Non-communicable diseases (NCDs), particularly cardiovascular diseases, diabetes, respiratory conditions and cancers, are the most common causes of morbidity and mortality globally. Information on the prevalence estimates of NCD risk factors such as smoking, low fruit & vegetable intake, physical inactivity, raised blood pressure, overweight, obesity and abnormal blood lipid are scarce in Somaliland. The aim of this study was to determine the prevalence of these selected risk factors for NCDs among 20–69 year old women and men in Hargeisa, Somaliland.
A cross-sectional study was conducted in five districts of Hargeisa (Somaliland), using the STEP-wise approach to non-communicable disease risk factor surveillance (STEPS) to collect data on demographic and behavioral characteristics and physical measurements (n = 1100). The STEPS approach is a standardized method for collecting, analyzing and disseminating data on NCD risk factor burden. Fasting blood sugar, serum lipids (total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides) were collected in half of the participants.
The WHO STEP-wise approach to Surveillance (STEPS) is a simple, standardized method for collecting, analyzing and disseminating data in WHO member countries.
By using the same standardized questions and protocols, all countries can use STEPS information not only for monitoring within-country trends, but also for making comparisons across countries. The approach encourages the collection of small amounts of useful information on a regular and continuing basis
The vast majority of participants had less than or equal to 1 serving of fruits daily (97.7%) and less than or equal to 1 serving of vegetables daily (98.2%). The proportion of participants with low physical activity levels was 78.4%. The overall prevalence of high salt intake was 18.5%. The prevalence of smoking and Khat chewing among men was 27 and 37% respectively, and negligible among women. In women, the prevalence of hypertension increased from 15% in the age group 20–34 years to 67% in the age group 50–69 years, the prevalence of overweight and obesity (Body Mass Index greater than or equal to 25 kg/m2) from 51 to 73%, and the prevalence of diabetes from 3 to 22%. Similar age-trends were seen in men.
Most of the selected risk factors for non-communicable diseases were high and increased by age in both women and men. Overweight and obesity and low physical activity needs intervention in women, while hypertension and low fruit and vegetable consumption needs intervention in both men and women. Somaliland health authorities should develop and/or strengthen health services that can help in treating persons with hypertension and hyperlipidemia, and prevent a future burden of NCDs resulting from a high prevalence of NCD risk factors.
This study reported that selected risk factors of non-communicable diseases were prevalent among both women and men in Hargeisa, suggesting a significant threat to the Somali population related to an upcoming NCDs epidemic. For most risk factors, the prevalence increased with age. Smoking and khat chewing were a problem among men only, whereas a higher proportion of women than men reported low levels of physical activity. Overweight and obesity was higher in women and high blood pressure was high in both women and men. Age is an unmodifiable risk factor for chronic diseases across all populations. In our study, age was associated with the increasing prevalence of many of the investigated selected NCD risk factors in both women and men, and our findings are consistent with studies that were conducted among other Sub-Saharan African countries.
Another finding in our study was the higher prevalence of behavior risk factors like khat and smoking among the older age group of men (35 to 69 years) than the younger (20 to 34 years).
Our finding of smoking being higher among the oldest age group is contrary to a previous study conducted among Nigerians. As it is known that smoking and khat chewing are both social habits among men in East African countries, we are unsure if the lower prevalence seen among the younger age group will increase, as they grow older. Little is known about khat chewing in East African countries, and changing trends with the ageing population and rising economy should be further investigated.
Strengths and limitations
In general, data on the prevalence of risk factors for NCDs among Somalis in the Horn of Africa is very limited, and to our knowledge, this is the first study that has been carried out in Somaliland using the WHO STEP-wise approach to non-communicable disease risk factor surveillance (STEPS). This provides important baseline data on the prevalence of risk factors for CVDs for comparison to other Somali regions and for inclusion in follow-up studies of longitudinal design. The tools used in the study were standardized and checked every morning.
This study was carried out in an urban setting. The sample was drawn from a big city with Somali inhabitants originating from all regions throughout the Horn of Africa. Thus, our results could possibly be representative of other cities in Somaliland and Somalia.
This study has some limitations. The low participation of men in this study limits the interpretation of data pertaining to them. In our survey we used the Kish grid, as the Kish grid addresses the selection of gender and age in a sample, but there is a discussion of whether the Kish grid can provide a representative sample for gender. During the survey, more women were in the households than men. Moreover, fifty eligible men refused or were not available after several contacts. If the selected person was not at home, we left a note that our team would come back next day, and if they were not present for two attempts, we selected the next eligible person from the Kish grid. According to Somali culture, women are often in the houses during the daytime while men are away working or socializing with other men. Therefore, there also might have been a selection bias among men who were home and included in the study, as they may have been home and willing to participate for special reasons such as poor health or lack of work. Again, results pertaining to the low number of men in this study should be treated cautiously.
The lower number of participants who participated in the blood sample analysis (54.3%) is also a possible limitation of this study. This might have been due to negative perceptions towards blood sampling in Somali culture or the location of the blood collection was far for some of the participants (health center). It is possible that those who took the blood tests are those who have a more active awareness of their personal health. However, the BMI, SBP and DBP of the participants who did not take blood samples were not significantly different from the participants in the analysis.
Lastly, recall bias may have been introduced from the questions on the self-reported variables such as that pertaining to vegetable and fruit intake, as it possible that participants didn’t report boiled or cooked vegetables (such as cabbage, tomatoes, carrots, and onions) with main dishes such as rice and spaghetti.
The prevalence of selected NCDs risk factors are high in Somaliland. Overweight and obesity and low physical activity needs intervention in women, while hypertension and low fruit and vegetable consumption needs intervention in both men and women. Policy makers and stakeholders in the health sector need to institute nationwide population-based strategies to create awareness about these selected NCDs risk factors, as well as its consequences. In addition, more research should be undertaken to generate representative data on NCDs risk factors differences among urban and rural areas, genders, and socio-economic conditions.
ANOVA: Analysis of variance BMI:Body mass index CI: Confidence interval CVDs: Cardiovascular diseases MET:Metabolic equivalents NCDs: Non-communicable diseases PSUs: Primary sample units SSA: Sub-Saharan Africa WC: Waist circumference WHO: World Health Organization
The authors are grateful to the participants, data collectors and Hargeisa Group Hospital. We also thank Dr. Deria Ismail Ereg and University of Hargeisa for facilitating the study.
The study was supported by University of Oslo (UiO).
Ethics approval and consent to participate
The study was approved by the Regional Committee for Medical (study code: 2015/2448 REK South-East) and the Ministry of Health in Somaliland. Written informed consent was obtained from all participants.