Prevalence and Risk Factors Associated to Non-Communicable Diseases in Khartoum State

Introduction Non-communicable diseases are multifactorial including genetic, physiological, environmental behavioral factors. Our research aimed to determine the prevalence and risk factors associated with Non-communicable diseases in two administrative units of Khartoum State. Methods A community-based cross-sectional study was conducted in two administrative units of Khartoum State on a sample of 132 participants selected through multi-stage sampling technique. Firstly, a stratified random sampling technique was used to select Alshohada/Soba out of the six administrative units of Khartoum locality (mode of living was urban). In Jabaal Awliya locality of four administrative units, Al Jabal (with urban and rural mode of living) was selected. At second level, 50 households were selected in each of the two administrative units through the geographical information system to obtain a representative spatial distribution of households in each of the administrative areas. At third level, in each of the household selected participants experiencing at least one NCD were included in the study after obtaining his/her verbal well informed consent. The data collected were computerized through Epi Info 7 and analyzed through SPSS 23. The data were firstly summarized numerically and graphically. Association among variables were determined through chi-square tests and ANOVA. A multi-logistic regression was conducted to estimate the risk factors associated to NCDs. All statistical tests were considered significant when p < 0.05. Results Our findings revealed that NCDs prevailed with an overall prevalence of 24/100,000 population. Of the fifteen risk factors associated to NCDs in the two administrative units, seven were statistically associated (p < 0.05) to NCDs. Discussion In our research the risk factors statistically associated with NCDs were age and gender of the participants, their profession, educational level, physical activities, follow-up visits and having meals outside home. In conclusion NCDs were public health priorities with particular attention to diabetes and hypertension to avoid premature deaths.


ABSTRACT Introduction
Non-communicable diseases are multifactorial including genetic, physiological, environmental behavioral factors.Our research aimed to determine the prevalence and risk factors associated with Noncommunicable diseases in two administrative units of Khartoum State.

Methods
A community-based cross-sectional study was conducted in two administrative units of Khartoum State on a sample of 132 participants selected through multi-stage sampling technique.Firstly, a stratified random sampling technique was used to select Alshohada/Soba out of the six administrative units of Khartoum locality (mode of living was urban).In Jabaal Awliya locality of four administrative units, Al Jabal (with urban and rural mode of living) was selected.At second level, 50 households were selected in each of the two administrative units through the geographical information system to obtain a representative spatial distribution of households in each of the administrative areas.At third level, in each of the household selected participants experiencing at least one NCD were included in the study after obtaining his/her verbal well informed consent.The data collected were computerized through Epi Info 7 and analyzed through SPSS 23.The data were firstly summarized numerically and graphically.
Association among variables were determined through chi-square tests and ANOVA.A multi-logistic regression was conducted to estimate the risk factors associated to NCDs.All statistical tests were considered significant when p < 0.05.

Results
Our findings revealed that NCDs prevailed with an overall prevalence of 24/100,000 population.Of the fifteen risk factors associated to NCDs in the two administrative units, seven were statistically associated (p < 0.05) to NCDs.

Discussion
In our research the risk factors statistically associated with NCDs were age and gender of the participants, their profession, educational level, physical activities, follow-up visits and having meals outside home.In conclusion NCDs were public health priorities with particular attention to diabetes and hypertension to avoid premature deaths.

