalt totheirfood


4. SURVEY RESULTS

beforeeating.Although therewasnostatistically significantdifferenceat5%significance levelbetweenmen(29.3%)andwomen(26.8%)inthisregard,thereweresignificantdifferencesbetweenagegroups.Theproportionofalwaysoroftenaddingsalttotheirfoodbeforeeatingwashighestinthegroupsaged15–29(33.1%),andprogressivelydeclinedinthegroupsaged30–44(26.8%),45–59(26.3%),60–69(23.1%)and≥ 70(22.8%).Similarly,aboutaquarteroftherespondents(26.0%)statedthattheyalwaysoroftenaddedsalttotheirfoodwhencookingorpreparingmealsathome,andthisproportionshoweddecliningtrendwithage:29.7%ofthoseaged15–29,26.8%ofthoseaged30–44,25.6%ofthoseaged45–59,20.2%ofthoseaged60–69and15.4%ofthoseaged≥ 70.Table39alsoshowstheproportionofrespondentswhoreportedalwaysorofteneatingprocessedfoodshighinsalt(25.5%);thiswashigherinmales(27.8%)thanfemales(23.3%).

Table 39. Respondents’ use of dietary salt by sex and age group

UseAge group (years)


N % 95% CI N % 95% CI N % 95% CI

Always or often add salt before eating or when eating

15–29 482 35.5 30.4–40.6 668 30.7 26.4–35.0 1150 33.1 29.7–36.5

30–44 640 25.8 21.5–30.0 1043 27.9 24.4–31.4 1683 26.8 24.0–29.7

45–59 634 28.4 23.6–33.2 970 24.2 19.5–28.8 1604 26.3 22.9–29.7

60–69 379 24.5 18.8–30.1 461 21.8 16.8–26.9 840 23.1 19.3–27.0

≥ 70 272 25.2 17.9–32.5 440 21.0 15.8–26.3 712 22.8 18.4–27.2

Total 2407 29.3 26.7–31.9 3582 26.8 24.6–29.0 5989 28.1 26.3–29.9

Always or often add salt when cooking or preparing food at home

15–29 461 29.7 24.7–34.7 662 29.8 25.4–34.2 1123 29.7 26.3–33.2

30–44 626 26.2 22.1–30.3 1041 27.4 23.5–31.3 1667 26.8 23.9–29.7

45–59 621 24.6 20.1–29.2 967 26.6 22.1–31.2 1588 25.6 22.3–28.9

60–69 365 21.8 16.4–27.2 458 18.8 14.2–23.5 823 20.2 16.6–23.9

≥ 70 262 16.5 11.0–22.1 432 14.6 10.2–19.1 694 15.4 11.7–19.2

Total 2335 25.9 23.3–28.5 3560 26.1 23.8–28.4 5895 26.0 24.2–27.9

Always or often consume processed food high in salt

15–29 484 35.1 30.1–40.0 665 32.2 27.6–36.7 1149 33.6 30.1–37.1

30–44 641 26.8 22.7–30.9 1044 23.5 19.7–27.2 1685 25.1 22.2–28.1

45–59 632 25.4 20.8–30.0 970 17.9 13.6–22.2 1602 21.6 18.4–24.9

60–69 381 18.3 13.7–22.8 459 16.1 11.8–20.5 840 17.2 13.9–20.4

≥ 70 267 17.5 11.9–23.1 427 11.5 6.4–16.6 694 14.1 10.3–17.9

Total 2405 27.8 25.3–30.3 3565 23.3 21.0–25.6 5970 25.5 23.7–27.4

Table39alsoshowsthatthepercentageofmenandwomenalwaysoroftenaddingsaltwhencookingorpreparingfoodathome(25.9%and26.1%,respectively).

Fig. 14 presents estimates of the proportions of the study populationwho thought lowering their dietarysaltintakeisveryimportant:75.6%overall.Theproportionwashigherinwomen(78.1%)thanmen(73.2%),althoughthedifferenceisnotsignificant.Thepercentagesofthestudypopulationgivinghighimportancetoloweringsaltintheirdietsdidnotvarymuchacrossagegroupsforeithermenandwomen,butwassomewhatlowerforthegroupaged15–29.

55

Fig. 14. Respondents who think lowering salt in diet is very important

6


Fig. 10. Proportions of respondents not engaging in a vigorous physical activity by sex and age group

65.8

75.3

75.2

84.2

77.4

73.2

73.8 77

.3

83.2

81.4

80.0

78.1

69.8

76.3 79

.2 82.8

78.9

75.6

0

10

20

30

40

50

60

70

80

90

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


60.268.1

74.5

85.691.3

70.1

89.8 93.1 91.3 94.5 97.892.2

74.880.6 82.9

90.395.0

81.3

0

20

40

60

80

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


4.7.1. Conclusions

Someofthemostimportantresultsonrespondents’useofsaltincludedthefollowing:

● 28.1%alwaysoroftenaddedsaltorsaltysaucetotheirfoodbeforeeatingorastheywereeating(males:29.3%,andfemales:26.8%);

● 25.5%alwaysoroftenateprocessedfoodshighinsalt(males:27.8%,andfemales:23.3%); ● 75.6%thoughtthatreducingsaltintheirdietswasveryimportant(males:73.2%,andfemales:78.1%).

4.8. Physical activity

FortheanalysisofSTEPSdata,existingguidelineswerefollowedinthestudy:aperson’senergyconsumptionwhenbeingmoderatelyactiveisestimatedtobefourtimesashighasit iswhensittingquietly,andeighttimesashighwhenbeingvigorouslyactive.Throughoutaweek,includingactivityforwork,duringtransportandleisuretime,WHOrecommendsthat adultsshouldengageinatleast(44) :

● 150minutesofmoderate-intensityphysicalactivity;or ● 75minutesofvigorous-intensityphysicalactivity;or ● anequivalentcombinationofmoderate-andvigorous-intensityphysicalactivityachievingat least600MET-minutes.

Table 40 presents the physical activity of the study population using the definitions of levels of physicalactivitygiveninsection3.14.1.4:26.0%ofrespondentsperformedmoderateactivity;24.6%,highactivity;and49.4%,lowactivity.Asexpected,thegroupaged≥ 70reportedsignificantlylowerproportionswithmoderateorhighactivity(18.6%and10.8%,respectively)andagreaterproportionwithlowphysicalactivity(70.6%).Whilebothmenandwomenshowedthesametendencyforactivitytodeclinewithage,moremen(36.3%)thanwomen(13.1%)engagedinhighlevelsofphysicalactivity,astatisticallysignificantdifferenceatthe5%level(astheresultswith95%CIdonotoverlap–33.6–39.0%formenversus11.5–14.6%forwomen).Forthemoderatephysicalactivity levels, theproportion ishigher,butnotstatisticallysignificantat the5%level,26.3%formenand25.8%forwomen.Thepercentageswithlowlevelsofphysicalactivityshowedthesamepattern:37.4%formenandasignificantlyhigher(at5%level)61.1%forwomen.


4. SURVEY RESULTS

Table 40. Respondents’ levels of total physical activity as defined by WHO by sex and age group


NLow activity Moderate activity High activity

% 95% CI % 95% CI % 95% CI

Men 15–29 467 31.7 26.3–37.2 25.6 20.9–30.3 42.6 37.0–48.3

30–44 623 37.3 32.6–42.1 23.4 19.0–27.9 39.2 34.5–44.0

45–59 626 37.5 33.0–42.0 28.5 24.2–32.9 34.0 29.0–38.9

60–69 371 47.2 41.0–53.4 30.8 25.4–36.2 22.0 16.8–27.3

≥ 70 272 51.5 44.0–59.0 29.1 22.4–35.8 19.5 13.2–25.7

Total 2359 37.4 34.7–40.1 26.3 23.9–28.7 36.3 33.6–39.0

Women 15–29 646 56.2 51.6–60.9 29.3 25.1–33.5 14.5 11.1–17.9

30–44 1009 58.0 53.9–62.1 28.2 24.5–31.8 13.9 11.1–16.6

45–59 946 58.4 53.9–62.9 26.3 22.2–30.3 15.3 12.4–18.3

60–69 449 72.1 66.9–77.3 19.1 14.7–23.5 8.8 5.6–12.0

≥ 70 439 84.9 81.0–88.7 10.9 7.5–14.2 4.3 2.0–6.6

Total 3489 61.1 58.9–63.3 25.8 23.8–27.8 13.1 11.5–14.6

Both sexes

15–29 1113 43.8 40.1–47.6 27.4 24.3–30.6 28.7 25.2–32.2

30–44 1632 47.7 44.5–50.9 25.8 22.9–28.7 26.5 23.6–29.4

45–59 1572 48.0 44.7–51.3 27.4 24.4–30.4 24.6 21.7–27.6

60–69 820 60.2 56.0–64.3 24.7 21.2–28.2 15.1 12.0–18.3

≥ 70 711 70.6 66.4–74.8 18.6 15.1–22.2 10.8 7.6–14.0

Total 5848 49.4 47.6–51.2 26.0 24.5–27.6 24.6 22.9–26.2

Thestudypopulationspentamedianof30.0minutes (interquartile range:4.3–90.0) inphysicalactivityonaverageperday.Thisvaluewashigherinmales(51.4minutes–interquartilerange:11.4–180.0)thanfemales(17.1minutes–interquartilerange:0.0–55.0).

Table41reportsrespondents’meanminutesofwork-relatedphysicalactivityonaverageperdaybysexandagegroup:56.4minutes.Themeanamountofwork-relatedphysicalactivitywassignificantlyhigherinmen(91.5minutes)thanwomen(22.1minutes).Thehighestamountswere132.6minutesformeninthegroupaged30–44yearsand26.9minutesforwomeninthegroupaged45–59.

Table 41. Respondents’ mean minutes of work-related physical activity on average per day by sex and age group

Agegroup (years)


NMean

(minutes)95% CI

(minutes)N

Mean (minutes)

95% CI (minutes)

NMean

(minutes)95% CI

(minutes)

15–29 467 80.4 58.6–102.2 646 23.4 14.4–32.3 1113 52.2 40.2–64.3

30–44 623 132.6 100.0–165.1 1009 25.8 18.9–32.6 1632 79.1 62.1–96.2

45–59 626 93.3 72.9–113.7 946 26.9 18.1–35.6 1572 60.1 48.8–71.4

60–69 371 40.4 23.4–57.3 449 9.6 4.7–14.6 820 24.4 15.6–33.1

≥ 70 272 15.9 7.6–24.2 439 6.2 3.2–9.3 711 10.4 6.3–14.4

Total 2359 91.5 77.8–105.2 3489 22.1 18.1–26.1 5848 56.4 49.2–63.6

57

Table42presentsthemeanminutesoftransport-relatedphysicalactivityonaverageperdaybysexandagegroup:33.1minutes(41.0minutesformenand25.3minutesforwomen).Themeanwashighestinthegroupaged45–59inbothmen(43.7minutes)andwomen(28.0minutes).Table43presentstherespondents’meanminutesofrecreation-relatedphysicalactivityonaverageperdaybysexandagegroup(10.2minutes),whichwassignificantlyhigherinmen(14.7minutes)thanwomen(5.8minutes).Thismeanishighestintheyoungestagegroup:22.2minutesformenand9.4minutesforwomen.

Table 42. Respondents’ mean minutes of transport-related physical activity on average per day by sex and age group

Age group (years)


NMean

(minutes)95% CI

(minutes)N

Mean (minutes)

95% CI (minutes)

NMean

(minutes)95% CI

(minutes)

15–29 467 43.5 36.7–50.4 646 26.6 23.2–29.9 1113 35.2 31.3–39.0

30–44 623 37.2 31.8–42.6 1009 27.6 23.6–31.6 1632 32.4 29.1–35.7

45–59 626 43.7 37.5–49.9 946 28.0 24.2–31.9 1572 35.9 32.1–39.6

60–69 371 37.8 30.6–45.1 449 20.7 15.0–26.4 820 28.9 23.9–33.9

≥ 70 272 42.0 29.1–54.8 439 10.3 7.7–12.8 711 23.8 17.8–29.8

Total 2359 41.0 37.7–44.4 3489 25.3 23.3–27.4 5848 33.1 31.0–35.1

Table 43. Respondents’ mean minutes of recreation-related physical activity on average per day by sex and age group

Age group (years)


NMean

(minutes)95% CI

(minutes)N

Mean (minutes)

95% CI (minutes)

NMean

(minutes)95% CI

(minutes)

15–29 467 22.2 17.4–27.0 646 9.4 4.4–14.3 1113 15.9 12.4–19.4

30–44 623 11.9 6.1–17.7 1009 4.7 3.1–6.2 1632 8.3 5.2–11.4

45–59 626 13.9 8.2–19.7 946 4.2 3.0–5.4 1572 9.1 6.1–12.0

60–69 371 7.1 2.8–11.5 449 5.4 1.3–9.5 820 6.2 3.2–9.2

≥ 70 272 4.6 1.7–7.5 439 1.2 0.0–2.5 711 2.7 1.2–4.1

Total 2359 14.7 12.0–17.5 3489 5.8 4.1–7.4 5848 10.2 8.6–11.8

Table44presentstheestimatesforthepercentageofrespondentswhodidnotmeettheWHOrecommendationsonphysicalactivityforhealth(< 150minutesofmoderate-intensityactivityperweek,orequivalent),brokendownbyagegroupandsex.Thepercentagewas43.6%overall,althoughmorewomen(53.6%)fellshortthanmen(33.1%):astatisticallysignificantdifferenceat5%level.ThepercentageofstudypopulationnotmeetingtheWHOrecommendationsshowedarisingtrendwithage:37.8%forthegroupaged15–29,risingto66.1%forthoseaged≥ 70whenbothsexesareconsideredjointly.


4. SURVEY RESULTS

Table 44. Proportions of respondents not meeting the WHO recommendations on physical activity for health by sex and age group

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

15–29 467 26.7 21.5–31.9 646 49.2 44.4–54.0 1113 37.8 34.2–41.5

30–44 623 33.7 29.0–38.3 1009 49.8 45.6–54.0 1632 41.7 38.5–45.0

45–59 626 32.7 28.2–37.1 946 50.9 46.1–55.6 1572 41.8 38.4–45.2

60–69 371 43.8 37.7–50.0 449 66.2 60.6–71.8 820 55.5 51.3–59.7

≥ 70 272 47.8 40.3–55.3 439 79.8 75.4–84.2 711 66.1 61.8–70.5

Total 2359 33.1 30.5–35.6 3489 53.9 51.6–56.3 5848 43.6 41.8–45.4

Fig.15showstheproportionsofrespondentswhodidnotengageinvigorousphysicalactivity:81.3%overall,althoughmorewomen(92.2%)thanmen(70.1%)wereinactive.Theseproportionsrosewithage.


6



65.8

75.3

75.2

84.2

77.4

73.2

73.8 77

.3

83.2

81.4

80.0

78.1

69.8

76.3 79

.2 82.8

78.9

75.6

0

10

20

30

40

50

60

70

80

90

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


60.268.1

74.5

85.691.3

70.1

89.8 93.1 91.3 94.5 97.8 92.2

74.880.6 82.9

90.395.0

81.3

0

20

40

60

80

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


4.8.1. Conclusions

Someofthemostimportantresultsonrespondents’physicalactivityincludedthefollowing:

● 43.6%hadinsufficientphysicalactivity,definedas<150minutesofmoderate-intensityactivityperweek,orequivalent(males:33.1%,andfemales:53.9%);

● themediantimespentinphysicalactivityonaverageperdaywas30.0minutes(males:51.4minutes,andfemales:17.1minutes);

● 81.3%ofrespondentsdidnotengageinvigorousactivity(males:70.1%,andfemales:92.2%).

4.9. History of raised blood pressure

Highsaltandfatconsumption,reducedintakeoffruitsandvegetables,overweightandobesity,harmfuluseofalcohol,physicalinactivity,psychologicalstress,socioeconomicdeterminantsandinadequateaccesstohealthcarearemodifiableriskfactorsforhypertension.Formostofthepeoplewithhypertension,however,

59

theprecise reason for thecondition isnotknown.Theaforementioned risk factorspredisposepeople toraisedbloodpressure.Themodifiablenatureofmostofthesefactorsshouldbeviewedasanopportunity.

Hypertensionhasahigherprevalenceamongmenthanwomen,andseemstobemorecommoninlow-incomecountries than high-income countries (7). Nearly a quarter of the population of Turkey has hypertension(52,53).

The survey assessedhypertension as a risk factor forNCDbymeasuring bloodpressure. Theproportionofrespondentswhohadneverhadtheirbloodpressuremeasuredwas13.6%;16.1%formenand11.1%forwomen.Thefrequencyofraisedbloodpressureorhypertensionhistoryinthestudypopulationwas16.2%;12.3%formenand20.0%forwomen(Fig.16).

Fig. 16. Blood pressure measurement and hypertension diagnosis among respondents by sex

7


Fig. 12. Blood sugar measurement and diabetes diagnosis among respondents by sex

16.1

71.5

8.04.3

11.1

68.9

10.2 9.813.6

70.2

9.1 7.1

0

10

20

30

40

50

60

70

80

Never measured Measured, not diagnosed Diagnosed, but not withinpast 12 months

Diagnosed withinpast 12 months

Perc

enta

ge


39.9

52.5

4.2 3.4

30.2

59.2

5.4 5.2

35.0

55.9

4.8 4.3

0

10

20

30

40

50

60

70


Diagnosed within past 12months

Perc

enta

ge


Althoughitwasknownthat72.7%ofthosepreviouslydiagnosedwithraisedbloodpressureorhypertensionwere currently takingmedication, ratesof useof thismedication variedbetweenagegroups. Theywerelowestinthegroupaged15–29(29.6%)andhighestinthoseaged≥ 70(85.4%).

Participantswhowerecurrentlytakingmedicationforraisedbloodpressurewereaskedabouttheiractivitiesformanaginghypertension;75.7%usedmedicationregularlywhile11.9%werenotdoinganything(Table45).

Table 45. Respondents’ activities to manage hypertension by sex

Sex

Activities (%)

Regular medication

Irregular medication

Herbal medicines

Physical activity

Diet Nothing Other

Men 72.9 5.2 2.1 3.4 12.1 12.0 3.2

Women 77.5 5.7 0.6 1.5 10.7 11.8 0.8

Both sexes 75.7 5.5 1.2 2.3 11.2 11.9 1.7


4. SURVEY RESULTS

4.9.1. Conclusions

Someofthemostimportantresultsonrespondents’hypertensionincludedthefollowing:

● 13.6%ofrespondentshadneverhadtheirbloodpressurelevelsmeasured; ● 16.2%hadraisedbloodpressureorhypertension(men:12.3%,andwomen:20.0%),withfrequencyrisingwithage;

● 75.7%ofthosepreviouslydiagnosedwithraisedbloodpressureorhypertension,werecurrentlytakingmedication.

4.10. History of diabetesTheprevalenceofdiabetesisincreasinginTurkey:from7%ofthepopulationover20yearsofagein1997to13%in2009(53).Atpresent,13.2%ofthepopulationhasdiabetes.DiabetesistheeighthmostcommoncauseofdeathbydiseaseinTurkey(accountingfor2.2%ofdeaths).NearlyoneinthreepeopleinTurkeyhasmetabolicsyndrome.Females(41.1%)havehigherriskthanmales(28.8%)(42).

Thepercentageofrespondentswhohadneverhadtheirbloodglucoselevelsmeasuredwas35.0%;39.9%formenand30.2%forwomen.Accordingtotheparticipants’statements,thefrequencyofraisedbloodsugarordiabeteswas9.1%;7.6%formenand10.6%forwomen(Fig.17).Thefrequencyofraisedbloodsugarordiabetesinthestudypopulationincreasedfrom1.1%inthegroupaged15–29to28.8%inthegroupaged≥ 70.

Of all the respondents previously diagnosedwith raised blood glucose or diabetes, 23.7%were currently takingmedicationprescribedfordiabetes:26.4%formen21.7%forwomen.Further,72.1%ofallthosepreviouslydiagnosedwithraisedbloodglucoseordiabeteswerecurrentlytakinginsulin:69.8%formenand73.8%forwomen(Fig.18).

Theuseofmedicationfordiabetesvariedbetweentheagegroups.Itwasatthelowestlevelinthoseaged30–44(18.6%)andhighestinthoseaged60–69(29.5%).Participantswhowerecurrentlytakingmedicationforraisedbloodsugarwereaskedabouttheiractivitiesformanagingdiabetes:75.8%wereusingmedicationregularly,while12.5%werenottakinganything(Table46).