INTRODUCTION
Non-communicable diseases (NCDs), also named chronic diseases, are multifactorial including genetic, physiological, environmental and behavioral factors as reported by the World Health Organization [1].
WHO reported that globally 41 million deaths occurred yearly due to NCDs with 15 million of those losing life were aged 30 to 69 years; over 85% of these premature deaths occurred in low-and middleincome countries.The four leading killers accounting for 80% of all premature NCD deaths were cardiovascular diseases (17.9 million death/year), cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million).The risk of dying from NCDs increases with tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets.By reducing these risk factors, WHO challenged the participant countries to meet the sustainable development goal (SDG) related to noncommunicable diseases and mental health by reducing by one third the premature NCD mortality [1].
Regarding the socioeconomic impact of NCDs, there is a close relation between poverty and NCDs.
People at lower socioeconomic position get sicker and die earlier than people at higher social class.This is due to many reasons such as improper diet and poor access to health services [2].A systematic analysis carried on age-sex specific mortality for 282 causes of death in 195 countries and territories revealed that non-communicable diseases, as a leading cause of deaths, contributed by 73.4% to the total deaths in 2017 [3].
In Sudan, the proportional mortality rate ranked cardiovascular disease as first accounting for 28% of the total deaths, follow up by cancers (6%), chronic respiratory diseases (3%) and diabetes (2%).In the overall, NCDs in Sudan accounted for 52% of all deaths.The risk of premature death between 30-70 years in Sudan was reported to 26% with a gender variation between males (28%) and females 24% [4].
A multi-country longitudinal study on aging and health [5] revealed a prevalence of hypertension was high in all six countries covered (China, Ghana, India, Mexico, Russia and South Africa).The selfreported prevalence of hypertension ranged from 14.1% in Ghana to 40.8% in Russia.Followed by selfreported arthritis with a prevalence ranging from 7% in Mexico to 27.2% in Russia.The prevalence of self-reported asthma was 7.7% in India, whereas in the remaining countries the prevalence was < 5%.
The prevalence of both self-reported and algorithm based chronic lung diseases were lowest in Ghana 0.5% and 3% respectively, and highest in Russia 13.7% and 21.4% respectively.The adjusted prevalence of self-reported depression varied from 0.3% in China to 13.9% in Mexico.Whereas, the algorithm based indicated a low prevalence of depression in China (2.1%) and a high prevalence in India (18.5%).
retrospective study conducted in Ethiopia in 2015 on 22,320 medical records revealed that the reason for the visits due to NCDs represented 29.7% of the records.The prevalence of cardiovascular diseases was 18.8% and of diabetes mellitus 13.1% [19].A systematic review [20] of five hospital-based studies from eastern Ethiopia revealed a prevalence of CVD was 7.2% and 2.4% for hypertensive heart diseases among all age groups.The only available study among adult outpatients of the capital city indicated that prevalence of CVD was 24%.Two studies investigated the prevalence of hypertensive heart diseases in the capital city, the findings revealed a prevalence of 12% among adults aged ≥11 years.The prevalence of diabetes was assessed through two studies one in the Southern region among adults aged ≥ 18 years and the second in urban region.Two additional hospital based studies, one in all age group and the second in patients aged ≥ 20 years revealed a prevalence of diabetes of respectively 0.5% and 1.2%.
These two studies reported a prevalence of diabetes of respectively 4.9% and 5.3%.Regarding cancer, one hospital-based study on outpatient adults aged ≥ 20 years reported a prevalence of 0.3%.The prevalence of asthma was estimated through one community based study and two hospital-based studies patients aged ≥ 20 years.The three studies revealed a prevalence of asthma of respectively 0.6%, 1% and 3.5%.
In Sudan, published articles [21,22] revealed a prevalence of hypertension ranging from 27.6% to 35.7%.Abdalla EAM et al. reported that diabetes mellitus among 236 adults was 18.6% with no significant gender difference in the prevalence rate [23].
The risk factors associated to non-communicable disease are multifactorial.Ahmed Reza Hosseinpoor et al. reviewed 2002-04 WHS Data from the 41 countries that had available data about NCD risk factors, and relevant socioeconomic and demographic variables.Their findings revealed that angina, asthma, arthritis and depression prevalence were inversely associated to wealth and education, on the contrary the prevalence of diabetes showed a strong association with wealth and education [24].
A cross sectional study, using the WHO Stepwise approach for surveillance of NCDs, was implemented on sample of 3,489 participants (51.7% urban and 48.3) aged 15-64 years.Their findings revealed that the prevalence of daily smoking was 6.6% in urban and 12.29% in rural participants.The prevalence of low physical activity of 38.9% in urban participants was lower (14.2%) in rural; the prevalence of low fruit and vegetables consumption of 92.7% was higher (96.4%) in rural participants.Raised blood pressure of 29.1% in urbans was found to be 15.4% in rural participants [26].Another cross-sectional study in Ibadan (Nigeria) using the WHO Stepwise approach [27] to assess the risk factors of NCDs among 606 civil servants indicated that the prevalence of smoking, harmful use of alcohol, low physical activity, insufficient fruit and vegetables intake, obesity were respectively 6.5%, 7.8%, 62.2%, 69.7%, 57.3%.In the same country, Agaba EL et al. implemented a survey of non-communicable diseases and their risk factors among university employees by using WHO Stepwise approach [28].Of 883 participants of the University of Jos (Nigeria), the most common NCDs were hypertension (48.5%), chronic kidney disease (13.6%), and diabetes mellitus (8.0%).The most common NCD risk factors reported were inadequate intake of fruit and vegetables (94.6%), physical inactivity (77.8%), obesity (26.7%), alcohol use (24.0%) and cigarette smoking (2.9%).In Uganda, a community-based crosssectional study using WHO stepwise approach to chronic disease risk factors surveillance revealed on a sample of 518 participants, that 20.5% of females and 22.1% of males had hypertension, 9.0% of participants were diabetics, 4.9% of men and 9.0% of women were obese, and 51% of participants were physically inactive [29].
In Sudan, Ghebreselasie D.T. [30] reported during the 2nd annual congress of medicare expo on primary care and general pediatrics, that NCDs accounted for 44.0% of the overall deaths in Sudan.Based on a sample 380 participants aged ≥ 30 years selected through a stratified random sampling technique he pointed out that a prevalence of smoking in males of 18.4% and 0.3% in females; alcohol consumption in males was 3.9%, physical inactivity in both gender was 75.0% and adequate consumption of fruits and vegetables was prevalent in 72.9% of the study population.History of NCDs was statistically associated (p < 0.05) to cigarette/tobacco use, as well as physical activity and educational level with a p-value of respectively 0.003 and 0.011.
Our study attempted determine the prevalence and risk factors associated with non-communicable diseases in two administrative units (Alshohada/Soba and Al Jabal) of Khartoum State.

Methodology
A community-based cross-sectional study was conducted.The research was implemented in two administrative units of Khartoum State, namely Alshohada & Soba and Al Jabal with a total population of 552,955 people, 51.1% living in Alshohada & Soba and 48.9% in Al Jabal as per Sudan Census Bureau of Statistics (http://cbs.gov.sd/).The population of Alshohada/ Soba is distributed in 33,608 households and 270,662 inhabitants of Al Jabal live in a total of 32,537 households.A multistage sampling technique was used to select the study participants.At first level the two localities (administrative level 2) which administratively constitute Khartoum were all included in the study.Al Khartoum locality comprise six administrative units, one administrative unit (Alshohada & Soba) was randomly selected.In the locality of Jabal Awliya, subdivided in four administrative units, the only administrative unit where the population mode of living is rural and urban, Al Jabal was purposely included in the study to enable to have in the total sample both urban and rural setting.At second level, in each of the two select administrative units, 50 households spatially distributed were included in the study under the assumption that in every one of the households selected one case of NCD will be available.When no case of NCD was found in a selected household, it was systematically replaced by the nearest household.This led to an estimated sample size of at least 100 participants (50 households x 2 administrative units).
Inclusion and exclusion criteria.Were included in the study, the residents of Alshohada/Soba and Al Jabal harboring a non-communicable disease, regardless their gender and age; for the participants below < 15 years the questionnaire was addressed by the care giver present at the time of the data collection.
Were excluded from the all residents from other administrative units of Khartoum State and the residents of the two selected administrative units who refused to participate in the study.
A standardized interviewer-administrated questionnaire, pre-tested, primarily developed in English, was administrated in Arabic by the researcher.The data collected included the socio-demographic characteristics of the study participants (age, gender, residence, occupation, household size), the type of NCD, its duration, comorbidity and factors associated to the NCD including the lifestyle of the participants and the management of the NCD.
The data collected were computerized through a template developed in Epi-Info7 and analyzed through the statistical package for social sciences (SPSS 23).The data were summarized numerically (mean, standard deviation, median) and graphically (frequency tables for estimating prevalence and graphics).
Association between categorical variables were through chi-square tests (Pearson Chi-square, Fischer Exact Test and Likelihood Ratio).A multi-logistic regression analysis was performed to assess the relationship between NCDs and its related risk factors.All statistical tests were considered as statistically significant when p < 0.05.(112/130) were educated and the remaining 13.8% (18/130) did not attend a school.Their respective household size varied from 2 to 14 members with a median of 6 members.

Distribution of non-communicable diseases (NCDs) in two localities of Khartoum State Chronic Diseases reported by the study population
The two most frequent NCDs reported were Diabetes mellitus and Hypertension affecting respectively 33.0% (44/132) and 23.5% (31/132) of the participants.21.1% (28/132) of the participants harbored the two NCDs (diabetes mellitus associated to hypertension).22.1% (29/132) of the participants suffered from a single NCD or combined two to three NCDs.