7



16.1

71.5

8.04.3

11.1

68.9

10.2 9.813.6

70.2

9.1 7.1

0

10

20

30

40

50

60

70

80



Perc

enta

ge


39.9

52.5

4.2 3.4

30.2

59.2

5.4 5.2

35.0

55.9

4.8 4.3

0

10

20

30

40

50

60

70


Diagnosed within past 12months

Perc

enta

ge


61

Fig. 18. Percentages of respondents with raised blood glucose who are currently taking medication or insulin, by sex

8


Fig. 14. Cholesterol measurement and raised-cholesterol diagnosis among respondents by sex

26.421.7 23.7

69.873.8 72.1

0

10

20

30

40

50

60

70

80


Perc

enta

ge

Taking medication Taking insulin

50.4

41.1

4.9 3.6

40.9

47.3

5.7 6.1

45.6 44.2

5.3 4.8

0

10

20

30

40

50

60

Never measured Measured,not diagnosed

Diagnosed, but not withinpast 12 months


Perc

enta

ge


Table 46. Respondents’ activities to manage diabetes by sex

Sex

Activities (%)

Regular medication


Herbal medicines

Physical activity

Diet Nothing Other

Men 73.3 6.8 1.7 3.2 9.3 13.4 4.1

Women 77.6 2.9 0.1 3.3 15.5 11.8 1.7

Both sexes 75.8 4.5 0.7 3.3 13 12.5 2.7

4.10.1. Conclusions

Someofthemostimportantresultsonrespondents’bloodsugaranddiabetesincludedthefollowing:

● morethanoneoutofthreeneverhadtheirbloodglucoselevelsmeasured; ● 9.1%ofTurkey’sadultpopulationhadraisedbloodsugarordiabetes(7.6%formenand10.6%forwomen),withprevalenceincreasingwithage;and

● 23.7% of those previously diagnosed with raised blood glucose or diabetes were currently takingmedication,and72.1%werecurrentlytakinginsulinfordiabetes.

4.11. History of raised total cholesterol

CVDarethemostcommoncauseofdeathworldwideandoneofthemajormodifiableriskfactorsisabnormalbloodlipidprofile(54).AccordingtoOnatetal.(55),meantotalcholesterollevelsweresimilarinwomenandmen inTurkey, increasing from 149 mg/dl in thegroupaged20–29 to 187 mg/dl in thegroupaged40–49,whencomparedwithwesterncountries,Turkeycurrentlyhasrelativelylowlevelsoftotalcholesterolinblood.Nevertheless,12millionTurkishcitizenshavetotalcholesterollevelshigherthan200mg/dl(4).Cholesterol


4. SURVEY RESULTS

levelsseemtohaveincreasedoverthelast20years.Meanbloodtriglyceridelevelsincreasedbyapproximately25mg/dlinmenand20mg/dlinwomensince1990(56).

Thepercentageofrespondentswhohadneverhadtheirbloodcholesterolmeasuredwas45.6%;50.4%formenand40.9%forwomen.Thefrequencyofahistoryofraisedcholesterol in thesurveypopulationwas10.1%(8.5%formenand11.8%forwomen–Fig.19)androsefrom1.2%inthegroupaged15–29to22.3%inthoseaged60–69.


8



26.421.7 23.7

69.873.8 72.1

0

10

20

30

40

50

60

70

80


Perc

enta

ge

Taking medication Taking insulin

50.4

41.1

4.9 3.6

40.9

47.3

5.7 6.1

45.6 44.2

5.3 4.8

0

10

20

30

40

50

60

Never measured Measured,not diagnosed

Diagnosed, but not withinpast 12 months


Perc

enta

ge


Of all the respondents previously diagnosed with raised total cholesterol, 36.9% were currently takingmedicationprescribedforthecondition;39.8%formenand34.9%forwomen.Theuseofmedicationvariedsignificantlybetweenagegroups;itwaslowestinthegroupaged30–44(10.4%)andhighestinthoseaged≥ 70 (55.0%).Respondentswhowerecurrently takingdrugs (medication) for raisedtotalcholesterolwereaskedabouttheiractivitiesformanagingthecondition:38.5%wereusingmedicationregularly,while33.9%werenotdoinganything(Table47).

Table 47. Respondents’ activities to manage total cholesterol by sex

Sex

Activities (%)

Regular medication


Herbal medicines

Physical activity

Diet Nothing Other

Men 39.2 3.0 3.3 4.5 22.2 34.6 1.0

Women 38.1 5.9 3.6 4.4 19.0 33.4 1.1

Both sexes 38.5 4.7 3.5 4.5 20.3 33.9 1.0

4.11.1. Conclusions

Someofthemostimportantresultsonrespondents’bloodcholesterolincludedthefollowing:

● almosthalfofrespondents(45.6%)hadneverhadtheirtotalcholesterollevelsmeasured; ● 10.1%ofTurkey’s adult populationhadhistory of raised total cholesterol (8.5% formenand 11.8% forwomen),andprevalenceincreasedwithageingeneral;

● 36.9%ofthosepreviouslydiagnosedwithraisedtotalcholesterolwerecurrentlytakingmedicationforit.

63

4.12. History of CVD

CVDareagroupofdiseasesaffectingtheheartandbloodvessels,suchasCHD,cerebrovasculardiseaseandperipheralarterialdisease.WhileNCDsaccountedforanestimated36milliondeaths(63%ofthe57milliondeathsthatoccurredgloballyin2008),CVDaccountedfor48%ofdeathsfromNCDs(7,9).CVDarethemostcommoncauseofdeathworldwide.

MortalityduetoCVDisprojectedtoincreasefrom17.5millionin2012to22.2millionin2030(13).WhilemortalityduetoCVDdeclinedinhigh-incomecountries,itwasrelativelyflatinmanylow-andmiddle-incomecountries(57).

NCDswere estimated to be responsible for 86% of total deaths in Turkey; CVD responsible for the 47%(37).Thetwomostcommoncausesofdeathbydisease inTurkeyare ischaemicheartdisease (22%)andcerebrovasculardiseases(15%)(53).TheprevalenceofCVDisincreasinginTurkey(53);CVDaccountedforthedeathsof102 386malesand103 071femalesin2000.Thesenumbersareprojectedtoriseto175 663and144 297in2020,and235 567and180 530in2030,respectively.By2030,mortalityduetoCVDisprojectedtoincreasebyabout2.3timesinmalesandabout1.8timesinfemales.

Thepercentageofrespondentswhohadhadaheartattackorchestpainfromheartdisease(angina)orastroke (cerebrovascularaccidentor incident)was5.0%;5.2%formenand4.8%forwomen.Womenhavealowerfrequencyinallagegroupsexceptthoseaged15–29and45–59.Inaddition,thefrequencyofheartattackorchestpainfromheartdisease,orstrokeincreasedwithage:from1.3%inthegroupaged15–29to18.8%inthoseaged≥ 70(Fig.20).

Fig. 20. Respondents who ever had a heart attack or chest pain from heart disease, or a stroke, by sex and age group

9


Fig. 16. Percentages of respondents who are currently taking aspirin or statins regularly to prevent or treat heart disease by sex

1.2 1.4

6.6

20.1

19.5

5.2

1.4 1.0

7.2

10.6

18.3

4.8

1.3 1.2

6.9

15.2

18.8

5.0

0

5

10

15

20

25

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


6.0

1.9

5.3

1.8

5.6

1.8

0

1

2

3

4

5

6

7

Taking asprin Taking statins

Perc

enta

ge


Ofalltherespondents,5.6%werecurrentlytakingaspirinregularlytopreventortreatheartdisease;6.0%formenand5.3%forwomen.Inaddition,1.8%ofthestudypopulationwerecurrentlytakingstatinsregularlyforthispurpose;1.9%formenand1.8%forwomen(Fig.21).Theagegroupsvariedintheiruseofaspirinorstatinstopreventortreatheartdisease.Thelevelofdrugusewaslowestinthegroupaged15–29(0.3%takingaspirinand0.5%,statins)andhighestinthoseaged≥ 70(24.4%takingaspirinand7.3%,statins).Theuseofaspirintopreventortreatheartdiseasealsovariedbetweenthesexes,asmorewomenusedituptotheageof44,andmoremenuseditfrom45yearsonward.Ontheotherhand,morewomenthanmenusedstatinsonlyinthegroupaged15–29.


4. SURVEY RESULTS


9



1.2 1.4

6.6

20.1

19.5

5.2

1.4 1.0

7.2

10.6

18.3

4.8

1.3 1.2

6.9

15.2

18.8

5.0

0

5

10

15

20

25

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


6.0

1.9

5.3

1.8

5.6

1.8

0

1

2

3

4

5

6

7

Taking asprin Taking statins

Perc

enta

ge


4.12.1. Conclusions

Someofthemostimportantresultsonrespondents’historyofCVDincludedthefollowing:

● 5.0%ofrespondentshadhadaheartattackorchestpainfromheartdisease,orstroke(5.2%formenand4.8%forwomen)andthefrequencyincreasedwithage;

● 5.6%of respondentswerecurrently takingaspirinand 1.8%werecurrently takingstatins regularly topreventortreatheartdisease,althoughtheuseofaspirinand/orstatinsvariedbetweenthesexes.

4.13. Family history of chronic diseases

WhilemajormodifiableriskfactorsforNCDsincludephysicalinactivity,unhealthydiet,abnormalbloodlipids,obesityanddiabetes,aswellashighbloodpressure,tobaccouseandharmfulalcoholuse,thenonmodifiableriskfactorsincludeage,geneticfeaturesorfamilyhistory,genderandethnicbackground(54).

Almost half of participants’ parents or siblings (45.8%) had a known, diagnosed chronic disease requiringmedication.

Themostcommonlydiagnosedconditionswere:hypertension(51.0%),type-2diabetes(46.4%)andheartattack(22.4%)(Fig.22).Amongrespondents’parentsorsiblings,19.8%hadhadaheartattackorchestpainfromheartdisease(angina)orastroke(cerebrovascularaccidentorincident).

65

Fig. 22. Types of diagnosed chronic disease requiring medication for respondents’ parents or siblings

2.3

6.2

21.5

29.7 30.5

11.9

0.6

4.6

21

34.7

34.5

12.2

1.5

5.4

21.3

32.3 32.9

12

0

5

10

15

20

25

30

35

40

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


51

46.4

22.4

11.3 11.17.2

1.8

11.1

0

10

20

30

40

50

60

Hypertension Type 2 diabetes Heart attack Cancer Hypercholes-terolemia

Chest painfrom heart

disease (angina)

Stroke(cerebrovascular

accidentor incident)

Other

Perc

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4.13.1. Conclusions

Someofthemostimportantresultsonrespondents’familyhistoryofNCDsincludedthefollowing:

● Almosthalfofparticipants’(45.8%)parentsorsiblingshadaknown,diagnosedchronicdiseaserequiringmedication;

● hypertensionwasthemostcommonconditiondiagnosed.

4.14. History of asthma, chronic obstructive pulmonary disease or cancer

Chronicrespiratorydiseasesarealeadingcauseofdeathworldwide,andtendtohavehighunderdiagnosisrates.Mostofthedeathsduetochronicrespiratorydiseasesoccur in low-incomecountries.Generalriskfactorsincludecigarettesmoke,occupationaldustandchemicals,second-handsmoke,indoor/outdoorairpollution,genetics,infections,socioeconomicfactorsandageing(58).

Asthmaischaracterizedbyrecurrentattacksofbreathlessnessandwheezing.Thesymptomscandifferinseverityandasthmamaycausefatigueandsleepiness.Eventhoughthefatalityrateis low,thediseaseisusuallyunderdiagnosed.Asthmaaffectsapproximately235millionpeople(59).

Chronicobstructivepulmonarydisease(COPD)isagroupoflungdiseasesthatpreventproperlungairflow.Gathering accurate epidemiological data on COPD prevalence, morbidity and mortality is difficult andexpensive.WHOestimatedthat65millionpeopleworldwidehadmoderate-to-severeCOPDandapproximately3millionpeoplediedofitin2015(5%ofalldeaths)(60).

Cancer killed 7.6million people in 2008 and about 70%of such deaths occur in low- andmiddle-incomecountries.Cancermortalityisprojectedtoreach13.1millionby2030.Approximately30%ofcancercasesareassociatedwithbehaviouralriskfactors(61,62).

Lung,breast,colorectal,stomachandlivercancercausemorethan50%ofcancerdeaths.Inhigh-incomecountries, themost frequentcauseofcancerdeaths in thepopulation is lungcancer, followedbybreastcanceramongwomenandcolorectalcanceramongmen.Thetypesandfrequenciesofcancerdifferamong


4. SURVEY RESULTS

countries.Insub-SaharanAfrica,cervicalcancerisstilltheleadingcauseofcancerdeathamongwomen(7).

Cancerisanimportantpublichealthconcern.InTurkey,itisthesecondmostimportantcauseofdeathbutisprojectedtobetheleadingcauseofdeathby2030.Approximately175 000newcancercaseswerediagnosedinTurkeyin2012(63).

Thepercentageof respondentswhohadeverbeendiagnosedwith asthma (includingallergic asthma)by adoctorwas6.9%;5.0%formenand8.7%forwomen.Thefrequencyofdiagnosisrosefrom4.7%inthegroupaged15–29to12.5%inthegroupaged≥ 70,demonstratingthatthevalueingeneralincreasedwithage(Fig.23).

Fig. 23. Proportions of respondents with an asthma diagnosis, by sex and age group

10

Fig. 17. Types of diagnosed chronic disease requiring medication for respondents’ parents or siblings

Fig. 18. Proportions of respondents with an asthma diagnosis, by sex and age group

4,1 4.25.7

6.8

8.5

5.05.47.0

12.0 11.7

15.5

8.7

4.75.6

8.8 9.3

12.5

6.9

0

2

4

6

8

10

12

14

16

18

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


COPDisthethirdmostcommoncauseofdeathbydiseaseinTurkey(accountingfor6%),followingischaemicheartdiseaseandcerebrovasculardiseases(36):3.6%oftherespondentshadbeendiagnosedwithCOPDbyadoctor;3.1%formenand4.1%forwomen.Likeasthmadiagnoses,thefrequencyofCOPDdiagnosisrosewithage,from1.8%inthegroupaged15–29to8.6%inthegroupaged≥ 70(Fig.24).

Fig. 24. Proportions of respondents with COPD diagnoses, by sex and age group

11


Fig. 20. Respondents’ perception of their weight by sex

1,3

2.7 3.

4

7.4

8.0

3.1

2.4

3.2

4.2

7.4

9.1

4.1

1.8

3.0

3.8

7.4

8.6

3.6

0

1

2

3

4

5

6

7

8

9

10

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


10.8

56.3

28.8

3.6

0.5

7.6

44.9

38.1

8.7

0.8

9.2

50.5

33.5

6.1

0.6

0

10

20

30

40

50

60

Low weight Normal weight Overweight Obese Morbidly obese

Perc

enta

ge


67

Amongrespondents,0.7%hadreceivedacancerdiagnosisbyadoctorintheprevious12months;0.4%formenand0.9%forwomen.Thefrequencyofcancerdiagnosis,too,increasedwithage,from0.3%inthegroupaged15–29to2.2%inthegroupaged≥ 70.

4.14.1. Conclusions

Someofthemostimportantresultsonrespondents’historyofasthma,COPDorcancerincludedthefollowing:

● 6.9%hadbeendiagnosedwithasthma,includingmorewomen(8.7%)thanmen(5.0%); ● 3.6%hadbeendiagnosedwithCOPD,includingmorewomen(4.1%)thanmen(3.1%); ● 0.7%hadbeendiagnosedwithcancerintheprevious12months,includingmorewomen(0.9%)thanmen(0.4%);

● Thefrequencyofasthma,COPDandcancerdiagnosesincreasedwithage.

4.15. Lifestyle advice

Severalapproacheshavebeenproposedtoreduceand/orpreventNCDs.WHOdescribesasetofevidence-based best-buy interventions that are cost-effective and feasible (64). These interventions’ aims includeto reduce or prevent tobacco use and to promote physical activity and adequate and balanced nutrition,includingreducingsaltandfatintake,andconsumingatleastfiveservingsoffruitorvegetablesaday(65,66).

Respondentswereaskedabouttheirperceptionsoftheirweight:9.2%thoughttheywerethin;50.5%,normal;33.5%,overweight;and6.1%,obese(Fig.25).Perceptionsofnormalorlowweightweremorecommonamongmen,andperceptionsofoverweightandobesityweremorecommonamongwomen.


11



1,3

2.7 3.

4

7.4

8.0

3.1

2.4

3.2

4.2

7.4

9.1

4.1

1.8

3.0

3.8

7.4

8.6

3.6

0

1

2

3

4

5

6

7

8

9

10

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


10.8

56.3

28.8

3.6

0.5

7.6

44.9

38.1

8.7

0.8

9.2

50.5

33.5

6.1

0.6

0

10

20

30

40

50

60

Low weight Normal weight Overweight Obese Morbidly obese

Perc

enta

ge


Perceptions of weight varied among the age groups. The proportion of those perceiving their weightas low and normal decreased from 15.8% and 60.5%, respectively, in the group aged 15–29 to 4.7% and41.4%,respectively,inthegroupaged60–69.Conversely,perceptionsofexcessweightrosewithage,withproportionsofrespondentsconsideringthemselvesoverweightrisingfrom21.0%inthegroupaged15–29to42.9%inthegroupaged45–59,andtheshareofthoseconsideringthemselvesobeseincreasingfrom2.3%inthegroupaged15–29to10.7%inthegroupaged≥ 70.


4. SURVEY RESULTS

Fig.26showstheproportionsofrespondentswhohadreceivedarangeofadviceonchangingtheirlifestylesfromadoctororotherhealthworker:

● 14.8%(18.6%formenand11.1%forwomen)wereadvisedtoquitornottostartusingtobacco,withthefrequencydecreasingfrom17.2%inthegroupaged30–44to8.1%inthegroupaged≥ 70;

● 22.3% (20.8% formenand23.9% forwomen)were advised to reduce salt intake,with the frequencyincreasingingeneralwithage,from13.3%inthegroupaged15–29to39.1%inthegroupaged≥ 70;

● 19.9%(19.3%formenand20.4%forwomen)wereadvisedtoeatfiveormoreservingsoffruitand/orvegetableseachday,with thefrequency increasing ingeneralwithage, from15.7% in thegroupaged15–29to31.0%inthegroupaged≥ 70;

● 22.4%(19.6%formenand25.2%forwomen)wereadvisedtoreducefatintheirdiets,withthefrequencyincreasingingeneralwithage,from13.9%inthegroupaged15–29to35.7%inthegroupaged≥ 70;

● 23.2%(20.3%formenand26.2%forwomen)wereadvisedtoincreasetheirphysicalactivity,withthefrequencyincreasingfrom15.0%inthegroupaged15–29to34.2%inthegroupaged60–69;

● 22.1%(18.9%formenand25.4%forwomen)wereadvisedtomaintainahealthybodyweightortoloseweight,withthefrequency increasingfrom14.5%inthegroupaged15–29,to31.3%inthegroupaged60–69.

Fig. 26. Percentage of respondents who received lifestyle advice from a doctor or health worker during the previous 12 months by age group

12


Fig. 22. Percentage of respondents who could name two or more negative health effects of any of the selected NCD risk factors

12.2

0

13.3

0 15.7

0

13.9

0

15.0

0

14.5

017.2 19

.7

19.1 20

.5 21.5

20.6

16.2

27.5

21.0

28.1 30

.8

29.8

17.6

37.0

25.5

34.7

34.2

31.3

8.1

39.1

31.0

35.7

29.8

27.3

14.8

22.3

19.9 22

.4

23.2

22.1

0

5

10

15

20

25

30

35

40

45

Tobacco Salt Fruit and/orvegetables

Fat Physical activity Body weight

Perc

enta

ge

15–29 30–44 45–59 60–69 ≥70 TOTAL

87.8 92

.3

90.1

86.6

79.2

89.1

89.1

90.0

84.9

76.7

66.9

85.588

.4 91.2

87.5

81.5

72.1

87.3

0

20

40

60

80

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


Thepercentageofrespondentswhohadreceivedcounsellingoreducationfromhealthworkersononeormoresubjects related tohealthy living (healthynutrition,weight reduction,smokingcessationorphysicalactivity) during theprevious 12monthswas40.5%; 38.1% formenand42.9% forwomen.The frequencyincreasedfrom29.7%inthegroupaged15–29to55.3%inthegroupaged60–69.

69

4.15.1. Conclusions

Someofthemostimportantresultsonlifestyleadvicegiventorespondentsincludedthefollowing:

● morementhanwomenperceivedtheirweightasnormal,andmorewomenthanmenperceivedthemselvesasoverweight;

● adoctororhealthworkerhadadvised:

� fewerthanoneoutofsevenindividualstoquitusingtobaccoornottostart;

� fewerthanoneoutoffourindividualstoreducesaltintheirdiets;

� fewerthanoneoutoffiveindividualstoeatfiveormoreservingsoffruitand/orvegetableseachday;

� fewerthanoneoutoffourindividualstoreducefatintheirdiets;

� fewerthanoneoutoffourindividualstostartbeingorbemorephysicallyactive;

� fewerthanoneoutoffourindividualstomaintainahealthybodyweightortoloseweight;

● ingeneral,moremenwereadvisedtoquitusingtobaccoornottostart,andmorewomenwereadvisedtoreducesaltinthediet,toeatfiveormoreservingsoffruitand/orvegetablesperday,toreducefatintheirdiets,tostartbeingorbemorephysicallyactive,andtomaintainahealthybodyweightortoloseweight;

● two infiveofrespondents (40.5%–38.1%formenand42.9%forwomen)hadreceivedcounsellingoreducationfromhealthworkersononeormoresubjectsrelatedtohealthylivingduringtheprevious12months.

4.16. Awareness of harm to health from selected risk factors for NCDs

Tobaccoisoneofthemostimportantcausesofpreventabledeath;tobaccouseaccountsforthedeathof7%ofmenand12%ofwomenannually(24,64).WHOestimatedthat8millionpeoplewilldiefromtobaccouseby2030(24).Inaddition,tobaccouseisaprominentcauseofmorbidityincludingCVD,chronicrespiratorydisease,canceranddiabetes.