Prevalence of non-communicable diseases Alshohada-Soba and Al Jabal
The overall prevalence of the NCDs in the two administrative units surveyed was 24/100,000 population.It ranged from 22/100,000 population in Al Jabal to 26/100,000 population in Al shohada-Soba.
Diabetes Mellitus was the most prevalent (8/100,000) NCD in the two administrative units.This prevalence was the same in Al shohada-Soba and Al Jabal with a prevalence of respectively 7.79/100,000 and 8.13/100,000 (table 1).
Hypertension ranked second in term of prevalence, it affected 6 persons per 100,000 populations.This burden was equal in the two administrative units.
Twenty-eight participants reported harboring diabetes mellitus and hypertension, this represented an average of 5 per 100,000 total populations.This average varied across the two administrative units with 7 persons affected out of 100,000 populations in Alshohada-Soba and 3 persons/100,000 in Al Jabal.

Adherence to treatment by the study participants
Of 132 participants, the majority (93.9%, 124/132) replied that they were under treatment, the proportion of participants under treatment was higher (97.2%, 70/124) in Alshohada & Soba than in Al Jabal (90.0%, 54/124).This difference between the two administrative units was not statistical significant (p=0.14).Most (72.6%, 90/124) of the participants were under treatment for ≥ 5 years and only 8.1% (10/124) were under treatment for < 1 year.19.4% (24/124) of those were under treatment between 1-4 years.The participants were asked to provide the type of treatment they were using.The question offered three options which were namely medical, traditional or combined treatment.91.9% (114/124) of the participants were under medical treatment and the remaining 8.1% (10/124) were under combined treatment (medical and traditional).In Alshohada & Soba, 54.4% and 80.0% of the participants were respectively under medical and combined treatment; whereas in Al Jabal those under medical treatment or combined were respectively 45.6% and 20.0%.The differences recorded between the two administrative units and the type of treatment were not statistically significant (p=0.107);this indicated that the type of treatment was equally used in both administrative units.
The participants were asked to address the question related to the adherence to treatment.Firstly 52.4% (65/124) have forgotten at least once to take his/her treatment and 47.6% (59/124) had never forgotten to take their treatment.Secondarily, 76.6% (95/124) of the participants were taking always their treatment.

Adherence to follow up as prescribed by the treating doctor
The participants were asked if "they have a regular follow up visit for their condition by their treating doctor".More than half (52.3%, 69/132) always had regular visit, 9.8% (13/132) never visit their treating doctor for following their condition and 37.9% (50/132) visited their treating doctor only when necessary (Only when feel the need and only when suffered from the condition).
Sixty participants provided their reasons for not having regular follow up.The predominant (53.3%, 32/60) reason was the participant assumed that the follow-up visit was not a necessity, followed up by "being too busy" with 16.7% (10/60).Financial constraints and others (including long waiting time to see the doctor, home follow-up) ranked equally third with 15.0% (9/60).

Physical activities of the study participants
Of the 132 participants, 37.1% (49/132) reported to practice physical exercises with walking as the predominate exercise.62.9% (83/132) did not practice any physical exercise.In working place, 60.8% (31/51) of the participant sat for > 2 hours at work and 55.3% (73/132) sat at home for > 2 hours.64.4% (85/132) of the participants had an unhealthy sitting time either at work or at home.
In each of the two administrative units, the proportion of participants with an unhealthy sitting time at work/home was higher (70.8% in Alshohada-Soba vs 56.7% in Al Jabal) than those who had a healthy sitting time (29.2% vs 43.3%).However, there was no statistically significant association (p= 0.091) between administrative unit and time spent in sitting at workplace/home.A statistically significant association (p= 0.028) was found between the sitting time spent at workplace/home and gender.
The frequency of regular ("always) consumption of salty foods in a week was higher (71.4%, 20/28) in Al Jabal than in Alshohada-Soba (28.6%, 8/28) where 60.2% (59/98) "never" consumed processed salty foods.The frequency of consumption of salty foods was statistically different (p=0.004) between the administrative units.The frequency of the foods was not statistically associated (p > 0.05) with the gender of the participants.
Having meals outside home in a week was recorded as "always", "occasionally" for the participants who replied either once a week or occasionally and "never".Having meals occasionally was reported by 69.7% (92/132) of the participants, 10.6% (14/132) had meals outside and 19.7% (26/132) had never ate outside home in a week.Of the 26 participants who reported never eat outside home, 50.0%lived in Alshohada-Soba and the remaining 50% resided in Al Jabal.The observed differences between frequency of having meals outside home and the administrative area of residence was not statistically significant (p= 0.158).The chi-square for trend of 2.638 indicated a not statistically difference (p=0.267) between gender and having meals outside.
Soft drink consumption collected as "always", "once a week", "occasionally" and "never" was recorded as healthy soft drink habit when participants answered "never" and those who replied either "once a week", "occasionally" or "always" were recorded as having unhealthy habits towards soft drinks.50.8% (67/132) reported having a healthy habit towards soft drinks.
Healthy juice drink habits were compared with unhealthy juice drink behavior.Participants who replied "drinking always juice without sugar" and those who answered that they "never drink juice with sugar" were coded as having a healthy juice drinking habits and those who answered by any other response to drinking juice without sugar or with sugar had their replies coded as an unhealthy juice drinking habits.
In the overall, the majority (85.6%, 113/132) of the participants had an unhealthy habit towards drinking juice and only 14 participants out of hundred (19/132) had a healthy habit.
Regarding consumption of sweets, cakes and ice cream in a week, 78.8% (104/132) had an unhealthy habit and 21.2% (28/132) had healthy habits towards sweets.86.4% reported to consume tea, 60.6% took coffee, smokers of cigarettes at the time of interview represented 5.3% and 1.5% reported that they used to have alcohol.