Physically inactivepeoplehavehigher riskofdeath than thoseengaging inaminimumof 150minutesofmoderate-intensity physical activity per week (19). Physical activity has been shown to reduce body fat,decrease risksofCVDandmetabolicdisease, improvebonehealth,anddecreaseanxietyanddepressionsymptoms(19).

WHOreportedthat23%ofadults(> 18years)and81%ofadolescents(11–17years)wereinsufficientlyphysicallyactive in 2010 (11).Womenareusuallylessactivethanmen,andolderpeoplelessactivethanyoungerpeople.TheidealmedianBMIforadultsisacceptedas21–23kg/m2andthetargetedBMIrangeis18.5−24.9kg/m2. OverweightisdefinedashavingaBMI≥ 25kg/m2,whileobesityisconsideredashavingaBMI≥ 30kg/m2.Bothmayresultinanincreasedriskforseveralconditions(31).Combined,theycauseabout3.4milliondeathsand93.6millionDALYseachyear(18).

The respondents’ awarenessofhealth risks fromNCD risk factorswasassessedbyasking them to statetwoormorenegativehealtheffectsofanyoftheselectedriskfactors:87.3%(89.1%formenand85.5%forwomen)coulddoso.Thefrequencydecreasedfrom91.2%inthegroupaged30–44to72.1%inthegroupaged≥ 70(Fig.27).


4. SURVEY RESULTS


12



12.2

0

13.3

0 15.7

0

13.9

0

15.0

0

14.5

017.2 19

.7

19.1 20

.5 21.5

20.6

16.2

27.5

21.0

28.1 30

.8

29.8

17.6

37.0

25.5

34.7

34.2

31.3

8.1

39.1

31.0

35.7

29.8

27.3

14.8

22.3

19.9 22

.4

23.2

22.1

0

5

10

15

20

25

30

35

40

45

Tobacco Salt Fruit and/orvegetables

Fat Physical activity Body weight

Perc

enta

ge

15–29 30–44 45–59 60–69 ≥70 TOTAL

87.8 92

.3

90.1

86.6

79.2

89.1

89.1

90.0

84.9

76.7

66.9

85.588

.4 91.2

87.5

81.5

72.1

87.3

0

20

40

60

80

100

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


Varyingproportionsofrespondentscouldstatetwoormorenegativehealtheffectsofeachriskfactor(Table48):

● smoking tobacco: 76.2% (77.0% formen and 75.5% forwomen),with the frequency decreasing from80.4%inthegroupaged30–44to61.2%inthegroupaged≥ 70;

● high-saltdiet:71.6%(72.3%formenand71.0%forwomen),withthefrequencydecreasingfrom76.7%inthegroupaged45–59to56.8%inthegroupaged≥ 70;

● lowconsumptionoffruitsand/orvegetables(32.8%formenand33.6%forwomen),withthefrequencydecreasingfrom35.2%inthegroupaged30–44to20.7%inthegroupaged≥ 70;

● physicalinactivity:58.3%(59.6%formenand57.1%forwomen); ● high-fatdiet:64.3%(65.7%formenand62.8%forwomen),withthefrequencydecreasingfrom69.9%inthegroupaged30–44to45.0%inthegroupaged≥ 70;

● alcoholuse:74.2%(75.9%formenand72.5%forwomen),withthefrequencydecreasingfrom79.9%inthegroupaged30–44to54.1%inthegroupaged≥ 70;

● substanceabuse:73.4%(75.5%formenand71.4forwomen),withthefrequencydecreasingfrom79.3%inthegroupaged30–44to53.7%inthegroupaged≥ 70;

Nogender differenceswere found in termsof indicating twoormorenegative health effects of different riskfactors.

Table 48. Proportions of respondents that could state two or more negative health effects of different risk factors, by age group

Age group (years)

Risky behaviour (%)

Smoking tobacco

High-salt diet

Low fruits and/or vegetable intake

Physical inactivity

High-fat diet

Harmful alcohol use

Substance abuse

15–29 76.1 68.8 34.0 57.2 62.2 73.7 74.2

30–44 80.4 75.9 35.2 63.5 69.9 79.9 79.3

45–59 77.7 76.7 34.7 60.1 67.5 76.6 74.2

60–69 70.8 66.8 30.0 55.5 59.6 67.0 64.6

≥ 70 61.2 56.8 20.7 39.8 45.0 54.1 53.7

Total 76.2 71.6 33.2 58.3 64.3 74.2 73.4

71

4.16.1. Conclusions

MostrespondentscouldstatetwoormorenegativehealtheffectsofNCDriskfactors:

● anyoftheselectedNCDriskfactors:nearlynineoutof10; ● smokingtobacco:threeoutoffour; ● high-saltdiet:approximatelythreeoutoffour; ● alcoholuseandsubstanceabuse:nearlythreeoutoffour; ● high-fatdiet:morethansixoutof10; ● physicalinactivity:nearlythreeoutoffive; ● lowconsumptionoffruitsand/orvegetables:approximatelyoneoutofthree.

4.17. Cancer screening tests

Breastcancermainlyoccursinwomen,althoughtherearerarecasesinmen(61).Awoman’slifetimeriskofbeingdiagnosedwithbreastcancer isaboutone ineight.Riskfactorsforbreastcancer includehormonetherapy,overweightandphysicalinactivity,ethnicbackground,genetics/familyhistory,genemutations,andolderage.Colorectalcancer is thethirdmostcommontypeofcancer.Therisk factors for thiscancerofthedistalpartofthedigestivesystemincludeageing,Africanethnicbackground,unhealthydiet,physicalinactivity,diabetesandfamilyhistory (66).Cervicalcancer isacancerofthefemalereproductivesystem.Nearly all cases are linked to genital infectionwith human papillomavirus (HPV); HPV infection, smoking,immunedeficiencies,poverty,lackofaccesstothePaptestandfamilyhistoryareamongtheriskfactors.

The respondentswereaskedwhat theyknewabout theavailabilityofvariousscreening tests forcancer:42.1%(37.8%formenand46.4%forwomen)hadheardthatcancerscreeningwasavailablefreeofchargeinfamilyhealthcentres(FHC)andcancerearlydiagnosisscreeningandtrainingcentres(CEDSTC).

TheproportionsthathadheardthatcancerscreeningwasavailableinFHCandCEDSTCincreasedfrom34.8%inthegroupaged15–29to50.0%inthegroupaged45–59,andthendeclinedinthetwooldestgroups(Fig.28).

Fig. 28. Percentages of respondents who have heard that the cancer screenings are available free in FHC and CEDSTC, by sex and age group

13


Fig. 24. Types of accidents causing injuries suffered by the respondents in the previous 12 months, by sex

32.1

19.1

37.0

13.916.7

55.7

8.3

19.3

27.330.5

28.1

15.6

0

10

20

30

40

50

60

Traffic Household Occupational work Other

Perc

enta

ge


27.5

41.6

45.5

46.4

32.0

42.4

51.854.6

40.3

27.3

34.8

46.7 50.0

43.2

29.3

20

30

40

50

60

15–29 30–44 45–59 60–69 ≥70

Perc

enta

ge



4. SURVEY RESULTS

Varyingpercentagesofrespondentshadhadvariouscancertests:

● 74.5%(76.5%formenand72.4%forwomen)ofthoseaged50–70hadneverhadaguaiacfaecaloccultbloodtest;

● 12.1%(11.1%formenand13.2%forwomen)aged50–70hadhadacolonoscopyintheprevious10years; ● 57.4%ofwomenaged40–69hadeverhadmammography; ● 54.2%ofwomenaged30–65hadeverhadcervicalcancerscreening.

4.17.1. Conclusions

Someofthemostimportantresultsonrespondents’historyofcancerscreeningincludedthefollowing:

● two out of five respondents had heard that cancer screening was available free of charge, althoughawarenesswaslowerinmen(37.8%)thanwomen(46.4%);

● threeoutoffourparticipantsaged50–70hadneverhadaguaiacfaecaloccultbloodtest; ● approximatelyoneoutofnineindividualsaged50–70hadhadacolonoscopyintheprevious10years; ● twooutoffivewomenaged40–69hadneverhadmammography; ● approximatelyhalfofwomenaged30–65hadneverhadcervicalcancerscreening.

4.18. Accidents and injuriesInjurieswereestimatedtoberesponsiblefor7%oftotaldeathsinTurkey(37).Amongthesurveypopulation,3.9% (5.4% formenand2.4% forwomen)hadbeen injuredasa result of anaccident in theprevious 12months.Thisproportionwashighest(7.5%)inmalesintheyoungestagegroup.Fig.29showstheleadingtypesofaccidentscausing injuriessuffered intheprevious12months:trafficaccidents (27.3%of injuredrespondents),householdaccidents(30.5%ofinjuredrespondents),occupationalaccidents(28.1%)andothertypesofaccidents(15.6%).


13



32.1

19.1

37.0

13.916.7

55.7

8.3

19.3

27.330.5

28.1

15.6

0

10

20

30

40

50

60

Traffic Household Occupational work Other

Perc

enta

ge


27.5

41.6

45.5

46.4

32.0

42.4

51.854.6

40.3

27.3

34.8

46.7 50.0

43.2

29.3

20

30

40

50

60

15–29 30–44 45–59 60–69 ≥70

Perc

enta

ge


Among respondents injured as a result of an accident in the previous 12 months 58.5% had receivedambulatorycare(53.9%formenand68.6%forwomen)and27.0%hadreceivedinpatientcare(31.5%formenand17.0%forwomen).

These proportions varied among the age groups. The share of thosewho had received ambulatory careranged from66.6% in thegroupaged 15–29 to40.4% in thoseaged60–69.Theproportionwho receivedinpatientcarerosefrom20.6%inthegroupaged15–29andto38.3%inthoseaged60–69(Fig.30).

73

Fig. 30. Percentages of respondents injured as a result of an accident in the previous 12 months who received ambulatory or inpatient care, by age group

14


Fig. 26. Type and length of care received by respondents who had visited a hospital for the treatment of hypertension, CVD, diabetes, cancer, COPD or asthma in the previous 12 months

66.6

59.5

50.3

40.4

59.9 58.5

20.623.7

35.438.3

31.427.0

0

10

20

30

40

50

60

70

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

Ambulatory care Inpatient treatment

79.8

11.1 13.0

81.8

14.08.0

81.0

12.8 10.1

0

10

20

3040

50

60

70

80

90

Ambulatory care Inpatient care lasting lessthan 24 hours

Inpatient care lasting longerthan 24 hours

Perc

enta

ge


4.18.1. Conclusions

Someof themost important resultson injuries to respondents fromaccidents in theprevious 12monthsincludedthefollowing:

● 3.9%hadbeeninjuredasaresultofanaccident; ● accidentsintraffic(27.3%),thehousehold(30.5%)andtheworkplace(28.1%),andothertypesofaccidents(15.6%)weremainlyresponsiblefortheseinjuries;

● morethaneightoutof10injuredrespondentshadreceivedmedicalcare; ● thefrequencyandcausesofinjuries,andthetypesofmedicalcarereceivedvariedbetweenthesexes:moremenwereinjuredasaresultoftrafficandoccupational/workaccidents,whilemorewomenwereinjuredasaresultofhouseholdandothertypesofaccidents;andmoremenreceivedinpatienttreatment,whilemorewomenreceivedambulatorycare.

4.19. Ambulatory or inpatient care

Thepercentageofthoseinthesurveypopulationwhohadvisitedahospitalforthetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious12monthswas30.3%;28.8%formenand31.4%forwomen.Theseproportionsrosefrom15.9%inthegroupaged15–29to39.7%inthegroupaged≥ 70(Table49).

Table 49. Percentages of respondents who had visited a hospital for the treatment of hypertension, CVD, diabetes, cancer, COPD or asthma in the previous 12 months, by sex and age group

Age group (years)


% 95% CI % 95% CI % 95% CI

15–29 12.6 2.6–22.7 18.5 8.3–28.8 15.9 8.3–23.4

30–44 18.1 9.5–26.8 22.9 16.8–28.9 20.8 15.7–25.8

45–59 28.5 22.1–34.9 32.3 25.5–39.0 30.6 25.8–35.5

60–69 39.1 31.9–46.2 39.5 32.4–46.6 39.3 34.2–44.4

≥ 70 42.0 32.7–51.3 38.2 31.5–45.0 39.7 34.1–45.3

Total 28.8 25.1–32.5 31.4 27.9–34.9 30.3 27.6–32.9


4. SURVEY RESULTS

Ofthosewhohadvisitedahospitalforthetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious12months,81%hadreceivedambulatorycare(79.8%formenand81.8%forwomen),12.8%hadreceivedinpatientcarelastingfewerthan24hours(11.1%formenand14.0%forwomen)and10.1%hadreceivedcarelastinglongerthan24hours(13.0%formenand8.0%forwomen)(Fig.31).


14



66.6

59.5

50.3

40.4

59.9 58.5

20.623.7

35.438.3

31.427.0

0

10

20

30

40

50

60

70

15–29 30–44 45–59 60–69 ≥70 TOTALPe

rcen

tage

Ambulatory care Inpatient treatment

79.8

11.1 13.0

81.8

14.08.0

81.0

12.8 10.1

0

10

20

3040

50

60

70

80

90

Ambulatory care Inpatient care lasting lessthan 24 hours

Inpatient care lasting longerthan 24 hours

Perc

enta

ge


4.19.1. Conclusions

Someofthemostimportantresultsonhospitaltreatmentofrespondentsincludedthefollowing:

● nearlyoneoutofthreehadvisitedahospitalforthetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious12months;

● morethanfouroutoffiveofthosewhovisitedahospitalforthesereasonsreceivedambulatorycare.

4.20. Ambulatory diagnosis, treatment and home care

Investigatorsdeterminedtheproportionsofrespondentsthathadreceivedvarioustypesofhealthcare.Forexample,12.9%ofrespondentshadnevervisitedadentist,but6.7%hadvisitedadentistwithinthepreviousmonth.Inaddition,15.5%ofrespondentshadnevervisitedageneralpractitioner(GP)orfamilydoctor,while17.6%haddonesowithinthepreviousmonth.Similarly,10.7%hadnevervisitedaspecialistphysicianwhile16.8%haddonesowithinthepreviousmonth.

ThepercentageofrespondentswhohadvisitedsomehealthpersonnelisgiveninFig.32bysex.

75

Fig. 32. Percentages of respondents who had visited health personnel, by sex

15


Fig. 28. Percentages of respondents who had visited health personnel within the previous month, by age group

5.6 7.8

15.6

16.3

13.0

13.5

50.9

51.6

14.9

10.813

.8

21.4 26

.0 28.3

14.1

13.4

29.0

22.9

17.1

13.9

12.9

20.6 27

.1 32.2

15.9

13.5

31.1

25.2

12.9

8.5

0

10

20

30

40

50

60

Men Women Men Women Men Women Men Women Men Women

Within the last month More than 1, less than6 months ago

More than 6, less than12 months ago

12 months or moreago

Never

Perc

enta

ge

Dentist GP Specialist

6.27.4 6.7 7.2

5.36.7

13.9 12.8

20.2

30.6 29.9

17.614.7

13.5

18.3

25.0 24.4

16.8

0

5

10

15

20

25

30

35

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

Visited dentist Visited a GP or family doctor Visited a specialist physician

Visitstohealthcareprovidersalsovariedbetweenagegroups:17.9%ofrespondentsinthegroupaged15–29hadnevervisitedadentist,butthisfrequencywasapproximatelyoneoutof10inotheragegroups.Amongrespondents in thegroupaged 15–29, 16.3%hadnevervisitedaGPor familydoctorand 13.9%hadnevervisitedaspecialistphysician;thecorrespondingfiguresfortheotheragegroupsdecreased,to13.4%and6.9%,respectively,inthegroupaged≥ 70.

Visitstohealthprofessionalsincreasedwithage.Inthegroupaged15–29,6.2%ofrespondentshadvisitedadentistwithinthepreviousmonth,13.9%hadvisitedaGPorfamilydoctorand14.7%hadvisitedaspecialist.Thecorrespondingfiguresforthegroupaged60–69were7.2%,30.6%and25.0%,respectively(Fig.33).


15



5.6 7.8

15.6

16.3

13.0

13.5

50.9

51.6

14.9

10.813

.8

21.4 26

.0 28.3

14.1

13.4

29.0

22.9

17.1

13.9

12.9

20.6 27

.1 32.2

15.9

13.5

31.1

25.2

12.9

8.5

0

10

20

30

40

50

60

Men Women Men Women Men Women Men Women Men Women

Within the last month More than 1, less than6 months ago

More than 6, less than12 months ago

12 months or moreago

Never

Perc

enta

ge

Dentist GP Specialist

6.27.4 6.7 7.2

5.36.7

13.9 12.8

20.2

30.6 29.9

17.614.7

13.5

18.3

25.0 24.4

16.8

0

5

10

15

20

25

30

35

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

Visited dentist Visited a GP or family doctor Visited a specialist physician

Theaverage(mean)numberoftimesinwhichrespondentshadvisitedaGPorfamilydoctorinthepreviousfourweekswas1.2;1.3timesformenand1.2timesforwomen.Menandwomenhadmadethesameaverage(mean)numberofvisitstospecialistphysiciansinthepreviousfourweeks:1.4.


4. SURVEY RESULTS

Further,1.2%ofrespondentshadreceivedmedicalcareathomeintheprevious12months(1.1%formenand1.3%forwomen).Thisproportionrosewithage:from0.6%inthegroupaged30–44to5.0inthegroupaged≥ 70(Fig.34).

Fig. 34. Percentages of respondents who had received medical care at home in the previous 12 months

16


Fig. 30. Respondents’ mean SBP and DBP (mmHg) by sex and age group

1.1

0.60.8

1.9

5.0

1.2

0

1

2

3

4

5

6

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

121.7

121.1 12

8.3 135.

3

138.

7

125.

3

74.1 78

.5 81.8

82.2

79.7

78.2

112.7

114.6 12

7.0 134.

2

140.

7

120.

8

75.0 78.0 82

.1

82.6

81.2

78.7

117.3

117.8 12

7.6 134.

7

139.

9

123.

0

74.5 78.2 81.9

82.4

80.6

78.4

0

20

40

60

80

100

120

140

160

15–29 30–44 45–59 60–69 ≥70 Total 15–29 30–44 45–59 60–69 ≥70 TOTAL

Mean SBP Mean DBP

mm

Hg


4.20.1. Conclusions

Someofthemostimportantresultsonrespondents’useofcareincludedthefollowing:

● nearlyoneoutofeighthadnevervisitedadentist, althoughmore thanhalfhadvisitedadentist≥ 12monthspreviously;

● about16%oftherespondentshadnevervisitedaGPorafamilydoctor,butnearly45%haddonesowithintheprevioussixmonths;

● themeannumbersofvisits toaGPor familydoctorand tospecialistphysicians (in theprevious fourweeks)were1.2and1.4,respectively;

● morethanoneoutof10hadnevervisitedaspecialistphysician; ● about1%hadreceivedmedicalcareathomewithintheprevious12months.

4.21. Physical measurements

HypertensionasariskfactorforNCDswasassessedbymeasuringbloodpressure.ThemeanSBPofthestudypopulation,includingthosecurrentlyonmedicationforraisedbloodpressure,was123.0mmHg;125.3mmHgformenand120.8mmHgforwomen.SBProsefrom117.3mmHginthegroupaged15–29to139.9mmHginthegroupaged≥ 70,underliningthatthevalueingeneralincreaseswithage(Fig.35).ThemeanDBPofthestudypopulation,includingthosecurrentlyonmedicationforraisedbloodpressure,was78.4mmHg;78.2mmHgformenand78.7mmHgforwomen.DBPalsoincreasedwithage:from74.5mmHginthegroupaged15–29to82.4mmHginthoseaged60–69(Fig.35).

77


16



1.1

0.60.8

1.9

5.0

1.2

0

1

2

3

4

5

6

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

121.7

121.1 12

8.3 135.

3

138.

7

125.

3

74.1 78

.5 81.8

82.2

79.7

78.2

112.7

114.6 12

7.0 134.

2

140.

7

120.

8

75.0 78.0 82

.1

82.6

81.2

78.7

117.3

117.8 12

7.6 134.

7

139.

9

123.

0

74.5 78.2 81.9

82.4

80.6

78.4

0

20

40

60

80

100

120

140

160

15–29 30–44 45–59 60–69 ≥70 Total 15–29 30–44 45–59 60–69 ≥70 TOTAL

Mean SBP Mean DBP

mm

Hg


Fig.36showstheproportionsofrespondentswhohadraisedbloodpressureorwerecurrentlyonmedicationfortheconditionattwodifferentlevels:27.7%hadanSBP≥ 140and/orDBP≥ 90mmHgand17.1%,anSBP≥ 160and/orDBP≥ 100mmHg.

Fig. 36. Percentages of respondents with raised blood pressure or currently on medication for raised blood pressure, by sex

17


Fig. 32. Percentages of respondents with raised blood pressure, excluding those on medication for raised blood pressure, by age group

26.1

29.327.7

14.7

19.417.1

0

5

10

15

20

25

30

35


Perc

enta

ge

SBP ≥140 and/or DBP ≥ 90 mmHg SBP ≥160 and/or DBP ≥ 100 mmHg

10.0 13

.3

26.0

36.7

50.0

18.0

4.2

3.1 7.

6 11.9

22.3

5.8

0

10

20

30

40

50

60

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


The proportions of respondents who had raised blood pressure or were currently on medication for itincreasedwithage,from11.2%inthegroupaged15–29to73.0%inthegroupaged≥ 70forthosewithanSBP≥ 140and/orDBP≥ 90mmHg,andfrom5.5%inthegroupaged15–29to58.0%inthegroupaged≥ 70forthosewithanSBP≥ 160and/orDBP≥ 100mmHg.

Ofalltherespondentsexcludingthoseonmedicationforthecondition,18.0%hadanSBP≥ 140and/orDBP≥ 90mmHg;18.6%formenand17.3%forwomen.


4. SURVEY RESULTS

Theproportionsof theserespondentsrosewithage, from10.0%inthegroupaged15–29to50.0%inthegroupaged≥ 70.Similarly,5.8%oftherespondentshadanSBP≥ 160and/orDBP≥ 100mmHg;6.0%formenand5.7%forwomen.Theseproportionsalsorose,from4.2%inthegroupaged30–44to22.3%inthoseaged≥ 70(Fig.37).


17



26.1

29.327.7

14.7

19.417.1

0

5

10

15

20

25

30

35


Perc

enta

ge


10.0 13

.3

26.0

36.7

50.0

18.0

4.2

3.1 7.

6 11.9

22.3

5.8

0

10

20

30

40

50

60

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


57.1%oftherespondentswithraisedbloodpressure(SBP≥140and/orDBP≥90mmHg)werenotonmedication(64.7%formenand50.5%forwomen).

Theproportionofallhypertensivepeoplewithcontrolledbloodpressurewerecalculatedtoshowhypertensioncontrolinthepopulation.Bloodpressurewasundercontrolfor23.8%ofthepopulation;18.5%formenand28.4%forwomen(Table50).

Table 50. Proportion of all hypertensive people with controlled blood pressure in the population

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

15–29 55 6,9 (0,5-14,3) 60 8,5 (1,4-15,7) 115 7,6 (1,3-13,9)

30–44 100 7,2 (0,5-13,8) 181 23,0 (14,3-31,7) 281 15,2 (9,4-21,0)

45–59 230 20,0 (13,6-26,4) 412 32,4 (24,1-40,8) 642 26,7 (21,1-32,2)

60–69 201 26,5 (19,8-33,1) 293 35,4 (28,5-42,2) 494 31,4 (26,6-36,3)

≥ 70 185 31,0 (22,5-35,2) 336 29,3 (23,1-35,5) 521 30,0 (24,8-35,1)

TOTAL 771 18,5 (15,2-21,7) 1282 28,4 (24,5-32,3) 2053 23,8 (21,0-26,5)

Anthropometric measurements such as height, weight, and waist and hip circumference were used tocalculateBMIandmeanwaist–hipratio(WHR),inordertoestimatetheprevalenceofoverweightandobesityinthestudypopulation(excludingpregnantwomen)byageandsex.Themeninthestudypopulationhadameanheightof171.4cmandmeanweightof78.0kg;thecorrespondingfiguresforwomenwere157.7cmand70.1kg.Therespondents’meanBMIwas27.4kg/m2;26.6kg/m2formenand28.3kg/m2forwomen.Thevaluesincreasedfrom23.8 kg/m2inthegroupaged15–29to31.1kg/m2inthoseaged60–69(Fig.38).

79

Fig. 38. Respondents’ mean BMI, by sex and age group

18


Fig. 34. Distribution by BMI category, by sex

23.9

27.128.4 28.9 28.4

23.7

28.0

31.3

33.132.1

23.8

27.5

29.931.1

30.5

20

22

24

26

28

30

32

34

15–29 30–44 45–59 60–69 ≥70

kg/m

2


1.5

2.2

1.8

35.7

31.8

33.8

41.2

30.1

35.6

21.6

35.9

28.8

0 10 20 30 40 50 60 70 80 90 100

Men

Women

Both sexes

Underweight Normal weight Overweight Obese

Ofall the respondents, 1.8%wereunderweight (BMI< 18.5);33.8%werenormalweight (BMIof 18.5–24.9);35.6%overweight(BMIof25.0–29.9);and28.8%wereobese(BMI≥30.0)(Fig.39).Overweightpredominatedamongmales,andobesityamongfemales.


18



23.9

27.128.4 28.9 28.4

23.7

28.0

31.3

33.132.1

23.8

27.5

29.931.1

30.5

20

22

24

26

28

30

32

34

15–29 30–44 45–59 60–69 ≥70

kg/m

2


1.5

2.2

1.8

35.7

31.8

33.8

41.2

30.1

35.6

21.6

35.9

28.8

0 10 20 30 40 50 60 70 80 90 100

Men

Women

Both sexes

Underweight Normal weight Overweight Obese

Menhadagreatermeanwaistcircumference(91.3cm)thanwomen(87.9cm),whilewomenhadagreatermeanhipcircumference(102.5cm)thanmen(98.7cm).WHRwascomputedforallrespondents,excludingpregnant women, usingmeasurements of waist and hip circumferences, showing thatmen (0.93) had agreaterWHRthanwomen(0.86).


4. SURVEY RESULTS

4.21.1. Conclusions

Someofthemostimportantresultsonphysicalmeasurementsofrespondentsincludedthefollowing:

● themeanbloodpressurewasanSBPof123.0mmHgandaDBPof78.4mmHg; ● 26.1%ofmenand29.3%ofwomenhadraisedbloodpressureorcurrentlyonmedicationforraisedbloodpressure,andthepercentageofrespondentswithraisedbloodpressureincreasedwithage;

● 57.1%of therespondentswith raisedbloodpressure (SBP≥ 140and/orDBP≥90mmHg) werenotonmedication(64.7%formenand50.5%forwomen);

● proportionofallhypertensivepeoplewithcontrolledbloodpressureinthepopulationwas23.8%(18.5%ofmenand28.4%ofwomen);

● whilemenweretallerandweighedmorethanwomen,womenhadahighermeanBMI; ● themeanBMIwas27.4kg/m2forbothsexes(26.6kg/m2formenand28.3kg/m2forwomen); ● 64.4%wereoverweight(BMI≥ 25kg/m2)and28.8%obese(BMI≥ 30kg/m2):62.8%and21.6%ofmenand66.0%and35.9%ofwomen,respectively;

● whilemenhadagreatermeanwaistcircumference(91.3cmversus87.9cm),womenhadagreatermeanhipcircumference(102.5cmversus98.7cm).

4.22. Biochemical measurements

DiabetesasariskfactorforNCDswasassessedbymeansoffastingbloodglucoseandHbA1cmeasurements.Fig.40showsthemeanfastingbloodglucoseofthestudypopulation,includingthosecurrentlyonmedicationfordiabetes(butexcludingnon-fastingrecipients),was97.8 mg/dl.The increases in levelsforbothsexes,from86.3mg/dl in thegroupaged 15–29 to 116.2mg/dl in thegroupaged≥ 70,underlines that this valueincreasesingeneralwithage.

Fig. 40. Mean fasting blood glucose, by sex and age group

19


Fig. 36. Prevalence of impaired fasting glycaemia by sex and age group

86.3 93

.8 102.

3

118.8

106.

5

96.2

86.4 95

.8

106.

5 115.1 12

3.0

99.3

86.3 94

.8

104.

4 116.9

116.2

97.8

0

20

40

60

80

100

120

140

15–29 30–44 45–59 60–69 ≥70 TOTAL

mg/

Dl


4.5

9.1 9.

9 10.4

13.2

8.1

5.0

4.0

11.9

14.9

12.2

7.7

4.7

6.6

10.9

12.8

12.6

7.9

0

2

4

6

8

10

12

14

16

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


Ofalltherespondents,7.9%hadimpairedfastingglycaemia(plasmavenousvalueof110–126mg/dl);8.1%formenand7.7%forwomen.Thefrequencyincreasedfrom4.7%inthegroupaged15–29to12.6%inthegroupaged≥ 70(Fig.41).

81


19



86.3 93

.8 102.

3

118.8

106.

5

96.2

86.4 95

.8

106.

5 115.1 12

3.0

99.3

86.3 94

.8

104.

4 116.9

116.2

97.8

0

20

40

60

80

100

120

140

15–29 30–44 45–59 60–69 ≥70 TOTAL

mg/

Dl


4.5

9.1 9.

9 10.4

13.2

8.1

5.0

4.0

11.9

14.9

12.2

7.7

4.7

6.6

10.9

12.8

12.6

7.9

0

2

4

6

8

10

12

14

16

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


Further,11.1%ofthestudypopulationhadraisedbloodglucose(plasmavenousvalue≥ 126mg/dl)orwerecurrentlyonmedicationfordiabetes;10.6%formenand11.5%forwomen.Thefrequencyincreasedfrom1.5%inthegroupaged15–29to29.3%inthegroupaged≥ 70(Fig.42).

Fig. 42. Proportions of respondents who had raised blood glucose or were currently on medication for diabetes, by sex and age group

20

Fig. 37. Proportions of respondents who had raised blood glucose or were currently on medication for diabetes, by sex and age groups

Fig. 38. Percentage of respondents with raised HbA1c.� 6.5%. by sex and age group

2.1

7.8

14.5

30,6

27.0

10.6

0.9

8.9

18.4

21.8

30.9

11.5

1.5

8.4

16.5

26.0

29.3

11.1

0

5

10

15

20

25

30

35

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

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TheproportionofrespondentswithmeanHbA1cresults,includingthosecurrentlyonmedicationfordiabetes(butexcludingnon-fastingrespondents),was5.9%;5.9%forbothmenandwomen(Table51).ThemeanHbA1clevelincreasedfrom5.5%inthegroupaged15–29to6.5%inthoseaged≥70.


4. SURVEY RESULTS

Table 51. Proportions of respondents with mean HbA1c, by sex and age group

Age group (years)


N Mean (%) 95% CI N Mean (%) 95% CI N Mean (%) 95% CI

15–29 251 5.5 5.4–5.6 319 5.4 5.4–5.5 570 5.5 5.4–5.5

30–44 332 5.7 5.6–5.9 524 5.7 5.6–5.7 856 5.7 5.6–5.8

45–59 348 6.2 6.0–6.4 557 6.3 6.1–6.5 905 6.3 6.1–6.4

60–69 226 6.8 6.4–7.2 283 6.5 6.3–6.8 509 6.7 6.4–6.9

≥ 70 182 6.4 6.2–6.6 316 6.6 6.3–6.9 499 6.5 6.3–6.7

Total 1339 5.9 5.8–6.0 1999 5.9 5.8–6.0 3338 5.9 5.8–6.0

Ofalltherespondents,12.0%hadraisedHbA1c;11.9%formenand12.2%forwomen.Thefrequencyincreasedfrom1.5%inthegroupaged15–29to32.9%inthoseaged≥ 70(Fig.43).

Fig. 43. Percentage of respondents with raised HbA1c ≥ 6.5%, by sex and age group

2.3

6.2

21.5

29.7 30.5

11.9

0.6

4.6

21

34.7

34.5

12.2

1.5

5.4

21.3

32.3 32.9

120

5

10

15

20

25

30

35

40

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


51

46.4

22.4

11.3 11.17.2

1.8

11.1

0

10

20

30

40

50

60

Hypertension Type 2 diabetes Heart attack Cancer Hypercholes-terolemia

Chest painfrom heart

disease (angina)

Stroke(cerebrovascular

accidentor incident)

Other

Perc

enta

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13.3%ofthestudypopulationhadraisedHbA1C(≥6,5%)orwerecurrentlyonmedicationfordiabetes(12.7%formenand13.8%forwomen)(Table52).

Table 52. Proportion of respondents with raised HbA1C (≥6.5%) or who were currently on medication for diabetes

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

15–29 240 2.3 0.2–4.5 310 1.4 0.0–2.9 550 1.9 0.6–3.2

30–44 324 7.0 3.8–10.2 511 6.1 2.9-9.4 835 6.6 4.3–8.9

45–59 336 22.4 15.9–28.9 546 22.2 16.0–28.3 882 22.3 17.8–26.8

60–69 224 32.5 23.3–41.8 283 39.0 30.5–47.5 507 35.9 29.6–42.1

≥ 70 179 32.7 21.1–44.4 304 36.2 27.0–45.4 483 34.8 27.6–42.0

Total 1303 12.7 10.4–15.1 1954 13.8 11.5–16.1 3257 13.3 11.6–14.9

83

In addition, 17.3%of the studypopulationhad raisedHbA1cor raisedbloodglucoseorwere currently onmedication;16.3%formenand18.3%forwomen.Thefrequencyincreasedfrom2.8%inthegroupaged15–29to43.0%inthegroupaged≥ 70(Fig.44).

Fig. 44. Proportions of respondents with raised HbA1c or raised blood glucose or were currently on medication, by sex and age group

21


Fig. 40. Percentages of respondents with total cholesterol levels � 190 mg/dl or � 240 mg/dl or currently on medication for raised cholesterol, by sex

4.0

10.9

26.8

38.2

38.9

16.3

1.6

10.9

30.4

44.3 45

.9

18.3

2.8

10.9

28.6

41.3 43

.0

17.3

0

5

10

15

20

25

30

35

40

45

50

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


20.9

6.5

28.5

9.5

24.7

8.0

0

5

10

15

20

25

30

Total cholesterol ≥ 190 mg/dl Total cholesterol ≥ 240 mg/dl

Perc

enta

ge


Themeantotalcholesterollevelofthestudypopulation,includingthosecurrentlyonmedicationforraisedcholesterol,was161.2mg/dl;154.9mg/dlformenand167.3mg/dlforwomen.Themeanlevelrosefrom139.7mg/dlinthegroupaged15–29to178.6mg/dlinthoseaged45–59(Table53).

Table 53. Mean total cholesterol, by sex and age group

Age group (years)


NMean

(mg/dl)95% CI (mg/dl)

NMean


NMean


15–29 246 137.8 132.4–143.2 311 141.8 136.6–147.0 557 139.7 135.9–143.6

30–44 326 160.4 153.6–167.2 520 163.4 158.3–168.5 846 161.9 157.7–166.1

45–59 342 168.1 161.1–175.2 551 189.5 180.9–198.2 893 178.6 173.0–184.2

60–69 226 164.4 156.4–172.4 287 191.2 184.9–197.5 513 178.4 172.9–183.8

≥ 70 180 156.9 148.9–165.0 314 192.0 177.8–206.2 494 177.5 167.7–187.4

Total 1320 154.9 151.4–158.5 1983 167.3 163.7–171.0 3303 161.2 158.5–163.8

Therespondentscurrentlyonmedicationforraisedcholesterolincluded24.7%withatotalcholesterol≥ 190mg/dl(20.9%formenand28.5%forwomen)and8.0%withatotalcholesterol≥ 240mg/dl(6.5%formenand9.5%forwomen)(Fig.45).Table54showsthemeanHDLlevelinthestudypopulation:45.9mg/dl(40.5mg/dlformenand51.2mg/dlforwomen).ThemeanHDLcholesterolofwomenwas50.1mg/dlinthegroupaged15–29andingeneralincreasedwithage,reaching52.5mg/dlinthoseaged≥70.ThemeanHDLcholesterolfor


4. SURVEY RESULTS

menwasthelowestwith38.8mg/dlinthoseaged30–44andincreasedwithage,risingto43.2mg/dlinthegroupaged≥70.

Fig. 45. Percentages of respondents with total cholesterol levels ≥ 190 mg/dl including ≥ 240 mg/dl or currently on medication for raised cholesterol, by sex

21


Fig. 40. Percentages of respondents with total cholesterol levels � 190 mg/dl or � 240 mg/dl or currently on medication for raised cholesterol, by sex

4.0

10.9

26.8

38.2

38.9

16.3

1.6

10.9

30.4

44.3 45

.9

18.3

2.8

10.9

28.6

41.3 43

.0

17.3

0

5

10

15

20

25

30

35

40

45

50

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge


20.9

6.5

28.5

9.5

24.7

8.0

0

5

10

15

20

25

30

Total cholesterol ≥ 190 mg/dl Total cholesterol ≥ 240 mg/dl

Perc

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Table 54. Respondents’ mean HDL cholesterol levels, by sex and age group

Age group (years)


NMean


NMean


NMean

(mg/dl)95% CI(mg/dl)

15–29 246 42.0 39.8–44.2 317 50.1 48.1–52.1 563 46.0 44.4–47.6

30–44 328 38.8 37.2–40.4 522 51.2 49.2–53.2 850 44.9 43.5–46.4

45–59 343 39.3 37.5–41.1 556 51.8 49.8–53.9 899 45.5 44.0–47.1

60–69 224 41.6 39.2–44.1 284 52.0 50.0–54.0 508 47.0 45.3–48.8

≥ 70 182 43.2 39.9–46.5 315 52.5 49.9–55.1 497 48.7 46.6–50.7

Total 1323 40.5 39.4–41.5 1994 51.2 50.2–52.2 3317 45.9 45.0–46.7

Low HDL is defined as a plasma venous value < 50mg/dl for women and < 40mg/dl for men; 52.3% ofrespondentshadlowHDL(55.6%formenand49.1%forwomen)(Fig.46).Inaddition,61.7%ofthemenaged30–44wasbelowtheoptimallevelofHDLcholesterol;thisproportionfellto40.4%inthoseaged≥70;thispercentagedecreasedwithage ingeneral.ThepercentageofHDLcholesterolbelowtheoptimal level forwomenwassimilarinallagegroups.

85

Fig. 46. Percentages of respondents with low HDL cholesterol, by sex and age group (< 50 mg/dl for women and < 40 mg/dl for men)

22


Fig. 42. Percentages of respondents with fasting triglycerides levels � 150 mg/dl and � 180 mg/dl, by sex

50.1

61.7 60.8

52.1

40.4

55.6

48.050.9 48.7 48.9 48.4 49.1

0

10

20

30

40

50

60

70

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

Men Women

30.2

19.921.0

13.6

25.6

16.7

0

5

10

15

20

25

30

35

Fasting triglycerides ≥ 150 mg/dl Fasting triglycerides ≥ 180 mg/dl

Perc

enta

ge


Table55showsthatthemeanfastingtriglycerideslevelforallrespondents(excludingnon-fastingrespondents)was122.8mg/dl;129.0mg/dlformenand116.7mg/dlforwomen.Themeanlevelincreasedfrom99.1mg/dlinthegroupaged15–29to144.5mg/dlinthegroupaged45–59,andtendedtodecreaseinolderage.

Table 55. Respondents’ mean fasting triglycerides by sex and age group

Age group (years)


NMean


NMean

(mg/dl)95% CI(mg/dl)

NMean


15–29 239 109.9 99.9–119.8 306 87.7 82.2–93.2 545 99.1 93.0–105.1

30–44 321 137.1 126.7–147.5 509 112.2 102.4–122.0 830 124.8 117.5–132.1

45–59 331 143.1 132.6–153.6 540 145.8 128.7–162.9 871 144.5 134.3–154.6

60–69 220 144.0 126.1–162.0 281 141.4 128.9–154.0 501 142.7 131.7–153.6

≥ 70 173 116.4 105.2–127.6 297 135.6 123.0–148.3 470 127.7 118.6–136.8

Total 1284 129.0 123.2–134.9 1933 116.7 110.8–122.5 3217 122.8 118.5–127.1

Ofalltherespondents,25.6%hadfastingtriglycerides≥ 150mg/dl(30.2%formenand21.0%forwomen)and16.7%hadfastingtriglycerides≥ 180mg/dl(19.9%formenand13.6%forwomen)(Fig.47).


4. SURVEY RESULTS

Fig. 47. Percentages of respondents with fasting triglycerides levels ≥ 150 mg/dl and ≥ 180 mg/dl, by sex

22


Fig. 42. Percentages of respondents with fasting triglycerides levels � 150 mg/dl and � 180 mg/dl, by sex

50.1

61.7 60.8

52.1

40.4

55.6

48.050.9 48.7 48.9 48.4 49.1

0

10

20

30

40

50

60

70

15–29 30–44 45–59 60–69 ≥70 TOTAL

Perc

enta

ge

Men Women

30.2

19.921.0

13.6

25.6

16.7

0

5

10

15

20

25

30

35

Fasting triglycerides ≥ 150 mg/dl Fasting triglycerides ≥ 180 mg/dl

Perc

enta

ge


Respondents’meansaltintakewas9.9gperday;11.0gformenand8.7gforwomen.

4.22.1. Conclusions

Someofthemostimportantresultsfrombiochemicalmeasurementsofrespondentsincludedthefollowing:

● themeanfastingglucoselevelwas97.8mg/dl(96.2mg/dlformenand99.3mg/dlforwomen)andlevelsincreasedinolderage,includingthosecurrentlyonmedicationfordiabetes;

● 7.9%hadimpairedfastingbloodglycaemia levels (≥ 110mg/dland< 126mg/dlandthisproportionwashigheramongmen(8.1%)thanwomen(7.7%);

● 11.1% had raised fasting blood glucose or currently on medication for diabetes, without significantdifferencesbetweenmenandwomen;

● meanHbA1clevelswerealsosimilarinmenandwomen,althoughthefrequencyofraisedHbA1c(≥ 6.5%)was12.0%andincreasedwithage;

● 13.3%hadraisedHbA1C(≥6,5%)orwerecurrentlyonmedicationfordiabetes(12.7%formenand13.8%forwomen)

● 17.3%hadfastingplasmavenousglucose≥ 126mg/dlorHbA1c≥ 6.5%orwerecurrentlyonmedicationforraisedbloodglucose;thefrequencyofallthreeincreasedwithage;

● themeantotalbloodcholesterollevelwas161.2mg/dl,althoughwomen(167.3mg/dl)tendedtohavehigherlevelsthanmen(154.9mg/dl);

● 24.7%hadaraisedtotalcholesterollevel,withahigherproportioninwomen(28.5%)thanmen(20.9%); ● suboptimallevelsofHDLcholesterolwerefoundin55.6%ofmen(< 40mg/dl)and49.1%ofwomen(< 50mg/dl);

● menhadhighermeanlevelsoffastingtriglycerides,and19.9%ofmenand13.6%ofwomenhadraisedtriglycerides(≥ 180mg/dl);

● themeandailyintakeofsaltwas9.9gandmenconsumedmorethanwomenonaverage(11.0gperdayversus8.7gperday).