Relationship between non-communicable diseases and their associated factors
The NCDs reported by the study participants were regrouped in five categories namely diabetes mellitus Cardiovascular Disease associated to diabetes mellitus and Hypertension; the highly statistically significant contributor associated to this three conditions was having meals outside home contributing for 63 times ([95% CI: 3.786-1063.733],p=0.004).Another statistically significant risk factor was gender (p=0.020) and its coefficient of contribution of -4.169 indicated that males might be more likely to have the association of the three conditions.Table 2b revealed an increasing contribution ranging from 2 times to 5.2 times for treatment duration, education, time of sitting (home/work place), fruit consumption, adherence to treatment, physical activity and marital status.
In conclusion, in our research the risk factors statistically associated with NCDs were age, gender of the participants, their profession, education level, physical activities, follow-up visits and having meals outside home (Tables 2a and 2b).Non-communicable diseases are the results of complex interactions between the genetic make-up of an individual, lifestyle and environmental factors.In Sudan, age, gender, ethnic group, education level, family history of hypertension, family history of diabetes, residence, obesity, smoking, physical activity, salt and sugar intakes, renal problems, and pancreatic disease have been reported as risk factors of NCDs by various authors [21][22][23]30,36].In the neighboring Ethiopia, low fruit consumption was reported [37] to account for 11.9% of NCD deaths which occurred in 2013, other risk factors published were alcohol consumption [31,33].

Conclusions
Our research revealed that NCDs prevailed in Al shohada-Soba and Al Jabal with an overall prevalence of 24/100,000 populations.They were more frequent in Al shohada-Soba where 26 people out 100,000 were affected compared to Al Jabal where the prevalence was 22/100,000 populations.Of the fifteen risk factors associated to NCDs in the two administrative units, seven were statistically associated (p < 0.05) with NCDs.
NCDs should be a public health priority with particular attention to diabetes and hypertension which both well managed will prevent early deaths.Prevention and control of NCDs appeal collaborative efforts and sustained partnership between health services and the communities affected backed up by a strong political will and engagement to enable Sudan to implement WHO strategy towards reducing by one third the premature deaths related to NCDs by 2030.

Table 1 : Prevalence (case/100000 population) of NCDs in Alshohada & Soba and Al Jabal (n=132) Number and prevalence of NCDs per administrative unit Non-communicable disease
*Prevalence calculated as number of cases of NCDs divided by 100,000 total populations.
35.2%, 43/122), hypertension (23.0%, 28/122), diabetes mellitus associated to hypertension (23.0%, 28/122), cardiovascular disease associated to diabetes mellitus and hypertension (9.8%, 12/122) and other NCDs (9.0%, 11/122).The other NCDs included asthma, osteoarthritis, cancer, rheumatoid arthritis, hyperthyroidism and hypothyroidism.A logistic regression analysis was performed to estimate the risk factors associated to the NCDs above listed and the reference group in the model was the other p=0.421).Education, age in years, administrative unit, time of sitting at home/work place, consuming fruits, marital status contributed to model by more than 1 time.