4.23. CVD risk

ThemodernconceptofprimarypreventionofCVDentailsassessingaperson’sglobalriskandchoosingtherightmanagementinaccordancewiththeseresults.Aten-yearCVDriskof≥ 30%isdefinedaccordingtoage,sex,bloodpressure,smokingstatus(currentsmokersorthosewhoquitsmokinglessthanayearbeforethe

87

assessment),totalcholesterolanddiabetes(previouslydiagnosedorafastingplasmaglucoseconcentration> 126mg/dl).Amongrespondentsbetween40–69yearsold,10.5%hadaten-yearCVDrisk≥ 30%oralreadyhadCVD;13.3%formenand7.8%forwomen.

Thefrequencymorethandoubled,from6.3%inthegroupaged40–54to17.0%inthoseaged55–69(Table56).Ofalltheeligiblerespondents(definedasthoseaged40–69yearswithaten-yearCVDrisk≥ 30%,includingthosewhoalreadyhadCVD),49.2%werereceivingdrugtherapyandcounsellingtopreventheartattacksandstrokes.Counsellingisdefinedasreceivingadvicefromadoctororotherhealthworkertoquitornottostartusingtobacco,reducesaltindiet,eatatleastfiveservingsoffruitand/orvegetablesperday,reducefatinthediet,startordomorephysicalactivity,andmaintainahealthybodyweightorloseweight.

Table 56. Percentage of respondents who had a ten-year CVD risk ≥ 30% or already had CVD, by sex and age group

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

40–54 310 7.2 3.0–11.3 530 5.4 3.2–7.7 840 6.3 3.9–8.6

55–69 338 22.5 14.8–30.2 471 11.6 6.4–16.8 809 17.0 12.3–21.7

Total 648 13.3 9.2–17.4 1001 7.8 5.3–10.3 1649 10.5 8.1–12.9

Halfofmen(50.7%)and46.8%ofwomenreceivedcounsellingtopreventheartattacksandstrokes:33.7%in thegroupaged45–54and58.0% in thegroupaged55–69.Theproportions receivingdrug therapyandcounsellingforthispurposevariedwithageandsex.Inthegroupaged45–54,moremen(41.2%)thanwomen(24.1%)were receivingdrug therapyandcounselling; thegroupaged55–69showedtheoppositepattern:morewomen(63.3%)thanmen(55.3%)werereceivingdrugtherapyandcounselling(Fig.48).

Fig. 48. Percentage of respondents with a ten-year CVD risk ≥ 30% or already with CVD and receiving drug therapy and counselling to prevent heart attacks and strokes, by sex and age group

23

Fig. 43. Percentage of respondents with a ten-year CVD risk � 30% or already with CVD and receiving drug therapy and counselling to prevent heart attacks and strokes, by sex and age group

Fig. 44. Summary of combined risk factors in respondents aged 18–69 by sex and age group

41.2

55.350.7

24.1

63.3

46.8

33.7

58.0

49.2

0

10

20

30

40

50

60

70

45–54 55–69 TOTAL

Perc

enta

ge


2.1

1.0

1.7

1.3

.0 1

0.8

1.7

0.5

1.3

52.3

37.5

46.8

59.8

29.9

48.7

56.1

33.6

47.8

45.6

61.5

51.5

38.9

70.0

50.5

42.2

65.9

51.0

0 10 20 30 40 50 60 70 80 90 100

18–44

45–69

TOTAL

18–44

45–69

TOTAL

18–44

45–69

TOTAL

Men

Wom

enBo

th s

exes

Percentage

0 risk factors 1–2 risk factors 3–5 risk factors

The proportion of eligible persons who were receiving drug therapy and counseling (including glycemiccontrol)topreventheartattacksandstrokeswere55.9%forbothsexes,55.1%formenand57.0%forwomen(Table57).


4. SURVEY RESULTS

Table 57. Proportion of eligible persons1 receiving drug therapy and counseling to prevent heart attacks and strokes

Age group (years)


N % 95% CI N % 95% CI N % 95% CI

40–54 28 41.2 10.2–72.2 33 24.1 9.0–39.1 61 33.7 14.5–52.9

55–69 65 55.3 33.8–76.8 48 63.3 40.2–86.5 113 58.0 41.4–74.6

≥ 70 35 78.4 62.9–93.8 50 78.7 65.1–92.3 85 78.6 68.6–88.5

Total 128 55.1 39.6–70.7 131 57.0 44.3–69.8 259 55.9 45.3–66.6

1 eligible persons:aged≥40yearswitha10-yearCVDrisk≥30%includingthosewithexistingCVD)

4.23.1. Conclusions

Someofthemostimportantresultsonrespondents’CVDriskincludedthefollowing:

● 10.5%of respondentsaged40–69 yearshada ten-yearCVD risk≥ 30%or alreadyhadCVD, andmen(13.8%)hadhigherrisksthanwomen(7.8%);

● lessthan50%ofthepeopleeligiblefordrugtherapyandcounsellingtopreventheartattacksandstrokeswerereceivingthem;

● theproportionsreceivingdrugtherapyandcounsellingvariedbysexandagegroup; ● the proportion of eligible personswhowere receiving drug therapy and counselling to prevent heartattacksandstrokeswere55.9%(55.1%formenand57.0%forwomen).

4.24. Summary of combined risk factors

InvestigatorsassessedthesummaryofcombinedriskfactorsforNCDsbydeterminingthepercentagesofrespondentswithzero,1–2or3–5ofthefollowingriskfactors:currentdailysmoking,consumingfewerthanfiveservingsoffruitand/orvegetablesperday,notmeetingWHOrecommendationsonphysicalactivityforhealth(<150minutesofmoderateactivityperweek,orequivalent),beingoverweightorobese(BMI≥ 25kg/m2),raisedbloodpressure(SBP≥ 140and/orDBP≥ 90mmHgorcurrentlyonmedication).

Fig.49showsthedistributionofriskfactorsamongrespondentsaged18–69years:1.3%hadnoriskfactors;47.8%had1–2riskfactorsand51.0%had3–5.Thepercentageswithnoand1–2riskfactorsdecreasedwithage (from1.7%and56.1% in thegroupaged 18–44to0.5%and33.6%in thoseaged45–69, respectively),whilethepercentageswith3–5riskfactorsincreasedwithage(from42.2%inthegroupaged18–44to65.9%inthoseaged45–69).Resultsalsovariedbetweenthesexes:1.7%ofmenand0.8%ofwomen(aged18–69)hadnoriskfactors;46.8%ofmenand48.7%ofwomenhad1–2riskfactors;and51.5%ofmenand50.5%ofwomenhad3–5riskfactors.

89


23

Fig. 43. Percentage of respondents with a ten-year CVD risk � 30% or already with CVD and receiving drug therapy and counselling to prevent heart attacks and strokes, by sex and age group


41.2

55.350.7

24.1

63.3

46.8

33.7

58.0

49.2

0

10

20

30

40

50

60

70

45–54 55–69 TOTAL

Perc

enta

ge


2.1

1.0

1.7

1.3

.0 1

0.8

1.7

0.5

1.3

52.3

37.5

46.8

59.8

29.9

48.7

56.1

33.6

47.8

45.6

61.5

51.5

38.9

70.0

50.5

42.2

65.9

51.0

0 10 20 30 40 50 60 70 80 90 100

18–44

45–69

TOTAL

18–44

45–69

TOTAL

18–44

45–69

TOTAL

Men

Wom

enBo

th s

exes

Percentage


Fig.50showstheresultsforallrespondents,distributedintothreegroups:thoseaged15–44,45–69and≥ 70years.Thepatternshownissimilar:1.3%hadnoriskfactors(1.9%formenand0.8%forwomen);47.5%had1–2riskfactors(47.8%formenand47.3%forwomen);and51.2%had3–5riskfactors(50.3%formenand51.9%forwomen).Theproportionswithlowernumbersofriskfactorsdeclinedwithage,andtheproportionswiththehighestnumberincreasedwithage.

Fig. 50. Summary of all respondents’ combined risk factors by sex and age group

24

Fig. 45. Summary of all respondents’ combined risk factors by sex and age groups

Fig. 46. Respondents’ perceptions of their health status by sex

Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan

2.5

1.0

1.0

1.9

1.3

0.1

0.2

0…

1.9

0.5

0.6

1.3

54.7

37.5

33.1

47.8

61.4

29.9

11.7

47.3

58.1

33.6

21.1

47.5

42.8

61.5

65.9

50.3

37.3

70.0

88.1

51.9

40.0

65.9

78.3

51.2

0 10 20 30 40 50 60 70 80 90 100

15–44

45–69

≥70

TOTAL

15-44

45-69

≥70

TOTAL

15-44

45-69

≥70

TOTAL

Men

Wom

enBo

th s

exes

Percentage


19.6

54.8

20.7

4.2

0.7

12.7

51.8

26.6

8.1

0.8

16.1

53.3

23.6

6.2

0.8

0

10

20

30

40

50

60

Very good Good Average Bad Very bad

Perc

enta

ge



4. SURVEY RESULTS

4.24.1. Conclusions

Someofthemostimportantresultsonrespondents’combinedriskfactorsincludedthefollowing:

● lessthan2%ofthestudypopulationhadnoneofthestatedriskfactors,while51.2%had3–5; ● thefrequencyofhaving3–5riskfactorsincreasedwithagewhilethefrequencyofhaving0–2riskfactorsdecreasedwithage.

4.25. Health perception

Health perception (or perceived health status) are people’s subjective ratings of their health status.Investigators assessed respondents’ healthperceptionswith thequestion typically used in the literature:Whatdoyouthinkofyourhealthstatusingeneral?Inanswering,respondentschoseanumberrangingfrom1(verygood)to5(verybad).

Morethanhalfoftherespondents(53.3%)perceivedtheirhealthstatusasgood;54.8%formenand51.8%forwomen(Fig.51).Table58presentstheperceptionofhealthstatusbyage.Theperceptionsofhealthstatusasverygoodandgooddecreasedwithage,whileincreasingproportionschosetheotheroptions.


24

Fig. 45. Summary of all respondents’ combined risk factors by sex and age groups


Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan

2.5

1.0

1.0

1.9

1.3

0.1

0.2

0…

1.9

0.5

0.6

1.3

54.7

37.5

33.1

47.8

61.4

29.9

11.7

47.3

58.1

33.6

21.1

47.5

42.8

61.5

65.9

50.3

37.3

70.0

88.1

51.9

40.0

65.9

78.3

51.2

0 10 20 30 40 50 60 70 80 90 100

15–44

45–69

≥70

TOTAL

15-44

45-69

≥70

TOTAL

15-44

45-69

≥70

TOTAL

Men

Wom

enBo

th s

exes

Percentage


19.6

54.8

20.7

4.2

0.7

12.7

51.8

26.6

8.1

0.8

16.1

53.3

23.6

6.2

0.8

0

10

20

30

40

50

60


Perc

enta

ge


4.25.1. Conclusions

Themostimportantresultsonrespondents’perceptionsoftheirhealthincludedthefollowing:

● 53.3%perceivedtheirhealthstatusasgood(54.8%formenand51.8%forwomen); ● Whilethemostpositiveperceptionsofhealthdecreasedwithage,theothersincreased.

91

Table 58. Health status perception of individuals, by age group

Age group (years)

N


%%95 CI

(%)%

%95 CI (%)

%%95 CI

(%)%

%95 CI (%)

%%95 CI

(%)

15–29 1166 27.0 23.6–30.3 58.5 55.0–62.1 11.9 9.9–14.0 2.2 1.2–3.2 0.4 0.0–0.8

30–44 1700 15.4 13.1–17.7 57.9 54.7–61.1 23.0 20.3–25.7 3.4 2.0–4.8 0.3 0.0–0.6

45–59 1612 9.3 7.3–11.4 51.6 48.2–55.0 30.5 27.6–33.4 8.2 5.9–10.5 0.4 0.1–0.6

60–69 843 6.5 4.1–8.8 43.4 39.0–47.9 37.8 33.4–42.1 10.9 8.7–13.1 1.4 0.4–2.5

≥ 70 720 4.2 2.1–6.3 28.6 24.3–32.9 39.2 34.8–43.6 23.3 19.4–27.2 4.7 2.2–7.1

Total 6041 16.1 14.6–17.6 53.3 51.5–55.1 23.6 22.3–25.0 6.2 5.3–7.0 0.8 0.5–1.0


CONCLUSION

Concernabout theprevalenceofNCDs is growingaround theworld, andmanycountrieshaveprioritizedthepreventionofNCDsintheirnationalpublicpolicies.PoliciestopreventNCDsrequiretheparticipationofvarioussectors(includinghealth,educationandtransport),so that strategies for population intervention to prevent and control the evaluated riskfactorsandtopromoteahealthylifefromanearlyageareimplementedandsustainedinacoordinatedmanner.ThisrequirescontinuousmonitoringoftheNCDriskfactorsbasedonsamplesrepresentativeofthepopulation.

ThisresearchstudiesasampleoftheadultpopulationofTurkey,ofbothsexesandwithinthegroupaged≥ 15years, toobtain informationon therisk factors forNCDs.This is thefirststudyconductedinTurkeythatusedtheSTEPSmethodologydevelopedbyWHOforthesurveillanceofriskfactorsforchronicdiseases.

ThemethodologyusedfollowstheestablishedstandardsoftheWHOSTEPwiseapproach,whichensures the technical and scientificquality of the survey. The studyhasobtainedvaluable informationonawiderangeofNCDriskfactors inTurkey:tobaccouse;harmfulalcoholuse;lowconsumptionoffruitsandvegetablesandhighconsumptionofsaltinthediet;physicalinactivity;andoverweightandobesity.

For example, the survey showed that 31.6% of respondents currently used tobacco(smokedorsmokeless);43.6%formenand19.7%forwomen.Ofdailysmokers,97.3%usedmanufactured cigarettes; 97.3% for men and 97.2% for women. Users of manufacturedcigarettessmokedameanof15.5cigarettes;16.8formenand12.7forwomen.

As to alcohol consumption, the survey showed that 8.0%of respondents had consumedalcohol in theprevious30days; 13.1%formenand3.0%forwomen. Inaddition,5.2%ofrespondentshadengagedinheavyepisodicdrinking(≥ 6ormoredrinksonanyoccasionintheprevious30days);8.7%formenand1.8%forwomen.

Thesurveyresultsshowthatrespondentsatefruitandvegetablesonmeannumbersof4.6and5.1days,respectively,inatypicalweek;4.5formenand4.8forwomen,and4.9formenand5.2forwomen,respectively.Further,87.8%atefewerthanfiveservingsoffruitand/orvegetablesonaverageperday;87.8%formenand87.9%forwomen.

Respondents’salt intakecamefromvarioussources:28.1%alwaysoroftenaddedsaltorsaltysaucetotheirfoodbeforeorwhileeating(29.3%formenand26.8%forwomen),and25.5%alwaysoroftenateprocessedfoodshighinsalt(27.8%formenand23.3%forwomen).

Thesurveyshowedlowlevelsofphysicalactivity;43.6%hadinsufficientphysicalactivity(< 150minutesofmoderate-intensityactivityperweekorequivalent);33.1%formenand53.9%forwomen.Italsoshowedthatthemediantimespentinphysicalactivityonaverageperdaywas30.0minutes;51.4formenand17.1forwomen.Inaddition,81.3%(70.1%ofmenand92.2%ofwomen)werenotengaginginvigorousphysicalactivity.

Further, 40.5% of respondents (38.1% for men and 42.9% for women) had receivedcounsellingoreducationfromhealthworkersononeormoresubjects related tohealthylivingduringtheprevious12months.

CONCLUSION

93

AwarenessofhealthrisksfromtheselectedNCDriskfactorsvariedbetweenthesexes.Morementhanwomencouldstatetwoormorenegativehealtheffectsof:anyoftheselectedNCDriskfactors(89.1%versus85.5%),smokingtobacco(77.0%versus75.5%),ahigh-saltdiet (72.3%versus71.0%),physical inactivity (59.6%versus57.1%),ahigh-fatdiet (65.7%versus 62.8%), twoormorenegativehealth effectsof alcohol use (75.9%versus 72.5%)andsubstanceabuse(75.5%versus71.4%).Incontrast,morewomenthanmencouldstatetwoormorenegativehealtheffectsoflowconsumptionoffruitsand/orvegetables(33.6%versus32.8%).

Oneinfourrespondentsaged50–70yearsoldhadhadafaecaloccultbloodtest.Whilemorethanhalfofwomenaged30–65(54.2%)reportedhavingbeenscreenedforcervicalcancer,threeinfivewomenaged40–69hadhadmammography.

Moreover,inthepreviousmonth,6.7%oftherespondentshadvisitedadentist;17.6%,aGPorfamilydoctor;and16.8%,aspecialistphysician.

Raisedbloodpressurewasfoundin26.1%ofmenand29.3%ofwomen,andpercentagesofrespondentswithraisedbloodpressureincreasedwithage.

ThemeanBMIwas27.4kg/m2forbothsexes;64.4%ofrespondentswereoverweight(BMI≥ 25kg/m2)and28.8%wereobese(BMI≥ 30kg/m2).

Almostoneinsixofparticipants(17.3%)hadfastingplasmavenousglucose≥ 126mg/dlorHbA1c ≥ 6.5%orwere currently onmedication for raised blood glucose. This proportionincreasedwithage.

Oneinfourrespondents(24.7%)hadaraisedtotalcholesterollevel,withtheproportionofbeinghigher inwomen (28.5%) thanmen (20.9%).ThepercentageswithsuboptimalHDLcholesterolwere55.6%formen(< 40mg/dl)and49.1%forwomen(< 50mg/dl).

Meandailysaltintakewas9.9g,andmenconsumedmoresaltthanwomenonaverage(11.0gperdayversus8.7gperday).

Tosummarizeall therisk factors, thesurveyconsideredthecombinedrisk factorsasanintegratedriskmetric.Forexample,10.5%ofrespondentshadaten-yearCVDrisk≥ 30%oralreadyhadCVD.Lessthan2%didnothaveanyofthestatedriskfactors,while51.2%had3–5ofthem,and47.8%had1–2.Thefrequencyofhaving3–5riskfactorsincreasedwithageandthefrequencyofhavingfewerthanthreedecreasedwithage.

In addition to obtaining valuable information on NCD risk factors for people of differentagegroups,sexandregions,theresultsofthesurveyprovideasignificantinputforpolicy-makers.TheresultsobtainedinthestudyshowthecurrentprevalenceofNCDriskfactorsamongtheTurkishpopulation.RepeatedSTEPS-basedassessmentsofNCDriskfactorscanhelppolicy-makerstomonitortheprogressofNCDpolicyinTurkey.


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ANNEX 1

Supervisors Health professionals Data collectors

Istanbul region (İstanbul, Edirne, Kırklareli, Tekirdağ)

MrMehmetKaragöz

MsHaticeKaragöz

MsCemileKis

MsSemaÜngör

MrMehmetÇakar

MsÖzlemÇengel

MsMenekşeÇinel

MrEyüpSabriGenç

MrFurkanMaden

MrSerdarMurat

MsFatmaSelbi

MsNesrinTüysüz

MsEbrarAkyüz

MrEsatBekdemir

MrMehmetBilecen

MrBatuhanBerkKarasu

MrMuratKurt

MsEbruMaden

MrSerdarMurat

MsTuğbaYavuz

MrBurakYazgan

MrGürkanYüksel

Konya region (Konya, Karaman, Aksaray, Afyon)

MsPınarTuran

MrRızaTuran

MsDilekAydın

MrZiyaEmreBosnalı

MrAkifGezeroğlu

–

İzmir region (İzmir, Aydın, Denizli, Manisa, Muğla, Uşak)

MrHüseyinMertElik

MrMehmetKarasu

MrYasinAksoy

MsNurayÇelik

MsAşkınÇevirgen

MrTuranGörkemDoğan

MsNurNisaÖğük

MrFurkanÖzkan

MsHabibeSeyman

MsMuallaTuran

MrHüseyinMertElik

MsRojdaErat

MrOkanÖztürk

MsTuğçeŞivga

MrMertSolak

MsGizemYelizYücel

Trabzon region (Trabzon, Giresun, Rize, Bayburt, Gümüşhane, Artvin)

MsHülyaÖzdin

MsDilekTomar

MsElvanArmutçu

MsSemihaKöse

MrYetkinSamancı

MrVuralEmbiya

MrMehmetKeremSerin

MsBernaUsta

Samsun region (Samsun, Ordu, Sinop, Amasya, Bartın, Zonguldak, Kastamonu, Tokat)

MsMihriArzuKıyıcı MrZeydGüdül

MsEsraKalyoncu

MrAliKemalKul

MsNazliSarıoğlu

MrArdaCermen

MsDeryaCermen

MrTemelHakkıYazıcı

ANNEX 1. FIELD TEAMS BY REGION

99

Supervisors Health professionals Data collectors

Diyarbakır region (Diyarbakır, Batman, Bingöl, Bitlis, Elazığ, Mardin, Muş, Siirt, Tunceli, Van, Adıyaman, Gaziantep, Kahramanmaraş, Kilis, Malatya, Şanlıurfa)

–

MrMetinBişkin

MsDidemEr

MsDilanUğurlu

MrMesutAyberk

MsHavvaYüce

Erzurum region (Erzurum, Ağrı, Ardahan, Artvin, Bayburt, Erzincan, Kars, Iğdır)

–MrOnurKorkmaz

MrOğuzhanTurgut

MsNilayKalaycı

MrOnurTurgut

Adana region (Adana – excluding Anamur, Mersin)

MsNihalBilgin MsYeşimÇoşkun MrNiyaziBerk

MrAbdullahDemir

Antalya region (Antalya–including Anamur, Burdur, Isparta)

MrİbrahimAkkol MsCansuBulut

MsFidanTosun

MrİbrahimSarıkaş

Ankara region (Ankara, Afyon, Çankırı, Eskişehir, Kırıkkale)

MrTolgaÇomak

MsİlaydaUrvaylıoğlu

MrHüseyinAltun

MsEsraKüçükoğlu

MsNecmiyeSarıyıldız

MsMerveTemizyürek

MrSerkanAytaş

MsBüşraGüdek

MrMuratSarıyıldız

Hatay region (Hatay, Osmaniye)

MsSerapMiroğluKoçak MrOktayİnanç

MrFurkanMaden–

Bursa region (Bursa, Balıkesir, Bilecik, Bolu, Çanakkale, Karabük, Düzce, Kocaeli, Kütahya, Sakarya,Yalova)

MrGürcanŞenol

MrSerkanŞenol

MsDamlaBilir

MsHaticeDikmen

MrMuhammedÖzkan

MsAleynaSoytürk

MrMücahitYıldırım

MsSaadetAçık

MsNurcanDeleş

MsAyşegülDuran

MrTalhaSerkanKaragöz

MsElifŞenbiçer

Kayseri region (Kayseri, Çorum, Sivas, Tokat, Yozgat)

MrEmreYıldız MrAdemAltunbaş

MsGülerCeylan

MrMuzafferAliAteş

MsGamzeBoynueğri

MsSemaŞahin


ANNEX 2

TheWHOSTEPwiseapproachtosurveillance(STEPS)isasimple,standardizedmethodforcollecting,analysinganddisseminatingdataonnoncommunicablediseases(NCDs)andriskfactors.Dataarecollectedon theestablished risk factorsandconditions thatdeterminethemajorshareoftheNCDburden,including:tobaccouse,useofalcohol,unhealthydiet,insufficient physical activity, overweight and obesity, raised bloodpressure, raised bloodglucose and abnormal blood lipids. Countries can use data from STEPS surveys to helpmonitortheirprogressinmeetingtheglobalvoluntarytargetsrelatedtospecificriskfactorssuchastobacco,alcohol,dietandphysicalinactivity.

ASTEPSsurveyinTurkeywascarriedoutfromApriltoSeptember2017inthreesteps:

1. collectionofsociodemographicandbehaviouralinformation;

2. collectionofphysicalmeasurements,suchasheight,weightandbloodpressure;

3. collection of biochemicalmeasurements to assess bloodglucose, haemoglobinA1c orglycatedhaemoglobin(HbA1c),totalcholesterollevels,andmeandailysaltconsumption.

Thepopulation-based surveyof adults aged≥ 15 yearsusedamultistagecluster sampledesigntoproducerepresentativedataforthepopulationinthatagerangeinTurkey.Atotalof6053adultsparticipatedinthesurvey.Theoverallresponseratewas(70.0%).Arepeatsurveyisplannedfor2019toassesschanges.

Highlights

Tobacco use

● 43.6%ofmen,19.7%ofwomenand31.6%overallwerecurrenttobaccousers. ● 43.4%ofmen,19.7%ofwomenand31.5%overallwerecurrenttobaccosmokers. ● 3in10currentsmokershadtriedtoquitintheprevious12months.

Alcohol use

● 13.1%ofmen,3.0%ofwomenand8.0%overallwerecurrentalcoholusers. ● 1in20currentalcoholusersengagedinheavyepisodicdrinking.

Diet

● 87.8%ofmen,87.9%ofwomenand87.8%overallatefewerthanfiveservingsoffruitand/orvegetablesperday.

● meandailysaltconsumptionwas9.9goverall,11.0gformenand8.7gforwomen.

ANNEX 2. NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY – PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017 FACT SHEET

101

Physical activity

● 4in10adultshadinsufficientphysicalactivity(< 150minutesofmoderateactivityperweek).

Cancer screening

● 5in10womenaged30–65yearshadeverhadacervicalsmeartest. ● 6in10womenaged40–69yearshadeverhadmammography. ● 1in10adultsaged50–70yearshadhadacolonoscopyintheprevious10years.

Obesity

● 62.8%ofmen,66.0%ofwomenand64.4%overallwereoverweight (bodymass index(BMI)≥ 25kg/m2).

● 21.6%ofmen,35.9%ofwomenand28.8%overallwereobese(BMI≥ 30kg/m2).

High blood pressure

● 26.1%ofmen,29.3%ofwomenand27.7%overallhadraisedbloodpressure.

High blood glucose

● 10.6%ofmen,11.5%ofwomenand11.1%overallhadraisedbloodglucose.

The following table gives the survey results for adults aged ≥ 15 years, including 95%confidenceinterval(Cl).Adultsrefertopersonsaged≥ 15years.ThedatawereweightedtoberepresentativeofallmenandwomeninthatagegroupinTurkey.

Topics Both sexes (95%CI)

Men (95%CI)

Women (95%CI)

Tobacco use

Respondentswhocurrentlyusedtobacco(smokedorsmokeless)(%)

31.6

(29.8–33.4)

43.6

(40.9–46.2)

19.7

(17.6–21.8)

Respondentswhocurrentlysmokedtobacco(%) 31.5

(29.7–33.3)

43.4

(40.8–46.0)

19.7

(17.6–21.8)

Respondentswhocurrentlysmokedtobaccodaily(%)

29.2

(27.5–31.0)

40.4

(37.8–43.0)

18.2

(16.1–20.3)

Dailysmokers

● Averageageofstartingsmoking(years)

18.1

(17.8–18.5)

17.2

(16.9–17.5)

20.2

(19.5–20.9)

● Useofmanufacturedcigarettes(%) 97.3

(96.3–98.3)

97.3

(96.1–98.5)

97.2

(95.4–99.0)

● Meannumberofmanufacturedcigarettessmokedperday(bysmokersofmanufacturedcigarettes)

15.5

(14.8–16.2)

16.8

(16.0–17.7)

12.7

(11.6–13.7)


ANNEX 2


Men (95%CI)

Women (95%CI)

Respondentswhocurrentlyusedsmokelesstobacco(%)

0.3

(0.1–0.6)

0.6

(0.1–1.0)

0.1

(0.0–0.3)

Currentnon-usersofsmokedand/orsmokelesstobacco

● Formertobaccosmokers(%)10.7

(9.7–11.8)

14.8

(13.1–16.5)

6.6

(5.5–7.8)

● Neversmokers(%) 57.8

(55.9–59.7)

41.8

(39.0–44.5)

73.7

(71.4–75.9)

Currentsmokerswhohadtriedtoquitintheprevious12months(%)

27.4

(24.5–30.4)

29.4

(25.8–33.1)

23.0

(18.5–27.6)

Currentsmokersadvisedbyahealthcareprovidertostopsmokingintheprevious12months1(%)

22.3

(19.5–25.1)

21.2

(17.8–24.6)

24.7

(20.0–29.3)

Alcohol consumption

Lifetimeabstainers(%) 83.6

(82.1–85.1)

74.4

(72.0–76.8)

92.7

(91.3–94.1)

Abstainersfortheprevious12months(%) 4.3

(3.6–5.0)

6.5

(5.3–7.6)

2.1

(1.4–2.9)

Currentdrinkers(haddrunkalcoholintheprevious30days)(%)

8.0

(7.0–9.1)

13.1

(11.2–15.0)

3.0

(2.1–4.0)

Respondentsengaginginheavyepisodicdrinking(≥ 6drinksonanyoccasionintheprevious30days)(%)

5.2

(4.2–6.2)

8.7

(7.0–10.3)

1.8*

(1.0–2.6)

Diet

Fruitconsumption

● Meannumberofdaysinatypicalweek 4.6

(4.5–4.7)

4.5

(4.4–4.6)

4.8

(4.7–4.9)

● Meannumberofservingsonaverageperday 1.4

(1.3–1.5)

1.4

(1.3–1.5)

1.5

(1.3–1.6)

Vegetableconsumption

● Meannumberofdaysinatypicalweek 5.1

(5.0–5.2)

4.9

(4.8–5.1)

5.2

(5.1–5.3)

103


Men (95%CI)

Women (95%CI)

● Meannumberofservingsonaverageperday 1.7

(1.5–1.8)

1.6

(1.4–1.8)

1.7

(1.6–1.9)

Respondentswhoate≤ 5servingsoffruitand/orvegetablesonaverageperday(%)

87.8

(86.4–89.3)

87.8

(85.8–89.8)

87.9

(86.3–89.5)

Respondentswhoalwaysoroftenaddedsaltorsaltysaucetotheirfoodbeforeorduringeating(%)

28.1

(26.3–29.9)

29.3

(26.7–31.9)

26.8

(24.6–29.0)

Respondentswhoalwaysoroftenateprocessedfoodshighinsalt(%)

25.5

(23.7–27.4)

27.8

(25.3–30.3)

23.3

(21.0–25.6)

Respondentsthinkingloweringsaltindietisveryimportant(%)

75.6

(73.7–77.6)

73.2

(70.0–76.0)

78.1

(75.9–80.3)

Physical activity

Respondentswithinsufficientphysicalactivity(< 150minutesofmoderate-intensityactivityperweek,orequivalent)2 (%)

43.6

(41.8–45.4)

33.1

(30.5–35.6)

53.9

(51.6–56.3)

Mediantimespentinphysicalactivityonaverageperday(presentedwithinterquartilerange)(minutes)

30.0

(4.3–90.0)

51.4

(11.4–180.0)

17.1

(0,0–55.0)

Respondentsnotengaginginvigorousactivity(%)

81.3

(79.7–82.8)

70.1

(67.5–72.6)

92.2

(90.8–93.6)

Cancer screening

Womenaged30–65yearswhohadeverhadacervicalsmeartest(%)

54.2

(51.2–57.1)

Womenaged40–69yearswhohadeverhadmammography(%)

57.4

(54.1–60.7)

Respondentsaged50–70yearswhohadeverhadafaecaloccultbloodtest

25.5 23.5 27.6

(22.8–28.2) (19.7–27.2) (24.0–31.3)

Respondentsaged50–70yearswhohadhadacolonoscopyintheprevious10years(%)

12.1 11.1 13.2

(10.1–14.2) (8.1–14.0) (10.4–16.0)

Physical measurements

MeanBMI(kg/m2) 27.4 26.6 28.3

(27.2–27.6) (26.3–26.8) (28.0–28.6)

Overweightrespondents(BMI≥ 25kg/m2)(%) 64.4 62.8 66.0

(62.6–66.2) (60.2–65.4) (63.7–68.4)


ANNEX 2


Men (95%CI)

Women (95%CI)

Obeserespondents(BMI≥ 30kg/m2)(%) 28.8 21.6 35.9

(27.3–30.4) (19.5–23.8) (33.8–38.0)

Averagewaistcircumference(cm)_

91.3 87.9

(90.5–92.2) (87.1–88.8)

Averagehipcircumference(cm)_

98.7 102.5

(97.9–99.4) (101.8–103.2)

Meansystolicbloodpressure(SBP),includingthoseonmedicationforraisedbloodpressure(mmHg)

123.0 125.3 120.8

(122.1–123.8) (124.2–126.3) (119.7–121.8)

Meandiastolicbloodpressure(DBP),includingthoseonmedicationforraisedbloodpressure(mmHg)

78.4 78.2 78.7

(78.0–78.9) (77.6–78.8) (78.2–79.2)

Respondentswithraisedbloodpressure(SBP≥ 140and/orDBP≥ 90mmHg)orcurrentlyonmedicationforraisedbloodpressure

27.7 26.1 29.3

(26.0–29.4) (23.7–28.5) (27.2–31.5)

Respondentswithraisedbloodpressure(SBP≥ 140and/orDBP≥ 90mmHg)whowerenotonmedication(%)

57.1 64.7 50.5

(53.8–60.3) (60.3–69.1) (46.4–54.6)

Proportionofallhypertensivepeoplewithcontrolledbloodpressureinthepopulation(%)

23.8 18.5 28.4

(21.0-26.5) (15.2-21.7) (24.5-32.3)

Biochemical measurement

Meanfastingbloodglucose,includingthosecurrentlyonmedicationforraisedbloodglucose(mg/dl)

97.8 96.2 99.3

(95.6–99.9) (93.7–98.8) (96.0–102.5)

Respondentswithimpairedfastingglycaemia(plasmavenousvalue≥ 110mg/dland< 126mg/dl)

7.9 8.1 7.7

(6.3–9.5) (5.9–10.4) (5.5-10.0)

Respondentswithraisedfastingbloodglucose(plasmavenousvalue≥ 126mg/dl)orcurrentlyonmedicationfordiabetes

11.1

(9.4–12.8)

10.6

(8.3–13.0)

11.5

(9.1–13.9)

RespondentswithHbA1c≥ 6.5% 12.0 11.9 12.2

(10.5–13.6) (9.6–14.1) (10.1–14.4)

RespondentswithHbA1c≥ 6.5%orcurrentlyonmedicationfordiabetes(%)

13.3 12.7 13.8

(11.6–14.9) (10.4–15.1) (11.5–16.1)

Meantotalbloodcholesterol,includingthosecurrentlyonmedicationforraisedcholesterol(mg/dl)

161.2 154.9 167.3

(158.5–163.8) (151.4–158.5) (163.7–171.0)

Respondentswithraisedtotalcholesterol(≥ 190mg/dl)orcurrentlyonmedicationforraisedcholesterol(%)

24.7 20.9 28.5

(22.3–27.1) (17.6–24.1) (25.0–31.9)

105


Men (95%CI)

Women (95%CI)

Respondentswithraisedtriglycerides(≥ 180mg/dl)(%)

16.7 19.9 13.6

(14.6–18.9) (16.4–23.4) (11.2–16.0)

RespondentswithsuboptimalHDLcholesterol(< 40mg/dlformenand< 50mg/dlforwomen)(%)

52.3 55.6 49.1

(49.4–55.3) (51.3–59.9) (45.1–53.1)

Meanintakeofsaltperday(g) 9.9 11.0 8.7

(9.7–10.1) (10.8–11.3) (8.5–8.8)

Risk of CVD

Respondentsaged40–69yearswithaten-yearCVDrisk≥ 30%orwithexistingCVD3(%)

10.5 13.3 7.8

(8.1–12.9) (9.2–17.4) (5.3–10.3)

Theproportionofeligiblepersonswhowerereceivingdrugtherapyandcounsellingtopreventheartattacksandstrokes(%)

55.9 55.1 57.0

(45.3–66.6) (39.6–70.7) (44.3–69.8)

Summary of combined risk factors: current daily smokers, fewer than 5 servings of fruits and vegetables per day, insufficient physical activity, overweight, raised blood pressure

Respondents(aged≥ 15)with0riskfactors(%) 1.3* 1.9* 0.8*

(0.7–2.0) (0.7–3.1) (0.4–1.2)

Respondents(%)with≥ 3riskfactors:

● aged18–44years 42.2 45.6 38.9

(39.4–44.9) (41.4–49.8) (35.6–42.3)

● aged45–69years 65.9 61.5 70.0

(63.2–68.6) (57.5–65.5) (66.5–73.5)

● aged18–69years 51.0 51.5 50.5

(48.9–53.0) (48.5–54.5) (47.8–53.1)

● aged≥ 15years 51.2 50.3 51.9

(49.3–53.0) (47.5–53.2) (49.5–54.4)

Lifestyle advice on selected NCD risk factors

Respondentswhohadreceivedcounsellingoreducationfromhealthworkerson≥ 1subjectsrelatedtohealthyliving(healthynutrition,weightreduction,smokingcessationorphysicalactivity)duringprevious12months(%)

40.5

(38.4–42.5)

38.1

(35.3–40.9)

42.9

(40.4–45.3)

Awareness of health harm from selected NCD risk factors

Adults(%)thatcanstate≥ 2negativehealtheffectsof:

● anyoftheselectedNCDriskfactors587.3 89.1 85.5

(85.9–88.6) (87.4–90.8) (83.8–87.1)

● smokingtobacco 76.2 77.0 75.5

(74.4–78.1) (74.3–79.6) (73.4–77.6)


ANNEX 2


Men (95%CI)

Women (95%CI)

● high-saltdiet 71.6 72.3 71.0

(69.8–73.5) (69.8–74.9) (68.8–73.2)

● high-fatdiet 64.3 65.7 62.8

(62.2–66.3) (63.0–68.4) (60.3–65.4)

● lowconsumptionoffruitsand/orvegetables 33.2 32.8 33.6

(31.2–35.2) (30.1–35.6) (31.2–36.1)

● physicalinactivity 58.3

(56.2–60.5)

59.6

(56.7–62.4)

57.1

(54.5–59.8)

● alcoholuse 74.2 75.9 72.5

(72.3–76.1) (73.4–78.4) (70.3–74.7)

● substance abuse 73.4 75.5 71.4

(71.6–75.3) (73.1–77.9) (69.1–73.6)

1 Among those who visited a health care provider in the previous 12 months.

2 For complete definitions of insufficient physical activity, refer to the Global Physical Activity Questionnaire (GPAQ) analysis guide (Geneva: World Health Organization; 2018 (http://www.who.int/ncds/surveillance/steps/resources/GPAQ_Analysis_Guide.pdf?ua=1)) or theWHOglobal recommendationsonphysical activity forhealth (In:WorldHealthOrganization [website]. Geneva: World Health Organization; 2018 (http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html).

3 A 10-years CVD risk ≥ 30% is defined according to age, sex, blood pressure, smoking status (current smokers OR those who quit smoking less than 1 year before the assessment), total cholesterol and diabetes (previously diagnosed or a fasting plasma glucose concentration >126 mg/dl).

4 NCD risk factors include tobacco smoking, high salt diet, high fat diet, less consumption of fruits and/or vegetables, physical inactivity, alcohol use and substance abuse.

* N < 50.

Foradditional information,pleasecontact:DrTokerErgüder([email protected]),NationalProfessional Officer, Noncommunicable Diseases and Life-course, WHO Country Office,Turkey.

FinancialsupportforthesurveywasprovidedbytheMinistryofHealthoftheRepublicofTurkey under the “Health Systems Strengthening and Support Project” loan agreementthatwassignedby theGovernmentof theRepublicofTurkeyand the InternationalBankforReconstructionandDevelopment(WorldBank).TechnicalassistanceforthesurveywasprovidedbyWHOtotheMinistryofHealthoftheRepublicofTurkeywithinthescopeoftheAgreementsignedon10November2016betweenWHOandtheGovernmentoftheRepublicofTurkey.

107

ANNEX 3. WHO STEPS INSTRUMENT FOR NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY: PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017 (SURVEY INFORMATION QUESTIONNAIRE)Survey Information

Participant Identification Number └─┴─┴─┘└─┴─┴─┘└─┴─┴─┘

Location and Date Response Code

InterviewNumber(first4digitsclusterID,next2digitshouseholdranknumber,lastdigitisforsubstitutionnumber)

Enter information from list provided.

└─┴─┴─┴─┴─┴─┘

IX1

Provincename IX2

Townname IX3

Cluster/Centre/VillageID

EnterCluster,CentreorVillageIDfromlistprovided. └─┴─┴─┴─┴─┴─┘I1

Cluster/Centre/Villagename

EnterCluster,CentreorVillagenameasappropriate. └─┴─┴─┴─┴─┴─┘I2

InterviewerID(NameandSurname)

Enter interviewer’s identification.I3

Dateofcompletionoftheinstrument

Enter date when instrument actually completed. └─┴─┘ └─┴─┘ └─┴─┴─┴─┘

ddmmyear

I4


ANNEX 3

Consent, Interview Language and Name Response Code

Consenthasbeenreadandobtained

Select relevant response.

Yes 1I5

No 2 If NO, END

Timeofinterview

(24hourclock)

Enter time interview started.

└─┴─┘: └─┴─┘hrsmins

I7

FamilySurname

Enter family surname (reassure the participant on the confidential nature of this information and that this is only needed for follow up).

I8

FirstName

Enter first name of respondent (reassure the participant on the confidential nature of this information and that this is only needed for follow up).

I9

Contactcellphonenumberoftheparticipantwherepossible

Enter phone number (reassure the participant on the confidential nature of this information and that this is only needed for follow up).

I10

Contacthomephonenumberoftheparticipantwherepossible


IX4

Contactphonenumberoftheparticipant’srelativewherepossible


X5

109

Step 1 Demographic Information

CORE: Demographic Information

Question Response Code

Sex(Record Male / Female as observed)

Select Male / Female as observed.

Male1

Female2

└─┴─┘ └─┴─┘ └─┴─┴─┴─┘ If known, Go to C4

ddmmyear

C2

C1

Whatisyourdateofbirth?

Don’t Know 77 77 7777

Enter date of birth of participant. If unknown, select “don’t know”.

Interviewer Note: If age is told directly then birth date will be calculated and entered

Howoldareyou?

If the age is unknown, help participant estimate their age by interviewing them about their recollection of widely known major events.

Years└─┴─┘ C3

Intotal,howmanyyearshaveyouspentatschoolandinfull-timestudy(excludingpre-school)?

Enter total number of years of education (excluding pre-school and kindergarten).

Years└─┴─┘ C4

Whatisthehighest level of educationyouhavecompleted?

If a person attended a few months of the first year of secondary school but did not complete the year, select “primary school completed”. If a person only attended a few years of primary school, select “less than primary school”.

Select appropriate response.

The last completed school will be asked. if f a person has not completed a school then if he/she is illiterate or not will be asked

İlliterate 1

C5

Literate,butnotcompletedformalschool

2

Primaryschoolcompleted 3

Primary,secondaryorvocationalsecondaryschool

completed4

Highschoolorvocationalhighschoolcompleted

5

2or3yearcollegecompleted 6

4yearcollegeorfacultycompleted

7

Masterdegree(Including5or6yearfaculties)completed

8

PhDdegreecompleted 9

Whatisyourmarital status?

Select the appropriate response.

Single 1

C7

Married 2

Divorced 3

Widowed 4


ANNEX 3

Areyourparentsrelatives?


Yes 1CC1

No 2

Whichofthefollowingbestdescribesyourmainworkstatusoverthepast12months?

(USESHOWCARD)

The purpose of this question is to help answer other questions such as whether people in different kinds of occupations may be confronted with different risk factors.


Governmentemployee

Non-governmentemployee

Self-employed

Non-paid

Student

Homemaker

Retired

Unemployed(abletowork)

Unemployed(unabletowork)

Refused

1

2

3

4

5

6

7

8

9

88

C8

Howmanypeopleliveinyourhouseholdincludingyou? Numberofpeople└─┴─┘ CC2

Howmanypeopleolderthan15years,includingyourself,liveinyourhousehold?

Enter the total number of people living in the household who are 15 years or older. Definition of 15 years and older will be indicated as years

Numberofpeople└─┴─┘ CC3

Howmanypeopleolderthan18years,includingyourself,liveinyourhousehold?

Enter the total number of people living in the household who are 18 years or older. Definition of 18 years and older will be indicated as years

Numberofpeople└─┴─┘ C9

Whatisthetotalaveragemonthlyincomeofyourhousehold,consideringthelastone-yearperiod?TurkishLira/month

Enter the average earnings of the household by month If refused to answer, skip to X7.

permonth└─┴─┴─┴─┴─┴─┴─┘Go to X7

C10

Refused88 C10d

Doyouhaveaccesstoanymeansofsocialsecurity?

Yes,SocialSecurityInstitution(GovernmentRetirement

Fund,Pensionfund)1

CC4Yes,GreenCard 2

Yes,PrivateInsurance 3

Other 4

No 5

Don’tknow 6

111

Health Status


Whatdoyouthinkaboutofyourhealthstatusingeneral?

Read options

VeryGood 1

HS 1

Good 2

Average 3

Bad 4

VeryBad 5

Step 1 Behavioural Factors Affecting Health

Tobacco Use

NowIamgoingtoaskyousomequestionsabouttobaccouse.


Doyoucurrentlysmokeanytobaccoproductssuchascigarettes,hand–rolledcigarettes,pipes,cigarsandwaterpipes/shisha?

(USESHOWCARD)

Ask the participant to think of any tobacco products he/she is smoking currently.

Yes 1

No2IfNo,gotoT8

T1

Doyoucurrentlysmoketobaccoproductsdaily?

This question is only for current smokers of tobacco products.

Yes 1

No 2T2

Howoldwereyouwhenyoufirst started smoking?

For current smokers only. Ask the participant to think of the time when he/she started to smoke any tobacco products.

Age(years)

Don’tknow77└─┴─┘ If Known, go to T5a/T5aw

T3

Doyourememberhowlongagoitwas?

(RECORD ONLY 1, NOT ALL 3)

Don’t know 77

If the participant doesn’t remember his/her age when smoking started, then record the time in years, months or weeks as appropriate.

InYears└─┴─┘ IfKnown,gotoT5a/T5aw T4a

ORinMonths└─┴─┘ If Known, go to T5a/T5aw T4b

ORinWeeks└─┴─┘ T4c


ANNEX 3

Onaverage,how manyofthefollowingproductsdoyousmokeeach day/week?

(IF LESS THAN DAILY, RECORD WEEKLY)

(RECORD FOR EACH TYPE, USE SHOWCARD)

Don’t Know 7777

For current smokers only. Specify zero if no products were used in each category instead of leaving categories blank.

Record daily consumption for daily smokers. If products are smoked less than daily by daily smokers, enter weekly consumption. Also enter weekly consumption for current, non-daily smokers.

VERIFY THIS IS # OF CIGARETTES, NOT PACKS

DAILY↓ WEEKLY↓Manufactured

cigarettes└─┴─┴─┴─┘└─┴─┴─┴─┘ T5a/T5aw

Hand-rolledcigarettes

└─┴─┴─┴─┘└─┴─┴─┴─┘ T5b/T5bw

Pipesfulloftobacco └─┴─┴─┴─┘└─┴─┴─┴─┘ T5c/T5cw

Cigars,cheroots,cigarillos

└─┴─┴─┴─┘└─┴─┴─┴─┘ T5d/T5dw

NumberofWaterpipe/Shisha

sessions└─┴─┴─┴─┘└─┴─┴─┴─┘ T5e/T5ew

Other└─┴─┴─┴─┘└─┴─┴─┴─┘

If Other, go to T5other, else go to T6 T5f/T5fw

Other(pleasespecify):

└─┴─┴─┴─┴─┴─┘T5other/

T5otherw

Ifyouareusingdailyorweeklywaterpipe(Shisha)howoldwereyouwhenyoufirststartedusing?

Age └─┴─┘ TX1

Duringthepast12months,haveyoutriedto stop smoking?

For current smokers only. Ask the participant to think of any quit attempt during the past 12 months.

Yes 1

No 2 T6

Duringanyvisittoadoctororotherhealthworkerinthepast12months,wereyouadvisedtoquitsmokingtobacco?

For current smokers only. Ask the participant to think of visits to a doctor or other health worker during the past 12 months. If no visit, select “no visit during the past 12 months”.

Yes1IfT2=Yes,gotoT12;ifT2=No,gotoT9

No2IfT2=Yes,gotoT12;ifT2=No,gotoT9

Novisitduringthepast12months

3IfT2=Yes,gotoT12;ifT2=No,gotoT9

T7

Inthepast,didyouever smokeanytobaccoproducts? (USE SHOWCARD)

Ask the participant to think of the time when he/she may have been smoking tobacco products.

Yes 1

No2IfNo,gotoT12T8

Inthepast,didyoueversmokedaily?

Ask the participant to think of the time when he/she may have been smoking tobacco products on a daily basis.

Yes1IfT1=Yes,gotoT12,elsegotoT10

No2IfT1=Yes,gotoT12,elsegotoT10T9

113

Howoldwereyouwhenyoustopped smoking?

Ask the participant to think of the time when he/she stopped smoking tobacco products.

Age(years)└─┴─┘ If Known, go to T12

Don’tKnow77T10

Howlong agodidyoustopsmoking?

(RECORD ONLY 1, NOT ALL 3)

Don’t Know 77

If the participant doesn’t remember his/her age when they stopped smoking, then record the time in weeks, months or years as appropriate.

Yearsago └─┴─┘ If Known, go to T12 T11a

ORMonthsago └─┴─┘ If Known, go to T12 T11b

ORWeeksago └─┴─┘ T11c

Whatwasthemostimportantreasonforquittingsmokingtobacco?

Inordertoprotectmyfamily1

TX2

Iwassick 2

Myfamily,friendswantedmetoquit

3

IwasaffectedbyPublicService

Announcements4

Iwasadvisedbyhealthpersonnel(doctors,

nurses,pharmacists,etc.)

5

Other 6

Doyoucurrently use anysmokeless tobaccoproductssuchas[snuff, chewing tobacco, betel]?

(USE SHOWCARD)

Ask the participant to think of any smokeless tobacco products that he/she is using currently.

Yes 1

T12No 2

Doyoucurrently use smokeless tobaccoproductsdaily?

For current users of smokeless tobacco products only.

Yes 1

T13No 2

Do you currently use electronic cigarette?Yes 1

TX3No 2

Duringthepast30days,didsomeonesmoke in your home?

The participant should only think about other people, not about him-/herself. Smokers should exclude themselves.

The question is asking about inside the participant’s home. This only includes fully enclosed areas of the home.

Yes

No

1

2T17


ANNEX 3

Duringthepast30days,didsomeonesmokeinclosedareas in your workplace(inthebuilding,inaworkareaoraspecificoffice)?

For those not working in a closed area, record “don’t work in a closed area”. Ask the participant to think of seeing somebody smoke or smelling the smoke in indoor areas at work during the past 30 days.

Yes 1

T18

No 2

Don’tworkinaclosedarea

3

Doyousupporttobaccocontrollawsimposingabanonsmokinginclosedplacesandpublicareassuchasrestaurants,cafes,coffeehousesandbars?

Yes 1

TX4No 2

Notsure/Don’tknow 3

Alcohol Consumption

Thenextquestionsaskabouttheconsumptionofalcohol.


Haveyoueverconsumedanyalcoholsuchasbeer,wine,raki,vodka,ginorspirits?

(USE SHOWCARD OR SHOW EXAMPLES)

Ask the participant to think of any drinks that contain alcohol, with the exception of alcohol-based medication that is taken due to health reasons.

Yes

No

1

2 A1

Haveyouconsumedanyalcoholwithinthepast 12 months?

Ask the participant to think of any drinks that contain alcohol, with the exception of alcohol-based medication that is taken due to health reasons.

Even if the participant has only consumed a few sips of alcohol in the past 12 months, the response should be “Yes”.

Yes

No

1

2A2

Haveyouconsumedanyalcoholwithinthepast 30 days?

Select the appropriate response. Even if the participant has only consumed a few sips of alcohol in the past 30 days, the response should be “Yes”.

Yes

No

1

2 A5

Duringthepast30days,howmanytimesdidyouhave

six or morestandarddrinksinasingledrinkingoccasion?

Ask the participant to think of the past 30 days only, and to report the number of occasions when he/she had six or more standard drinks.

Numberoftimes

Don’tKnow77 └─┴─┘ A9

115

Addictive Drug (Substance) Consumption for example: cannabis and derivatives, volatiles (glue, bally, thinner), stimulants (ecstasy, energy drinks) heroin, cocaine

Thenextquestionsareabouttheconsumptionofaddictive(substance)andwillbeaskedonlytoobtaininformationforyourhealthstatus


Haveyoueverusedaddictivedrugs(substances)otherthantobaccooralcohol?

Neverused 1

ADD1

Tried 2

Used,butquitonmyown 3

Used,butquitwithtreatment 4

Currentlyusing 5

Haveyoubeenaskedwhetheryouusedrugs(substances)byhealthworkersordoctorsatahealthcenterduringthelast12months

YesataFamilyHealthCenter 1

ADD2Yesatadifferenthealth

institution2

No 3

Duringthepast12monthsHaveyounoticedanyinformationaboutharmsofdrugs(substances)usethroughbrochures/posters,trainingbyprofessionals,informativemeetings,publicserviceannouncements

(detailedexplanationoninterviewerguidethatdrugs(substances)shouldbeotherthanalcoholortobacco)

Yes 1 ADD3

No 2

Haveyouheardabout“Alo191”Anti-SubstanceAbuseCounsellingandSupportLine?

Yes 1 ADD4

No 2

CORE: Diet

Thenextquestionsaskaboutthefruitsandvegetablesthatyouusuallyeat.Ihaveanutritioncardherethatshowsyousomeexamplesoflocalfruitsandvegetables.Eachpicturerepresentsthesizeofaserving.Asyouanswerthesequestionspleasethinkofatypicalweekinthelastyear.


Inatypicalweek,onhowmanydaysdoyoueat fruit?

(USE SHOWCARD)

Ask the participant to think of any fruit on the showcard. A typical week means a “normal” week when the diet is not affected by cultural, religious, or other events. Ask the participant to not report an average over a period.

Numberofdays Don’tKnow77

└─┴─┘ IfZerodays,goto D3 D1

Howmanyservingsoffruitdoyoueatononeofthosedays?(USE SHOWCARD)

Ask the participant to think of one day he/she can recall easily. Refer to the showcard for serving sizes.

Numberofservings

Don’tKnow77└─┴─┘ D2


ANNEX 3

In a typical week, on how many days do you eat vegetables? (USE SHOWCARD)

Ask the participant to think of any vegetable on the showcard. A typical week means a “normal” week when the diet is not affected by cultural, religious, or other events. Ask the participant to not report an average over a period.

Numberofdays Don’tKnow77

└─┴─┘ IfZerodays,goto D5

D3

Howmany servingsofvegetablesdoyoueatononeofthosedays?(USE SHOWCARD)

Ask the participant to think of one day he/she can recall easily. Refer to the showcard for serving sizes.

Numberofservings

Don’tknow77└─┴─┘ D4

Howoftendo you consumesugar addedbeverages(fizzy or unfizzy) such as juice, fruit nectars,concentrated juice, fruitsyrupandsugaradded teaorcoffeeetc.?

Always 1

DX1

Often 2

Sometimes 3

Rarely 4

Never 5

Don’tknow 77

How often do you consume processed food high insugar?Byprocessedfoodhighinsugar,Imeanfoodsthathavebeenalteredfromtheirnaturalstate,suchascandies,sweets,jellybeans,hard/softcandies,allchocolatetypes(soldseparately,oradded;chocolatechips, creamy chocolate, chocolate drops etc.),desserts with sherbet or syrups; cake, pastry andcookieswithcreamorchocolatefillingorjelly.

Always 1

DX2

Often 2

Sometimes 3

Rarely 4

Never 5

Don’tknow 77

Dietary salt

Withthenextquestions,wewouldliketolearnmoreaboutsaltinyourdiet.Dietarysaltincludesordinarytablesalt,unrefinedsaltsuchasseasalt, iodizedsalt,saltystockcubesandpowders,andsaltysaucessuchassoyasauceorfishsauce(seeshowcard).Thefollowingquestionsareonaddingsalttothefoodrightbeforeyoueatit,onhowfoodispreparedinyourhome,oneatingprocessedfoodsthatarehighinsalt,andquestionsoncontrollingyoursaltintake.Pleaseanswerthequestionsevenifyouconsideryourselftoeatadietlowinsalt.Readthisopeningstatementoutloud.Don’tforgettousetheshowcardwhichwillhelptherespondentwhenansweringtothequestions.

Howoftendoyouadd salt or a salty sauce such as soya sauce toyourfoodrightbeforeyoueatitorasyouareeatingit?

(SELECT ONLY ONE)

(USE SHOWCARD)

Read out all the answer options. Use the showcard that shows

salt and salty sauces.

Always 1

D5

Often 2

Sometimes 3

Rarely 4

Never 5

Don’tknow 77

Howoftenissalt, salty seasoning, meaty bullions, premade mixes with high spice and salt content etc. or a salty sauce addedincookingorpreparingfoodsinyourhousehold?

Read out all the answer options. Select the appropriate response.

Always 1

D6

Often 2

Sometimes 3

Rarely 4

Never 5

Don’tknow 77

117

How often do you eat processed food high in salt? Byprocessed food high in salt, I mean foods that have beenaltered from their natural state, such as packaged saltysnacks, canned salty food including pickles and preserves,salty food prepared at a fast food restaurant, cheese,pastrami, fermented sausage, sausage, fermented carrotjuice andprocessedmeat (USE SHOWCARD) Read out all the answer options. Use the showcard that shows processed food high in salt.

Always 1

D7

Often 2

Sometimes 3

Rarely 4

Never 5

Don’tknow 77

How much salt or salty sauce doyouthinkyouconsume?

Read out all the answer options and select the appropriate response.

Fartoomuch 1

D8

Toomuch 2

Justtherightamount 3

Toolittle 4

Fartoolittle 5

Don’tknow 77

How important to you is lowering the salt in your dietconsideringyourhealthstatus?


Veryimportant 1

DX3

Somewhatimportant 2

Notatallimportant 3

Don’tknow 77

Doyoudoanyof the followingona regularbasis tocontrolyoursaltintake?

(RECORDFOREACH)

Limitconsumptionofprocessedfood

Lookatthesaltorsodiumcontentponthefoodlabels

Buylowsalt/sodiumalternatives

Usespeciesotherthansaltwhencooking

Avoideatingfoodpreparedoutsiteofahome

Dootherthingsspeciallytocontrolyoursaltintake

Other(pleasespecify)

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

└─┴─┘└─┴─┘└─┴─┘

1

2

1

2

1

2

1

2

1

2

1(ifyesgotoD11other)

2

D11a

D11b

D11c

D11d

D113e

D11f

D11Other


ANNEX 3

Whattypeofoil or fat is most oftenusedformealpreparationinyourhousehold?

(USE SHOWCARD)

(SELECT ONLY ONE)


Oliveoil,nutoil 1

D12

Sunflowerseedoil,soyaoil,cornoil

2

Lard 3

Butter 4

Margarine 5

OtherIfOther,gotoD12other 6

Noneinparticular 7

Noneused 8

Don’tknow 77

Other └─┴─┘ D12other

Onaverage,howmanymealsperweekdoyoueatthatwerenot prepared at a home? By meal, I mean breakfast, lunchanddinner.Record the number of meals. Ask the participant to think of

meals those were not prepared at a home, including his/her own home, the home of other family members or friends.

Number └─┴─┘

D13Don’tknow 77

Howmanyglassesofwateryoudrinkperday?Number └─┴─┘

DX4Don’tknow 77

119

Physical Activity

NextIamgoingtoaskyouaboutthetimeyouspenddoingdifferenttypesofphysicalactivityinatypicalweek.Pleaseanswerthesequestionsevenifyoudonotconsideryourselftobeaphysicallyactiveperson.

Thinkfirstaboutthetimeyouspenddoingwork.Thinkofworkasthethingsthatyouhavetodosuchaspaidorunpaidwork,study/training,householdchores,harvesting food/crops,fishingorhunting for food,seekingemployment.[Insert other examples if needed]. Inansweringthefollowingquestions‘vigorous-intensityactivities’areactivitiesthatrequirehardphysicaleffortandcauselargeincreasesinbreathingorheartrate,‘moderate-intensityactivities’areactivitiesthatrequiremoderatephysicaleffortandcausesmallincreasesinbreathingorheartrate.

Read this opening statement out loud. It should not be omitted. The respondent will have to think first about the time he/she spends doing work (paid or unpaid work, household chores, harvesting food, fishing or hunting for food, seeking employment [Insert other examples if needed]), then about the time he/she travels from place to place, and finally about the time spent in vigorous as well as moderate physical activity during leisure time.

Remind the respondent when he/she answers the following questions that ‘vigorous-intensity activities’ are activities that require hard physical effort and cause large increases in breathing or heart rate, ‘moderate-intensity activities’ are activities that require moderate physical effort and cause small increases in breathing or heart rate. Don’t forget to use the showcard which will help the respondent when answering to the questions.


Work

Doesyourworkinvolvevigorous-intensityactivitythatcauseslarge increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] foratleast10minutescontinuously?

[INSERT EXAMPLES] (USE SHOWCARD)

Ask the participant to think about vigorous-intensity activities at work only. Activities are regarded as vigorous intensity if they cause large increases in breathing and/or heart rate.

Yes 1

P1

No 2 If No, go to P 4

In a typical week, on how many days do you do vigorous-intensityactivitiesaspartofyourwork?

“Typical week” means a week when the participant is engaged in his/her usual activities. Valid responses range from 1-7.

Numberofdays └─┘ P2

How much time do you spend doing vigorous-intensityactivitiesatworkonatypicalday?

Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in vigorous-intensity activities at work. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.

Hours:minutes └─┴─┘: └─┴─┘hrsmins

P3 (a-b)

Does your work involve moderate-intensity activity thatcauses small increases in breathing or heart rate such asbriskwalking [or carrying light loads] forat least 10minutescontinuously?


Ask the participant to think about moderate-intensity activities at work only. Activities are regarded as moderate intensity if they cause small increases in breathing and/or heart rate.

Yes 1

P4No 2 If No, go to P 7


ANNEX 3

In a typical week, on howmany days do you do moderate-intensityactivitiesaspartofyourwork?



How much time do you spend doing moderate-intensityactivitiesatworkonatypicalday?

Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in moderate-intensity activities at work. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.

Hours:minutes └─┴─┘: └─┴─┘hrsmins

P6 (a-b)

Travel to and from places

Thenextquestionsexcludethephysicalactivitiesatworkthatyouhavealreadymentioned.

NowIwouldliketoaskyouabouttheusualwayyoutraveltoandfromplaces.Forexampletowork,forshopping,tomarket,toplaceofworship. [Insert other examples if needed]

The introductory statement to the following questions on transport-related physical activity is very important. It asks and helps the participant to now think about how they travel around getting from place-to-place. This statement should not be omitted.

Doyouwalkoruseabicycle(pedal cycle)foratleast10minutescontinuouslytogettoandfromplaces?


Yes 1

P7No 2 If No, go to P 10

Inatypicalweek,onhowmanydaysdoyouwalkorbicycleforatleast10minutescontinuouslytogettoandfromplaces?



Howmuchtimedoyouspendwalkingorbicyclingfortravelonatypicalday?

Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in transport-related activities. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.

Hours:minutes└─┴─┘:└─┴─┘hrsmins

P9 (a-b)

Recreational activities

Thenextquestionsexcludetheworkandtransportactivitiesthatyouhavealreadymentioned.

NowIwouldliketoaskyouaboutsports,fitnessandrecreationalactivities(leisure) [Insert relevant terms].

This introductory statement directs the participant to think about recreational activities. This can also be called discretionary or leisure time. It includes sports and exercise but is not limited to participation in competitions. Activities reported should be done regularly and not just occasionally. It is important to focus on only recreational activities and not to include any activities already mentioned. This statement should not be omitted.

121

Doyoudoanyvigorous-intensitysports,fitnessorrecreational(leisure) activities that cause large increases in breathingorheartrate like[running or football] forat least10minutescontinuously?


Ask the participant to think about recreational vigorous-intensity activities only. Activities are regarded as vigorous intensity if they cause large increases in breathing and/or heart rate.

Yes 1


P10

In a typical week, on how many days do you do vigorous-intensitysports,fitnessorrecreational(leisure)activities?


Numberofdays└─┘ P11

Howmuchtimedoyouspenddoingvigorous-intensitysports,fitnessorrecreationalactivitiesonatypicalday?

Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in recreational vigorous-intensity activities. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.


P12

(a-b)

Do you do any moderate-intensity sports, fitness orrecreational (leisure) activities that cause a small increasein breathing or heart rate such as brisk walking, [cycling, swimming, and volleyball] foratleast10minutescontinuously?


Ask the participant to think about recreational moderate-intensity activities only. Activities are regarded as moderate intensity if they cause small increases in breathing and/or heart rate.

Yes 1


P13

In a typical week, on howmany days do you do moderate-intensitysports,fitnessorrecreational(leisure)activities?


Numberofdays└─┘P14

Howmuchtimedoyouspenddoingmoderate-intensitysports,fitnessorrecreational (leisure) activitiesonatypicalday?

Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in recreational moderate-intensity activities. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.


P15 (a-b)

Sedentary behaviour

Thefollowingquestionisaboutsittingorrecliningatwork,athome,gettingtoandfromplaces,orwithfriendsincludingtimespentsittingatadesk,sittingwithfriends,travelingincar,bus,train,reading,playingcardsorwatchingtelevision,butdonotincludetimespentsleeping.

(USE SHOWCARD)


ANNEX 3

Howmuch time do you usually spend sitting or reclining onatypicalday?Ask the participant to consider total time spent sitting at work, in an office, reading, watching television, using a computer, doing hand craft like knitting, resting etc. The participant should not include time spent sleeping.


P16

(a-b)

History of Raised Blood Pressure


Haveyoueverhadyourbloodpressuremeasuredbyadoctororotherhealthworker?

Ask the participant to only consider measurements done by a doctor or other health worker.

Yes 1

No 2 If No, go to H6H1

Haveyoueverbeentoldbyadoctororotherhealthworkerthatyouhaveraisedbloodpressureorhypertension?


Yes 1

No 2 If No, go to H6H2a

Haveyoubeentoldinthepast12months?

Only for those that have previously been diagnosed with raised blood pressure.

Yes 1

No 2 H2b

Inthepasttwoweeks,haveyoutakenanydrugs(medication)for raised blood pressure prescribed by a doctor or otherhealthworker?

Ask the participant to only consider drugs for raised blood pressure prescribed by a doctor or other health worker.

Yes 1

No 2H3

Whichofthefollowingdoyoucurrentlydoformanagingyourhypertension?

(select one or more)?

Regularmedication1

Irregularmedication2

Herbalmedication3

Physicalactivity4

Diet 5

Nothing6

Other7

HX1

History of Diabetes


Haveyoueverhadyourbloodsugarmeasuredbyadoctororotherhealthworker?


Yes 1


Haveyoueverbeentoldbyadoctororotherhealthworkerthatyouhaveraisedbloodsugarordiabetes?


Yes 1



Only for those that have previously been diagnosed with diabetes.

Yes 1

No 2 H7b

123

Whatisyourdiabetestype?

Type11

Type22

Other(gestational,etc.)3

Don’tknow4

HX2

Inthepasttwoweeks,haveyoutakenanydrugs(medication)fordiabetesprescribedbyadoctororotherhealthworker?

Ask the participant to only consider drugs for diabetes prescribed by a doctor or other health worker.

Yes 1

No 2 H8

Areyoucurrentlytakinginsulinfordiabetesprescribedbyadoctororotherhealthworker?

Ask the participant to only consider insulin that was prescribed by a doctor or other health worker.

Yes 1

No 2 H9

Whichofthefollowingcurrentlydoyoudoformanagingyourdiabetes?

(select one or more)

Regularmedication1


Herbalmedication3

Physicalactivity4

Diet 5

Nothing6

Other7

HX3

WhatistheresultofyourlatestHbA1ctestdoneinthelast3months?

Notmeasured1

Lessthan6%2

Between6-8%3

Between8-10%4

10%andabove5

Measuredbutdonot6remember

HX4

History of Raised Total Cholesterol

Questions Response Code

Haveyoueverhadyourcholesterol (fat levels in yourblood)measuredbyadoctororotherhealthworker?


Yes 1


Haveyoueverbeentoldbyadoctororotherhealthworkerthatyouhaveraisedcholesterol?


Yes 1



Only for those that have previously been diagnosed with raised total cholesterol.

Yes 1

No 2 H13b


ANNEX 3

In the past two weeks, have you taken any oral treatment(medication)forraisedtotalcholesterolprescribedbyadoctororotherhealthworker?

Ask the participant to only consider drugs for raised total cholesterol prescribed by a doctor or other health worker.

Yes 1

No 2 H14

Whichofthefollowingdoyoucurrentlydoformanagingyourhighcholesterol?

(select one or more)

Regularmedication1


Herbalmedication3

Physicalactivity4

Diet 5

Nothing6

Other7

HX5

History of Cardiovascular Diseases


Have you ever had a heart attack or chest pain from heartdisease (angina) or a stroke (cerebrovascular accident orincident)?


Yes 1

No2SkiptoH18H17

Atwhatagedidyoufirsthavetheheartattackorchestpainfrom heart disease (angina) or a stroke (cerebrovasculardisease)?

Years]---------- HX6

Areyoucurrently takingaspirin regularly topreventor treatheartdisease?

“Regularly” means on a daily or almost daily basis.

Yes 1

No 2 H18

Are you currently taking statins (Lovastatin/Simvastatin/Atorvastatinoranyotherstatin)regularlytopreventortreatheartdisease?

“Regularly” means on a daily or almost daily basis.

Yes 1

No 2 H19

125

Family History of Chronic Diseases


Doanyofyourparentsorsiblingshavea known diagnosed chronic diseasethatrequiresmedication?

Yes 1

FH1No

2 SKIP to next section

Doyourparentsorsiblingshavewhichof thediagnosedchronicdisease thatrequiresmedication?

(checkalltheapply)

Type2Diabetes

Hypertension

Hypercholesterolemia

heartattack

chestpainfromheartdisease(angina)

stroke(cerebrovascularaccidentorincident)

Cancer


No

1

2

3

4

5

6

7

8

9

FH2

Doanyofyourparentsorsiblingshaveexperiencedanyheartattackorchestpainfromheartdisease(angina)beforetheageforman55andforwoman65?

Yes 1

FH3No 2

Asthma, Chronic Obstructive Pulmonary Disease (COPD), Cancer History

Code Response Code

Haveyoubeendiagnosedwithasthma(includingallergicasthma)byadoctor?

Yes 1CD1

No 2

HaveyoubeendiagnosedwithChronicObstructivePulmonaryDisease(COPD/emphysema/chronic bronchitis by adoctor)?

Yes 1

CD2No 2

In the past 12months, have you beendiagnosedwithanytypeofcancer?

Yes 1CD3

No 2skiptonextsection

Couldyoupleasespecifywhichkindofcancerhaveyoubeendiagnosedwith?

SpecifythenameofthecancerCD4

CORE: Lifestyle Advice


Howdoyoufeelaboutyourweight?

Thin(lowweight)

Normalweight

Overweight

Obese

Morbidobese

1

2

3

4

5

BW1


ANNEX 3

Duringthepasttwelvemonths,hasadoctororotherhealthworkeradvisedyoutodoanyofthefollowingspecificforyourhealthcondition?

(RECORDFOREACH)

Selecttheappropriateresponse.Asktheparticipanttoonlyconsideradvicefromadoctororotherhealthworker.

Quitusingtobaccoordon’tstartYes 1

H20aNo 2

Reducesaltinyourdiet Yes 1H20b

No 2

Eatatleastfiveservingsoffruitand/orvegetableseachday

Yes 1H20c

No 2

ReducefatinyourdietYes 1

H20dNo 2

StartordomorephysicalactivityYes 1

H20eNo 2

Maintainahealthybodyweightorloseweight

Yes 1H20f

No 2

Adverse Effects of Risk Factors on Health

Notefortheinterviewer:oneormoreoptionscanbeselected


Basedonwhatyouknoworbelieve,smokingtobaccocauseswhichthefollowinghealthproblems

Morethanoneresponsepossible

Lungdisease

Cancer

Heartattack

Stroke

Highbloodpressure

None

Don’tknow/Havenoidea

1

2

3

4

5

6

77

RF1

Basedonwhatyouknoworbelieve,usingtoomuchsaltorsaltysauces/tomatopasteinyourdietcauseswhichofthefollowinghealthproblems

Hypertension

Heartattack

Renaldisease

Stroke

Stomachcancer

None


1

2

3

4

5

6

77

RF2

Basedonwhatyouknoworbelieve,doesconsuminglessfruitsorvegetablescausewhichofthefollowinghealthproblem?

Heartattack

Stroke

Cancer

Diabetes

None


1

2

3

4

5

77

RF3

127

Basedonwhatyouknoworbelieve,beingphysicallyinactivecauseswhichofthefollowinghealthproblem?

Heartattack

Stroke

Cancer

Diabetes

None


1

2

3

4

5

77

RF4

Basedonwhatyouknoworbelieveconsumingtoomuchfatcauseswhichofthefollowinghealthproblem?

Heartattack

Stroke

Cancer

Diabetes

None


1

2

3

4

5

77

RF5

Basedonwhatyouknoworbelievealcoholconsumptioncauseswhichofthefollowinghealthproblem?

Heartattack

Stroke

Cancer

Livercirrhosis

Psychologicaldamageandaddiction

No


1

2

3

4

5

6

77

RF6

Basedonwhatyouknoworbelieveaddictivedrugs(substances)consumptioncauseswhichofthefollowinghealthproblem?

Liverfailure

Braindamage

Psychiatricdiseases(depression,schizophreniaetc.)

Sexualimpotence

None


1

2

3

4

5

77

RF7

Cancer Screening Tests


HaveyouheardthattheCancerScreeningsareavailableforfreeinFamilyHealthCentersandCancerEarlyDiagnosisScreeningandTrainingCenters(KETEM)?

Yes

No

1

2CA1

Whenyouwerelasttestedforguaiacfaecaloccultbloodtest?

Notefortheinterviewer:Foragesbetween50-70

Inthelast12months

Morethan1,lessthan2yearsago


Morethan5yearsago

Never

1

2

3

4

5

CA2

HaveyouhadacolonoscopyInthelast10years?

Yes

No

1

2CA3


ANNEX 3

Whendidyoulasthaveamammogram?

Notefortheinterviewer:X-raysofbreasts,Forfemalesagedbetween40-69

Inthelast12months



Morethan5yearsago

Never

1

2

3

4

5

CA4

Whendidyoulasthaveacervicalsmeartest?

Notefortheinterviewer:Forfemalesagedbetween30-65)

Inthelast12months



Morethan5yearsago

Never

1

2

3

4

5

CA5

Accidents and Injuries


Inthelast12month,wereyouinjuredasaresultofanaccident?

Yes

No

Don’tknow

Refused

1

2 If No, go to TRT1

77 If don’t know, go to TRT1

88 If Refused, go to TRT1

AC1

Pleaseindicatewhichofthefollowingwasthecauseofthisinjury.

Notefortheinterviewer:IncludingpoisoningandinjuriescausedbyanimalorinsectbitesExcludingtheinjuriesstemmingfromothers’deliberateactions

Traffic

Household

Occupational-work


1

2

3

4

AC2

Ifyouhadanyaccidentdidyouneedmedicalcare?

Notefortheinterviewer:Iftherearemorethanoneoccurrencesinthetypeconsidered,thequestioncoversthemostseriousone(seriousinjuriesthatrequireseriousmedicalattention).

Yes,anambulatorycare

Yes,inpatienttreatment

No,didnotneedmedicalhelp

1

2

3

AC3

129

Ambulatory or Inpatient CareNotefortheinterviewer:TheinterventionsinscopeofOne-DayTreatmentaretreatmentslastinglessthan24hourswithouthavinginpatientanddischargeprocedures.Theseinterventionsarechemotherapytreatment;radiotherapytreatment;alldiagnosticandoperational treatmentsdonebygeneraland localanesthesia, intravenousor inhalationsedation;capsuleendoscopy;dialysistreatments;intravenousinfusionofblood,bloodproductofmedicationetc.(MinistryofHealth,MedicalEnforcementDeclaration)

ThisquestionshouldonlybeaskedoftheparticipantswhohavesaidyestoH2a,H7a,H13a,H17,CD1,CD2,CD3.


Inthepast12months,didyouvisitahospitalforyourtreatmentofhypertension,cardiovasculardisease,stroke,diabetes,cancer,chronicobstructiverespiratorydiseaseorasthma?

Yes

No

1

2skiptonextsectionTRT1

Whatkindoftreatmentdidyouhave?

Notefortheinterviewer:oneormoreoptionscanbeselected

anambulatorycare

acarelastinglessthan24hours

acarelastinglongerthan24hours

1

2

3

TRT2

Ambulatory Diagnosis, Treatment and Home Care The following questionswill be asked to you for hypertension, cardiovascular disease, stroke, diabetes, cancer, chronicobstructiverespiratorydiseaseorasthma

Note to interviewer: Home care is examination, tests, analysis, treatment, medical care, monitoring and rehabilitationservicesincludingsocialandpsychologicalcounsellingservicesathomeinfamilyenvironmentprovidedtoindividualswhoneedhomecareduetovariousdiseases(MinistryofHealthofferedhomeApplicationProceduresandPrinciplesonHealthServicesDirective)


When did you last go to the dentist foryourself (apart from accompanying yourchildrenorrelatives)?

Withinthelastonemonth

Lessthan6monthsago

Morethan6,lessthan12monthsago

12monthsormoretimeago

Never

1

2

3

4

5

ACH1

When did you last visit a generalpractitioner or your family doctor, foryourself?


Lessthan6monthsago


12monthsmoretimeago

Never

1

2

3

4

5

ACH2

Inthelast4weeks,howmanytimeshaveyou visited a general practitioner or yourfamilydoctor,foryourself?

└─┴─┘ times ACH3


ANNEX 3

When did you last visit a specialistphysicianforyourself?


Lessthan6monthsago


12monthsagoormore

Never

1

2

3

4

5

ACH4

Inthelast4weeks,howmanytimeshaveyou visited a specialist physician foryourself?

└─┴─┘ times ACH5

Have you visited any health personnelotherthanmedicaldoctorsforyourselfinthelast4weeks?

Yes

No

1

2ACH6

Whichofthefollowinghealthpersonnelotherthanmedicaldoctorshaveyouvisitedforyourselfwithinthelast4weeks?

Physicaltherapist

Psychologist

Dietician

Other

1

2

3

4 ifotherthengotoACH7other

ACH7

Other(pleasespecify) └─┴─┴─┴─┴─┘ ACH7other

Haveyoureceivedmedicalcareathomeoverthelast12months?

Yes

No

1

2ACH8

Step 2 Physical Measurements

Blood PressureInterviewerID

Record interviewer ID (in most cases interviewer would be the same as for behavioural measurements).

└─┴─┴─┘ M1

DeviceIDforbloodpressure

Record device ID.└─┴─┘ M2

Cuffsizeused

Select cuff size used.

Small

Medium

Large

1

2

3

M3

Reading1

Record first measurement after the participant has rested for 15 minutes. Wait 3 minutes before taking second measurement.

Systolic(mmHg) └─┴─┴─┘ M4a

Diastolic(mmHg) └─┴─┴─┘M4b

Reading2

Record second measurement. Ask the participant to rest for another 3 minutes before taking the third measurement.


Diastolic(mmHg)

└─┴─┴─┘

M5b

Reading3

Record third measurement.


Diastolic(mmHg) └─┴─┴─┘ M6b

131

Duringthepasttwoweeks,haveyoubeentreatedforraisedbloodpressurewithdrugs(medication)prescribedbyadoctororotherhealthworker?


Yes

No

1

2M7

Height and Weight


For women: Areyoupregnant?

Pregnant women skip over height, weight, waist and hip measurements.

Yes

No

1 If Yes, go to M16

2 M8

InterviewerID

Record interviewer ID (in most cases interviewer would be the same as for behavioural and blood pressure measurements).

└─┴─┴─┘ M9

DeviceIDsforheightandweight

Record device IDs.Height

Weight

└─┴─┘

└─┴─┘

M10a

M10b

Height

Record participant’s height in cm with one decimal point.

inCentimetres(cm) └─┴─┴─┘. └─┘ M11

Weight

If too large for scale 666.6

Record participant’s weight in kg with one decimal point.

inKilograms(kg) └─┴─┴─┘.└─┘ M12

WaistDeviceIDforwaist

Record device ID.└─┴─┘ M13

Waistcircumference

Record participant’s waist circumference in centimetres with one decimal point.

inCentimetres(cm) └─┴─┴─┘.└─┘ M14

Hip Circumference and Heart RateHipcircumference

Record participant’s hip circumference in centimetres with one decimal point.

inCentimeters(cm) └─┴─┴─┘.└─┘ M15

HeartRateRecord the three heart rate readings.M16a

Reading1 Beatsperminute └─┴─┴─┘

Reading2 Beatsperminute └─┴─┴─┘ M16b

Reading3 Beatsperminute └─┴─┴─┘ M16c


ANNEX 3

Step 3 Biochemical Measurements

Blood Glucose


Duringthepast12hourshaveyouhadanythingtoeatordrink,otherthanwater?

It is essential that the participant has fasted.

Yes

No

1

2B1

TechnicianID

Record ID of the person taking the measurement.

└─┴─┴─┘ B2

Device ID

Record device ID.└─┴─┘ B3

Timeofdaybloodspecimentaken(24hourclock)

Enter time measurement started.

Hours:minutes └─┴─┘: └─┴─┘hrsmins B4

Fastingbloodglucose

Double check that the participant has fasted.

mg/dl └─┴─┴─┘.└─┘ B5

Today,haveyoutakeninsulinorotherdrugs(medication)thathavebeenprescribedbyadoctororotherhealthworkerforraisedbloodglucose?


Yes

No

1

2B6

Blood LipidsDevice ID

Record device ID.└─┴─┘ B7

Totalcholesterol

Record value for total cholesterol.mg/dl └─┴─┴─┘.└─┘ B8

Duringthepasttwoweeks,haveyoubeentreatedforraisedcholesterolwithdrugs(medication)prescribedbyadoctororotherhealthworker?


Yes

No

1

2B9

Triglycerides and HDL CholesterolTriglycerides

Record value for triglycerides.mg/dl └─┴─┴─┘.└─┘

B16

HDLCholesterol

Record value for HDL cholesterol.mg/dl └─┴─┴─┘.└─┘

B17

HbA1C

Record value for HbA1Cmmol/mol └─┴─┘.└─┴─┘

B18

133

Urinary sodium and creatinineHadyoubeenfastingpriortotheurinecollection?

It is required that the urine collection should be made while fasting in the morning and after the first urinating

Yes

No

1

2B10

TechnicianID

Record technician ID.└─┴─┴─┘ B11

Device ID

Record device ID. └─┴─┘B12

Timeofdayurinesampletaken(24hourclock)

Record time of day urine sample taken as reported by the participant.

Hours:minutes └─┴─┘: └─┴─┘hrsmins B13

Urinarysodium

Record value for urinary sodium.mmol/l └─┴─┴─┘.└─┘ B14

Urinarycreatinine

Record value for urinary creatinine.mmol/l └─┴─┘. └─┴─┘ B15


NOTES

NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY PREVALENCE OF NONCOMM

UNICABLE DISEASE RISK FACTORS, 2017

NATIONALHOUSEHOLD HEALTHSURVEY IN TURKEYPREVALENCE OF NONCOMMUNICABLEDISEASE RISK FACTORS2017


World Health Organization Regional Office for EuropeUN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark

Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01Email: [email protected]

Website: www.euro.who.int

The WHO Regional Office for EuropeThe World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.

Member StatesAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzechiaDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe former Yugoslav Republic of MacedoniaTurkeyTurkmenistanUkraineUnited KingdomUzbekistan

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